Clinical study of percutaneous microwave ablation of uterine myometrium benign lesions / 中国医师杂志

Objective To study the clinical value of percutaneous microwave ablation of uterine myometrium benign lesions.Methods 100 cases of patients with benign lesions of myometrium in our hospital from January 2016 to January 2017 were enrolled in the study.According to the treatment methods,they were divided into observation group (percutaneous microwave ablation,n =50) and control group (uterine artery embolization,n =50).Relevant perioperative indicators,postoperative complications,hemoglobin (Hb),serum carbohydrate antigen 125 (CA125),menstrual status and follow-up results were observed in both groups.Results The operative time and ambulation time were significantly shortened in observation group (P ＜ 0.05).The postoperative adverse reaction rates in observation group and control group were 44.00％ and 100.00％ respectively (P ＜ 0.05),and the 1-year recurrence rates were 4.00％ and 12.00％ (P ＞0.05).After 1 month and 3 months of treatment,the menstrual period,menstrual volume and dysmenorrhea degree score were gradually decreased in the two groups,and the differences withingroups were significant (P ＜ 0.05).Compared with the corresponding time points of the control group,the level of each index in the observation group was lower,and there was significant difference between the two groups.At 3 months and 12 months after operation,the level of Hb in the two groups was gradually increased while the serum CA125 concentration was gradually decreased (P ＜ 0.05).Compared with the control group at each time point,the level of each index was better in observation group (P ＜ 0.05).At 6 months and 12 months after operation,the uterus volume and fibroid volume in the two groups were gradually decreased (P ＜ 0.05).Compared with the control group at each time point,the uterus volume and fibroid volume were smaller in observation group (P ＜ 0.05).Conclusions Microwave ablation has high safety in the treatment of benign lesions of myometrium,and it has the advantages of few postoperative complications,quick recovery and definite efficacy.Thus it is worthy of clinical promotion.

Effect of Shengxuening tablets combined with ethinylestradiol and cyproterone acetate on thickness of endometrium and hemoglobin levels in patients with endometrial polyps for transcervical resection of polyp / 国际中医中药杂志

Objective To investigate the effects of Shengxuening tablets combined with ethinylestradiol and cycloproterone acetate on endometrial thickness and hemoglobin level in patients with endometrial polyps for transcervical resection of polyp. Methods A total of 150 patients with hysteroscopic endometrial polypectomy were randomly divided into three groups, 50 in each group. The control group was treated with hysteroscopy endometrial polyp electrotomy, while the western medicine group was treated with ethinylestradiol and cycloprogesterone acetate tablets on the basis of the control group, and the combined group was treated with Shengxuening tablets on the basis of the western medicine group. The menstrual volume, endometrial thickness and hemoglobin levels were observed before treatment, at 3 month, 6 month and 12 month after treatment, and the clinical efficacy and recurrence during follow-up were evaluated. Results The total effective rate was 98.0％(49/50) in the combined group, 96.0％ (48/50) in the western medicine group, 86.0％ (43/50) in the control group. The total effective rate in the combined group and the western medicine group was significantly higher than that in the control group (χ2=6.643, P=0.036). The menstrual volume (F=28.096, 49.096, 33.303), endometrial thickness (F=11.214, 20.265, 63.947) in the three groups were significantly different after treatment (P<0.01), and which in the combined group were significantly lower than those in the western medicine group, menstrual volume at 36,12 after treatment (t value were 4.747, 2.244, 4.489, P<0.01); endometrial thickness at 3, 6, 12 month after treatment (t value were 3.293, 3.356, 5.293, P<0.01); there were significant differences in hemoglobin levels in the three groups (F=11.002, 8.662, 8.958, P<0.01), and which in the combined group was significantly higher than that in the western medicine group at 3,6,12 month after treatment (t value were 2.722, 2.074, 2.028, P<0.05). During the follow-up period, 2 cases (4.1％) recurred in the combined group, 3 cases (6.3％) recurred in the western medicine group and 9 cases (20.9％) recurred in the control group. The recurrence rate in the combined group or the western medicine group was significantly lower than that in the control group (χ2=6.775, P=0.034). There was no significant difference in the recurrence rate in the combined group and the western medicine group (χ2=0.211, P=0.646). Conclusions The Ethynestradiol and Cyproterone acetate combined with Shengxuening tablets could improve the curative effect, reduce menstrual volume and endometrial thickness, increase hemoglobin level and reduce recurrence rate in patients with endometrial polyps for transcervical resection of polyp.

Ablação endometrial: para qual paciente indicar? / Endometrial ablation: for whom is indicated?

O sangramento uterino anormal tem, como primeira linha de tratamento, o uso de medicação. Na sua falha ou impossibilidade de utilização, indica-se a histerectomia ou a ablação endometrial. A adequada seleção da paciente para realizar esse último método é essencial para minimizar os riscos de falhas e eventos adversos. Assim, esse estudo objetiva buscar evidências sobre as características das pacientes com maior chance de sucesso na ablação e avaliar se há diferença no resultado com o uso da primeira ou da segunda geração. Buscou-se artigos na base de dados Medline com os termos endométrio e ablação associados ao sangramento menstrual aumentado e sangramento uterino anormal. Foram selecionados 19 artigos dos últimos quatro anos. Comparando-se os dois métodos cirúrgicos, a ablação endometrial tem enorme vantagem perante à histerectomia, tendo menores riscos de complicações, menor custo e por ser de rápida realização. O prévio reconhecimento dos fatores, como adenomiose, laqueadura tubária, anormalidade uterina e dismenorreia, entre outros, pode reduzir a chance de falha da ablação endometrial, além de se sugerir a melhor técnica a ser aplicada. Assim, o alcance do sucesso no tratamento junto à melhora da qualidade de vida da paciente deve ser feito de modo individualizado.(AU)

The first line of treatment for abnormal uterine bleeding is medicine. If it fails or if the patient cannot use it, it is indicated hysterectomy or endometrial ablation. In order to minimize the risk of failure or adverse effects, it is recommended that patients should be selected with criteria for endometrial ablation. Therefore, this study aims to look for evidence of characteristics that could enhance the chances of success for endometrial ablation and observe if there is a difference in results when using either the first or the second generation. Nineteen articles published between 2013-2016 were selected from the Medline base ­ the terms endometrial, ablation, heavy menstrual bleeding and abnormal uterine bleeding were used as key words. Endometrial ablation has advantage over hysterectomy because it shows fewer risks for complications and has lower costs, besides being faster. Previous recognition of factors like adenomyosis, tubal sterilization, uterine abnormality and dysmenorrhea can reduce the chances of failure of endometrial ablation. Moreover, the best technique is suggested to be applied. Thus, the achievement of success in the treatment and improvement in the patient's quality of life should be individualized.(AU)

Comparison of the effect of NovaSure endometrial ablation and transcervical resection of endometrium in the treatment of dysfunctional uterine bleeding / 中国基层医药

Objective To explore the clinical effects of NovaSure endometrial ablation and transcervical resection of endometrium in the treatment of dysfunctional uterine bleeding(DUB).Methods There were 45 DUB patients,20 cases among them received NovaSure endometrial ablation were selected as observation group, and 25 cases received transcervical resection of endometrium were selected as control group.The average operation time, mean bleeding volum,average treatment cost were compared between the two groups.Results The observation group had better average operation time[(7.55 ±3.17)min]and mean bleeding volume[(5.10 ±3.08)mL]than the con-trol group,the differences were statistically significant (t=-9.04,-6.16,all P<0.01).While the observation group had higher average treatment cost[(13 682.25 ±1 679.04)yuan]than the control group,and the difference was statistically significant(t=10.95,P<0.01).Postoperative follow-up of 6 months to evaluate bleeding,the total effective rate between the two groups had no statistically significant difference (χ2 =0.03,P=0.87).Conclusion Implementation of NovaSure endometrial ablation can provide precise effect in treating DUB, with shorter operation time,less mean bleeding volume and other advantages,and it is worth clinical promotion and application.

Tratamento do sangramento uterino anormal: uma análise sob a perspectiva dos custos no Sistema Único de Saúde e da medicina suplementar / Treatment of abnormal uterine bleeding: an analysis from the perspective of costs in the public health system and supplementary medicine

Objetivos: Comparar os custos diretos e indiretos do sistema intra‐uterino de liberação de levonorgestrel (SIU‐LNG), ablação endometrial com balão térmico (AEBT) e histerectomia no tratamento de mulheres com sangramento uterino anormal (SUA). Métodos: Foram avaliadas retrospectivamente 88 pacientes tratadas para SUA pelo SIU‐LNG (n = 30), AEBT (n = 28) e histerectomia (n = 30). Foram considerados todos os procedimentos, consultas e exames envolvidos no tratamento das pacientes por um período de 5 anos, assim como os custos resultantes das falhas dos tratamentos utilizados. Foram estimados os custos pelo Sistema Único de Saúde (SUS) e sistema de saúde suplementar. As diferenças entre os grupos foram avaliadas pelo teste do t de Student ou ANOVA. Resultados:O custo do tratamento do SUA com AEBT foi significante mais elevado em comparação ao SIU‐LNG e histerectomia após um e cinco anos de seguimento, tanto no SUS quanto na medicina suplementar (p < 0,001). No SUS, o tratamento com o SIU‐LNG foi de 38,2% dos custos da histerectomia no primeiro ano (R$ 769,61 vs. R$ 2.012,21, p < 0,001) e de 45,2% após cinco anos (R$ 927,83 vs. R$ 2.052,21, p < 0,001). Na saúde suplementar essa diferença foi ainda mais expressiva. Nesse contexto, o custo do SIU‐LNG foi de 29,1% dos custos da histerectomia no primeiro ano (R$ 1.551,92 vs. R$5.324,74, p < 0,001) e de 37,4% após cinco anos (R$ 2.069,35 vs. R$ 5.538,74, p < 0,001). Conclusões: O uso do SIU‐LNG resulta em custos diretos e indiretos menores do que a AEBT e histerectomia no tratamento do SUA. A custo‐efetividade do SIU‐LNG aliado à reversibilidade e por ser um procedimento ambulatorial reforçam o seu papel no tratamento de mulheres com SUA tanto na perspectiva do SUS quanto na saúde suplementar.

Objectives: To compare direct and indirect costs of the levonorgestrel‐releasing intrauterine system (LNG‐IUS), thermal balloon endometrial ablation (TBEA) and hysterectomy in the treatment of women with abnormal uterine bleeding (AUB). Methods: 88 patients treated for AUB by LNG‐IUS (n = 30), TBEA (n = 28) and hysterectomy (n = 30) were retrospectively evaluated. All procedures, medical appointments and tests involved in the treatment of patients were considered for a period of five years, as well as all costs arising from failures of the treatments used. The costs for the Unified Health System (SUS) and the private health care system were estimated. Differences between groups were evaluated by the test t of Student or ANOVA. Results: The cost of the treatment of AUB with TBEA was significantly higher versus LNG‐IUS and hysterectomy after a five‐year follow‐up in both SUS and private health care system (p <0.001). In SUS, the treatment with the LNG‐IUS represented 38.2% of the hysterectomy cost in the first year (R$ 769.61 vs. R$ 2,012.21, p <0.001) and 45.2% after five years (R$ 927.83 vs. R$ 2,052.21, p <0.001). As for the private health care system, this difference was even more significant. In this context, the cost of LNG‐IUS represented 29.1% of the hysterectomy cost in the first year (R$ 1,551.92 vs. R$ 5,324.74, p <0.001) and 37.4% after five years (R$ 2,069.35 vs. R$ 5,538.74, p <0.001). Conclusions: The use of LNG‐IUS results in lower direct and indirect costs versus TBEA and hysterectomy in the treatment of women with AUB. The cost‐effectiveness of LNG‐IUS, together with the reversibility and also by this being an outpatient procedure, highlights its role in the treatment of women with AUB, both in SUS perspective as in private health care system's.

Achados histeroscópicos na cavidade endometrial após ablação endometrial / Hysteroscopic appearance of the endometrial cavity after endometrial ablation

OBJETIVO: Verificar o aspecto da cavidade uterina após a ablação endometrial histeroscópica, a prevalência de sinéquias após o procedimento e, com isso, avaliar a importância da histeroscopia realizada no pós-operatório dessas pacientes. MÉTODOS: Foram avaliados, retrospectivamente, os laudos dos exames de 153 pacientes que haviam sido submetidas à histeroscopia ambulatorial após ablação do endométrio devido a sangramento uterino anormal de causa benigna, no período entre janeiro de 2006 e julho de 2011. As pacientes foram divididas em dois grupos: HIST≤60 (n=90), com pacientes submetidas ao exame no período de 40 a 60 dias após o procedimento, e grupo HIST>60 (n=63), das que foram examinadas entre 61 dias e 12 meses. RESULTADOS: No grupo HIST≤60, 30% das pacientes apresentavam algum grau de sinéquia; aderências grau I foram descritas em 4,4%; grau II em 6,7%; grau IIa em 4,4%; grau III em 7,8%; e 2,2% apresentavam grau IV. No HIST>60, sinéquias foram descritas em 53,9% dos casos, 3,2% tinham sinéquias grau I; 11,1%, grau II; 7,9%, grau IIa; 15,9%, grau III; e 4,8%, grau IV. Hematometra foi descrito em 2,2% dos casos do HIST≤60 e em 6,3% no HIST>60. CONCLUSÕES: A cavidade uterina de pacientes submetidas à histeroscopia ambulatorial até 60 dias após a ablação endometrial mostrou menor número de sinéquias quando comparada com as cavidades uterinas de pacientes que foram submetidas ao exame após 60 dias. Acompanhamento em longo prazo é necessário para avaliar plenamente o impacto da histeroscopia ambulatorial após a ablação endometrial. .

PURPOSE: To examine the aspect of the uterine cavity after hysteroscopic endometrial ablation, to determine the prevalence of synechiae after the procedure, and to analyze the importance of hysteroscopy during the postoperative period. METHODS: The results of the hysteroscopic exams of 153 patients who underwent outpatient hysteroscopy after endometrial ablation due to abnormal uterine bleeding of benign etiology during the period from January 2006 to July 2011 were retrospectively reviewed. The patients were divided into two groups: HIST≤60 (n=90) consisting of patients undergoing the exam 40-60 days after the ablation procedure, and the group HIST>60 (n=63) consisting of patients undergoing the exam between 61 days and 12 months after the procedure. RESULTS: In the HIST≤60 group, 30% of the patients presented some degree of synechiae: synechiae grade I in 4.4% of patients, grade II in 6.7% , grade IIa in 4.4%, grade III in 7.8%, and grade IV in 2.2%. In the HIST>60 group, 53.9% of all cases had synechiae, 3.2% were grade I, 11.1% grade II, 7.9% grade IIa, 15.9% grade III, and 4.8% grade IV. Hematometra was detected in 2.2 % of all cases in group HIST≤60 and in 6.3% of all cases in group HIST>60. CONCLUSIONS: The uterine cavity of the patients submitted to diagnostic hysteroscopy up to 60 days after endometrial ablation showed significantly fewer synechiae compared to the uterine cavity of patients who underwent the exam after 60 days. Long-term follow-up is necessary to fully evaluate the importance of outpatient hysteroscopy after endometrial ablation regarding menstrual patterns, risk of cancer and prevalence of treatment failure. .

Minirressectoscópio de Gubbini / Miniresectoscope of Gubbini

Os instrumentos empregados na histeroscopia cirúrgica experimentaram grandes avanços nos últimos 30 anos e permitiram escolher desde ressectoscópios de 26 e 21 Fr. acoplados a corrente mono ou bipolar até a office hysteroscopy, que contempla o uso de sistemas operatórios de diâmetros semelhantes àqueles empregados na histeroscopia diagnóstica. Essas opções ampliaram e fortaleceram as possibilidades de indicação cirúrgicas, minimizaram riscos e reduziram acentuadamente as contra indicações. A introdução do minirressectoscópio de Gubbini de 16 Fr. na prática histeroscópica permitiu, graças ao seu diâmetro reduzido, a execução de procedimentos ambulatoriais com a técnica de slicing, que aumenta e facilita as possibilidades do see and treat ambulatorial. A funcionalidade do instrumento tem se revelado satisfatória, já que permite a passagem da corrente de mono para bipolar no mesmo ressectoscópio em uso e nas mesmas alças multiuso. A nossa casuística, que compreende 1.350 pacientes e inclui variadas patologias intrauterinas e endocervicais, demonstra uma eficácia de 100% do instrumento, cuja limitação, não categórica, subordina-se aos miomas com diâmetro superior a 3 cm.

The instruments employed in surgical hysteroscopy experienced great advances in the last 30 years, allowing operators to choose from resectoscopes of 26 and 21 fr. coupled with mono or bipolar current, to the use of “office hysteroscopy”, which contemplates the use of operating systems of diameters similar to those employed in diagnostic hysteroscopy. All these options have broadened and strengthened the possibilities of surgical indications, minimizing risk and reducing sharply the contraindications. The introduction of the miniresectoscope of Gubbini of 16 fr. thanks to its reduced diameter, enabled the implementation of outpatient procedures with the technique of “slicing”, increasing andfacilitating the possibilities of “see and treat” outpatient. The functionality of the instrument has proved to be satisfactory as it allows the passage of current from mono to bipolar in the same resectoscope in use and under the same multipurpose handles. Our series,comprising 1,350 patients and including various intrauterine and endocervical pathology, demonstrates an effectiveness of 100% of the instrument, whose limitation, not categorical, is subordinated to the fibroids with diameter greater than 3 cm.