Resectoscopic Surgery Part III: Advanced Resectoscopic Surgery.

In this final section of our three-part series, we will apply the basic and intermediate skills described in the first two parts to advance the gynecologist's skills to accomplish the most demanding of resectoscopic surgical challenges. In Part I of this series, we reviewed the benefits of the continuous flow gynecologic resectoscope (CFGR) and how the motivated gynecologist can assemble an operative team and overcome the impediments to learning the use of this versatile and minimally invasive instrument. In this first section, we outlined and analyzed basic resectoscopic surgery-endometrial ablation, the resection of small submucous myomas and endometrial polyps, as well as the treatment of mild Asherman's syndrome and the removal of retained products of conception. In Part II-intermediate level resectoscopic surgery-we introduced procedures such as endomyometrial resection, the resection of intermediate-size submucous leiomyomas, hysteroscopic metroplasty, and endocervical resection. Though it is not considered an absolute requirement to accomplish procedures at this level, sonographic guidance was introduced in preparation for more challenging cases. In Part III, the author reviews advanced resectoscopic procedures in which sonographic guidance is a requirement for the management of severe intrauterine adhesions and late-onset endometrial ablation failures, the management of FIGO Type 3 and 4 intramural myomas, as well as large submucous myomas.

Resectoscopic Surgery Part II: Introducing Ultrasound Guidance for Intermediate-Level Surgical Procedures.

In Part I of this three-part series, the author reviewed the importance of resectoscopic surgery and the many advantages it provides to the patient and to the minimally invasive gynecologic surgeon. In Part I, we reviewed the obstacles to mastering this 30-year-old technology and how the motivated surgeon can overcome them. Although many basic resectoscopic procedures have been supplanted by global endometrial ablation (GEA) devices and hysteroscopic morcellators (HMs), the limitations of these restrictive technologies are quickly evident as the surgeon encounters increasingly complex and demanding cases. In Part II, the author examines intermediate-level procedures that cannot be managed with global endometrial ablation or hysteroscopic morcellators-endomyometrial resection (EMR), the resection of larger and multiple submucous leiomyomas and endometrial polyps, the incision of uterine septae, and the management of severe cervical stenosis. In Part II, we will also describe how to incorporate ultrasound guidance into one's surgical armamentarium and its role in assisting the minimally invasive gynecologic surgeon in the safe execution of these more challenging cases.

Resectoscopic Surgery Part I: Overcoming Obstacles and Mastering the Basics.

The introduction of the continuous flow gynecologic resectoscope (CFGR) in 1989 revolutionized minimally invasive gynecologic surgery (MIGS) by introducing such intrauterine procedures as hysteroscopic myomectomy, polypectomy, and endometrial ablation. However, with the subsequent introduction of global endometrial ablation (GEA) devices and hysteroscopic morcellators (HMs), the CFGR has fallen into relative disuse-a regrettable situation since it remains ideally suited for accomplishing many procedures that are otherwise not achievable with these newer technologies. Procedures which involve greater precision and control-endomyometrial resection (EMR), hysteroscopic metroplasty, the correction of isthmoceles, the resection of intramural myomas, and the management of late-onset endometrial ablation failure-are only possible with the CFGR. In addition, the CFGR permits a variety of functions that would otherwise require several different disposable platforms. Despite the benefits of the gynecologic resectoscope, there are clear impediments to its use including a scarcity of educational resources and trained experts, medico-legal concerns, institutional obstacles to organizing an operative team, and the need to develop and maintain an adequate caseload. In Part I of this three-part series, the author will review why the CFGR remains a relevant and indispensable tool for the minimally invasive gynecologic surgeon, the composition of an operating room team, and the instrumentation and skills necessary to accomplish basic resectoscopic surgery. In Part II, we will describe how ultrasound guidance can be used to assist the execution of more challenging intermediate-level cases. Finally, in Part III, we will discuss the most demanding cases for the resectoscopic surgeon-the treatment of post-ablation failures and the removal of intramural leiomyomas-which are clinical scenarios that require ultrasound guidance and well-honed resectoscopic surgical skills.

Office-Based Gynecologic Surgery (OBGS): Past, Present, and Future: Part II.

Office-based gynecologic surgery (OBGS) has become an integral part of modern practice. The technological achievements of the past few decades have dramatically improved our ability to diagnose and treat a variety of common issues that affect fertility and menstruation. Procedures that once required the complex milieu of a hospital or outpatient setting-diagnostic hysteroscopy, endometrial ablation, hysteroscopic polypectomy, and myomectomy-are now well within the reach of motivated and well-trained practitioners. The recent changes in physician reimbursement and the ongoing need to contain healthcare spending have motivated many gynecologists to offer an array of office-based procedures. But, the transition from a hospital-based technique to one that can safely and comfortably be performed in an office requires thoughtful planning in the acquisition of equipment, the training of physicians, nurses, and support staff, and the management of pain. Finally, some form of accreditation should be considered not only to comply with state and local healthcare laws but as a means to offer public reassurance that the care provided in an office meets a well-recognized standard. In this second of a two-part series, we will review the current state of OBGS technology and offer training guidelines to facilitate the transition from the outpatient to the office setting. Additionally, we will discuss pain management for OBGS and the role of accreditation. The lead author will review his 40-year journey in performing both simple and complex gynecologic procedures in an office-based surgery (OBS) setting and offer recommendations for achieving proficiency, safety, and comfort in the office environment. Finally, the authors will offer their thoughts on what can be expected in the future of gynecologic office-based surgery.

Office-Based Gynecologic Surgery (OBGS): Past, Present, and Future: Part I.

The gynecologist's office was, historically speaking, the original setting for surgical practice. In 1809, Ephraim McDowell performed the first ovariotomy and removed a 22.5-pound tumor from Jane Crawford in his Danville, Kentucky office-decades before the development of anesthesia or the aseptic technique. Three developments-introduction of surgical anesthesia, improved operative techniques, and the evolution of the medical-economic environment-shaped surgical practice for over two centuries. The latter part of the 20th century also brought two dramatic changes that affected gynecologic practice. The first included social changes which created a demand for legalized abortion and elective sterilization. The second was a cascade of technological growth and innovations that created the field of minimally invasive gynecologic surgery (MIGS), allowing many procedures to be transferred from the hospital to the outpatient setting and then to the office. With the increasing demand for patient-centered care, effective operating room utilization, and the efficient use of physicians' time, many gynecologic procedures are now being performed in an office-based setting. But, at least three important obstacles remain: the need for widespread accreditation, the availability of teaching in an office-based environment, and meeting the ethical obligation for adequate analgesia and sedation in an office environment.

Endometrial Ablation: Past, Present, and Future Part II.

Endometrial ablation (EA) is the most commonly performed surgical procedure for the management of abnormal uterine bleeding unresponsive to medical therapy. In well-selected subjects, EA provides a safe, inexpensive, and convenient alternative to hysterectomy with a rapid return to normal function. The first generation of EA techniques were introduced in 1886 by Professor Sneguireff of Moscow. He was the first to apply super-heated steam to the uterine cavity to vaporize the endometrial basalis. This method-known as atmocausis-was refined by Ludwig Pincus of Danzig in 1895, and he went on to perform over 800 procedures. As the 20th century brought forth other energy sources-electricity, X-ray, radium, and even cryogenics-they were each used, in turn, to accomplish endometrial ablation. In 1981, Dr. Milton Goldrath successfully performed EA by co-locating a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser with a rod-lens hysteroscope to achieve photovaporization of the endometrium. The accomplishment of EA under direct visualization defined the second generation of EA. The challenges and risks of second-generation technology, however, was soon apparent, and though this practice continues today, it appears to be confined to a relatively small number of devoted and highly-skilled sub-specialists. The late 1990s saw increasing interest in safe, affordable, and easily-mastered EA technology. The result was a return to blind technology but modified with a variety of features that brought unprecedented safety to EA, even permitting its selected in-office application. This third generation of EA techniques and devices has propelled the growth of EA in the 21st century. Although much has been accomplished in the quest for safe, affordable, convenient, and easily-mastered EA, the future requires refinement of patient selection criteria, management strategies for late-onset endometrial ablation failures (LOEAFs), as well as minimally invasive methods for reducing them.

Endometrial Ablation: Past, Present, and Future Part I.

Endometrial ablation (EA) is a commonly performed minimally invasive technique to manage intractable uterine bleeding that is unresponsive to medical therapy. It originated in ancient times when chemical astringents were used to control uterine hemorrhage associated with childbirth and a variety of other gynecologic conditions. In the late 19th century, the use of astringents and chemical cauterants gave way to the application of a variety of thermal energy technologies to cause selective destruction of the endometrium. These energy sources-steam, electricity, and even gamma rays-were applied blindly and were, by all accounts, quite effective at a time when hysterectomy was unsafe, infrequent, and generally unavailable. With the emergence of improved optics and laser and video technology in the late 20th century, a resurgence of interest in endometrial ablation began-coinciding with a time when hysterectomy was commonly performed in developed countries. Endometrial ablation underwent a revolutionary change as physicians searched for new techniques to perform selective endometrial destruction under direct visual-hysteroscopic-control. In this first of a two-part series, we will explore the first and second generations of endometrial ablation to understand how this procedure has evolved into its present status and what issues remain to be solved.

Postablation Endometrial Carcinoma.

BACKGROUND: Many women have undergone both resectoscopic and nonresectoscopic (or global) endometrial ablation (EA) during the past 20 years. These women are now approaching their sixth and seventh decades of life, a time frame in which endometrial carcinoma (EC) is most frequently diagnosed. DATABASE: In several reports, surgeons have expressed concern that endometrial ablation may leave a sequestered island of EC that may escape detection, possibly delaying its diagnosis or causing it to appear at an advanced stage. Others suggest that EA artifact does not hinder the evaluation and treatment planning in the presence of EC. Data bases used are from Medline and PubMed. DISCUSSION: We introduce 6 new cases of postablation endometrial carcinoma (PAEC), 4 of which occurred after the introduction of global endometrial ablation (GEA) techniques. In addition, we examine several key questions regarding the impact of EA on the subsequent development of EC, including the manner in which PAEC presents, the efficacy of traditional diagnostic modalities, the ablation-to-cancer interval, and the stage of PAEC at the time of diagnosis. Finally, we explore the use of reoperative hysteroscopic surgery (RHS) as a diagnostic modality and address the possible role ultrasound surveillance as a screening method for women at risk of EC.

Should We Abandon the Gynecologic Resectoscope in Favor of Hysteroscopic Morcellators?

The treatment of intrauterine masses, such as endometrial polyps and leiomyomas, has undergone a technological revolution in the past few decades. Gynecologists may now choose from a variety of unipolar and bipolar resectoscopes as well as an assortment of both mechanical and bipolar hysteroscopic morcellators. We present a comparison of these technologies to better practitioners understanding of the strengths and limitations of these devices.

Late-onset endometrial ablation failure.

Endometrial ablation, first reported in the 19th century, has gained wide acceptance in the gynecologic community as an important tool for the management of abnormal uterine bleeding when medical management has been unsuccessful or contraindicated. The introduction of global endometrial ablation (GEA) devices beginning in 1997 has provided unsurpassed safety addressing many of the concerns associated with their resectoscopic predecessors. As of this writing the GEA market has surpassed a half-million devices in the United States per annum and has an expected compound annual growth rate (CAGR) projected to be 5.5% from 2016 to 2024. While the short term safety and efficacy of these devices has been reported in numerous clinical trials we only recently are becoming aware of the high incidence of late-onset endometrial ablation failures (LOEAFs) associated with these procedures. Currently, about a quarter of women who undergo a GEA procedure will eventually require a hysterectomy while an unknown number have less than satisfactory results. In order to reduce these suboptimal outcomes physicians must better understand the etiology and risk factors that predispose a patient toward the development of LOEAF as well as current knowledge of patient and procedure selection for EA as well as treatment options for these delayed complications.

Urinary ascites in late onset of bladder injury post laparoscopic hysterectomy.

Urinary tract injuries are unfortunate complications of pelvic surgery. With the increasing popularity of minimally invasive surgery, a thorough understanding of electrosurgical instrumentation and their thermal spread is important to reduce patient injuries. The index patient was a 50 year old woman who underwent a supracervical hysterectomy 5 years prior to her presentation with pelvic pain and dysuria. When her symptoms failed to improve despite antibiotic and analgesic therapy, an abdominal CT scan revealed an ovarian cyst and ascites. A subsequent laparoscopy disclosed the presence of a bladder fistula and a diagnosis of urinary ascites was made. The patient then underwent a subsequent bladder fistula repair. Vesicoperitoneal fistulae (VPF) are rare and should be included in the differential diagnosis of the patient with acute onset ascites following gynecologic surgery. This case is the first case report of a VPF occurring 5 years following surgery.

Post-Ablation Endometrial Carcinoma (PAEC) Following Radiofrequency Endometrial Ablation: A Case Report and Its Implications for Management of Endometrial Ablation Failures.

Endometrial ablation (EA) has become one of the most commonly performed gynecologic procedures in the United States and other developed countries. Global endometrial ablation (GEA) devices have supplanted resectoscopic ablation primarily because they have brought with them technical simplicity and unprecedented safety. These devices, all of which received FDA approval between 1997 and 2001, are typically used to treat abnormal uterine bleeding (AUB) in premenopausal women. Several million women in the US who have undergone a previous EA procedure are about to enter the risk pool for the development of endometrial cancer (EC). Ours is the 18th reported case of post-ablation endometrial carcinoma (PAEC) in the English literature. This case underscores the diagnostic challenges faced in evaluating women with a history of a previous EA who cannot be properly evaluated with conventional techniques such as endometrial biopsy and sonohysterography.

"See-and-Treat" Hysteroscopy in the Management of Endometrial Polyps.

Endometrial polyps (EPs) are a common cause of abnormal uterine bleeding (AUB) in perimenopausal and postmenopausal women and are typically suggested by a screening transvaginal ultrasound. In addition, the increasing use of pelvic imaging often discloses asymptomatic EPs. In the past, saline infusion sonography (SIS) has been advocated in order to triage patients to undergo a blind curettage or a diagnostic or operative hysteroscopy. The introduction of small diameter hysteroscopes and resectoscopes-often no larger than a SIS catheter-now allows most women with abnormal ultrasound findings to undergo a single-stage "see-and-treat" hysteroscopy for the management of endometrial polyps. In order to provide optimal management of endometrial polyps, however, a variety of known and unknown factors must be considered prior to "see-and-treat" hysteroscopy. For a woman wishing to preserve or enhance her fertility, hysteroscopic polypectomy-with care to avoid collateral endometrial damage-remains the standard of care. However, the literature reveals three issues that are important to address. First, that many premalignant and malignant lesions are found at the polyp base. Second, that there is a significant recurrence risk following simple polypectomy; this is especially true in tamoxifen-treated women. Third, that polypectomy alone is often insufficient for the satisfactory management of AUB. By offering a variety of options to women undergoing hysteroscopic polypectomy-including partial or total endomyometrial resection-the author addresses many of the limitations of traditional polypectomy. Moreover, the use of small diameter hysteroscopes and resectoscopes allow these procedures to be performed as a single stage "see-and-treat" hysteroscopy in the comfort and safety of an office-based setting.

Late-onset endometrial ablation failure--etiology, treatment, and prevention.

This review summarizes the history and demographics of nonresectoscopic endometrial ablation and global endometrial ablation procedures as well as the presentation, etiology, risk factors, treatment options, and prevention of late-onset endometrial ablation failures.

Ultrasound-guided reoperative hysteroscopy for managing global endometrial ablation failures.

STUDY OBJECTIVE: To determine whether ultrasound-guided reoperative hysteroscopy can reduce the need for hysterectomy in women experiencing delayed complications after global endometrial ablation (GEA) procedures. DESIGN: Retrospective review (Canadian Task Force classification III). SETTING: Private physician's office. PATIENTS: Fifty women who had experienced a delayed complication after a GEA procedure were referred to the author's private practice. INTERVENTION: All 50 women underwent ultrasound-guided reoperative hysteroscopy in which the uterine cavity was fully explored and areas of endometrial growth and other disease were identified and excised. MEASUREMENTS AND MAIN RESULTS: Intraoperative complications, patient satisfaction, and avoidance of hysterectomy were determined. There were no intraoperative or postoperative complications. The mean duration of follow-up was 18.1 months (95% confidence interval, 13.8-22.4). Forty-four of 49 patients (88.9%) were satisfied with the outcome, and further surgery was not necessary during the study period. CONCLUSION: Ultrasound-guided reoperative hysteroscopy is a safe and effective minimally invasive treatment for management of delayed complications after GEA procedures.

Sonographically guided hysteroscopic myomectomy (SGHM): minimizing the risks and maximizing efficiency.

Hysteroscopic myomectomy (HM), first described by Neuwirth and Amin in 1976,1 is an important technique in the management of selected women presenting with infertility, abnormal uterine bleeding (AUB), or both. The complications of HM include excessive bleeding, uterine perforation, prolonged operative times, and excessive intravasation of distention media. The author describes his technique of sonographically guided hysteroscopic myomectomy (SGHM). SGHM allows one to continuously monitor the progress of resectoscopic surgery while minimizing the risk of uterine perforation and permitting one to incorporate non-resectoscopic morcellation. The combination of both resectoscopic and non-resectoscopic techniques enable one to safely and efficiently remove submucous leiomyomas without the risk of excessive fluid absorption.

Operative hysteroscopy in an office-based surgical setting: review of patient safety and satisfaction in 414 cases.

STUDY OBJECTIVE: To determine the safety and satisfaction among patients undergoing operative hysteroscopy in an office-based setting. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: Physician's private office. PATIENTS: Women undergoing operative hysteroscopy in an office setting. INTERVENTIONS: Three hundred eighty-seven women underwent a total of 414 operative hysteroscopic procedures, with use of parenterally administered moderate sedation, a 9-mm operative resectoscope, and sonographic guidance. All patients were American Society of Anesthesiologists class I-III. MEASUREMENTS AND MAIN RESULTS: A total of 305 primary operative hysteroscopic procedures were performed including endomyometrial resection, myomectomy, polypectomy, removal of a uterine septum, and adhesiolysis. One hundred nine (26.3%) repeat operative procedures were performed in women in whom previous endometrial ablation and resection had failed. The average procedure required a mean (SD) of 37.6 (13.5) minutes to complete, and produced 14.1 (10.2) g of tissue. Ninety-nine percent of all procedures were completed. Only 1 patient required a hospital transfer for evaluation of a uterine perforation necessitating diagnostic laparoscopy. There were 8 (1.9%) postoperative infections, and no complications attributable to use of conscious sedation. Two hundred fifty-five women (65.6%) responded to our telephone survey. Two hundred fifty-two (98.8%) respondents were either "very satisfied" or "satisfied." Two hundred forty-nine women (97.6%) preferred the office to a hospital setting, whereas 6 (2.4%) would have preferred a hospital setting. All but 5 respondents would recommend this procedure to a friend. CONCLUSION: Major operative hysteroscopic surgery can be performed in an office-based setting with a high degree of safety and patient satisfaction.