Hysteroscopic treatment of the patient with intracavitary pathology (myomectomy/polypectomy).

Hysteroscopy is a simple and effective method for treating intrauterine leiomyomas and polyps. These lesions often cause abnormal uterine bleeding and infertility. Using the techniques in this article, most lesions can be removed in an office or outpatient setting.

Using amino-cerv after cervical LEEP.

OBJECTIVE: To evaluate the ability of Amino-Cerv to promote healing of the cervix following loop electrical excision procedure (LEEP) of the cervix for cervical intraepithelial neoplasia. STUDY DESIGN: A randomized study was conducted on 48 women in a private office setting. Patients were divided into two groups, to use or not use Amino-Cerv intravaginally for two weeks after the procedure. Statistical analysis of the findings were performed using the chi 2 test. RESULTS: Twenty of 24 (83%) of women using Amino-Cerv had completely healed tissue at four weeks, whereas 12 of 24 (50%) in the untreated group had healed tissue at four weeks. Findings were not statistically significant at two weeks but were statistically significant (P < .005, power = .55) at four weeks after the procedure. CONCLUSION: Amino-Cerv after LEEP of the cervix promotes healing.

Not so benign endometrial hyperplasia: endometrial cancer after endometrial ablation.

The masking or development of endometrial cancer after endometrial ablation is a concern often alluded to in discussions of complications of endometrial ablation. It is necessary to look for a common factor when this complication occurs. Six cases published in peer-reviewed literature were collected to establish a link between the development of endometrial cancer and endometrial ablation. Preexisting endometrial hyperplasia seems to be the common denominator, and should be considered a contraindication to endometrial ablation until more data are collected.

Photodynamic therapy of rat endometrium sensitized with tin ethyl etiopurpurin.

STUDY OBJECTIVE: To evaluate endometrial ablation in the rat using photodynamic therapy and the photosensitizer tin ethyl etiopurpurin (SnET2). DESIGN: Laboratory research. SETTING: A pharmaceutical and device manufacturing company. MATERIALS: Forty-five healthy female rats (age 8-10 wks). INTERVENTIONS: Groups of three to five rats were given SnET2 by either intrauterine or intravenous administration. Light treatment was given at either 3 or 24 hours after SnET2 administration at a light dose of 75, 150, or 200 J/cm. MEASUREMENTS AND MAIN RESULTS: A fluorescence detection system was employed to determine relative drug uptake of SnET2 into uterine tissue. The highest levels of SnET2 were detected at 3 hours. After light treatment, responses of uterine tissues were evaluated histologically. The best endometrial ablation was seen when SnET2 was given by intrauterine administration with light treatment at 150 J/cm 24 hours later. A consistent transmural response was seen with this route of administration at 200 J/cm. Intravenous SnET2 gave inconsistent responses. In light-only controls, all light doses caused no tissue response. The depth of necrosis in tissues treated with photodynamic therapy were light-dose dependent. CONCLUSION: With either route of SnET2 administration, drug uptake was confirmed and a light-dose-dependent response in the walls of rat uterine horns was demonstrated.

Control of intrauterine fluid pressure during operative hysteroscopy.

STUDY OBJECTIVE: To evaluate the safety of a commonly used piston pump that controls the infusion pressure of low-viscosity fluids in a continuous-flow hysteroscopic system during operative hysteroscopy. DESIGN: Consecutive patients requiring operative hysteroscopy. SETTING: Three hospital facilities in the Midwest. PATIENTS: Sequential sample of 250 women who underwent operative hysteroscopy. INTERVENTIONS: Endometrial ablations, resection of submucosal or pedunculated uterine leiomyomata with or without endometrial ablation, polyp resections, metroplasty, and lysis of synechiae. MEASUREMENTS AND MAIN RESULTS: The most serious complication of operative hysteroscopy is fluid overload due to intravasation into the patient's vascular system. Low-viscosity fluids were infused by the Zimmer Controlled Distention Irrigation System. The instrument uses a closed-feedback loop to monitor cavity pressure and automatically regulates the flow to maintain the set point pressure. It is designed to operate in a pressure range of 0 to 80 mm Hg and at flows in excess of 450 ml/minute. In 250 operative hysteroscopies no fluid complications occurred when intrauterine pressure was maintained below 80 mm Hg. No clinically significant differences in intravasation were seen in any type of operative hysteroscopy. CONCLUSIONS: This controlled mechanical pump system with exact intrauterine pressure measurement reduced many technical difficulties associated with low-viscosity media, and created a safe environment for the media's use in operative hysteroscopy.

Endometrial ablation. A report of four cases.

Three women had evidence of atypical endometrial hyperplasia at the time of endometrial ablation, discovered because they had mechanical preparation of the endometrium rather than medical preparation. In one of these patients, a frozen section revealed atypical endometrial hyperplasia, and the ablation was cancelled. A fourth woman had an unsuccessful endometrial ablation; repeat ablation was followed by nine months of amenorrhea, at which time she began spotting and requested a hysterectomy. The pathology report on the hysterectomy specimen revealed adenomatous hyperplasia. Gynecologists must be vigilant in their evaluation of the endometrium before, during and after endometrial ablation.

Mechanical preparation of the endometrium prior to endometrial ablation.

Of 143 women who underwent endometrial ablation between May 1986 and August 1991, 16 also had repeat procedures. Medical preparation of the endometrial lining (danazol, leuprolide acetate, or nafarelin acetate) was used in 109 patients; mechanical preparation in the form of suction curettage, in 28 patients; and no preparation, in 6 postmenopausal patients. Evaluation of the results following endometrial ablation showed that the results in mechanically prepared patients were comparable to those in patients receiving traditional medical preparation; thus mechanical preparation can make the procedure simpler, enhance patient compliance, and reduce side effects considerably.

Endometrial ablation repeat procedures. Case studies.

Of 143 women who underwent endometrial ablation from May 1986 through August 1991, 16 requested repeat endometrial ablation and 7 underwent hysterectomy. Only two of the hysterectomies were performed for bleeding, and no hysterectomy was needed for any woman who had a repeat endometrial ablation. For patients undergoing one ablation, the results were amenorrhea in 55 women (38%), staining in 32 (22%), light flow in 33 (23%), 7 hysterectomies (5%) and 16 patients requesting repeat endometrial ablation (11%). Repeat endometrial ablation resulted in amenorrhea in 10 women (63%), staining in 3 (19%) and light flow in 3 (19%). Repeat endometrial ablation can eliminate the need for hysterectomy in women who continue to have bleeding problems after one endometrial ablation. Gynecologists should not hesitate to offer repeat ablation since the results will usually be excellent.

Office hysteroscopy.

Most operative office surgery can be done easily. If, midway through a procedure in the office, the operator finds that a myoma is too large or deep to resect safely in the office, the procedure can be terminated and rescheduled for the operating room. Polyps, retained products, and the lost intrauterine device all can be treated similarly. With the proper equipment and patient selection, the well-trained hysteroscopist can do extensive operative hysteroscopy in the office. With experience, the hysteroscopist can do diagnostic and operative hysteroscopy at the same time, resulting in a substantial savings of both cost and time for the patient and the physician. The future of office hysteroscopy may include endometrial ablation and transcervical sterilization, in addition to the procedures described in this chapter. Diagnostic hysteroscopy is becoming a standard part of office gynecology. With continued training, operative hysteroscopy will move into the realm of office gynecology at the same level as diagnostic hysteroscopy.

Suction curettage with a tissue trap compared with sharp curettage for tissue sampling.

Recent reports have shown that various endometrial sampling techniques are comparable to each other. This study showed that suction curettage utilizing tissue traps is superior to sharp curettage in terms of adequacy of sampling. The results show that adequate tissue was obtained in all 114 cases, regardless of which type of curettage was utilized first. However, when sharp curettage was the second procedure, only 43 of 57 procedures yielded adequate tissue, whereas when suction curettage was the second procedure, 56 of 57 procedures yielded adequate tissue. Suction curettage utilizing tissue traps was more thorough than sharp curettage.

Comparison of tissue effects with sculptured fiberoptic cables and other Nd:YAG laser and argon laser treatments.

The use of a fiber optic cable in contact with tissue results in a complex thermal interaction between the cable and the tissue. The effect of the laser-tissue interaction was investigated using sculptured quartz fiber optic cables, sapphire contact rods, and bare fiber optic cables attached to the Nd:YAG laser. The laser-tissue effects of the Nd:YAG and argon lasers were compared. Examination of treated animals showed there to be a significant difference between immediate and 48-hour thermal effects. The sculptured fibers created significantly less tissue damage than the sapphire contact tips, the 0.6-mm bare fiber, or the argon laser with a 0.3-mm bare fiber either with or without contact. All Nd:YAG laser contact treatments were less damaging than the argon laser treatments.

Operative laparoscopy with the Nd:YAG laser in the treatment of endometriosis and pelvic adhesions.

A multicenter, prospective trial was initiated to test the effectiveness and safety of the Nd:YAG laser equipped with artificial sapphire contact tips for the laparoscopic treatment of pelvic pain. Ninety-three women were enrolled in the study, 37 with endometriosis alone, 47 with endometriosis complicated by pelvic adhesions, and 9 women with adhesions alone. In over 90% of adhesions and 96% of endometriotic implants the Nd:YAG laser could be delivered to the site and be used to restore normal anatomy. The exception was deep bowel involvement with endometriosis, which was not treated. The majority of women had marked reduction or resolution of their symptoms for up to 12 months postoperatively. We conclude that the use of the Nd:YAG laser is an appropriate method to laparoscopically treat pelvic pain resulting from endometriosis or pelvic adhesions.

An animal model for learning Nd:YAG laser ablation of the endometrium.

Gynecologists must have a good model for practice before performing Nd:YAG laser ablation on humans. The New Zealand white rabbit has been used as a teaching model in courses. Knowing the anatomy and technique enables gynecologists to acquire the skill and dexterity needed to perform this useful procedure.

Pulmonary edema after photocoagulation of the endometrium with the Nd:YAG laser. A case report.

A woman developed pulmonary edema as a result of fluid overload during Nd:YAG ablation of endometrial tissue. As a result of a miscalculation of fluid administration and collection, she was overhydrated with irrigation fluid. The clinical picture of pulmonary edema was noted in the immediate postoperative period and responded to positive pressure ventilation and diuretic therapy. The mechanism of pulmonary edema is postulated to have been the result of the absorption of irrigating fluid through open venous channels resulting from the laser ablation.