Late-onset endometrial ablation failure

Abstract

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.

Fig. 1

Bardenheuer's Kungelsondenelktrode.

Fig. 2

Hysteroscopic endometrial laser ablation.

Fig. 3

Hysteroscopic endometrial ablation with the “ball-end” electrode.

Fig. 4

Thermal Balloon System (ThermaChoice).

Fig. 5

Cryoendometrial ablation (Her Option).

Fig. 6

Heated Free-Fluid System (Hydro ThermAblator).

Fig. 7

Bipolar Radiofrequency ablation device (NovaSure).

Fig. 8

Microwave ablation system (MEA System).

Fig. 9

Radiofrequency ablation (Minerva).

Fig. 10

Global endometrial ablation devices in the U. S. – Market share by device.

Fig. 11

Sonographic view of failed GEA procedure demonstrating small bilateral cornual hematometra.

Fig. 12

Sonographic view of failed GEA procedure demonstrating large and asymmetrical cornual hematometra.

Fig. 13

a, b Sonographic and hysteroscopic view of endometrial growth following a GEA procedure in the presence of a uterine septum.

Fig. 14

Ultrasound-Guided Reoperative Hysteroscopic Surgery (UGRHS).

Fig. 15

An intramural leiomyoma is unroofed and removed during the course of UGRHS.

Fig. 16

a – h Dissection sequence of UGRHS in a woman with a cyclic left lower quadrant pain and abundant endometrium at the left cornua.

Fig. A1

The posterior distal lower segment has been removed enabling the continuous flow of distention fluid. The resectoscope, at this point, is just beyond the internal cervical os.

Fig. A2

Visualization of the left hemi-uterus.

Fig. A3

The right lateral wall has been removed in order to facilitate distention of the uterine cavity. Endometrial growth is seen along the left cornual region as well as the uterine fundus.

Fig. A4

Close-up of left cornua.

Fig. A5

In this view we can appreciate that the left cornua is quite deeply recessed. This suggests that there may have been a uterine septum at the outset.

Fig. A6

In addition to an excellent view of the left cornua, and some remaining endometrium, the patient’s right side reveals some evidence of adenomyosis as endometrium is interlaced with myometrial tissue.

Fig. A7

This is a panoramic view of the uterine fundus in the midline after much of the left cornua has been resected. Note some hemosiderin stained tissue at the patient’s right and some adenomyosis at the fundus in the center.

Fig. A8

After exploring the hemosiderin stained tissue to the right of midline some addition endometrium appears to have been uncovered.

Fig. A9

Further exploration of the right side is performed and an area of sequestration is noted toward the right cornua. At first glance this appears to be a uterine perforation. However, sonographic guidance reassures us at all times.

Fig. A10

Greater detail of the right cornua with abundant endometrial growth.

Fig. A11

Return to left cornua for inspection.

Fig. A12

Further dissection into left cornua reveals additional endometrial elements. Simultaneous ultrasound guidance reveals that the sero-muscular thickness at the left cornua is 4 mm.

Fig. A13

Return to inspect right cornua. No evidence of endometrial growth.

Fig. A14

Deep coagulation of the right cornua with a roller barrel electrode at 120 watts.

Fig. A15

Deep coagulation of remaining endometrial elements at the left cornua.

Fig. A16

Panoramic view of left cornua.

Fig. A17

Panoramic view of right cornua.