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1.
Surg Technol Int. 2018 Jun 1;32:129-138.

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

Author information

1
Center for Menstrual Disorders, Clinical Associate Professor Gynecology, University of Rochester Medical Center, Rochester, New York.

Abstract

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.

PMID:
29689590
[Indexed for MEDLINE]
Icon for Universal Medical Press
2.
Int J Gynaecol Obstet. 2018 Jul;142(1):84-90. doi: 10.1002/ijgo.12503. Epub 2018 Apr 20.

Endometrial cancer after endometrial ablation or resection for menorrhagia.

Author information

1
Department of Gynecologic Oncology, Aberdeen Royal Infirmary, Aberdeen, UK.
2
Department of Obstetrics and Gynecology, Aberdeen Royal Infirmary, Aberdeen, UK.
3
Department of Pathology, Aberdeen Royal Infirmary, Aberdeen, UK.

Abstract

OBJECTIVE:

To assess the incidence of endometrial cancer after endometrial ablation or resection (EA/R) for menorrhagia.

METHOD:

The present retrospective observational cohort study included women who underwent EA/R for menorrhagia at Aberdeen Royal Infirmary between February 1, 1990 and December 31, 1997. Follow-up data until 2015 were examined. To assess risk of endometrial cancer, each woman was matched by age to the annual observed incidence of endometrial cancer in northeast Scotland for each year from the date of EA/R until 2015.

RESULTS:

During the 7-year study period, 901 eligible women (mean age 42.3 ± 5.7 years; range 26-50 years) underwent EA/R. Of these patients, 204 (22.6%) subsequently had a hysterectomy for reasons other than endometrial cancer, and 695 (77.1%) did not. The overall incidence of endometrial cancer was 0.2% (2/901); the risk of developing endometrial cancer after EA/R was calculated as 11.1 per 100 000 women years. The mean expected incidence for all women and the subgroup with no hysterectomy was estimated to be 26.5 and 35.6 occurrences per 100 000 women years, respectively. The observed incidence was significantly lower versus the mean expected risk for both groups (P<0.001).

CONCLUSION:

The findings indicate that the risk of endometrial cancer could be significantly reduced but not eliminated by EA/R.

KEYWORDS:

Endometrial ablation; Endometrial cancer; Endometrial cancer incidence; Endometrial cancer risk; Endometrial resection

PMID:
29637560
DOI:
10.1002/ijgo.12503
[Indexed for MEDLINE]
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3.
J Gynecol Obstet Hum Reprod. 2018 Jun;47(6):247-252. doi: 10.1016/j.jogoh.2018.02.005. Epub 2018 Mar 3.

Hysteroscopic resection on virtual reality simulator: What do we measure?

Author information

1
Department of Gynecology and Obstetrics, Centre Hospitalier de Versailles, 78157 Le Chesnay Cedex, France.
2
Department of Gynecology and Obstetrics, Centre Hospitalier de Versailles, 78157 Le Chesnay Cedex, France; Department of Gynecology and Obstetrics, Hôpital Bicêtre, GHU Sud, AP-HP, 94276 Le Kremlin-Bicêtre, France.
3
Delegation for Clinical Research and Investigation, Centre Hospitalier de Versailles, 78157 Le Chesnay Cedex, France; Inserm, Centre of Research in Epidemiology and Population Health (CESP), U1018, 94276 Le Kremlin-Bicêtre, France.
4
Ecole Normale Supérieure, CRAL, UMR CNRS 5574, 69364 Lyon Cedex 07, France.
5
Department of Gynecology and Obstetrics, Hôpital Bicêtre, GHU Sud, AP-HP, 94276 Le Kremlin-Bicêtre, France; Inserm, Centre of Research in Epidemiology and Population Health (CESP), U1018, 94276 Le Kremlin-Bicêtre, France.
6
Department of Gynecology and Obstetrics, Centre Hospitalier de Versailles, 78157 Le Chesnay Cedex, France; Department of Gynecology and Obstetrics, Hôpital Bicêtre, GHU Sud, AP-HP, 94276 Le Kremlin-Bicêtre, France. Electronic address: elodie_debras@hotmail.com.

Abstract

OBJECTIVE:

The objective was to compare results of two groups of population (novices and experts) on a virtual reality simulator of hysteroscopy resection for different metrics and for a multimetric score to assess its construct validity.

MATERIALS AND METHODS:

Nineteen gynecologist who had at least 5 years of experience with hysteroscopy and self-evaluated their expertise at 4/5 or 5/5 were included as expert population. Twenty first-year gynecology residents in Paris were included as novice population. A standardized set of 4 hysteroscopy resection cases (polypectomy, myomectomy, roller ball endometrial ablation and septum resection) was performed on a virtual reality simulator (HystSim™) by the group of novices and experts. Results obtained on the simulator for overall score and for the parameters were compared by applying the Mann-Whitney test.

RESULTS:

Overall score of novices and experts were significantly different for three resection cases (polypectomy P<0.001, myomectomy P<0.001, roller ball endometrial ablation <0.001). The overall score was not different in the septum resection (P=0.456). For the four cases, the economy score (included cumulative path length, procedure time and camera alignment) were statistically different between novices and experts (polypectomy P<0.001, myomectomy P=0.001, roller ball endometrial ablation P<0.001, septum resection P<0.001).

CONCLUSION:

The overall score on HystSim™ was able to discriminate novices between experts on polypectomy, myomectomy and roller ball endometrial ablation cases but not on septum resection. The economy score was the more reliable to reflect the surgeon experience. It could be used to evaluate and to train students on hysteroscopic resection on a virtual reality simulator.

KEYWORDS:

Hysteroscopy; Surgical education; Validity method; Virtual reality

PMID:
29510269
DOI:
10.1016/j.jogoh.2018.02.005
[Indexed for MEDLINE]
Icon for Elsevier Science
4.
Medicine (Baltimore). 2017 Dec;96(52):e9564. doi: 10.1097/MD.0000000000009564.

Radiofrequency-induced endometrial ablation for the treatment of postpartum hemorrhage after vaginal delivery: Case report.

Author information

1
Department of Anesthesiology.
2
Department of Obstetrics, Women and Children's Hospital of Jiaxing University, Jiaxing, China.

Abstract

RATIONALE:

Postpartum hemorrhage is a common complication and difficult problem in obstetrics. Radiofrequency-induced endometrial ablation (RFIEA) widely used in abnormal uterine bleeding and achieved good effects. This article will investigate the effect of RFIEA for treatment of postpartum hemorrhage.

PATIENTS CONCERNS:

A 26-year-old healthy full-term parturient woman presented with postpartum hemorrhage after vaginal delivery for 11 hours, who was ready to emergency surgery (hysterectomy) 7 hours after inserting an intrauterine balloon into uterine cavity.

DIAGNOSES:

Blood loss after vaginal delivery was more than 500 mL during 11 hours in the full-term parturient woman.

INTERVENTION:

We applied RFIEA to treatment of postpartum hemorrhage. With the patient in dorsal lithotomy position, we advanced the disposable device according to the instruction and operated the Novasure system in semi-automatic mode.

OUTCOMES:

There was no obvious endometrial bleeding found with hysteroscopy at the end of surgery. No complications (such as thermal injury to adjacent tissue, uterine perforation, bowel perforation) were observed.

LESSONS:

It is safe and effective to treat postpartum hemorrhage after vaginal delivery using RFIEA.

PMID:
29384976
DOI:
10.1097/MD.0000000000009564
[Indexed for MEDLINE]
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5.
Am J Obstet Gynecol. 2018 Feb;218(2):225.e1-225.e11. doi: 10.1016/j.ajog.2017.11.571. Epub 2017 Nov 15.

Utility of anesthetic block for endometrial ablation pain: a randomized controlled trial.

Author information

1
Department of Obstetrics & Gynecology, Christiana Care Health System, Newark, DE. Electronic address: Jklebanoff@christianacare.org.
2
Division of Minimally Invasive Gynecology, Christiana Care Health System, Newark, DE.
3
Department of Obstetrics & Gynecology, Christiana Care Health System, Newark, DE.

Abstract

BACKGROUND:

Second-generation endometrial ablation has been demonstrated safe for abnormal uterine bleeding treatment, in premenopausal women who have completed childbearing, in short-stay surgical centers and in physicians' offices. However, no standard regarding anesthesia exists, and practice varies depending on physician or patient preference and hospital policy and setting.

OBJECTIVE:

The aim of this study was to evaluate whether local anesthetic, in combination with general anesthesia, affects postoperative pain and associated narcotic use following endometrial ablation.

MATERIALS AND METHODS:

This was a single-center single-blind randomized controlled trial conducted in an academic-affiliated community hospital. A total of 84 English-speaking premenopausal women, aged 30 to 55 years, who were undergoing outpatient endometrial ablation for benign disease were randomized to receive standardized paracervical injection of 20 mL 0.25% bupivacaine (treatment group) or 20 mL normal saline solution (control group) upon completion of ablation. The study was designed to test a 40% 1-hour mean visual analog scale (VAS) pain score difference with an average standard deviation of 75% of both groups' mean VAS scores, using a 2-tailed test, a type I error of 5%, and statistical power of 80%. A sample of 36 patients per study group was required. Assuming a 15% attrition rate, the study enrolled 42 patients per study arm randomized in blocks of 2 (84 total). Two-tailed cross-tabulations with Fisher exact significance values where appropriate and Student t tests were used to compare patient characteristics. Backward stepwise regressions were conducted to control for confounding.

RESULTS:

Between April 2016 and February 2017, a total of 108 women scheduled for endometrial ablation were screened (refusals, n = 21; ineligible, n = 3) to determine whether there were meaningful differences in postoperative VAS pain scores and postoperative narcotic use. Of the 84 randomized women, 2 age-ineligible women were excluded. Intent-to-treat analyses included 1 incorrect randomization (in which the provider consciously decided to provide analgesia regardless of the protocol, after which the provider was excluded from further study participation) and 3 women having no ablation because of operative difficulties. Three were lost to second-day follow-up. Treatment group patients (n = 41) experienced 1.3 points lower 1-hour postoperative VAS pain scores than the control group (n = 41, P = .02). The difference diminished by 4 hours (P = .31) and was negligible by 8 hours (P = .62). Treatment group patients used 3.6 less morphine equivalents of postoperative pain medication (P = .05). Regression analyses controlled for confounding reduced the 1-hour postoperative treatment group pain score difference to 0.8 (confidence interval [CI], -0.6 to 0.1) but slightly increased the average postoperative morphine equivalents to 3.7 (CI, -6.8 to -0.7).

CONCLUSION:

This randomized controlled trial found that local anesthetic with low risk for complications, used in conjunction with general anesthesia, decreased postoperative pain at 1 hour and significantly reduced postoperative narcotic use following endometrial ablation. Further research is needed to determine whether the study results are generalizable and whether post procedure is the best time to administer the paracervical block to decrease endometrial ablation pain.

KEYWORDS:

endometrial ablation; general anesthesia; postoperative narcotic; postoperative pain

PMID:
29155035
DOI:
10.1016/j.ajog.2017.11.571
[Indexed for MEDLINE]
Icon for Elsevier Science
6.
PLoS One. 2017 Nov 15;12(11):e0188176. doi: 10.1371/journal.pone.0188176. eCollection 2017.

Medical therapy versus radiofrequency endometrial ablation in the initial treatment of heavy menstrual bleeding (iTOM Trial): A clinical and economic analysis.

Author information

1
Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, United States of America.
2
K. Long Health Economics Consulting LLC, St. Paul, Minnesota, United States of America.
3
Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, United States of America.
4
Division of Female Pelvic Medicine and Reconstructive Surgery, University Hospitals, Cleveland, Ohio, United States of America.

Abstract

BACKGROUND:

Radiofrequency endometrial ablation (REA) is currently a second line treatment in women with heavy menstrual bleeding (MHB) if medical therapy (MTP) is contraindicated or unsatisfactory. Our objective is to compare the effectiveness and cost burden of MTP and REA in the initial treatment of HMB.

METHODS:

We performed a randomized trial at Mayo Clinic Rochester, Minnesota. The planned sample size was 60 patients per arm. A total of 67 women with HMB were randomly allocated to receive oral contraceptive pills (Nordette ®) or Naproxen (Naprosyn®) (n = 33) or REA (n = 34). Primary 12-month outcome measures included menstrual blood loss using pictorial blood loss assessment chart (PBLAC), patients' satisfaction, and Menorrhagia Multi-Attribute Scale (MMAS). Secondary outcomes were total costs including direct medical and indirect costs associated with healthcare use, patient out-of-pocket costs, and lost work days and activity limitations over 12 months.

RESULTS:

Compared to MTP arm, women who received REA had a significantly lower PBLAC score (median [Interquartile range, IQR]: 0 [0-4] vs. 15 [0-131], p = 0.003), higher satisfaction rates (96.8%vs.63.2%, p = 0.003) and higher MMAS (median [IQR]: 100 [100-100] vs. 100 [87-100], p = 0.12) at 12 months. Direct medical costs were higher for REA ($5,331vs.$2,901, 95% confidence interval (CI) of mean difference:$727,$4,852), however, when indirect costs are included, the difference did not reach statistical significance ($5,469 vs. $3,869, 95% CI of mean difference:-$339, $4,089).

CONCLUSION:

For women with heavy menstrual bleeding, initial radiofrequency endometrial ablation compared to medical therapy offered superior reduction in menstrual blood loss and improvement in quality of life without significant differences in total costs of care.

CLINICAL TRIAL REGISTRATION:

NCT01165307.

PMID:
29141040
PMCID:
PMC5687740
DOI:
10.1371/journal.pone.0188176
[Indexed for MEDLINE]
Free PMC Article
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7.
Best Pract Res Clin Obstet Gynaecol. 2018 Jan;46:120-139. doi: 10.1016/j.bpobgyn.2017.10.003. Epub 2017 Oct 20.

Endometrial ablation.

Author information

1
Department of Obstetrics & Gynecology, David Geffen School of Medicine at UCLA, Director of Gynecologic Services, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA, United States. Electronic address: mmunro@ucla.edu.

Abstract

Endometrial ablation (EA) includes a spectrum of procedures performed with or without hysteroscopic direction, designed to destroy the endometrium for the treatment of the symptom of heavy menstrual bleeding (HMB) secondary to a spectrum of causes, but most commonly those that are endometrial in origin (AUB-E) or ovulatory disorders (AUB-O). Resectoscopic endometrial ablation (REA) is often mistakenly referred to as the "first generation" technique, while proprietary devices that do not use the resectoscope (nonresectoscopic EA or NREA) are often misperceived as "second generation" devices. Indeed, the origins of NREA date back to the late 19th century with the use of steam, and the early and mid 20th century, when radiofrequency and cryotherapy based NREA techniques were published - long before the resectoscope was used and reported. The NREA devices have also been mislabeled as "global", a misleading term borrowed from the marketing departments of device manufacturers - there is no device that predictably treats the entire endometrium. Consequently, none can be construed as being "global". Instead, EA is a procedure designed for women as an alternative to hysterectomy, or, perhaps, medical therapy, when future fertility is no longer desired. Women who select EA should anticipate a relatively low risk procedure that will likely reduce their HMB to normal levels or less. This paper will review the spectrum of EA techniques and devices, their clinical outcomes and adverse events, and explore their value compared to hysterectomy and selected medical therapies.

KEYWORDS:

Abnormal uterine bleeding; Endometrial ablation; Global ablation; Heavy menstrual bleeding; Menorrhagia

PMID:
29128205
DOI:
10.1016/j.bpobgyn.2017.10.003
[Indexed for MEDLINE]
Icon for Elsevier Science
8.
Best Pract Res Clin Obstet Gynaecol. 2018 Jan;46:84-98. doi: 10.1016/j.bpobgyn.2017.09.006. Epub 2017 Sep 28.

Endometrial resection and global ablation in the normal uterus.

Author information

1
King Edward Memorial Hospital for Women, 374 Bagot Road, Subiaco, WA 6008, Australia. Electronic address: sebastian.leathersich@health.wa.gov.au.
2
School of Women's and Infants' Health, The University of Western Australia, Australia; Osborne Park Hospital, Stirling, Perth, WA 6021, Australia. Electronic address: paul.mcgurgan@uwa.edu.au.

Abstract

There are various methods that can be used to destroy the endometrium as a treatment for menorrhagia. This chapter reviews the history, rationale, evidence, indications and long-term safety and efficacy of the current techniques. It also discusses endometrial ablation in the context of its clinical utility in comparison with existing alternative treatments.

KEYWORDS:

Cost; Efficacy; Endometrial ablation; Evidence-base; Resection; Safety

PMID:
29046244
DOI:
10.1016/j.bpobgyn.2017.09.006
[Indexed for MEDLINE]
Icon for Elsevier Science
9.
Int J Gynaecol Obstet. 2018 Jan;140(1):3-10. doi: 10.1002/ijgo.12340. Epub 2017 Nov 9.

Meta-analysis of bipolar radiofrequency endometrial ablation versus thermal balloon endometrial ablation for the treatment of heavy menstrual bleeding.

Author information

1
Department of Obstetrics and Gynecology, Capital Medical University Affiliated Beijing Chaoyang Hospital, Beijing, China.

Abstract

BACKGROUND:

Heavy menstrual bleeding is a common problem that can severely affect quality of life.

OBJECTIVES:

To compare bipolar radiofrequency endometrial ablation and thermal balloon ablation for heavy menstrual bleeding in terms of efficacy and health-related quality of life (HRQoL).

SEARCH STRATEGY:

Online registries were systematically searched using relevant terms without language restriction from inception to November 24, 2016.

SELECTION CRITERIA:

Randomized control trials or cohort studies of women with heavy menstrual bleeding comparing the efficacy of two treatments were eligible.

DATA COLLECTION AND ANALYSIS:

Data were extracted. Results were expressed as risk ratios (RRs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs).

MAIN RESULTS:

Six studies involving 901 patients were included. Amenorrhea rate at 12 months was significantly higher after bipolar radiofrequency endometrial ablation than after thermal balloon ablation (RR 2.73, 95% CI 2.00-3.73). However, no difference at 12 months was noted for dysmenorrhea (RR 1.04, 95% CI 0.68-1.58) or treatment failure (RR 0.78, 95% CI 0.38-1.60). The only significant difference for HRQoL outcomes was for change in SAQ pleasure score (12 months: WMD -3.51, 95% CI -5.42 to -1.60).

CONCLUSIONS:

Bipolar radiofrequency endometrial ablation and thermal balloon ablation reduce menstrual loss and improve quality of life. However, bipolar radiofrequency endometrial ablation is more effective in terms of amenorrhea rate and SAQ pleasure.

KEYWORDS:

Bipolar radiofrequency endometrial ablation; Heavy menstrual bleeding; Meta-analysis; Quality of life; Thermal balloon ablation

PMID:
28984905
DOI:
10.1002/ijgo.12340
[Indexed for MEDLINE]
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10.
J Low Genit Tract Dis. 2017 Oct;21(4):311-314. doi: 10.1097/LGT.0000000000000326.

Laser Excisional Treatment for Vaginal Intraepithelial Neoplasia to Exclude Invasion: What Is the Risk of Complications?

Author information

1
1Gynecological Oncology Unit, Centro di Riferimento Oncologico - National Cancer Institute, Aviano, Italy; 2Woman's Health Sciences Department, Gynecologic Section, Polytechnic University of Marche, Ancona, Italy; and 3Pathology Unit, Centro di Riferimento Oncologico - National Cancer Institute, Aviano, Italy.

Abstract

OBJECTIVE:

We undertook a retrospective analysis of the incidence of complications of carbon dioxide (CO2) laser excision for high-grade vaginal intraepithelial neoplasia (HG-VaIN).

MATERIALS AND METHODS:

Retrospective large case series on 128 CO2 laser excisions for HG-VaIN in 106 women treated at the Department of Gynecologic Oncology, Oncologic Referral Center, Aviano, Italy. These procedures were performed under local anesthesia with a 20-W continuous laser beam focused to a 0.2-mm spot size. Complications were defined as "minor" when limited to vagina, and "major" when surrounding organs were injured or the vaginal vault was opened.To identify possible factors associated with surgical complications, we performed a univariate analysis with the t test for continuous variables and χ or Fisher exact test for qualitative variables as appropriate.

RESULTS:

The overall rate of complication was 7.8% (10/128); nine of them were vaginal bleeding, and only one (0.8%) was a major complication with vaginal vault perforation.A greater number of previous destructive treatments and of two or more previous laser vaginal excisional treatments was present in patients with complications compared with ones without complications (10% vs 3.9 %, p = .92, and 30% vs 15.2%, p = .44, respectively), although these differences were not statistically significant. A total of 10.5% (6/57) of occult vaginal cancer was detected in women with initial diagnosis of VaIN3 (HG-VaIN) on biopsy.

CONCLUSIONS:

Carbon dioxide laser excision for HG-VaIN seems to be a safe approach with low rate of complications, probably because of the better accuracy achieved by CO2 laser resections, and permits diagnosis of occult invasive disease.

PMID:
28953124
DOI:
10.1097/LGT.0000000000000326
[Indexed for MEDLINE]
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11.
J Low Genit Tract Dis. 2017 Oct;21(4):299-303. doi: 10.1097/LGT.0000000000000346.

Should the Risk of Invasive Cancer in Pregnancy and the Safety of Loop Electrosurgical Excision Procedure During the First 15 Weeks Change Our Practice?

Author information

1
1Department of Obstetrics and Gynecology, Carmel Medical Ctr; Haifa; 2Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa; 3Rambam Health Care Campus; Haifa; 4Assaf Haroffe Medical Ctr.; Zeriffin; and 5Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel.

Abstract

OBJECTIVE:

The aim of this article was to describe the outcome of women diagnosed with cervical intraepithelial neoplasia (CIN) grades 2 or 3 in pregnancy either observed or treated by loop electrosurgical excision procedure (LEEP) in the first 15 weeks of gestation.

METHODS:

Loop electrosurgical excision procedure during the first 15 gestational weeks compared with observation of CIN2/3. This is a retrospective analysis of a nonrandomized study at tertiary, academic, and referring centers in Israel. Ninety-three pregnant women diagnosed with CIN2/3 between 2006 and 2016 were included in this study. Fifty patients with CIN2/3 on cervical biopsy were conservatively followed-up, and 43 patients have undergone LEEP during the first 15 gestational weeks. Main outcome measures were ultimate diagnosis of invasive cancer or CIN, pregnancy outcome, and complications.

RESULTS:

In 5.4% of CIN2/3 during pregnancy, the final diagnosis was invasive cancer. The postpartum results of 50 women who were conservatively observed were as follows: 3 (6.0%) had cervical cancer and undergone radical hysterectomy, 33 (66.6%) had CIN2/3, and 14 (28%) had CIN1 or normal histology. The diagnoses of the 43 patients who have undergone LEEP were invasive cancer in 2 patients (4.6%) but did not undergo hysterectomy, CIN2/3 or adenocarcinoma in situ (AIS) in 38 patients (88.4%), and 3 women (7%) had CIN1 or normal histology. None of them suffered severe bleeding. Thirty-seven women continued their pregnancy, 34 (91.9%) had term deliveries, 2 (5.4%) gave birth at 34 and 36 weeks, and 1 patient had missed abortion (2.7%).

CONCLUSIONS:

The LEEP procedure during the first 15 weeks of pregnancy is safe. A total of 5.4% of the women with CIN2/3 during pregnancy were diagnosed with invasive cancer. It is time to reconsider the recommendations about CIN2/3 in early gestation.

PMID:
28953123
DOI:
10.1097/LGT.0000000000000346
[Indexed for MEDLINE]
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12.
J Low Genit Tract Dis. 2017 Oct;21(4):294-298. doi: 10.1097/LGT.0000000000000327.

Positive Correlation Between Clearance of High-Risk Human Papillomavirus and Lack of Residual Disease After Loop Excision of the Transformation Zone in Early Stage Cervical Cancer.

Author information

1
1Department of Obstetrics & Gynecology, Carmel Medical Center, Haifa, Israel; 2Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; 3Department of Pathology, Carmel Medical Center, Haifa, Israel; and 4Clinical Serology and Virology Laboratory, Carmel Medical Center, Haifa, Israel.

Abstract

OBJECTIVES:

In cervical cancer, a number of pathological parameters have been explored for their utility in tailoring a less aggressive approach for patients with low-risk early stage disease. We examined whether, in patients with cervical cancer stage IA1 to IB1, diagnosed by loop excision of the transformation zone (LLETZ), positive for high-risk human papillomavirus (hrHPV), clearance of hrHPV after LLETZ correlates with absence of residual disease at the final pathology after definitive or further surgery.

MATERIALS AND METHODS:

Data were collected from patients diagnosed with early stage invasive cervical cancer and positive hrHPV DNA, who had a repeat cervical HPV test 3 to 12 weeks after LLETZ and before final surgical treatment. We compared characteristics of patients with post-LLETZ negative and positive hrHPV.

RESULTS:

Of 28 patients, 13 were post-LLETZ negative hrHPV; of these, 11 did not have residual cancer in the final pathological specimen; two patients had cervical intraepithelial neoplasia 3. Of the 15 women who had post-LLETZ positive hrHPV, 10 had residual cancer in the final pathological specimen and 3 had cervical intraepithelial neoplasia or adenocarcinoma in situ; only 2 were negative for cancer. The post-LLETZ hrHPV test shows a sensitivity of 86.7% and specificity of 84.6%.

CONCLUSIONS:

Clearance of hrHPV from the cervix after LLETZ was found to correlate with the absence of residual cancer in the final surgical specimen. Testing for hrHPV post-LLETZ might serve as a new parameter for risk assessment and tailoring of a less radical operation in women with early stage cervical cancer.

PMID:
28953122
DOI:
10.1097/LGT.0000000000000327
[Indexed for MEDLINE]
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13.
J Low Genit Tract Dis. 2017 Oct;21(4):284-288. doi: 10.1097/LGT.0000000000000349.

Post-Loop Electrosurgical Excision Procedure High-Risk Human Papillomavirus Testing as a Test of Cure: The British Columbia Experience.

Author information

1
1BC Cancer Agency, Vancouver, British Columbia, Canada; 2Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; 3BC Centre for Disease Control, Vancouver, British Columbia, Canada; and 4Lower Mainland Laboratories, Vancouver, British Columbia, Canada.

Abstract

OBJECTIVES:

To determine whether Hybrid Capture 2 High-Risk HPV DNA Test (HC2) can be used as a test of cure in women treated for cervical intraepithelial neoplasia grade 2 or worse (CIN 2+) and allow discharge from colposcopy follow-up with a return to a cytology-based screening program for HC2-negative women.

MATERIALS AND METHODS:

Data were analyzed for all women who underwent a loop electrosurgical excision procedure between August 1, 2008, and June 30, 2011, and had a valid HC2 result after loop electrosurgical excision procedure and follow-up histopathology result, to determine risk of persistent or recurrent CIN 2+ in HC2-positive and HC2-negative women.

RESULTS:

Two thousand three hundred forty women had adequate biopsies and valid HC2 results. Of 460 HC2-positive women, 118 (25.7%) were diagnosed with CIN 2+, whereas of 1,880 HC2-negative women, 35 (1.9%) had a subsequent diagnosis of CIN 2+ (p < .0002) yielding a HC2-negative predictive value of 98.1% (95% confidence interval = 97.4-98.7). Of 460 HC2-positive women, 306 initially had negative biopsies. In the subsequent 36 months, 38 of the 306 were diagnosed with CIN 2+.

CONCLUSIONS:

We conclude that women with a negative HC2 test can safely return to routine annual cytology screening by primary care providers while women who test HC2 positive are at higher risk and should continue to be followed by colposcopy, even if their initial biopsy is negative.

PMID:
28953120
DOI:
10.1097/LGT.0000000000000349
[Indexed for MEDLINE]
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14.
J Low Genit Tract Dis. 2017 Oct;21(4):279-283. doi: 10.1097/LGT.0000000000000340.

Cervical Excision Procedure: A Trend of Decreasing Length of Excision Observed in a Multicenter Survey.

Author information

1
1Woman's Health Sciences Department, Gynecologic Section, Università Politecnica delle Marche, Ancona, Italy; 2Gynecologic Oncology Unit, Department. of Obstetrics & Gynecology Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, University of Milano, Milan, Italy; 3Center for Gynecologic Oncology Prevention, AULSS 20, Verona, Italy; 4Local Health Authority of Reggio Emilia, Division of Obstetrics and Gynecology, Cesare Magati Hospital, Scandiano, Italy; and 5Gynecological Oncology Unit, Centro di Riferimento Oncologico - National Cancer Institute, Aviano, Italy.

Abstract

OBJECTIVES:

The aim of the present study was to observe the trend of length of cone excisions in women treated with cervical excision procedure in five institutions of Central and Northern Italy.

MATERIALS AND METHODS:

A multicenter retrospective cohort study was conducted on women who underwent a cervical excision procedure between January 2006 and December 2014. The pertinent clinical, histopathological, and sociodemographic characteristics of each woman were collected. In particular, the length of the cone specimen was evaluated and all of the factors that potentially influenced the length of excision were considered.

RESULTS:

A total of 1482 women who underwent a cervical excision procedure from January 2006 to December 2014 were included. A mean (SD) cone length of 12.9 (5.0) mm was reported, and mostly, a significant decrease during the whole study period emerged. Age (r = 0.1, p = .007) and preoperative diagnosis of glandular lesions (r = 0.1, p < .001) were significantly related to the length of cone excision on multivariate analysis. Compared with the carbon dioxide laser excisional procedure, loop electrosurgical excision procedure showed a negative correlation with the length of excision (r = -0.2, p < .001).

CONCLUSIONS:

During the study period, a significant decrease in the length of cone excision was observed, probably reflecting the gynecologists' acquired awareness of the increased risk of adverse obstetric outcomes for future pregnancies in the case of wide cone excisions.

PMID:
28953119
DOI:
10.1097/LGT.0000000000000340
[Indexed for MEDLINE]
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15.
J Low Genit Tract Dis. 2017 Oct;21(4):272-278. doi: 10.1097/LGT.0000000000000329.

Large Loop Excision of the Transformation Zone Versus True Cone Biopsy Electrode Excision: A Randomized Trial.

Author information

1
From the Department of Gynecology and Obstetrics, Ruhr-Universität Bochum, Bochum, Germany.

Abstract

OBJECTIVES:

The aim of the study was to compare two conization techniques, large loop excision of the transformation zone (LLETZ), and true cone biopsy electrode excision (TCBEE) in women with cervical dysplasia.

MATERIALS AND METHODS:

In a randomized clinical trial, we compared LLETZ and TCBEE in women undergoing surgical treatment of cervical dysplasia in a 1:1 ratio. The primary endpoint was resection margin status (RMS), secondary endpoints were fragmentation of the surgical specimen, resection volume, operation time, time to complete hemostasis, blood loss, intraoperative and postoperative complications, surgeon's preference, and patient's postoperative pain, estimated by an 11-level visual analog scale (nVAS11), and a 5-level pictogram.

RESULTS:

One hundred seventy-two women were randomized. No difference in the primary outcome, resection margin status, was observed between LLETZ and TCBEE (involved margins: 12/91 [13%] vs 7/81 [9%], respectively; p = .4). However, fragmentation rate (1 vs >1 fragment: 85 [93%] and 6 [7%] for LLETZ vs 63 [78%] and 18 [22%] for TCBEE; p = .004) and surgeon preference (nVAS11: 1 [0-2] vs 3 [1-7]; p < .001) favored LLETZ. Postoperative pain, however, was lower after TCBEE (nVAS11: 1 [0-3] vs 0 [0-2]; p = .02). The secondary outcome parameters resection volume, operation time, time to complete hemostasis, blood loss, intraoperative complications, and postoperative complications were not different between the study groups. In a multivariate analysis, age, body mass index, and parity did not affect the primary and secondary outcome parameters.

CONCLUSIONS:

LLETZ and TCBEE are equally safe and efficacious procedures, but specimen fragmentation and surgeon preference favor loop excision.

PMID:
28953118
DOI:
10.1097/LGT.0000000000000329
[Indexed for MEDLINE]
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16.
J Low Genit Tract Dis. 2017 Oct;21(4):268-271. doi: 10.1097/LGT.0000000000000333.

The Current Burden of Follow-up of Stage 1A1 Cervical Cancer.

Author information

1
1Glasgow Royal Infirmary, Glasgow, United Kingdom; and 2Daisy Hill Hospital, Newry, Northern Ireland.

Abstract

OBJECTIVE:

The aim of this study was to assess the current burden and consistency of stage 1A1 cervical cancer follow-up within Greater Glasgow and Clyde Health Board.

METHODS:

A retrospective review was undertaken of women diagnosed with and treated of, between 2007 and 2011, stage 1A1 cervical cancer in Greater Glasgow and Clyde Health Board. Data were collected on referral cytology, definitive method of treatment, posttreatment cytology, and rate of recurrence. Outcomes included rate of recurrence, abnormal cytology, and number of interventions during follow-up.

RESULTS:

Of the 78 women diagnosed with stage 1A1 cervical cancer, 43 had a LLETZ (large loop excision of the transformation zone) as definitive treatment. Ninety percent of stage 1A1 cervical cancers were diagnosed following abnormal screening cytology. Almost 86% of all cytology post-LLETZ were negative. Only 1 woman had a recurrence. No posthysterectomy vault smears were low-grade dyskaryosis or worse.

CONCLUSIONS:

There is a very low rate of abnormal cytology after LLETZ. Vault smears are of limited benefit in the management of women posthysterectomy for stage 1A1 cervical cancer.

PMID:
28953117
DOI:
10.1097/LGT.0000000000000333
[Indexed for MEDLINE]
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18.
Hum Pathol. 2017 Sep;67:211-216. doi: 10.1016/j.humpath.2017.08.013. Epub 2017 Aug 24.

Postablation neuroma of the myometrium-a report of 5 cases.

Author information

1
Department of Pathology, Rochester General Hospital, University of Rochester School of Medicine, Rochester, 14621, NY.
2
Department of Pathology and Laboratory Medicine, Rutgers New Jersey Medical School, Newark, 07103, NY. Electronic address: hellerds@njms.rutgers.edu.

Abstract

When hysterectomy is performed for chronic pelvic pain, routine pathology examination often provides no explanation. However, analysis of small uterine nerves using immunostains may help to address this deficiency. Small uterine nerves tend to be sparse or absent in wide areas of normal myometrium. Some studies of uterine nerves have suggested that endometriosis, adenomyosis, and fibroids are not inherently painful, with increased small nerves in the inner uterine wall associated with the history of pelvic pain. Although such areas may appear normal on hematoxylin and eosin (H&E), we have found a subtle inner wall lesion termed inner myometrial elastosis, best detected with trichrome or elastic stains, which may be a reaction to microscopic tears of inner myometrium. Such tears may induce increased inner wall innervation via the generation of nerve growth factor in granulation tissue. In the course of studying uterine nerves with immunostains, we found 5 cases with florid nerve proliferation, after deep endometrial ablation for abnormal uterine bleeding led to increased pelvic pain. We suggest that immunostains for postablation neuromas should be done in hysterectomies when pelvic pain increases after endometrial ablation. This may offer gynecologists and their patients an objective finding with a rational, scientific explanation for the pelvic pain.

KEYWORDS:

Chronic pelvic pain; Endometrial ablation; Hysterectomy; Neuroma; Uterus

PMID:
28843713
DOI:
10.1016/j.humpath.2017.08.013
[Indexed for MEDLINE]
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19.
Int J Gynaecol Obstet. 2017 Nov;139(2):121-129. doi: 10.1002/ijgo.12293. Epub 2017 Sep 1.

Comparison of the levonorgestrel-releasing intrauterine system, hysterectomy, and endometrial ablation for heavy menstrual bleeding in a decision analysis model.

Author information

1
Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
2
Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
3
Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Abstract

BACKGROUND:

A better understanding of the relative risks and benefits of common treatment options for abnormal uterine bleeding (AUB) can help providers and patients to make balanced, evidence-based decisions.

OBJECTIVES:

To provide comparative estimates of clinical outcomes after placement of levonorgestrel-releasing intrauterine system (LNG-IUS), ablation, or hysterectomy for AUB.

SEARCH STRATEGY:

A PubMED search was done using combinations of search terms related to abnormal uterine bleeding, LNG-IUS, hysterectomy, endometrial ablation, cost-benefit analysis, cost-effectiveness, and quality-adjusted life years.

SELECTION CRITERIA:

Full articles published in 2006-2016 available in English comparing at least two treatment modalities of interest among women of reproductive age with AUB were included.

DATA COLLECTION AND ANALYSIS:

A decision tree was generated to compare clinical outcomes in a hypothetical cohort of 100 000 premenopausal women with nonmalignant AUB. We evaluated complications, mortality, and treatment outcomes over a 5-year period, calculated cumulative quality-adjusted life years (QALYs), and conducted probabilistic sensitivity analysis.

MAIN RESULTS:

Levonorgestrel-releasing intrauterine system had the highest number of QALYs (406 920), followed by hysterectomy (403 466), non-resectoscopic ablation (399 244), and resectoscopic ablation (395 827). Ablation had more treatment failures and complications than LNG-IUS and hysterectomy. Findings were robust in probabilistic sensitivity analysis.

CONCLUSIONS:

Levonorgestrel-releasing intrauterine system and hysterectomy outperformed endometrial ablation for treatment of AUB.

KEYWORDS:

Abnormal uterine bleeding; Decision analysis; Endometrial ablation; Hysterectomy; Levonorgestrel intrauterine device; Menorrhagia; Outcomes; Treatment

PMID:
28796898
DOI:
10.1002/ijgo.12293
[Indexed for MEDLINE]
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20.
Obstet Gynecol. 2017 Sep;130(3):554-560. doi: 10.1097/AOG.0000000000002166.

Long-term Follow-up After Endometrial Ablation in Finland: Cancer Risks and Later Hysterectomies.

Author information

1
Department of Obstetrics and Gynecology, Hyvinkää Hospital, Hyvinkää, the Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, the Department of Obstetrics and Gynecology, Helsinki University Hospital, and the University of Helsinki, Helsinki, the Department of Obstetrics and Gynecology, Turku University Hospital, and the University of Turku, Turku, the Faculty of Medicine and Life Sciences, University of Tampere, the Department of Obstetrics and Gynecology, Tampere University Hospital, and the Faculty of Social Sciences, University of Tampere, Tampere, and the National Institute for Health and Welfare, Department of Information Services, Helsinki, Finland; and the Department of Neurobiology, Care Sciences and Society, Division of Family Medicine, Karolinska Institute, Stockholm, Sweden.

Abstract

OBJECTIVE:

To study the risk of endometrial cancer and breast cancer and the hysterectomy rate after endometrial ablation.

METHODS:

In this retrospective cohort study, records of all women with endometrial ablation at ages 30-49 years in Finland (1997-2014) were extracted from the Hospital Discharge Register and linked to the Cancer Registry and Finnish Central Population Register. The primary outcome was cancer incidences in the endometrial ablation cohort compared with those in the background population of the same age. Secondarily, the postablation hysterectomy rate was compared with that of a control cohort of similar-aged women extracted from the Finnish Central Population Register. Multivariate regression models with adjustment for age, parity, number of cesarean deliveries, history of sterilization, and the duration of follow-up were evaluated as risk factors for postablation hysterectomy.

RESULTS:

In total, 154 cancers (standardized incidence ratio [observed-to-expected ratio] 0.96, 95% CI 0.82-1.13) were diagnosed among 5,484 women treated with endometrial ablation during the follow-up of 39,892 women-years. The standardized incidence ratio for endometrial cancer was 0.56 (95% CI 0.12-1.64) and for breast cancer 0.86 (95% CI 0.67-1.09). A total of 1,086 (19.8%) women had postablation hysterectomy. Risk of hysterectomy was almost fourfold in the endometrial ablation cohort compared with 26,938 women in a control group (adjusted hazard ratio [HR] 3.63, 95% CI 3.32-3.96). Factors predisposing to postablation hysterectomy were leiomyomas (adjusted HR 1.78, 95% CI 1.03-3.10), age younger than 35 years (adjusted HR 1.44, 95% CI 1.15-1.81), at least two prior cesarean deliveries (adjusted HR 1.27, 95% CI 1.04-1.55), and history of sterilization (adjusted HR 1.15, 95% CI 1.01-1.32).

CONCLUSION:

Endometrial ablation was not associated with an elevated endometrial cancer or breast cancer risk in Finland. Leiomyomas, young age, and history of prior cesarean deliveries or sterilization were associated with an increased risk of postablation hysterectomy.

PMID:
28796675
DOI:
10.1097/AOG.0000000000002166
[Indexed for MEDLINE]
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