Endometrial ablation as a treatment for heavy menstrual bleeding.

Until the 1980s, the only available definitive treatment for heavy menstrual bleeding (HMB) was hysterectomy, usually performed abdominally, and sometimes vaginally. Historically, multiple attempts to effect ablation of the endometrium were developed, including using steam and toxic chemicals, such as chloriquine. The advent of Nd-YAG laser endometrial ablation in the mid-1980s offered the first minimally invasive alternative to hysterectomy for the treatment of HMB. Nd-YAG ablation, however, was expensive, cumbersome, and difficult to learn; rollerball resectoscopic ablation was initially described by DeCherney in 1987, and soon overtook laser as the main method of ablation, although adoption continued to be limited because of the hysteroscopic skills necessary to perform the technique were not widely available. In 1994, the first "global" endometrial ablation, the Thermachoice™ (Ethicon Women's Health and Urology, Somerville, NJ) balloon was introduced in the U.S. Soon thereafter, four other techniques were introduced, namely microwave (MEA™, Microsulis, Hampshire, UK), circulating hot water (HTA™, Boston Scientific, Boston, MA), cryo-ablation (HerOption™, CooperSurgical, Trumbull, CT), and bipolar radiofrequency (Novasure™, Hologic, Bedford, MA). All of these techniques are done in an outpatient setting, often office-based, with little or no anesthesia, and success rates ranging from 50% to 70% amenorrhea, and 80% to 95% patient satisfaction. Although there have been few head-to-head comparisons of various techniques, current data suggests that they are all relatively effective, quite safe, and well-tolerated. This article describes the history and development of various ablation technologies, and explores each technique in depth, including published data, indications, risks, and benefits.

Positive symptom improvement with laparoscopic uterosacral ligament repair for uterine or vaginal vault prolapse: interim results from an active multicenter trial.

STUDY OBJECTIVE: To evaluate the use of laparoscopic uterosacral ligament repair for long-term patient symptom improvement in patients with uterine prolapse or posthysterectomy vaginal vault prolapse and to evaluate how laparoscopic instrumentation kits facilitate procedure performance for the surgeon. DESIGN: Nonrandomized, prospective, multicenter case series (Canadian Task Force classification II-2). SETTING: Five clinical sites consisting of 4 community hospitals and 1 university medical center. PATIENTS: Seventy-two patients with stage II or worse uterine prolapse (58%, n = 42) or posthysterectomy vaginal vault prolapse (42%, n = 30). One patient with stage I vaginal vault prolapse was included in the group due to her significant symptoms. INTERVENTIONS: Laparoscopic uterosacral ligament repair was performed on all patients; round ligament truncation was also performed selectively on patients with uterine prolapse. Fifty-seven percent (41 patients) had concomitant pelvic procedures. MEASUREMENTS AND MAIN RESULTS: At 12-month follow-up, Pelvic Organ Prolapse Quantification (POP-Q) scores and patient self-reported symptom scores were significantly improved over baseline after laparoscopic repair of pelvic organ prolapse. Positive mean change in POP-Q score was 14.4 (p = .0003) for uterine prolapse repair and 9.28 (p = .017) for vaginal vault prolapse repair. Positive mean change in total symptom score was 20.36 (p <.0001) for uterine prolapse repair and 11.43 (p = .005) for vaginal vault prolapse repair. Surgeons reported a mean procedure time of 31.6 minutes for uterine prolapse repair and 21.7 minutes for vaginal vault prolapse repair. A mean rating of 7.5 was documented for ease of use for the uterine prolapse kit and 4.1 for the vaginal vault prolapse kit on a scale of 1 to 10. CONCLUSION: Laparoscopic uterosacral ligament repair improves symptoms and POP-Q scores over the long term in patients with uterine or vaginal vault prolapse. Laparoscopic instrumentation kits facilitate procedure performance for the surgeon with expedited surgery times.