Pre-operative anemia prior to gynecologic surgery is associated with increased healthcare costs.

OBJECTIVE: To compare healthcare utilization costs between anemic and non-anemic patients undergoing elective hysterectomy and myomectomy for benign indications from the date of surgery to 30-days postoperatively. DESIGN: Retrospective population-based cohort study. SETTING: Single-payer publicly funded healthcare system in Ontario, Canada between 2013-2020. PARTICIPANTS: Adult women (≥18 years of age) who underwent elective hysterectomy or myomectomy (laparoscopic/laparotomy) for benign indications. INTERVENTIONS: Our exposure of interest was pre-operative anemia, defined as the most recent hemoglobin value <12g/dL on the complete blood count measured before the date of surgery. Our primary outcome was healthcare costs (total and disaggregated) from the perspective of the single-payer publicly funded healthcare system. RESULTS: Of the 59,270 patients in the cohort, 11,802 (19.9%) had pre-operative anemia. After propensity matching, standardized differences in all baseline characteristics (N=10,103 per group) were <0.10. In the matched cohort, the mean total healthcare cost per anemic patient was higher compared to cost per non-anemic patient ($6,134.88 ± $2,782.38 vs. $6,009.97 ± $2,423.27, p<0.001). Anemic patients, compared to non-anemic patients, had a higher mean difference in total healthcare cost of $124.91 per patient (95%CI $53.54 - $196.29) translating to an increased cost attributable to anemia of 2.08% (95%CI 0.89% - 3.28%, p<0.001). In a subgroup analysis of patients undergoing hysterectomy (N=9041), the cost was also significantly higher for anemic patients (mean difference per patient of $117.67, 95%CI $41.58 - $193.75). For those undergoing myomectomy (N=1062) the difference in cost was not statistically significant (mean difference $186.61, 95%CI -$17.42 - $390.65). CONCLUSION: Pre-operative anemia was associated with significantly increased healthcare resource utilization and costs for patients undergoing elective gynecologic surgery. Although the cost difference per case was modest, when extrapolated to the population level, this difference could result in substantially significant cost to the healthcare system, attributable to pre-operative anemia.

Individualized Assessment of Risk of Complications after Benign Hysterectomy.

STUDY OBJECTIVES: The primary objective of this study is to identify patient characteristics associated with postoperative complications or readmissions after hysterectomy for a benign indication. DESIGN: Retrospective cohort. SETTING: The Surgical Gynecologic Scorecard Database includes performance metrics and patient outcomes for hysterectomies across 7 sites in Ontario, Canada. PARTICIPANTS: Individuals who underwent hysterectomy for benign gynecologic indication and were recorded in the Surgical Gynecologic Scorecard Database between July 2016 and June 2019 were included in this study. MEASUREMENTS AND MAIN RESULTS: Two outcomes of interest were considered: (1) complications grade II or greater on the Clavien-Dindo classification scale and (2) emergency room visits or hospital readmissions within 6 weeks after operation. Logistic models were generated to determine the associations between outcome of interest and potential predictors using a mixed-step AIC selection algorithm. A total of 2792 patients underwent hysterectomy for a benign indication during the study period, with a mean age of 52.6 ± 11.7 years and mean body mass index of 29.0 ± 0.7 kg/m2. The most common indications for surgery were abnormal uterine bleeding (33.3%) and myomas (33.6%). Previous cesarean delivery (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.04-1.42), American Society of Anesthesiologists class ≥3 (aOR, 2.31; 95% CI, 1.42-3.99), preoperative anemia (aOR, 1.51; 95% CI, 1.12-2.02), and laparotomic approach (aOR, 1.73; 95% CI, 1.30-2.29) were associated with increased odds of complication. Perioperative complications (aOR, 2.95; 95% CI, 2.12-4.08), preoperative anemia (aOR, 1.43; 95% CI, 1.03-1.98), and vaginal (aOR, 1.94; 95% CI, 1.26-2.96) or laparotomic (aOR, 1.64; 95% CI, 1.10-2.43) approach were associated with increased odds of emergency room visit or readmission to hospital. CONCLUSION: This study identified several important risk factors for complications after hysterectomy. The utility of these data is important to help improve counseling for patients undergoing a hysterectomy and potentially optimize modifiable risk factors when identified preoperatively.

Impact of Minimally Invasive Gynaecology Fellowship Training on Quality Performance Metrics for Hysterectomy.

OBJECTIVE: To evaluate differences in quality metrics between hysterectomies performed by fellowship-trained surgeons and those performed by generalists. METHODS: Retrospective review of 2845 consecutive hysterectomies by 75 surgeons (23 fellowship-trained, 52 generalists) at 7 hospitals in Ontario, Canada. The primary outcome was a composite of any complication or return to the emergency department (ED) within 30 days of hysterectomy. Secondary outcomes were 2 quality outcome measures (grade of complication and return to ED within 30 days) and 4 quality process measures (minimally invasive hysterectomy rate, rate of preoperative anemia, same-day discharge for laparoscopic hysterectomy [LH], and performing cystoscopy at LH). RESULTS: Fellowship-trained surgeons were more likely to perform concurrent resection of endometriosis, bilateral ureterolysis, lysis of adhesions, uterine/internal iliac artery ligation, and morcellation (all P < 0.001). Generalists performed more vaginal procedures, including vaginal repair, vault suspension, and insertion of mid-urethral sling (all P < 0.001). After controlling for patient and surgical factors, there was no difference in the primary outcome (adjusted odds ratio [aOR] 1.07; 95% CI 0.79-1.45, P = 0.667). Fellowship-trained surgeons were more likely to perform minimally invasive hysterectomy (aOR 2.38; 95% CI 1.15-4.93, P = 0.020), had higher rates of same-day discharge for LH (aOR 2.23; 95% CI 1.31-3.81, P = 0.003), and were more likely to perform cystoscopy (unadjusted OR 2.94; 95% CI 2.30-3.85, P < 0.001). There were no differences in the rates of preoperative anemia, surgical complications, and ED visits. CONCLUSION: Differences exist between fellowship-trained surgeons and generalists regarding case mix and process quality metrics. Postoperative complications and readmissions were comparable for both groups of surgeons.

Understanding Minimally Invasive Gynaecologic Surgery Fellowship Training in Canada: A National Survey of Recent Graduates.

OBJECTIVE: To characterize fellowship training experiences in the 11 Canadian minimally invasive gynaecologic surgery (MIGS) programs and compare the surgical exposure of fellows in these programs to that of the American Association of Gynecologic Laparoscopists (AAGL) accredited fellowship in MIGS (FMIGS). METHODS: In this cross-sectional study, 2017 and 2018 MIGS fellowship graduates across Canada were given a web-based survey via SurveyMonkey software to evaluate 5 key components of postgraduate fellowship curricula: 1) surgical exposure; 2) teaching and evaluation methods; 3) research experience; 4) clinical responsibilities; and 5) pursuit of other academic endeavours. Interest in creating a national standardized curriculum and seeking accreditation for MIGS fellowships were also examined. RESULTS: The survey attained a 91% (20/22) response rate of the target population. All Canadian MIGS programs met the minimum standards for at least 62% (8/13) of the surgical competencies listed by the AAGL, with office hysteroscopy being the procedure with the largest discordance. Half of respondents (10/20) attended a program with an established curriculum, and 75% (15/20) believed there would be a benefit to standardizing training nationwide. Seventy percent (14/20) had published at least one manuscript during their fellowship and 60% (12/20) pursued postgraduate degrees. The majority (55%; 11/20) felt certain that MIGS should become a credentialed fellowship in Canada. CONCLUSION: Canada has made meaningful progress in MIGS training over the past decade with 11 well-established fellowship programs. Although this survey identifies a general interest in standardized training and accreditation for Canadian MIGS programs, more research is needed on how best to accomplish this.

No. 371-Morcellation During Gynaecologic Surgery: Its Uses, Complications, and Risks of Unsuspected Malignancy.

OBJECTIVE: This guideline provides guidance to gynaecologists regarding the use of tissue morcellation in gynaecologic surgery. OUTCOMES: Morcellation may be used in gynaecologic surgery to allow removal of large uterine specimens, thus providing women with a minimally invasive surgical option. Adverse oncologic outcomes of tissue morcellation should be mitigated through improved patient selection, preoperative investigations, and novel techniques that minimize tissue dispersion. EVIDENCE: Published literature was retrieved through searches of PubMed and Medline in the spring of 2014 using appropriate controlled vocabulary (leiomyosarcoma, uterine neoplasm, uterine myomectomy, hysterectomy) and key words (leiomyoma, endometrial cancer, uterine sarcoma, leiomyosarcoma, and morcellation). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to July 2017. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence in this document was rated using the criteria described in the report of the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS: Gynaecologists offer women minimally invasive surgery, and this may involve tissue morcellation and the use of a power morcellator for specimen retrieval. Women should be counselled that in the case of unexpected uterine (sarcoma, endometrial), cervical, and/or tubo-ovarian cancer, the use of a morcellator is associated with increased risk of tumour dissemination. Tissue morcellation should be performed only after complete investigation, appropriate patient selection, and informed consent and by surgeons with appropriate training in the safe practices of tissue morcellation. SUMMARY STATEMENTS: RECOMMENDATIONS.

Decreasing Diagnostic Hysteroscopy Performed in the Operating Room: A Quality Improvement Initiative.

OBJECTIVES: At our institution, diagnostic hysteroscopy (DH), often combined with uterine curettage, commonly has been performed in the main OR with the patient under general anaesthesia. Our objective was to create targeted interventions aimed at decreasing the number of DHs performed in the OR by 75% over one year. METHODS: This quality improvement initiative had a quasi-experimental (time-series) design. To obtain baseline numbers of DHs performed each month, we conducted a retrospective chart audit at a university teaching hospital. We implemented the following three groups of interventions: (1) staff education and case review, (2) accessible sonohysterography, and (3) an operative hysteroscopy education program. Procedures were tracked prospectively over a 12-month intervention period and an additional 12-month maintenance period. RESULTS: One hundred eleven DHs were performed at baseline. During the intervention period, 33 DHs were performed, a 70% reduction from baseline. This resulted in related savings of $126 984 and 12.5 surgical days. In the final quarter of the intervention period, there was an 81% reduction in the number of DHs with adequate preoperative evaluation compared with baseline. Twenty DHs were performed in the maintenance period, an 82% reduction from baseline. The absolute number of complications from DH remained constant during the study period. CONCLUSION: Carefully planned and targeted interventions to change the culture at our institution decreased the number of DHs performed in the main OR. These initiatives improved patient care, saved costs, and improved OR utilization. Long-term follow-up showed maintenance of the improvements in the year subsequent to the interventions.

Endometrial ablation in the management of abnormal uterine bleeding.

BACKGROUND: Abnormal uterine bleeding (AUB) is the direct cause of a significant health care burden for women, their families, and society as a whole. Up to 30% of women will seek medical assistance for the problem during their reproductive years. OBJECTIVE: To provide current evidence-based guidelines on the techniques and technologies used in endometrial ablation (EA), a minimally invasive technique for the management of AUB of benign origin. METHODS: Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of both location in Canada and type of practice, as well as subspecialty expertise and general background in gynaecology. The committee reviewed all available evidence in the English medical literature, including published guidelines, and evaluated surgical and patient outcomes for the various EA techniques. Recommendations were established by consensus. EVIDENCE: Published literature was retrieved through searches of MEDLINE and The Cochrane Library in 2013 and 2014 using appropriate controlled vocabulary and key words (endometrial ablation, hysteroscopy, menorrhagia, heavy menstrual bleeding, AUB, hysterectomy). RESULTS were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English from January 2000 to November 2014. Searches were updated on a regular basis and incorporated in the guideline to December 2014. Grey (unpublished) literature was identifies through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). RESULTS: This document reviews the evidence regarding the available techniques and technologies for EA, preoperative and postoperative care, operative set-up, anaesthesia, and practical considerations for practice. BENEFITS, HARMS, AND COSTS: Implementation of the guideline recommendations will improve the provision of EA as an effective treatment of AUB. Following these recommendations would allow the surgical procedure to be performed safely and maximize success for patients. CONCLUSIONS: EA is a safe and effective minimally invasive option for the treatment of AUB of benign etiology. Summary Statements 1. Endometrial ablation is a safe and effective minimally invasive surgical procedure that has become a well-established alternative to medical treatment or hysterectomy to treat abnormal uterine bleeding in select cases. (I) 2. Endometrial preparation can be used to facilitate resectoscopic endometrial ablation (EA) and can be considered for some non-resectoscopic techniques. For resectoscopic EA, preoperative endometrial thinning results in higher short-term amenorrhea rates, decreased irrigant fluid absorption, and shorter operative time than no treatment. (I) 3. Non-resectoscopic techniques are technically easier to perform than resectoscopic techniques, have shorter operative times, and allow the use of local rather than general anaesthesia. However, both techniques have comparable patient satisfaction and reduction of heavy menstrual bleeding. (I) 4. Both resectoscopic and non-resectoscopic endometrial ablation (EA) have low complication rates. Uterine perforation, fluid overload, hematometra, and cervical lacerations are more common with resectoscopic EA; perioperative nausea/vomiting, uterine cramping, and pain are more common with non-resectoscopic EA. (I) 5. All non-resectoscopic endometrial ablation devices available in Canada have demonstrated effectiveness in decreasing menstrual flow and result in high patient satisfaction. The choice of which device to use depends primarily on surgical judgement and the availability of resources. (I) 6. The use of local anaesthetic and blocks, oral analgesia, and conscious sedation allows for the provision of non-resectoscopic EA in lower resource-intense environments including regulated non-hospital settings. (II-2) 7. Low-risk patients with satisfactory pain tolerance are good candidates to undergo endometrial ablation in settings outside the operating room or in free-standing surgical centres. (II-2) 8. Both resectoscopic and non-resectoscopic endometrial ablation are relatively safe procedures with low complication rates. The complications perforation with potential injury to contiguous structures, hemorrhage, and infection. (II-2) 9. Combined hysteroscopic sterilization and endometrial ablation can be safe and efficacious while favouring a minimally invasive approach. (II-2) Recommendations 1. Preoperative assessment should be comprehensive to rule out any contraindication to endometrial ablation. (II-2A) 2. Patients should be counselled about the need for permanent contraception following endometrial ablation. (II-2B) 3. Recommended evaluations for abnormal uterine bleeding, including but not limited to endometrial sampling and an assessment of the uterine cavity, are necessary components of the preoperative assessment. (II-2B) 4. Clinicians should be vigilant for complications unique to resectoscopic endometrial ablation such as those related to fluid distention media and electrosurgical injuries. (III-A) 5. For resectoscopic endometrial ablation, a strict protocol should be followed for fluid monitoring and management to minimize the risk of complications of distension medium overload. (III-A) 6. If uterine perforation is suspected to have occurred during cervical dilatation or with the resectoscope (without electrosurgery), the procedure should be abandoned and the patient should be closely monitored for signs of intraperitoneal hemorrhage or visceral injury. If the perforation occurs with electrosurgery or if the mechanism of perforation is uncertain, abdominal exploration is warranted to obtain hemostasis and rule out visceral injury. (III-B) 7. With resectoscopic endometrial ablation, if uterine perforation has been ruled out acute hemorrhage may be managed by using intrauterine Foley balloon tamponade, injecting intracervical vasopressors, or administering rectal misoprostol. (III-B) 8. If repeat endometrial ablation (EA) is considered following non-resectoscopic or resectoscopic EA, it should be performed by a hysteroscopic surgeon with direct visualization of the cavity. Patients should be counselled about the increased risk of complications with repeat EA. (II-2A) 9. If significant intracavitary pathology is present, resectoscopic endometrial ablation combined with hysteroscopic myomectomy or polypectomy should be considered in a non-fertility sparing setting. (II-3A).

Contexte : Les saignements utérins anormaux (SUA) sont directement à l'origine d'un fardeau de santé considérable que doivent porter les femmes, leur famille et la société en général. Jusqu'à 30 % des femmes chercheront à obtenir l'aide d'un médecin pour contrer ce problème au cours de leurs années de fertilité. Objectif : Fournir des lignes directrices factuelles à jour quant aux techniques et aux technologies utilisées aux fins de l'ablation de l'endomètre (AE), soit une intervention à effraction minimale permettant la prise en charge des SUA d'origine bénigne. Méthodes : Les membres du comité sur la directive clinique ont été sélectionnés en fonction de leurs spécialisations respectives en vue de représenter une gamme d'expériences pratiques et universitaires : le milieu de pratique au Canada, le type de pratique, la sous-spécialité et les antécédents généraux en gynécologie ont donc été pris en considération. Le comité a analysé les données pertinentes issues de la littérature médicale anglophone (y compris les lignes directrices publiées), en plus d'évaluer les issues chirurgicales et les issues qu'ont connues les patientes à la suite de l'utilisation de diverses techniques d'AE. Les recommandations ont été formulées par consensus. Données : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans MEDLINE et The Cochrane Library en 2013 et en 2014 au moyen d'un vocabulaire contrôlé et de mots clés appropriés (p. ex. « endometrial ablation ¼, « hysteroscopy ¼, « menorrhagia ¼, « heavy menstrual bleeding ¼, « AUB ¼, « hysterectomy ¼). Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs publiés en anglais entre janvier 2000 et novembre 2014. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en décembre 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Résultats : Le présent document passe en revue les données quant aux techniques et aux technologies disponibles en ce qui concerne l'AE, les soins préopératoires et postopératoires, le milieu d'intervention, l'anesthésie et les facteurs pratiques à prendre en considération. Avantages, désavantages et coûts : La mise en œuvre des recommandations de la présente directive clinique entraînera une amélioration de l'offre de l'AE à titre de traitement efficace contre les SUA. Le respect de ces recommandations permettrait l'exécution de l'intervention chirurgicale en cause de façon sûre et en maximiserait la réussite pour les patientes. Conclusions : L'AE est une option à effraction minimale sûre et efficace pour la prise en charge des SUA d'étiologie bénigne. Déclarations sommaires 1. L'ablation de l'endomètre est une intervention chirurgicale à effraction minimale sûre et efficace qui en est venue à constituer, dans certains cas, une solution de rechange bien établie au traitement médical ou à l'hystérectomie pour la prise en charge des saignements utérins anormaux. (I) 2. Une préparation de l'endomètre peut être mise en œuvre pour en faciliter l'ablation résectoscopique et peut également être envisagée dans le cas de certaines techniques non résectoscopiques. Lorsque l'on a recours à l'ablation résectoscopique de l'endomètre, l'amincissement préopératoire de ce dernier donne lieu à une hausse des taux d'aménorrhée à court terme, à une atténuation de l'absorption du liquide de distension et à une réduction de la durée opératoire, par comparaison avec l'absence de traitement. (I) 3. Les techniques non résectoscopiques sont techniquement plus faciles à utiliser que les techniques résectoscopiques, nécessitent des temps opératoires plus courts et permettent l'utilisation d'une anesthésie locale (plutôt que d'avoir recours à une anesthésie générale). Toutefois, ces deux techniques comptent des taux comparables de satisfaction des patientes et d'atténuation des saignements menstruels abondants. (I) 4. Les techniques résectoscopiques et non résectoscopiques d'ablation de l'endomètre comptent toutes de faibles taux de complication. La perforation utérine, la surcharge liquidienne, l'hématomètre et les lacérations cervicales sont plus courantes dans le cas de l'AE résectoscopique; les crampes utérines, la douleur et les nausées / vomissements périopératoires sont plus courants dans le cas de l'AE non résectoscopique. (I) 5. L'efficacité de tous les dispositifs d'ablation non résectoscopique de l'endomètre disponibles au Canada a été démontrée en ce qui concerne l'atténuation du flux menstruel; de plus, ils mènent tous à des taux élevés de satisfaction des patientes. Le choix du dispositif à utiliser dépend principalement de l'opinion du chirurgien et de la disponibilité des ressources. (I) 6. L'utilisation d'anesthésiques et de blocs locaux, d'une analgésie orale et d'une sédation consciente permet la tenue d'une ablation non résectoscopique de l'endomètre au sein de milieux nécessitant des ressources moindres, y compris dans des milieux non hospitaliers réglementés. (II-2) 7. Les patientes n'étant exposées qu'à de faibles risques et présentant une tolérance satisfaisante à la douleur sont de bonnes candidates pour ce qui est de la tenue d'une ablation endométriale dans un milieu autre qu'en salle d'opération ou dans un centre chirurgical autonome. (II-2) 8. Les techniques d'ablation de l'endomètre tant résectoscopiques que non résectoscopiques sont relativement sûres et ne comptent que de faibles taux de complication. Parmi les complications les plus graves, on trouve la perforation (s'accompagnant de lésions potentielles aux structures adjacentes), l'hémorragie et l'infection. (II-2) 9. La tenue concomitante d'une stérilisation hystéroscopique et d'une ablation endométriale peut être sûre et efficace tout en favorisant une approche à effraction minimale. (II-2) Recommandations 1. L'évaluation préopératoire devrait être exhaustive, de façon à pouvoir écarter toute contre-indication à l'ablation de l'endomètre. (II-2A) 2. Les patientes devraient être avisées de la nécessité d'une contraception permanente à la suite de l'ablation de l'endomètre. (II-2B) 3. Les évaluations recommandées en présence de saignements utérins anormaux (dont, entre autres, le prélèvement endométrial et l'évaluation de la cavité utérine) sont des composantes nécessaires de l'évaluation préopératoire. (II-2B) 4. Les cliniciens devraient demeurer à l'affût des complications propres à l'ablation résectoscopique de l'endomètre, comme celles qui sont associées au produit de distension et aux lésions électrochirurgicales. (III-A) 5. Dans le cas de l'ablation résectoscopique de l'endomètre, un protocole strict devrait être respecté pour ce qui est de la surveillance liquidienne et de la prise en charge, et ce, afin de minimiser le risque de voir se manifester des complications associées à la surcharge de produit de distension. (III-A) 6. Lorsque l'on soupçonne qu'une perforation utérine s'est manifestée au cours de la dilatation cervicale ou dans le cadre de l'utilisation du résectoscope (sans électrochirurgie), l'intervention devrait être abandonnée et la patiente devrait faire l'objet d'une surveillance étroite de façon à ce que l'on puisse demeurer à l'affût des signes d'hémorragie intrapéritonéale ou de lésion viscérale. Lorsque la perforation se manifeste dans le cadre d'une électrochirurgie ou lorsque le mécanisme de la perforation demeure incertain, la tenue d'une exploration abdominale est justifiée pour assurer l'hémostase et écarter la présence de lésions viscérales. (III-B) 7. Dans le cas de l'AE résectoscopique, lorsque la présence d'une perforation utérine a été écartée, l'hémorragie aiguë pourrait être prise en charge au moyen d'un tamponnement intra-utérin par sonde de Foley, d'une injection intracervicale de vasopresseurs ou de l'administration de misoprostol par voie rectale. (III-B) 8. Lorsqu'une nouvelle ablation de l'endomètre est envisagée à la suite d'une intervention non résectoscopique ou résectoscopique, elle devrait être menée par un chirurgien hystéroscopique sous visualisation directe de la cavité. Les patientes devraient bénéficier de services de counseling au sujet des risques de complications qui sont associés à la tenue d'une nouvelle ablation de l'endomètre. (II-2A) 9. En présence d'une pathologie intracavitaire considérable, la tenue concomitante d'une ablation résectoscopique de l'endomètre et d'une myomectomie / polypectomie hystéroscopique devrait être envisagée. (II-3A).