Abstract


Endometrial ablation (EA) is the most commonly performed surgical procedure for the management of abnormal uterine bleeding unresponsive to medical therapy. In well-selected subjects, EA provides a safe, inexpensive, and convenient alternative to hysterectomy with a rapid return to normal function.
The first generation of EA techniques were introduced in 1886 by Professor Sneguireff of Moscow. He was the first to apply super-heated steam to the uterine cavity to vaporize the endometrial basalis. This method—known as atmocausis—was refined by Ludwig Pincus of Danzig in 1895, and he went on to perform over 800 procedures. As the 20th century brought forth other energy sources—electricity, X-ray, radium, and even cryogenics—they were each used, in turn, to accomplish endometrial ablation. In 1981, Dr. Milton Goldrath successfully performed EA by co-locating a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser with a rod-lens hysteroscope to achieve photovaporization of the endometrium. The accomplishment of EA under direct visualization defined the second generation of EA. The challenges and risks of second-generation technology, however, were soon apparent, and though this practice continues today, it appears to be confined to a relatively small number of devoted and highly-skilled sub-specialists.
The late 1990s saw increasing interest in safe, affordable, and easily-mastered EA technology. The result was a return to blind technology but modified with a variety of features that brought unprecedented safety to EA, even permitting its selected in-office application. This third generation of EA techniques and devices has propelled the growth of EA in the 21st century.
Although much has been accomplished in the quest for safe, affordable, convenient, and easily-mastered EA, the future requires refinement of patient selection criteria, management strategies for late-onset endometrial ablation failures (LOEAFs), as well as minimally invasive methods for reducing them.

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.

Abstract


Since 1993 (and prior, WISAP® [WISAP Medical Technology GmbH, Brunnthal, Germany] hand morcellators), laparoscopic power morcellation has been an indispensably employed technique for minimally invasive gynecologic surgery, contributing both to laparoscopic myomectomies and hysterectomies. However, the technique was highlighted with concern by the FDA for the given potential to disseminate neoplastic and non-neoplastic cells by morcellating an unexpected uterine sarcoma (Fig. 1). Given this concern, many gynecologists are either resorting to performing traditional laparotomies or risking dissemination with uncontained power morcellation techniques. The purpose of this article is to address these concerns by illustrating three techniques to perform contained power morcellation, thereby reaping the benefits of the technique without the disadvantage of possible dissemination of neoplastic cells. The techniques outlined in this article include the use of trans-abdominal mini-laparotomy manual contained morcellation, trans-vaginal manual contained morcellation, and the new Contained Tissue Extraction (CTE) System (Olympus America, Inc., Center Valley, Pennsylvania) for power morcellation.

Abstract


The advancement of surgical innovation for both devices and techniques has directly impacted the number of hysterectomy options available to patients. These advancements have led to an expansion of options that has been exceptionally impactful for minimally invasive surgery. For individuals who are diagnosed with a health condition or disease that requires a hysterectomy, these advances allow the surgeon to consider an expanded variety of procedures that may improve patients’ outcomes and accommodate patient preferences. Automated suturing devices, improved energy systems, specialized mini-laparoscopic tissue handling instruments, and novel uterine manipulators, among other devices, all work together to provide hysterectomy options with cosmetically pleasing results from an aesthetic perspective. They also provide excellent medical outcomes from a surgeon’s perspective. Patients are no longer subjected to large incisional scars from total abdominal hysterectomies that were commonly performed 25 years ago.
All gynecological surgeons are obligated to provide patients with improved hysterectomy options that fit the indications and clinical needs of their patients. As the laparoscopic approach to a hysterectomy became the standard of care for many, variations in technique to successfully perform a laparoscopic hysterectomy has become a major limiting factor for generalists to incorporate this skillset into their practice. Maintaining the same procedural steps as the abdominal approach is one of the major hurdles that makes the transition to a laparoscopic approach more treacherous.
Over 20 years of experience has shaped the McCarus hysterectomy technique described here into a safe and reproducible procedure that prioritizes the patient’s aesthetic preferences while also providing optimal patient outcomes. The implementation of unique devices and instruments further expands the surgeon’s technical skills and augments the procedure to make it an effective and preferable choice.

Abstract


Background: There are large variations in the use of minimally invasive surgery (MIS), and outpatient hysterectomy (OP) among Medicare patients according to hospital surgical volume and geographical distribution.
Objective: To explore the changing trend in OP and MIS hysterectomy in the United States. Study Design: We used all Medicare fee-for-service claims data for 2012 and 2014 to determine the incidence of OP and MIS hysterectomy according to hospital surgical volume and geographical distribution. MIS included both laparoscopy and robotic surgery. OP procedures included only same-day discharge hysterectomies.
Results: A total of 55,562 and 53,054 hysterectomies were performed in the years 2012 and 2014, respectively. OP rate in 2014 in high-volume centers (16,828 [47.1%]) exceeded low-volume centers (136 [16%]) by 31.1% (p<0.001). Time trends between 2014 and 2012 show that a rise in OP rate was 17.7% and 7% for high- and low-volume hospitals (p<0.001), respectively. High-volume hospitals showed an increase of 3.1% (p=0.003) in MIS hysterectomy rate in 2014 (69%) as compared to 2012 (65.9%). There was no change in MIS rate among low-volume hospitals.
Conclusion: In the Medicare population, the rate of OP and MIS hysterectomy for high-volume centers is significantly different form low-volume centers. Over the years, outpatient hysterectomy is being practiced widely but an increase in MIS rate is limited to high-volume centers.

Abstract


Study objective: Our objective was to compare intrauterine pressures during resection and aspiration modes among three types of commercially-available hysteroscopic morcellators.
Design: This was a benchtop study (Canadian Task Force level II-1). This study cannot feasibly and ethically be done in-vivo, so an ex-vivo study design was chosen.
Setting: A silicone uterine model was attached to a manometer via tubing, with the tip inside the cavity to allow for intracavity pressure measurements. Each hysteroscopic morcellator was then introduced, and intracavity pressures were recorded every one to two seconds in three modes (static, resection, and aspiration) and at three set point pressures (45, 85, and 125 mmHg).
Patients: No human subjects were involved in this study.
Interventions: None.
Measurements and main results: There were a total of 4,872 pressure measurements during this study across the three devices, over the three modes, and at the three set point pressures combined. Using mixed-effects linear regression, the mean observed intracavity pressure was not greater than the set pressure for each of the three devices. This result held true in both aspiration and resection modes. In our statistical models, the coefficient on the terms representing the interaction between device and time were not statistically significant in either resection or aspiration modes. This indicates that, statistically, the change in intracavity pressure over time was not significantly different across the three devices.
Conclusion: In this first of its kind head-to-head benchtop study, we found that all three commercially-available hysteroscopic morcellators appear to be similar to each other in terms of their abilities to maintain intracavity pressure below the set pressure, which is important in avoiding intravasation in-vivo. These findings are important because many gynecologists do not have the ability to choose between the three available devices on the market at their institution.