Endometrial ablation and steam vaporisation: the true first generation ablative technique.

Abstract

Endometrial ablative techniques have become an established method of treatment for women with menstrual disorders. The study by Sambrook et al. and the Mini Commentary by Munro comparing balloon ablation and microwave ablation (Sambrook et al., BJOG 747–53) was a timely reminder of the long history of innovation that has led to the current endometrial ablation techniques. The underlying premise, that burning or cauterising the endometrium might produce a reduction in menstrual loss, is one that appealed to clinicians even in the 19th century, and where the mortality for hysterectomy was so high, a viable alternative worth investigating. One of the leading investigators in the UK in this field was G. F. Blacker, who is described as an Obstetric Physician to the University College Hospital, London, although in possession of the FRCS as well as FRCP and MD. He wrote an extensive description of the history of the developments in the field up until that point and his experience of the procedure (Blacker, Br J Obstet Gynaecol 1902;488–511). He subsequently described the histological effects of vaporisation after 14 days in a woman undergoing the operation and subsequently having a vaginal hysterectomy for suspected malignancy (Blacker, Br J Obstet Gynaecol 1903;3:444–7). Although not the first to attempt ‘vaporisation of the uterus’, the modern revival of the procedure is credited by Blacker to Professor Senguireff of Moscow (Figure 1). His equipment and techniques were improved by Ludwig Pincus of Danzig, whose modifications Blacker employed (Figure 2). Pincus employed steam in two ways: atmocautery, which was the direct application of steam to the endometrium, and zestocautery, where the steam was used to heat a hollow intra-uterine metal tube. Modern endometrial ablation techniques could therefore be considered a form of zestocautery by this definintion. Interestingly, while considering that anaesthesia is preferable in the great majority of cases, Blacker did suggest that uterine vaporisation could be conducted without anaesthetic, and even commented that the procedure could be conducted as an outpatient procedure. This has only recently become a practical reality (Oláh et al., BJOG 2005;112;1117–20). In the description by Blacker, Pincus had the largest series of patients at the time. He collected 833 cases, of whom 749 were cured or benefitted from the procedure, with three deaths. At this time this mortality rate was about the same as that experienced for the operation of curettage. It seems suprising, therefore, that the procedure did not find a more widespread application at the time. However, there were other techniques available to clinicians willing to try them, and the new and fashionable power source, electricity, formed the basis for galvanic cauterisation (Braxton Hicks, Br Med J 1874;2:672–3). However, as the improvements in surgical technique and aseptic conditions were adopted, surgical mortality and morbidity fell rapidly at the beginning of the 20th century. The result was that most of the techniques of endometrial ablation were forgotten until the end of the 20th century, when endometrial resection rekindled an interest in this aspect of management. These early techniques of ‘steam vaporisation’, and galvanic cauterisation are the true ‘first generation’ endometrial ablation methods. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.