Minimally invasive surgery for menorrhagia and intractable uterine bleeding: Time to set standards

Abstract

Many new techniques were developed over the last 20 years to accomplish endometrial destruction as a treatment option for women with menorrhagia and other forms of intractable uterine bleeding who wish to retain their uteri. Before they were available, women's choices were often limited to hysterectomy or difficult lifestyle adjustments. Introduction of various hysteroscopic techniques into mainstream gynecology offers women legitimate alternatives to more aggressive surgical procedures. In addition, physicians and patients will soon be able to choose among several nonhysteroscopic, or global, methods of endometrial destruction. With the plethora of techniques soon to be available, it is important for clinicians to have a valid method of comparing them. How do we decide? Is rollerball endometrial ablation more successful than transcervical resection of the endometrium? Are the results of thermal balloon therapy really equivalent to what can be achieved by an experienced hysteroscopist? To choose among these procedures it is necessary to compare some type of result--amenorrhea, patient satisfaction, or avoidance of hysterectomy. Moreover, other factors must be considered. Can the procedure be performed in an office setting, or does it require general anesthesia in an outpatient department? Measurement of complications is also important when seeking legitimate comparisons. To compare various methods of endometrial destruction, we must have a method of classifying them. All methods described thus far can be divided into two categories: those that do not provide a histologic specimen for analysis, and those that do. The former are appropriately termed ablation techniques and the latter as resection techniques. Endometrial destructive methods can also be divided into global or blind and hysteroscopic. Table 1 provides a classification and cites major publications associated with each method. M~ The future may hold many additional techniques too complex to fit into these categories; however, this seems to be a reasonable classification of existing modalities. Some practitioners developed combination procedures. For example, it is possible to combine the advantages of the neodymium:yttrium-aluminumgarnet (Nd:YAG) laser to treat the uterine fundus with the rollerball electrode to treat the remainder of the cavity, the so-called YAG-coag method of endometrial ablation. 14 A large series of 800 patients was reported, but careful analysis reveals that some patients were