Transcervical Endometrial Resection Research Articles

Impact of combined endometrial resection or ablation and levonorgestrel intrauterine device on postoperative bleeding pattern.

The aim of this study was to describe the rate of amenorrhea in women treated with transcervical endometrial resection (TCER) or radiofrequency endometrial ablation combined with levonorgestrel intrauterine contraceptive device (LNG-IUD) six months post-operatively. The study was performed as a prospective cohort study. All patients were included at four gynecological centers in Region of Southern Denmark. In total, 162 women referred due to menorrhagia, metrorrhagia or menometrorrhagia and offered TCER or radiofrequency endometrial ablation in combination with or without LNG-IUD included during November 2018 to June 2021 at the women's own discretion and without any cost (covered by the hospital). Data were analyzed using a multivariate regression model. In total, 58 women were offered TCER and 31 (53.4%) combined treatment with TCER + LNG-IUD. Among 104 women who received radiofrequency endometrial ablation, 46 (44.2%) underwent combined treatment with LNG-IUD. The incidence of amenorrhea was 26% among women who underwent treatment with TCRE and 52% when treated with TCER + LNG-IUD (adjusted OR 5.16; 95% CI 1.35-19.6;P < 0.016). Radiofrequency endometrial ablation was followed by a 41% incidence of amenorrhea, and when radiofrequency endometrial ablation was combined with LNG-IUD, the incidence of amenorrhea was 63% (adjusted OR 2.15; 95% CI 0.86-5.37;P < 0.1). We observed no statistically significant differences when comparing the groups across. Our study suggests that the combination of TCER or radiofrequency endometrial ablation with LNG-IUD was superior to TCER. However, the combined treatment of radiofrequency endometrial ablation with LNG-IUD did not reach statistical significance. Further studies are needed to evaluate the effects of different ablation techniques on the amenorrhea rate.

Endometrial ablation techniques in treating menorrhagia.

Menorrhagia is a frequent gynecological problem that is clinically described as excessive blood loss of 80 mL per menstrual cycle. It has the potential to lower their quality of life and to induce anemia. Medical therapy has typically been the first line of treatment; however, it is frequently ineffectual. Hysterectomy, on the other hand, is clearly 100 percent effective in stopping bleeding, but it is more expensive and can cause serious problems. So, the endometrial ablation is preferred when the endometrial layer is destroyed or removed during the procedure. To "ablate" (remove) the endometrial lining, a variety of procedures has been devised. The gold standard resectoscopic procedures (laser, transcervical endometrial resection, and rollerball) require hysteroscopic visualization of the uterus and while safe, necessitate expert surgeons. Several innovative procedures have lately been developed, the majority of which may be conducted blindly and take less time. Many nonresectoscopic procedures are still in the process of being developed, refined, and investigated. This article discusses the various techniques and procedures used in endometrial ablation, the importance of the physician using endometrial thinning agents because success rates are higher when thinning agents are used, and the importance of women understanding the complications mainly related to pregnancy. Women should be helped to make informed management decisions by discussing the risks and benefits of each treatment with their consultant. Since there are many treatment options available, with no one option being superior in all respects, patient preference and treatment preferences should be considered when deciding on management.

Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta-analysis.

Interventions for heavy menstrual bleeding; overview of Cochrane reviews and network meta-analysis.

Long-term incidence of endometrial cancer after endometrial resection and ablation: A population based Swedish gynecologic cancer group (SweGCG) study.

Minimally invasive methods to reduce menorrhagia were introduced in the 1980s and 1990s. Transcervical endometrial resection (TCRE) and endometrial ablation (EA) are two of the most frequently used methods. As none of them can guarantee a complete removal of the endometrium, there are concerns that the remaining endometrium may develop to endometrial cancer (EC) later in life. The primary aim was to analyze the long-term incidence of EC after TCRE and EA in a nationwide population. The secondary aim was to assess the two treatment modalities separately. The Swedish National Patient Registry and National Quality Registry for Gynecological Surgery were used for identification of women who had TCRE or EA performed between 1997-2017. The cohort was followed from the first TCRE or EA until hysterectomy, diagnosis of EC, or death. Follow-up data were retrieved from the National Cancer Registry and the National Death Registry. Expected incidence for EC in Swedish women was calculated using Swedish data retrieved from the NORDCAN project after having taken into account differences of age and follow-up time. Cumulative incidence of EC after TCRE and EA, was calculated. A standardized incidence ratio was calculated based on the expected and observed incidence, stratified by age and year of diagnosis. In total, 17 296 women (mean age 45.1 years) underwent TCRE (n=8626) or EA (n=8670). Excluded were 3121 who had a hysterectomy for benign causes during follow up. During a median follow-up time of 7.1 years (interquartile range 3.1-13.3 years) the numbers of EC were 25 (0.3%) after TCRE and 2 (0.02%) after EA, respectively. The observed incidence was significantly lower than expected (population-based estimate) after EA but not after TCRE, giving a standardized incidence ratio of 0.13 (95% confidence interval [CI] 0.03-0.53) after EA and 1.27 (95% CI 0.86-1.88) after TCRE. Median times to EC were 3.0 and 8.3 years after TCRE and EA, respectively. There was a significant reduction of EC after EA, suggesting a protective effect, whereas endometrial resection showed an incidence within the expected rate.

Clinical analysis of 44 cases of atypical polypoid adenomyoma of the uterus

BackgroundAtypical polypoid adenomyoma (APA) is a rare intrauterine polypoid lesion that occurs predominantly in premenopausal women. Although APA was previously considered a benign lesion and treated conservatively, an increasing number of cases show that APA has a high rate of recurrence or residual disease and that it precedes the development of carcinoma. The clinical management of APA remains to be established. The aim of this study was to analyse the clinicopathological features of APA and discuss its diagnosis and prognosis.MethodsForty-four patients with APA were admitted to Beijing Obstetrics and Gynecology Hospital from 2005 to 2019, and their clinical and histopathologic features were evaluated. B-ultrasound was performed, and all the patients (n = 44) underwent hysteroscopy. Endometrium excision was performed by means of the four-step diagnosis and treatment method. Hysteroscopic transcervical resection (TCR) was performed in 5 patients with APA-H and 11 with APA-L. Except for one patient who underwent transcervical endometrial resection, all the patients underwent hysterectomy and salpingectomy or salpingo-oophorectomy. Data from a median follow-up of 42 months (ranging from 3 to 174 months) were available for these patients.ResultsPathological diagnosis were made according to the degree of abnormality of the APA surface glands, resulting in APA-L in 36 patients and APA-H in 8 patients. Among these patients, 28 (25 APA-L and 3 APA-H) were treated conservatively. The effect of the four-step diagnosis and treatment method as an APA therapy was excellent. During the follow-up, no evidence of recurrence was found.ConclusionsFor patients with intracavitary lesions > 1 cm, the hysteroscopic four-step diagnosis and treatment method and pathological diagnosis are the basis of clinical treatment. More than 30% of APA surface glands have complex structures characterized by branching and budding or other high-risk factors, such as endometrial hyperplasia, which are indications for hysterectomy. For patients who desire to become pregnant or to preserve the uterus, hysteroscopy with complete excision of the lesions should be the preferred treatment method. The patients should be treated and followed up closely with regular hysteroscopy and endometrial biopsy.

Combined transcervical endometrial resection and levonorgestrel device treatment compared to transcervical endometrial resection for abnormal uterine bleed.

Transcervical resection of the endometrium (TCRE) is a first-line surgical treatment of abnormal uterine bleeding. However, many women experience unsuccessful results, causing hysterectomy in up 17% of cases. The aim of this study was to describe the odds of hysterectomy in women with abnormal uterine bleeding, treated with TCRE and levonorgestrel intrauterine contraceptive device (TCRE+LNG-IUCD) or TCRE alone. The secondary aim was to analyze the rate of amenorrhea. Designed as a retrospective cohort study, and conducted at Odense University Hospital, Denmark, the study included women with abnormal uterine bleeding, who underwent TCRE from January 2013 to December 2015. The decision of treatment with respect to LNG-IUCD was at the woman's discretion. Data were collected from medical records and a self-reported retrospective bleeding-pattern questionnaire. A multivariate regression model was used, enabling adjustment for potential and identified confounders. Out of 432 women, 276 (62%) consented to inclusion and of these, 16 (4%) were excluded. In total 88 (34%) received combined treatment and 172 (66%) received TCRE alone. Ten women (11%) treated with TCRE+LNG-IUCD underwent hysterectomy, compared with 27 (16%) treated with TCRE alone (OR=0.69, 95% CI 0.28-1.56; P=.34). Multivariate analysis disclosed a significant effect of TCRE+LNG-IUCD (OR=0.35, 95% CI 0.13-0.97; P=.04) on hysterectomy. The presence of fibromas was shown to increase the odds of treatment failure, resulting in hysterectomy (OR 2.69, 95% CI 1.15-6.31; P=.02). Furthermore, the incidence of amenorrhea was 59% in the TCRE+LNG-IUCD group and 36% in the TCRE alone group (OR=2.56, 95% CI 1.46-4.49; P<.01). The study showed significantly lower odds of hysterectomy in the TCRE+LNG-IUCD group when adjusted for confounders. Combination treatment improves the bleeding patterns significantly compared with monotherapy with TCRE.

The effect of transcervical endometrial resection on clinical symptoms related to intrinsic adenomyosis and junctional zone changes

ObjectivesTo assess the effect of transcervical endometrial resection on clinical symptoms related to histopathological findings of the junctional zone.Study designThis prospective study took place at a university hospital. Premenopausal women suffering from abnormal uterine bleeding and/or pelvic pain and scheduled for transcervical endometrial resection were enrolled (n = 112). Histopathological findings of the endomyometrial biopsies were categorized as follows: Adenomyosis of the inner myometrium (intrinsic adenomyosis): ≥ 2 mm myometrial invasion without contact to the basal endometrium, serrated junctional zone: > 3 mm myometrial invasion with contact to the basal endometrium and linear junctional zone: No or marginal myometrial invasion (≤ 3 mm) with contact to the basal endometrium. All study participants received a baseline and two follow-up questionnaires (6 and 18 months after surgery) regarding symptom severity, health-related quality of life and pelvic pain. Data regarding reintervention surgery was obtained from the National Database Patoweb. The rate of reintervention surgery and the improvement in symptom severity, health-related quality of life and pelvic pain were correlated to histopathological findings.ResultsTwenty-four patients had intrinsic adenomyosis, 31 had serrated junctional zone and 57 had linear junctional zone. Fifteen patients (13%) underwent reintervention surgery; three (20%) within 6 months, nine (60%) between 6–18 months and three (20%) > 18 months after transcervical endometrial resection. Reintervention surgery was more common in women with intrinsic adenomyosis compared to women without (33% (95% CI: 16–55) vs 8% (95% CI: 3–16)) (p-value: < .05). Nine patients (38%) with intrinsic adenomyosis were asymptomatic based on low symptom severity score, high health-related quality of life and no pelvic pain at 18 months follow-up. Patients with linear junctional zone had a higher improvement in symptom severity and health-related quality of life than patients with intrinsic adenomyosis or serrated junctional zone at 6 months follow-up after surgery (p-value < .05). However, there was no significant difference in pelvic pain reduction.ConclusionThe effect of transcervical endometrial resection may depend upon the degree of junctional zone changes, and patients with intrinsic adenomyosis are more likely to undergo reintervention surgery than patients with either linear or serrated junctional zone. However, intrinsic adenomyosis may also be successfully treated with endometrial resection.

Two- and three-dimensional ultrasonographic features related to histopathology of the uterine endometrial-myometrial junctional zone.

Our aim was to correlate junctional zone thickening and irregularity (junctional zone disease) and other ultrasonographic features of adenomyosis with the histopathology of the endometrial-myometrial junctional zone. Consecutively enrolled premenopausal women (n=110) scheduled for hysterectomy or transcervical endometrial resection due to abnormal uterine bleeding and/or menstrual pain, underwent two- and three-dimensional transvaginal ultrasonography on the day of surgery with the observer blinded to previous diagnosis. Junctional zone maximum thickness (JZmax ), junctional zone maximum irregularity (JZdif ) and ultrasonographic characteristics of adenomyosis were compared with histopathology of the junctional zone defined as (1) adenomyosis of the inner myometrium, ≥2mm myometrial invasion without contact to the basal endometrium, (2) serrated junctional zone, >3mm myometrial invasion with contact to the basal endometrium or (3) linear junctional zone, no or marginal myometrial invasion ≤3mm with contact to the basal endometrium. Adenomyosis of the inner myometrium, serrated junctional zone and linear junctional zone was present in 29%, 35% and 35% of the women, respectively. Median JZmax and median JZdif expanded from linear junctional zone (8.5 and 3.3mm) to serrated junctional zone (10.1 and 4.1mm) to adenomyosis of the inner myometrium (14.6 and 9.2mm) (P<0.05). In addition, the median number of characteristic adenomyosis-like ultrasonographic features increased from the linear junctional zone to the serrated junctional zone to adenomyosis of the inner myometrium (P<0.05). A slightly thickened and/or irregular junctional zone corresponds to a histopathologically defined serrated junctional zone. This study emphasizes three distinct appearances of the junctional zone: adenomyosis of the inner myometrium, junctional zone disease (serrated junctional zone) and linear junctional zone. This classification may be useful in future clinical studies.

Hysterectomy is not associated with de-novo urinary incontinence: A ten-year cohort study

ObjectiveTo determine prevalence, incidence proportion, and changes of urinary incontinence (UI) 10–13 years after hysterectomy compared to two control groups. Study designA longitudinal cohort study of 661 women with follow-up for ten years. Originally, 866 women answered a questionnaire on continence status preoperatively. Ten years postoperatively the queries were repeated in 371 with a hysterectomy, 89 with laparoscopic cholecystectomy (LC), and 201 with transcervical endometrial resection (TCRE). Significant incontinence was UI at least once a week. The main outcome measures were prevalence and incidence proportions of UI. ResultsThe overall prevalence of stress UI ten years after surgery was 23% compared to 12% preoperatively. Urge UI was prevalent in 12% compared to 5% preoperatively. Incidence proportions of stress UI were in hysterectomies 21%, in LC 15%, and in TCRE 18%. Similarly, incidence proportions of urge UI were in hysterectomies 11%, in LC 11%, and in TCRE 8%. No significant differences between surgical procedures were found; however, we found substantial amount of changes in continence status from continent to incontinent and vice versa in all three groups. ConclusionsNo significant difference was found after hysterectomy compared to controls in the prevalence or incidence proportions of UI after 10 years follow-up. Hysterectomy is not a risk factor of UI.

Fluid absorption and the ethanol monitoring method.

Fluid absorption is a well-known complication of endoscopic surgeries, such as transurethral prostatic resection and transcervical endometrial resection. Absorption of electrolyte-free fluid in excess of 1 L, which occurs in 5% to 10% of the operations, markedly increases the risk of adverse effects from the cardiovascular and neurological systems. Absorption of isotonic saline, which is used with the new bipolar resection technique, will change the scenario of adverse effects in a yet unknown way. Hyponatremia no longer occurs, but marking the saline with ethanol reveals that fluid absorption occurs just as much as with monopolar prostate resections. Ethanol monitoring is a method for non-invasive indication and quantification of fluid absorption that has been well evaluated. By using an irrigating fluid that contains 1% of ethanol, updated information about fluid absorption can be obtained at any time perioperatively by letting the patient breathe into a hand-held alcolmeter. Regression equations and nomograms with variable complexity are available for estimating how much fluid has been absorbed, both when the alcolmeter is calibrated to show the blood ethanol level and when it is calibrated to show the breath ethanol concentration. Examples of how such estimations should be performed are given in this review article. The difficulty is that the anesthesiologist must be aware of how the alcolmeter is calibrated (for blood or breath) and be able to distinguish between the intravascular and extravascular absorption routes, which give rise to different patterns and levels of breath ethanol concentrations.

Thermal balloon ablation versus transcervical endometrial resection: evaluation of postoperative pelvic pain in women treated for dysfunctional uterine bleeding

Purpose of the study: To evaluate postoperative pain after mini-invasive surgical treatment for dysfunctional uterine bleeding (DUB) with transcervical endometrial resection or thermal ablation balloon. Materials and Methods: A longitudinal observational study, analyzing 47 women affected by DUB who underwent endometrial ablation was conducted. The authors collected evaluation of pelvic pain at one and four hours after intervention and the individual necessity of analgesics. After 30 days, all patients underwent a gynecological visit to evaluate postoperative outcome. Results: Pelvic pain was higher one and four hours after procedure in thermal balloon ablation group, and patients in the same group required more analgesic rescue dose. There were no complications such as uterine perforation, heavy blood loss or thermal injuries with both the procedures. Conclusion: Thermal balloon ablation appears a more painful procedure than endometrial resection, both in the immediate postsurgical time and 30 days after surgery. Ad hoc anaesthesiologic and analgesic protocol should be adopted to ensure quick recovery and good acceptance of the procedure.

Proposal of a modified transcervical endometrial resection (TCER) technique for menorrhagia treatment. Feasibility, efficacy, and patients’ acceptability

The aim of this study is to evaluate the feasibility, efficacy, safeness, and patients’ acceptability of a modified transcervical endometrial resection (TCER) technique for the treatment of menorrhagia. Eighty-four premenopausal women with menorrhagia after careful investigation and 2 months therapy with GnRHa underwent a modified TCER. It was performed with a standard dual channel, 26 French irrigating resectoscope (Karl Storz, GmbH, Germany) after cervix dilatation to 10 mm and sorbitol mannitol solution used as distension medium. The modified technique was based on the resection of the endometrium and of the first myometrial layers only on the anterior and posterior walls, without treating fundus and cornual areas as usually performed. Endometrial resection was performed to a depth of 4 to 5 mm. Clinical and hysteroscopic follow-up was performed for 60 months. Early and late complications, changing in bleeding patterns, and patients’ satisfaction were recorded. Sixty-four out of 73 patients that completed the 60 months improved. Eumenorrhea was achieved in 68.5 %, hypomenorrhea in 5.5 %, and amenorrhea in 13.7 %. Most of the patients (86.3 %) showed satisfaction at the follow-up interview. Control hysteroscopy showed that post modified TCER uterine cavity maintained the possibility of macroscopic and histopathology investigation during follow-up. Modified TCER is a technique easy to perform and effective in the long-term resolution of menorrhagia. In particular, it avoids the formation of synechiae and the shrinkage of the uterine cavity that may be the cause of various long-term complications, such as the delay in the diagnosis of endometrial carcinoma onset.

Does Adjuvant Long-Acting Gestagen Therapy Improve the Outcome of Hysteroscopic Endometrial Resection in Women of Low-Resource Settings with Heavy Menstrual Bleeding?

To test for the hypothesis of the beneficial effect of long-acting gestagens as an adjuvant postoperative therapy on the outcome of hysteroscopic transcervical endometrial resection (TCRE) in women of low-resource settings and suffering from ovulatory heavy menstrual bleeding (menorrhagia).

Does Adjuvant Long-Acting Gestagen Therapy Improve the Outcome of Hysteroscopic Endometrial Resection in Women of Low-Resource Settings With Heavy Menstrual Bleeding?

ObjectiveTo test for the hypothesis of the beneficial effect of long-acting gestagens as an adjuvant postoperative therapy on the outcome of hysteroscopic transcervical endometrial resection (TCRE) in women of low-resource settings and suffering from ovulatory heavy menstrual bleeding (menorrhagia). DesignRandomized controlled trial (Canadian Task Force classification I). SettingLow-resource tertiary care university hospital. PatientsSeventy-one premenopausal women with established ovulatory menorrhagia. InterventionAfter randomization, 37 patients were treated with TCRE plus gestagen and 34 patients with TCRE alone. Measurements and Main ResultsVariations in menstrual patterns and bleeding scores, as well as amenorrhea and repeat surgery rates with treatment, were determined 1 year after resection. In those who continued to menstruate at 6 months, treatment with TCRE plus gestagen was associated with a significant reduction in the number of days bleeding from 7.2 to 3.4 (p ≤ .0001), increased cycle length from 24 to 30 (p = .02), a 60% reduction in dysmenorrhea score from 62 to 25 (p ≤ .0001), and a 60% reduction in premenstrual syndrome score from 55 to 22 (p = .04). Amenorrhea rates at 12 months in the TCRE plus gestagen and TCRE alone groups were 40% versus 26% (p = .02), with combined amenorrhea and hypomenorrhea rates of 75% versus 64% (p = .02), respectively. At 12 months, repeat surgery rates were higher in the TCRE alone group (21% vs 3%, p < .05). ConclusionIn a low-resource setting, the adjuvant postoperative long-acting gestagen therapy has proven to be superior in inducing amenorrhea after hysteroscopic TCRE.

A randomized clinical trial to compare levonorgestrel-releasing intrauterine system (Mirena) vs trans-cervical endometrial resection for treatment of menorrhagia.

Objective:To compare the acceptability, efficacy, adverse effects, and user satisfaction of the levonorgestrel intrauterine system (LNG-IUS) and trans-cervical resection of the endometrium (TCRE) for the treatment of menorrhagia.Method:104 women with menorrhagia were divided into 2 groups: 52 women had the LNG-IUS inserted and 52 underwent TCRE. Menstrual pattern, pictorial blood loss assessment chart score, adverse effects, and rates of acceptability and satisfaction, were recorded at 6 and 12 months after the procedure.Results:After a year there were reductions of 93.9% and 88.4% in menstrual blood loss in the TCRE and LNG-IUS groups, respectively. Amenorrhea was more common in the TCRE group and spotting and systemic effects in the LNG-IUS group. Satisfaction rates of the TCRE group were higher than the LNG-IUS group (80.8% vs 69.2%), but the difference was not statistically significant.Conclusion:Although both treatments were found to be equally effective, LNG-IUS was less invasive and can be advised for younger women with a desire to preserve fertility.

An RCT: Use of Oxytocin Drip during Hysteroscopic Endometrial Resection and Its Effect on Operative Blood Loss and Glycine Deficit

Objective To estimate the influence of oxytocin infusion on operative blood loss and glycine deficit during hysteroscopic transcervical endometrial resection (TCRE) for abnormal uterine bleeding (AUB). Design Prospective, randomized, placebo-controlled study (Canadian Task Force classification I). Setting Tertiary Care University Hospital. Patients Forty-eight women with abnormal uterine bleeding that was unresponsive to conservative medical management were randomly assigned to undergo hysteroscopic TCRE with either oxytocin infusion (group A) or saline (group B). Intravenous Ringer’s lactate solution was used during surgery. Interventions TCRE was carried out with glycine 1.5% mixed with 2% ethanol as a distension medium. For group A: one ampoule of oxytocin (10 U/mL/amp) was added to 500 mL Ringer’s lactate solution running at a rate of 400 mU/min during surgery. In group B, one ampoule of saline solution was added to the Ringer’s solution and run at a similar rate. The amount of distension medium used, fluid deficit, blood levels of albumin and ethanol, hematocrit, hemoglobin, changes in serum sodium levels (Na+), and central venous pressure were compared between the groups. Measurements and main results The mean volume of distension fluid used and operating time were not significantly different in both groups (4.18 ± 0.2 vs 4.5 ± 0.5 L, and 28.3 ± 4.2 vs 27.5 ± 5.4 min, respectively). Although operating time, volume of distension fluid used, decrease in albumin level and hematocrit were less in the oxytocin than in the saline group, the differences were not statistically significant. The ethanol levels in blood, decrease in serum Na+, and glycine deficit were significantly lower in the oxytocin than in the saline group (17.4 ± 3.8 vs 25.3 ± 4.2 mg/ml, 6.7 ± 1.2 vs 9.1 ± 0.9 mEq/L, and 0.49 ± 0.08 vs 0.66 ± 0.05 L, respectively; p <.05). There was no significant difference in mean total uterine size, endometrial thickness, weight of resected tissue, and other demographic data between the study groups. Conclusions Oxytocin infusion combined with skillful surgical techniques may prevent fluid overload and glycine deficit during hysteroscopic TCRE for abnormal uterine bleeding. Although there is a trend toward a decrease in operative blood loss, further randomized trials are required to confirm this finding.

Comparison of the long‐term effects of simple total abdominal hysterectomy with transcervical endometrial resection on urinary incontinence

To test the hypothesis that the hospital referral rate for urinary incontinence (UI) symptoms, within 10 years of a simple total abdominal hysterectomy (TAH) for dysfunctional uterine bleeding (DUB), would differ to that after a transcervical resection of the endometrium (TCRE). Retrospective case note review. Teaching hospital in north east Scotland. All women who had a TAH (316) or a TCRE (229) for DUB, during the period from 1 January 1990 to 31 December 1994, who had never been referred for symptoms of UI prior to their operation. Independent t tests, Mann-Whitney U tests and Chi-squared tests were used to compare the two study groups in terms of demographic details and outcome measures. Newcombe's method for the comparison of two unpaired proportions was used to calculate 95% CIs for the differences in outcome measures between the two operations. Logistic regression was conducted to investigate associations with hospital referral for UI. Hospital referral for UI at 10 years follow up. There were significantly more hospital referrals for UI in the TAH group compared with the TCRE group (46 [15%] versus 16 [7%]; OR 2.27, 95% CI 1.25-4.12). More women were referred for urological investigations after a TAH than after a TCRE (39 [12%] versus 13 [6%], 95% CI for the difference in proportions 2-11%). A higher, but statistically nonsignificant, proportion of women had objectively demonstrated UI after a TAH than after a TCRE (25 [8%] versus 10 [4%], 95% CI for the difference in proportions -1 to 8%). There were a greater number of hospital referrals for treatment of UI in the TAH group (36, 11%) than in the TCRE group (12, 5%), 95% CI for the difference in proportions (1-11%). After adjusting for age, weight, smoking status and mode of delivery, the increased rate of hospital referral for UI after TAH remained, with an odds ratio of 2.31, 95% CI 1.24-4.30. TAH is associated with a significantly increased incidence of hospital referral for UI, urological investigations and treatment for UI at 10 years of follow up compared with TCRE.

Influence of Body Mass Index on hysterectomy rates after endometrial resection

The influence of age on hysterectomy rates after transcervical endometrial resection (TCER) is well known (1). Other suggested, but inconsistently shown, risk factors are uterine size and the presence of leiomyomas (2). The influence of the Body Mass Index (BMI) on hysterectomy rates after TCER is unknown. The purpose of the present study was to investigate whether BMI was related to the frequency of hysterectomy after endometrial resection. From 1990 to 1996, a total of 367 women had a TCER procedure at the Department of Gynecology, Holstebro Hospital, Denmark. Women having a repeat TCER were only included with their first TCER. The criteria for TCER were at that time subjectively experienced meno-metrorrhagia, a uterine length <12 cm, and only minor submucous leiomyoma (maximum diameter 3–4 cm) with more than half of the mass projecting into the uterine cavity. No account was taken of the women's BMI status. GnRH-agonists were not used. Resection was carried out using a standard 9-mm resectoscope with glycine as distension medium. As part of another investigation on urological symptoms (3), all patient records were reviewed in 2005 using the central computerized patient registration system in Denmark, to clarify whether the women had a later hysterectomy. Statistical analysis was carried out with the SOLO software (BMPD, Los Angeles, USA). The Mann–Whitney test for unpaired analysis was used to test differences between two means, and the Kruskal–Wallis test for group means. Regression analysis was carried out with hysterectomy as the dependent variable, and BMI, age and operative data (uterine length, haemoglobin, glycin deficit, operative time, weight of the resected endometrium) as independent variables. Analysis of time until hysterectomy was by the Kaplan–Meier method. Potential variables affecting the outcome were compared using the Peto–Wilcoxon test after appropriate patient data grouping. Patient data investigated were BMI, age, cyclicity, parity, previous vaginal delivery, cesarean section, tubal sterilisation, preoperative knowledge of leiomyomas or adenomyosis, and histopathological endometrial phase. Values are given as medians with range, unless otherwise stated. A two-sided p-value <0.05 was considered significant. Patient characteristics and perioperative data are shown in Table I. A total of 96 women (26%) underwent hysterectomy after TCER. The association between BMI and hysterectomy rate is shown in Figure 1. Obese women had a significantly lower risk of hysterectomy than normal and overweight women. Obese women had a median age of 47 years (31–73) compared to 44 years (30–66) in the normal weight group (p<0.05). No other patient characteristics differed between obese and non-obese women. The cumulative hysterectomy rates for all women and different BMI groups after TCER. Rhomboids: BMI <25 kg/m2; squares: 25 kg/m2<BMI < 30 kg/m2; triangles broken: All BMI-classes; Triangles, full line: 30 kg/m2<BMI. Hysterectomy is the ultimate marker of treatment failure after TCER with a long-term prevalence of approximately 25%, as found in this study (2), (4). Age is the most important factor modifying this prevalence, given a normal-sized or only slightly enlarged uterus, with no or only minor submucous leiomyomas (1). In obese women, TCER is the primary surgical treatment of menorrhagia, since a high BMI is regarded by some, but not all investigators, as a risk factor for complications during or after major surgery (5). Theoretically, a higher estrogen level in obese postmenopausal women might contribute to long-term treatment failure after TCER. The increasing prevalence of obesity in the general population (6) makes it necessary to estimate subsequent hysterectomy rates in relation to the BMI. We found that, contrary to expectation, the risk was decreased in obese women after TCER, with a hysterectomy rate at the level described by others (4). Two factors may confound our results. First, reluctance to perform a hysterectomy in obese women may be present with individual gynaecologists, even though there are no specific guidelines for TCER or hysterectomy in relation to BMI. Secondly, obese women were slightly older than normal-weight women, which beforehand relates to a lower failure rate after TCER. These biases cannot, however, change the conclusion that a high BMI does not lead to a higher hysterectomy rate after TCER. Endometrial resection is an excellent first-line treatment of meno-metrorrhagia in obese women.

Hysterectomy Is Associated with Stress Incontinence in Women Who Previously Had a Transcervical Endometrial Resection

Objectives: To compare the prevalence of urological symptoms in a population of women, who had a transcervical endometrial resection (TCER) only, and a population of women, who had a TCER and a subsequent hysterectomy. The superior goal was to evaluate the possible association between hysterectomy and urinary incontinence. Design: All women, who had a TCER at our department during the period of 1990–1996 received a questionnaire with focus on urological symptoms. The answers from women, who later had a hysterectomy were compared to the answers from women, who were sufficiently treated with TCER only. Results: Of 356 women, who were alive, 16 were lost to follow-up, leaving 340 women to receive the questionnaire, which was returned by 310 women (85%). Ninety-three (31%) had a subsequent hysterectomy mainly indicated by metrorrhagia or dysmenorrhea. Of the hysterectomized women 24% reported bothersome stress incontinence against 14% in the group of women, who had TCER only (p = 0.03). No significant difference was seen with respect to urge incontinence, urgency, pollakisuria or nocturia. Significantly more women with a normal sized uterus reported bothersome stress incontinence after the hysterectomy compared to women with a slightly enlarged uterus. Conclusion:Hysterectomy is significantly associated with stress urinary incontinence in women, who previously had a TCER.

Levonorgestrel-releasing intrauterine system vs. transcervical endometrial resection for dysfunctional uterine bleeding

Objective To compare the acceptability, efficacy, adverse effects, and user satisfaction of a levonorgestrel intrauterine system (LNG-IUS) and transcervical resection of the endometrium (TCRE) for the treatment of dysfunctional uterine bleeding. Method Of 50 women with a pictoral blood loss assessment chart (PBAC) score of 100 or greater, 25 had a LNG-IUS inserted (Mirena; Schering, Berlin, Germany) and 25 underwent TCRE. Procedure-related complications, PBAC score, hemoglobin levels, adverse effects, and rates of acceptability and satisfaction were recorded at 3-month intervals for a period of 12 months. Results At the end of 1 year there were a 97% and a 94% reduction in menstrual blood loss in the LNG-IUS and TCRE groups, respectively, and hemoglobin concentration had increased by 5.5% in the LNG-IUS group and 5.2% in the TCRE group. Adverse effects were similar in both groups except for systemic effects, which were seen only in the LNG-IUS group. Satisfaction rates were about 80% in the 2 groups. Conclusion Both treatments were found to be equally effective but LNG-IUS placement requires less operator skill and entails no operative hazards, and the device provides effective contraception.