Minimum Access Techniques for D.U.B

By Dr. Sushma Chawla 9, Lajpat Nagar, Link Road, Jalandhar. MD.(PGI) Chawla Nursing Home & Maternity Hospital. 9, Lajpat Nagar, Link Road, Jalandhar.

TREATMENT OPTIONS FOR D.U.B ONLY OPTION FOR MENORRHAGIA EARLIER WAS DILATION & CURETTAGE OR HYSTERECTOMY. FOR GYNAECOLOGIST THE HYSTERECTOMY IS THE OPERATIVE PROCEDURE DEMANDING THE HIGHEST STANDARD OF SKILL AND REPRESENTS THE PINACLE OF HIS SURGICAL DEXTERITY . FOR THE PATIENT, THE OPERATION SYMBOLIZES THE DISINTEGRATION OF HER WOMANHOOD.

HYSTERECTOMY CREATES IATROGENIC PSYCHOREACTIVE PROBLEMS. DISTURBANCES OF BLADDER & RECTUM FUNCTION. REDUCED SEXUAL FEELING IN VAGINA BECAUSE OF EXCISION OF PARAVAGINAL AND PARACERVICAL NETWORK OF NERVES AND LIGATION OF UTERINE ARTERY.

A BOON FOR FEMINITY WITH ADVANCEMENT IN TECHNOLOGY, MINIMALLY INVASIVE TECHNIQUES HAS EMERGED AS A BOON WITH 2 FOLD BENEFITS. GET RID OF EXCESSIVE BLEEDING. UTERUS & OVARIES REMAIN INTACT TO MAINTAIN FEMINITY. UNFORTUNATELY, MANY YOUNG WOMEN UNDERGO SURGERY IN THE FORM OF HYSTERECTOMY

WHY NOT MINIMUM INVASIVE TECHNIQUE ? LACK OF EXPERTISE AT THE CENTRE FOR MIS. LACK OF FACILITIES INADEQUATE COUNSELLING BY DOCTORS MISGUIDANCE BY QUACKS AND FAMILY MEMBERS REPEATED VISITS TO CLINICS LACK OF KNOWLEDGE,TRANSPORT IN UNDERDEVELOPED RURAL AREAS

TREATMENT AVAILABLE FOR D.U.B TECHNIQUE METHOD D & C HYSTEROSCOPIC TECHNIQUES ENDOMETRIAL ABLATION ND: YAG LASER ELECTROSURGICAL BALL CRYO ABLATION ENDOMETRIAL RESECTION TCRE ENDOMETRIAL VAPORISATION NON HYSTEROSCOPIC OR GLOBAL TECHNIQUE THERMAL BALLOON VESTA SYSTEM HYDROTHERMAL ABLATION LAPAROSCOPIC HYSTERECTOMY LAVH, TLH, LSH

WITH EXPLOSION OF INFORMATION WOMEN ARE ASKING “WHY THEIR UTERUS IS BEING REMOVED?” HYSTERECTOMY is perhaps the EXCESSIVE SURGERY for MENORRHAGIA where ONLY ENDOMETRIUM is the culprit and not the UTERUS. VARIOUS METHODS OF ENDOMETRIAL DESTRUCTION CAN BE DIVIDED INTO 2 CATEGORIES:

ABLATION TECHNIQUE RESECTION TECHNIQUE THOSE DO NOT PROVIDE HISTOLOGICAL SPECIMEN FOR ANALYSIS. RESECTION TECHNIQUE THAT PROVIDES HISTOLOGICAL SPECIMEN FOR ANALYSIS. ENDOMETRIAL ABLATION HYSTEROSCOPIC NON – HYSTEROSCOPIC (GLOBEL TECHNIQUE )

Hysteroscopic Methods include: LASER ENDOMETRIAL ABLATION/N.D YAG LASER, ARGON, KTP & CO2 LASER (EXPENSIVE, WITH HAZARDS). ELECTRO SURGERY FOR ABLATION (ROLLER BALL). ENDOMETRIAL ELECTROSURGICAL RESECTION (TCRE) ENDOMETRIAL ELECTROSURGICAL VAPORIZATION & ELECTRO COAGULATION (VERSAPOINT).

Non-Hysteroscopic (Global Methods) Include: BALLOON ABLATION CAVATERM THERMAL BALLOON ABLATION RADIO FREQUENCY PROBE UNIPOLAR ELECTRODES BIPOLAR ELECTRODES MICROWAVE ENDOMETRIAL ABLATION (MEA). HYDROTHERMAL ABLATION (HTA) MICROSULIS. DIODE LASER PHOTODYNAMIC THERAPY. PHOTODYNAMIC THERAPY CRYO SURGERY

BOTH THE PROCEDURES ARE USED TO TREAT MENORRHAGIA Uterine Balloon Therapy Resection of Endometrium OR BOTH THE PROCEDURES ARE USED TO TREAT MENORRHAGIA BOTH TECHNIQUES ARE QUICK AND LESS TIME CONSUMING WITH SHORT ANAESTHESIA. PROCEDURAL RISKS ARE MINIMIZED WITH UBT WHEN USED IN PATIENTS WITH SEVERE MEDICAL DISORDERS HYSTERECTOMY CAN BE AVOIDED WITH HYSTEROSCOPIC ABLATIVE TECHNIQUES TCRE PROVIDES ENDOMETRIUM SAMPLING FOR HISTOPATHOLOGY WHEREAS UBT DOES NOT VISUAL TECHNIQUES (TCRE) ARE SUPERIOR TO NON- VISUAL TECHNIQUES (UBT) BUT IT NEEDS SKILL AND TRAINING

TRANSCERVICAL RESECTION OF THE ENDOMETRIUM

SELECTION CRITERIA FOR TCRE ABNORMAL OR EXCESSIVE MENSTRUAL BLEEDING JUSTIFYING HYSTERECTOMY. NO RELIEF FROM MEDICAL THERAPY OR MEDICAL TREATMENT NOT TOLERATED OR REJECTED BENIGN ENDOMETRIAL HISTOLOGY AND PAP SMEAR. UTERINE SIZE NOT MORE THAN THE EQUIVALENT OF 10WEEKS PREGNANCY OR UTERINE CAVITY<10 to 12CM. SUB MUCOUS FIBROID OF <6 CM IN SIZE. COMPLETED FAMILY. A THOROUGH COUNSELING IS DONE INFORMED CONSENT FOR RESULT, COMPLICATION & RISK OF PREGNANCY AND UNCERTAINTY OF LONG TERM EFFECT IS TAKEN.

ANAESTHESIA SEDATION. LOCAL ANAESTHESIA WITH OR WITHOUT VASOCONSTRICTING AGENTS. SPINAL OR EPIDURAL ANAESTHESIA: - AS IT GIVES LESS BLEEDING, PATIENT REMAINS CONSCIOUS AND CAN REPORT OF FLUID OVERLOAD. SHORT GENERAL ANAESTHESIA.

INSTRUMENTS FOR TCRE RESECTOSCOPE WITH CUTTING LOOP OR ROLLER BALL. HYSTEROSCOPE. HYSTEROMAT. LIGHT SOURCE CAMERA. TV & VIDEO. ELECTROCAUTERY UNIT.

FLUID USED I) 1 .5% GLYCINE. II) SALINE.

TECHNIQUE & SURGICAL STEPS AFTER FULL INVESTIGATIONS, MEDICAL EVALUATION, COUNSELLING AND WITH INFORMED CONSENT, IN EXCELLENT O.T. SETTING, TCRE IS PERFORMED. STEP 1:- UTERINE CAVITY IS VISUALIZED WITH HYSTEROSCOPE. STEP 2:- DIRECT BIOPSY IS TAKEN. STEP 3:- ANY FIBROID, SEPTUM/ADHESIONS, POLYP ARE REMOVED AND ADHESIONS ARE RESECTED. STEP 4:- CUTTING LOOP RESECTS THE ENDOMETRIUM POSTERIORLY, LATERALLY AND THEN ANTERIORLY. STEP 5:- FUNDUS AND CORNUA ARE ABLATED WITH ROLLER BALL. STEP 6:-BLEEDING POINTS ARE CAUTERIZED WITH ROLLER BALL.

Advantages ENDOMETRIAL SAMPLING FOR H.P.E UNDER VISION LOW RISK OF ENDOMETRIAL HYPERPLASIA OR CARCINOMA. PRIOR D & C REDUCES NEED OF PREOPERATIVE HORMONAL PREPARATION OF ENDOMETRIUM. SUPERFICIAL RESECTION OF MYOMETRIUM REDUCES FAILURE RATES WHEN ADENOMYOSIS IS PRESENT. RESECTION OF SUB MUCUS POLYP, SEPTUM, ADHESIONS AND MYOMA CAN BE DONE AT THE SAME SITTING.

Disadvantages REQUIRES GREATER HYSTEROSCOPY SKILL AND EXTENSIVE UNDERSTANDING OF UTERINE ANATOMY.

INTRAOPERATIVE COMPLICATION UTERINE PERFORATION, CERVICAL TRAUMA. INTRA PERITONEAL HEMORRHAGE. THERMAL INJURY TO ADJACENT STRUCTURES. INTRA OPERATIVE HEMORRHAGE. FLUID OVERLOAD HYPONATREMIA, HYPOOSMOLARITY & BRAIN OEDEMA EMBOLISM.

SHORT TERM INFECTION HAEMATOMETRA SECONDARY HAEMORRHAGE CYCLICAL PAIN TREATMENT FAILURE

LONG TERM RECURRENCE OF SYMPTOMS. PREGNANCY. CANCER.

STEPS TO AVOID COMPLICATIONS OF TCRE:- PREOPERATIVE GnRH ANALOGS, PROGESTERONE. INJECTION OF INTRACERVICAL VASOPRESSIN. USE LEAST PRESSURE TO MAINTAIN UTERINE DISTENSION BELOW MEAN ARTERIAL PRESSURE OF PATIENT. STRICT ADHERENCE TO A PROTOCOL FOR MEASUREMENT OF SYSTEMIC ABSORPTION. CONTINUOUS MONITORING OF DISTENSION MEDIA USED ACCURATE MEASUREMENT BY USING CLOSED SYSTEM FROM 3 SOURCES OUT FLOW CHANNEL, PERINEAL COLLECTION DRAPE, FLOOR SUCTION MAT. I/V FUROSEMIDE (10-40MG) IF DEFICIT REACHES 750-1000ML SERUM ELECTROLYTES SHOULD BE MEASURED TERMINATE THE PROCEDURE IF DEFICIT REACHES 1500-2000 OR SERUM SODIUM FALLS BELOW 125MEQ/L.

FASTER, SAFER, LESS COSTLY. LESS FLUID ABSORBED. COMPARISON OF LASER ABLATION AND TCRE TCRE FASTER, SAFER, LESS COSTLY. LESS FLUID ABSORBED. HIGHER SATISFACTION RATE. ADEQUATE TISSUE AVAILABLE FOR HPE.

Hysteroscopic TCRE – Comparative Results with Different Studies Author Cases Amenorrhea improvement Not improvement Repeat TCRE Mather & Hill (1990) 100 21% 95% 3% 3% 0% Magos et al (1991) 250 27-42% 92% 8% 7% 4% Pyper & Haeri (1991) 80 6-8% 81% 19% 19% 5%

CONCLUSION 10YRS OF EVIDENCE BASED STUDIES AND REVIEWS REVEAL THAT: TCRE IS AN EXCELLENT SUCCESSFUL TREATMENT AND A GENUINE ALTERNATIVE TO HYSTERECTOMY. VISUAL TECHNIQUES ARE DEFINITELY SUPERIOR TO NON VISUAL TECHNIQUES OF ABLATION SUCCESS RATE REPORTED AS 79 – 95% IT SHOULD BE OFFERED TO WOMEN WISHING SURGICAL TREATMENT.

WHY TCRE WAS NOT WIDELY ACCEPTED Extreme enthusiasm, thought hysterectomy was a thing of the past Untrained people started trying Found it difficult to perform. Had unexpected major complication. Did not find good results claimed by proponent because training programme were not available Gynecologist could not train themselves to the same level Long term results were not yet available. Patients expectations were too high.

Publication of first randomized trial comparing TCRE to hysterectomy gave credibility to the procedure & substantiated their use evaluation & development. 1st evidence based guidelines on endometrial ablation published & recommended that it is good alternative for hysterectomy and should be offered to all patients of DUB.

There is ongoing search for newer easier (global devices) techniques of endometrial ablation as classical as Hystroscopic method of ablation. Easier to perform With less skill & training With local anaesthesia

Novasure System Three dimensional Fan shaped expandable Bipolar device Porus metallic membrane draped around metallic skeleton Power used 180w Treatment time (3min) Depth of destruction 4-4.5mm in uterine corpus, at corneal region 2.2 – 2.9 mm Satisfaction rate 83%.

Cavaterm thermal balloon Ablation:- Introduced in 1996 Silicon balloon catheter attached with central unit. 1.5% glycine fills the balloon fluid heated for 15 minutes 1-3yrs followup showed 70% amenorrhea or minimum bleeding. Cavaterm Procedure & novasure procedure were found to be safe & effective.

Vasta D.U.B Treatment System 3minutes procedure Ablates 2-4mm with endometrium Multi Electrode balloon with handset Valleylab electro surgical generator Silicone inflatable electrode carrier has a triangular shape which unfurl when outer sheath is withdrawn There are 6 ventral and 6 electrode plates on the surface Cornual plate has fixed temperature of 72 C and other at 75 C 8-12ml air inflates the balloon 88% satisfaction o o

UTERINE BALLOON THERAPY (UBT) INDICATION YOUNG WOMEN WITH UTERUS OF NORMAL SIZE AND HEAVY BLEEDING. COMPLETED CHILD BEARING. PATIENT NOT KEEN FOR HYSTERECTOMY OR NOT FIT FOR MAJOR SURGERY BECAUSE OF MEDICAL DISORDERS. NOT A STERILIZATION PROCEDURE. ONLY ONE THERAPY CYCLE to BE PERFORMED IN A GIVEN TREATMENT CYCLE. CAN BE OFFERED TO MENTALLY DISABLED, BED RIDDEN, PARALYSIS, MEDICALLY UNFIT LIKE TOO OBESE, HYPERTENSIVE, DIABETES, RENAL FAILURE, TERMINAL CANCER PATIENT

CONTRAINDICATIONS PREGNANCY DESIRED. HISTORY OF LATEX ALLERGY. SUSPECTED ENDOMETRIAL CANCER. EXISTENCE OF WEAK MYOMETRIUM (C.S MYOMECTOMY). ACTIVE GENITAL OR URINARY TRACT INFECTION. IUCD.

PATIENT COUNSELLING PHYSICIAN NEEDS TO DISCUSS RISKS, BENEFITS & ALTERNATIVES PRIOR TO PROCEDURE. PATIENTS WITH CHILDBEARING CAPACITY SHOULD BE PROVIDED AN APPROPRIATE BIRTH CONTROL METHOD & SHOULD BE CAUTIONED OF THE COMPLICATIONS OF PREGNANCY. VAGINAL DISCHARGE IS EXPERIENCED DURING FIRST FEW DAYS.IT SHOULD ALSO BE EXPLAINED.

PRETREATMENT PREPARATION OF PATIENT THE LINING OF THE UTERUS SHOULD BE THINNED BY TIMING THE MENSTRUAL CYCLE TO THE EARLY PROLIFERATIVE PHASE WITH DRUGS OR CURETTAGE PRIOR TO PROCEDURE. A NON-STEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) BE GIVEN AT LEAST ONE HOUR PRIOR TO TREATMENT.

PROCEDURE THE PROCEDURE CAN BE DONE UNDER LOCAL ANAESTHESIA Or SEDATION. AS THERE IS NO NECESSITY OF CERVICAL DILATION PRIOR TO INSERTION OF THE CATHETER, SHORT GENERAL ANAESTHESIA CAN BE USED IN APPREHENSIVE PATIENT. STEP 1 AN INITIAL PV EXAMINATION REVEALS THE SIZE OF THE UTERUS AND RULES OUT OTHER PATHOLOGIES. STEP 2 A SUCTION CURETTAGE IS DONE TO THIN THE ENDOMETRIUM PRIOR TO THE PROCEDURE.

STEP 3 AFTER HOLDING THE CERVIX WITH AN ALLIS FORCEPS, THE CATHETER IS PRIMED & INSERTED UPTO THE FUNDUS. STEP 4 STERILE 5 PERCENT DEXTROSE WATER IS INJECTED INTO THE BALLOON SLOWLY UNTIL THE INTRAUTERINE PRESSURE STABILIZES BETWEEN 160 AND 180 MMHG. STEP 5 ENDOMETRIAL TISSUE IS THERMALLY ABLATED BY MAINTAINING TEMPERATURE 87 DEGREE CELCIUS FOR 8 MINUTES. STEP 6 FLUID IS DRAWN OUT AND THE DEFLATED CATHETER IS WITHDRAWN.FOR SAFETY, THE MACHINE AUTOMATICALLY SWITCHES OFF IF THE PRESSURE OR TEMPERATURE FLUCTUATES OR IS ABOVE PRESET VALUES.

DEVICE OF UBT

POST OPERATIVE CARE & FOLLOW UP CRAMPING / PELVIC PAIN – RANGES FROM MILD TO SEVERE. NAUSEA & VOMITING. VAGINAL DISCHARGE – MAY BE WATERY FOR 2 – 3 WEEKS. SEXUAL INTERCOURSE TO BE AVOIDED. REGULAR PAP SMEAR TO BE CONTINUED.

COMPLICATIONS UTERINE PERFORATION. THERMAL INJURY TO ADJACENT STRUCTURES. FALSE PASSAGE CAN OCCUR. HAEMATOMETRA. ENDOMETRITIS. PREGNANCY.

RESULTS 76% EUMENORRHOEA OR HYPOMENORRHOEA SUCCESS DEPENDS ON. – AGE OF PATIENT. – DURATION OF MENORRHAGIA. – THICKNESS OF ENDOMETRIUM. IF MORE THAN 4MM, THEN PREOPERATIVE MEDICAL PREPARATION SHOULD BE DONE.

CONCLUSION UBT IS AN EFFECTIVE METHOD AND CAN REDUCE HYSTERECTOMY RATE THUS REDUCING MORBIDITY IN WOMEN. WOMEN OF TODAY DISTRESSED WITH DUB IS LOOKING FOR MINIMUM INVASIVE TECHNIQUE WHICH CAN IMPROVE QUALITY OF LIFE WITH MINIMUM TIME, STAY, ANAESTHESIA, COMPLICATION & MINIMUM EXPENDITURE .

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