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Paul Indman, MD: I am Dr. Paul Indman. I am at the Las Vegas meeting of the AAGL and I am very fortunate to have with me one of the pioneers in hysteroscopic and resectoscopic surgery, as well as other endoscopic surgery, Dr. Bruno van Herendael, from Belgium and also who is a Professor of Endoscopy in Italy. One of the questions I would like to ask you: here at the AAGL, we have seen four or five, if not more, different devices for doing endometrial ablation and I hear people saying the resectoscope is dead. Do you think the resectoscope, or hysteroscopy, for that matter, is dead?
Bruno van Herendael, MD: I am generally not of that opinion because whatever so-called global ablation technique that you use over time, you still have to have a diagnosis before you start to ablate endometrium, because what we found in our series when we did resections was two very early endometrial carcinomas that had not been detected, even by us when we did our hysteroscopy. In that respect, I think, even in a global endometrial ablation, you should even if you intend to ablate all the endometrium, it could be that some of the patients do not really benefit. That is one thing, and with the new techniques, you need actually a completely normal cavity, except maybe for the hydro technique where you put hot water into the uterus and where you can treat endometrium over selected small myomas and when the cavity is not completely normal, it gets very difficult to actually ablate all of the endometrium and you will have recurrences of abnormal uterine bleeding because that is the complaint of the patients most of the time and menorrhagia, of course.
But the thing is I am convinced that hysteroscopy, especially ambulatory hysteroscopy, has its place to make a good diagnosis. From there, maybe select your cases. Another problem that we saw when we used the first generation of balloons and we tried to do it in outpatient, the patients at the moment of the actual burning or “cooking” of the endometrium, do not have so many problems, but about three to four hours later, they have very specific reactions, like pain and some cramps, and that is when they have already left the office, so that is something people should have in mind when they use these techniques. When we scoped them three to four weeks later, what we saw was that the cornual part of the uterus, the end of the tube, in most cases was not as done as was the rest and that endometrium that remained, so our problem in the beginning was definitely that we had a lot of patients with remaining endometrium having some small menstruation and then having a uterus full of blood after six to eight months. In three of the first twenty patients it happened that way.
There are now new techniques that are better, that do not need a distention of the cavity, like the ones using bipolar energy, that actually aspirate the cavity over the bipolar device and so they tend to go farther into the cornua and be better but, again, you need a very smooth cavity without any obstacles, polyps or myomas.
Paul Indman, MD: What percentage of women with abnormal bleeding, heavy enough to require a surgical approach, do you find have a normal cavity? Are most of them normal and suitable for the devices, or are most of them abnormal?
Bruno van Herendael, MD: If we look to the data and literature, what we know is that 18% to 20% of the patients have an anatomical abnormality, so that is one-fifth of the patients have myomas or polyps meaning one in five have myomas or polyps or small septa so they are not very suitable. But what people tend to forget is that, in most patients where the uterus is larger than, let’s say, the cavity is larger than five to six centimeters, again, there is a bit of a problem for the conventional global ablation technique. Maybe not, again, for the rinsing of the cavity with hot water, but all the rest of the techniques are limited in size so I think that if you look at it that way, I think that two in five or three in five patients maybe are not so suitable for the global endometrial ablation. There is a lot of indication that remains for classical resectoscopy, in my opinion.
Paul Indman, MD: Actually, I find the same thing. Two-thirds of my patients in need of ablations have abnormalities of the cavity. The other thing I have been seeing is that some gynecologists, who really do not know hysteroscopy, will do a hysteroscopy before an intended endometrial ablation, find intra-cavitary pathology and abandon the procedure. So I think it really stinks that doing office hysteroscopy, which is as basic as an ear, nose and throat doctor looking in an ear, they will not take you down to the operating room to look in your ear. I think that, similarly, we need to be looking into the uterus in an office setting if we are going to call ourselves a specialist on gynecology. That is my soap box. But getting back to selecting candidates, now one of the major causes of failure of ablation is adenomyosis. Is there anything we can do to diagnose this before we take someone in for an ablation?
Bruno van Herendael, MD: Again, that is the main option I know people or centers where they have selective criteria where a patient that has dysmenorrhea, so pain when they have their menstruation, are not suitable for either technique, be it resection or global ablation, because they are supposed to have adenomyosis. Now adenomyosis in ambulatory hysteroscopy is very difficult to diagnose except if it is a very large adenomyosis so you see a really big cript coming out of the myometrium in the beginning of the cycle, but I think the most or the best technique to diagnose is transvaginal ultrasound, where you have an idea of what the muscle of the myometrium looks like. That is what we do to select the patients. If they really have suspicion of adenomyosis, we tend to be rather, let’s say, aggressive. We would rather talk them into hysterectomy rather than do an ablation because we know the failure rate is so high and runs up to between 60% and 80%, so that is a problem with adenomyosis.
Paul Indman, MD: I think that is excellent advice because selection of your patients is one of the biggest factors in determining who is going to have a successful endometrial ablation. Any other tips you want to give the surgeons who are watching?
Bruno van Herendael, MD: I think that the thing you need to know is that you need experience for endometrial resection. I think that is important, but I think that should be in the curriculum of every surgeon to really have some experience and some teaching in hysteroscopy. Then where we talk about global ablation techniques, it is not so that it can be done by anybody, you really have to select your patients and every single problem in the cavity, be it in the muscle like adenomyosis or in the cavity itself, the volume of the cavity or the anatomical problems like myomas and polyps that you can find that are really contraindications for any of the techniques and, maybe, in these cases, better for the patient over 35 to have a hysterectomy rather than anything else.
Paul Indman, MD: Thank you. It is truly an honor to have you talking with us today.
Bruno van Herendael, MD: Thank you very much.