Treatment of Endometrial Ablation Failure

Why are we the only ones?

It’s a question I often get asked from women across the country and abroad. Let me try and explain this complex issue and why you don’t find this procedure readily available around the country—at least not yet.

  • The procedure known as ultrasound-guided reoperative hysteroscopic surgery (UGRHS) requires a great deal of experience in traditional resectoscopic or hysteroscopic surgery.  Many of these skills were lost with the introduction of Global Endometrial Ablation techniques (NovaSure, Hydrothermal Ablation, ThermaChoice and Minerva).  To date (January 2018) we have performed nearly 3500 major operative hysteroscopic procedures of which 471 are reoperative procedures.  But, it was the experience we gained–as far back as 1988–in operative hysteroscopy that provides us the skill and experience necessary to perform UGRHS.
  • Ultrasound-guided reoperative surgery also requires ultrasound expertise.  Ultrasound has been incorporated into our practice since 1993.  We do not employ ultrasound technicians—we perform our own ultrasound examinations.  Amy Daggett—our very skilled nurse practitioner—and I have worked together since 1986 and have extensive experience in both ultrasound and ultrasound-guided surgery.  Most sonographers that one finds in Ob Gyn Departments and in radiologist’s office have little or no experience ultrasound-guided surgery.  Between the 2 of us we perform thousands of ultrasound examinations per year and hundreds of procedures every year under ultrasound guidance.
  • We have assembled a “team” that includes an R. N, a nurse practitioner, and 3 highly trained operating room technicians that have worked together for many years.
  • Because we have a large volume of cases we are able to maintain our skills.  Our practice performs nearly 200 major operative hysteroscopic procedures and at least as many “minor” hysteroscopic procedures per year.
  • Honesty and integrity.  Finally, none of this matters if can’t provide a service and do so with honesty and integrity.  Let’s face it we, as physicians, we live in glass houses.  Word of mouth and the internet advertise both good and bad results—quickly.  Ultrasound Guided Reoperative Hysteroscopic Surgery IS NOT FOR EVERY WOMAN THAT HAS AN ENDOMETRIAL ABLATION FAILURE.  There are many women who are better off with the alternatives—including hysterectomy.  What we do provide is accurate information that is tailored to your particular case.  We refer many women every months for other management strategies.  Ultimately our reputation is dependent on honesty and not promising what we cannot deliver.

What is Ultrasound-Guided Reoperative Hysteroscopic Surgery?

Years ago when most endometrial ablation was performed using a hysteroscope –a lit telescope that allowed one to operate inside the uterus—a select group of physicians was able to perform repeat endometrial ablation.  Today, most endometrial ablations are performed blindly by what are called “Global Ablation” techniques.   In the past 20 years the U. S. Food and Drug Administration (FDA) has approved 6 such devices (see above); two them are no longer available.

Ultrasound-Guided Reoperative Hysteroscopic Surgery is comprised of the following elements:

  1. It is hysteroscopic surgery—surgery performed under direct vision—most of the time—through a hysteroscope or resectoscope—that is placed within the uterine cavity.  The image is displayed on a television monitor.
  2. Ultrasound guidance.  Because it is impossible to see everything through the hysteroscope—especially in the early stages of the procedure—visualization is also provided through transabdominal ultrasound.  Ultrasound allows us safely dissect through the scar tissue that often blocks entrance to the uterine cavity.  Once we have entered the cavity ultrasound is employed to make sure that we don’t remove too much tissue and accidentally perforate the uterus.If you look at our room arrangement (below) you’ll see that at the far end of the room there are 2 monitors on the wall—one for the “ultrasound view” and another for the “hysteroscopic view”.  This allows both the surgeon and the sonographer to see “the whole picture” and guide surgery accordingly.
  3. It is a resection technique identical to endomyometrial resectionnot an ablation technique.  No tissue is being burned or “cauterized”.   Instead tissue is removed.  Using the same “set-up” we can remove the following:
  • Adhesions
  • Endometrium which has regrown or was never destroyed in the first place
  • Fibroids within the uterine cavity or adjacent to it
  • Polyps
  • Mild to moderate adenomyosis
  • A uterine septum

One of the advantages of a resection technique is that all of the specimen –not a portion of it—is sent to the pathology lab to be analyzed.   That’s an important screen for endometrial cancer, its precursors and adenomyosis.

Can my own doctor do this?

I know of no other physician in the United States, Europe, Canada, South and Central America who performs this procedure.  There are physicians that have performed reoperative hysteroscopic surgery–I know of one physician in Hamilton, Ontario who performs this procedure, but without ultrasound guidance.  In recent years I have written numerous articles in peer-reviewed journals (see below) and have been invited to speak at many international gatherings of physicians.  It is my sincere hope that we can influence others around the country and in other parts of the world to adopt this technique.

 

How many have you done?

As of this writing (January 10, 2018) we have performed over 500 ultrasound-guided reoperative hysteroscopic surgeries over the past 25 years and we have written numerous scientific papers on this subject.  Our first report in the medical literature dates back to 2001.  Here is a sampling of the papers we’re written just on the subject of endometrial ablation failure and its management.

Wortman M, Daggett A. Reoperative hysteroscopic surgery in the management of patients who fail endometrial ablation and resection. J. Am Assoc. Gynecol Laparosc. Vol 8 No. 2; 2001:272-277.

Wortman M. Ultrasound Guided Reoperative Hysteroscopy: Managing Endometrial Ablation Failures. Surg Tech International. 2012; 21:163-69.

Wortman M, Daggett A, Deckman A. Ultrasound-Guided Reoperative Hysteroscopy for Managing Global Endometrial Ablation Failures. J Minim Invasive Gynecol. 2014; 21:238-244.

Wortman M. The MIGS approach to fixing failed EA. Contemporary Ob/Gyn. May 2014. Pp 24-32.

Wortman M, McCausland A, McCausland V, Cholkeri A. Late-Onset Endometrial Ablation Failure (LOEAF)—Etiology, Treatment and Prevention. J Minim Invasive Gynecol. 2015; 22: 323-331. 50.

Wortman M.  Diagnosis and treatment of global endometrial ablation failure.  Ob Gyn News.  January 6, 2017. http://www.cmdrc.com/wp-content/uploads/2017/01/Diagnosis-and-treatment-of-global-endometrial-ablation-failure-Ob.Gyn_.-News.pdf.

Wortman M.  Late-onset endometrial ablation failure. Case Reports in Women’s Health. 2017; 15; 11-28.  http://www.cmdrc.com/wp-content/uploads/2017/08/Late-onset-endometrial-ablation-failures-COLOR.pdf.

How successful is Ultrasound-Guided Reoperative Hysteroscopic Surgery?

In our work we have found that—on average—we can alleviate symptoms to avoid hysterectomy is close to 90% of women who are judged to be candidates for ultrasound guided reoperative hysteroscopy surgery.  The figure for an individual person may be greater or lesser than this number and depends on the following factors:

  • Their age at the time they undergo reoperative hysteroscopic surgery
  • Whether or not there are polyps or fibroids present in the uterine cavity
  • Whether or not there are fibroids in other portions of the uterus (intramural fibroids)
  • Their expectations.  
  • Their motivation to avoiding hysterectomy

So what are the benefits of UGRHS compared to hysterectomy?

The advantages of UGRHS include the following:

  1. It’s an office-based procedure performed with intravenous sedation.
  2. Rapid return to work—most women can return to their jobs (even lifting) in 48 hours.
  3. The complication rate of UGRHS is extremely low.  Infection occurs about 1% of the time.  Uterine perforation has occurred in 1 out of our 450 cases.  This rate is FAR LESS than the incidence of complications that are associated with all forms of hysterectomy.
  4. Its effectiveness in avoiding hysterectomy in approximately 85-90% of women.  To be clear it’s not perfect.   Failures are greater in younger women—those under 35.  The “ideal” age group for UGRHS is >45 years of age.

 

What are the disadvantages of UGRHS compared to hysterectomy?

The disadvantages of UGRHS include the following:

  1. It is not perfect.  It does not guarantee that you’ll never require a hysterectomy.  In some cases women have undergone UGRHS, had it work for a year or two (or longer) and experienced another “failure” in the form of pain or vaginal bleeding.  Many of these women can be “retreated” while others choose to undergo hysterectomy.  And while I don’t believe that reoperative hysteroscopic surgery will ever be “perfect” I believe that over the years our results will continue to improve as newer techniques are incorporated in our procedure.
  2. It is not convenient.  Unless you live within an hour or so of Rochester, New York you will need to so some traveling.  We’ve had some strongly motivated women who’ve traveled from Florida, Germany, Los Angeles and Calgary!  But for many women it’s simply not worth the time and the expense of time off from work, travel and hotels when they can undergo a hysterectomy in their home town.  My hope is that in time there will be other centers in the United States, Europe and Canada to accommodate some of these women.