Ultrasound-Guided Reoperative Hysteroscopic Surgery

Why are we the only ones?

One of the questions that women often ask—after they’ve done an exhaustive on-line search—is “why are you the only one?” In fact, to the best of my knowledge we are the only practice that offers a minimally invasive surgical alternative to hysterectomy for women who have “failed” following an endometrial ablation. In this article I’ll explain why—up to this point–we’re the only ones who perform this surgery. I’ll also do my best to explain the scope of the problem and the benefits and shortcomings of ultrasound-guided reoperative hysteroscopic surgery (UGRHS). In the end I’ll answer the question “why are you the only one?”

What is a late-onset endometrial ablation failure?

While there are few immediate complications of modern endometrial ablation the incidence of late-onset endometrial ablation failures (LOEAFs) is about 25%. I have written extensively about this issue and you can easily access those articles by clicking here. There are 3 types of late-onset failures:

1. Persistent troublesome bleeding that occurs after the first month postoperatively.
2. Either cyclic or continuous pelvic pain after the first month postoperatively.
3. The inability to gain access to the endometrial cavity in the months and years following an endometrial ablation should it be required for the evaluation of abnormal menstrual bleeding.

The scope of the problem?

As of this writing (2020) there are over 500,000 endometrial ablations performed in the United States per year. To the best of our knowledge this problem affects 25% of women within the first 5 years of their endometrial ablation (EA)—that’s a minimum of over 100,000 late-onset failures per year. We know that it can happen up to 15 years following EA but the vast majority of them occur within the first 3 years following EA. So if you’ve managed to make it 3 years without an issue it doesn’t mean you’re out of the woods. However, statistically-speaking, most issues happen within the first 3 years.

Why didn’t my doctor tell me that this could happen?

The most honest answer is that in all likelihood your physician didn’t know. Most doctor don’t perform hundreds of endometrial ablations per year. In fact most physicians probably don’t perform this procedure a dozen times a year. The majority of endometrial ablation procedures (75%) work well and women manage to avoid hysterectomy. Most physicians have not attended postgraduate courses that discuss the issue of endometrial ablation failure. Additionally, there are not many articles in the medical literature that discuss late-onset endometrial ablation failure. And there are far fewer articles that discuss how to manage them!

The most troubling kind of endometrial ablation failure!

Of the various kinds of endometrial ablation failure listed above the most troubling is cyclic pelvic pain (CPP). With cyclic pelvic pain women often experience cyclic pain–once a month at the time of their cycle–that may last anywhere from a day or two up to 2 weeks. In advanced cases there is no “break” and women then experience continuous lower abdominal pelvic pain that radiates into the back, groin or even their thighs. If the pain is associated with menstruation both the women and physician understand the cause of the pain. However, when there is NO VAGINAL bleeding the diagnosis of a late-onset endometrial ablation failure (LOEAF) is often missed. This can lead to some unfortunate results. Here’s why.

If women experience significant pain unaccompanied by vaginal bleeding it’s not necessarily obvious to them or to their physician that their pain is even related to their endometrial ablation (which may have occurred 3-4 years earlier). The pain, which may be described as “labor-like,” frequently leads to an emergency room (ER) visit. Often, the ER doctor is not a gynecologist and there can be a significant delay in the diagnosis. At other times, the diagnosis is missed entirely!

To summarize, the most troubling endometrial ablation failure is pelvic pain which is not accompanied by bleeding. The pain can be disabling and the diagnosis is often delayed or missed.

Why is the diagnosis delayed or missed?

Often the diagnosis is delayed or missed because the wrong tests are ordered–or the correct test was ordered and was misinterpreted. For instance, in the women we’ve seen who present with “the most troubling kind of endometrial ablation failure,” most of them have had CT Scans and pelvic ultrasounds. CT Scans–which are both expensive and time consuming—are very good in the diagnosis of bowel and kidney disease or for an acute appendicitis. However, they are far less sensitive than an ordinary transvaginal ultrasound for the diagnosis of a late-onset endometrial ablation failure!

Another common issue that I see when managing women with LOEAFs is that a surprising number of them have been told that their ultrasound examination is “normal.” This is NEVER TRUE. Let me explain. Even if you’ve had an endometrial ablation and it’s worked perfectly, your uterine lining has been totally or partially destroyed and your ultrasound is never “normal” again! So if someone has told you that you have a normal vaginal ultrasound examination a “red flag” should go up. In other instances the abnormality is clearly evident but the radiologist interpreting the examination simply doesn’t understand what post-ablation ultrasounds look like.

Does this mean I should not have had an endometrial ablation? Was the EA a bad idea?

Provided you were properly counseled about endometrial ablation and someone explained both the immediate and late-onset complications of EA I want to categorically state that EA has saved many women from undergoing more invasive surgeries such as hysterectomy. Even “minimally invasive” procedures such as “robotic hysterectomy” are, at best, misnomers and cannot compare to endometrial ablation in terms of safety, risks and recovery. If only 75% of endometrial ablations “work” that’s still a 75% chance of avoiding a hysterectomy and no matter what you read on-line those are pretty good odds.

What are the major risk factors for Late-Onset Endometrial Ablation Failure (LOEAF)?

Several important risk factors have been identified that increase a woman’s risk for “failure” with endometrial ablation. These are as follows:

• Age < 35 years of age
• Submucous or intramural fibroids. Remember that endometrial ablation is NOT a treatment for fibroids. If you have fibroids inside your uterus (submucous) they should be removed at the time of your endometrial ablation or endomyometrial resection.
  

• Polyps. Polyps, like fibroids, need to be removed prior to your endometrial ablation.
  

• Anomalies of the uterus. The presence of a uterine septum or a bicornuate uterus. These are present a birth. Most women who have them already know about it. However, it is important to have an ultrasound and a hysteroscopy prior to an endometrial ablation just to be sure you don’t have one. This can be done at the same time! If you have a uterine septum or a bicornuate uterus you should consider another form of treatment such as endomyometrial resection.
• Active infection. This is self-explanatory
• Uterine cancer or atypical endometrial hyperplasia. This is also self-explanatory. Since an ablation is a “burning procedure” you don’t want the “evidence burned.”
• Motivation. If you understand the risks and consequences of endometrial ablation and you’re simply more “comfortable” with a hysterectomy, don’t let someone “talk you into” an EA. Women who are poorly motivated to undergo EA—after they review the information—will likely not do well.

Why not have a hysterectomy in the first place?

Hysterectomy isn’t a bad choice for many women but keep in mind that it is far more aggressive than is medically warranted. Importantly, some women are just simply poor operative risks for hysterectomy. This includes women who are obese (BMI > 30), diabetic, or ones who’ve had multiple abdominal surgical procedures such as appendectomy, cholecystectomy, multiple Cesarean sections, gastric-bypass procedures. Other women who should avoid hysterectomy are those with bleeding disorders, women who take “blood thinners” or have a history of pulmonary disease, coronary artery disease or strokes.

Finally, it’s important to realize that even though endometrial ablation and similar procedure are far from perfect they are simple office-based procedures with a quick recovery and rapid return to a normal life style. EAs work on a sizeable majority of women and are far less risky than hysterectomy. If endometrial ablation doesn’t work you can, in most cases, have a hysterectomy.

What can be done about endometrial ablation failures?

For most women –over 100,000 per year in the U. S.–the choices include

• Living with the problem if it’s not too bad
• Trying to control it with hormonal suppression–birth control pills, norethindrone, Depo-Provera, oral medroxyprogesterone acetate, or megestrol (Megace).
• Subtotal hysterectomy
• Ultrasound-Guided Reoperative Hysteroscopic Surgery (UGRHS)

What should not be done following an endometrial ablation failure?

Many physicians offer a variety of treatments following a late-onset failure. The following procedures should be avoided if you’re had an endometrial ablation that’s failed.

• IUD insertion—Although IUDs can be inserted following EA this needs to be done by a highly trained physician and under ultrasound guidance!
• A “repeat” ablation of one of the following types:
  • NovaSure
  • Minerva
  • ThermaChoice Balloon (unavailable after 2016)
  • Hydrothermal Ablation (HTA)
  • Microwave endometrial ablation (no longer available)
  • Cryoendometrial ablation (HerOption)

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 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.

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 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 resection—not 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.

Our Operating Room Setup

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. At the present time 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 (February 4, 2020) we have performed over 600 ultrasound-guided reoperative hysteroscopic surgeries over the past 25 years. We have written numerous 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. Click here to read.
• Wortman M. Late-onset endometrial ablation failure. Case Reports in Women’s Health. 2017; 15; 11-28. Click here to read.

So why are you the only one?

So I’ll end where I began–explaining why you don’t find this procedure readily available around the country—at least not yet.

1. 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. To date we have performed nearly 3500 major operative hysteroscopic procedures of which 450 are reoperative procedures. But, it was the experience we gained–as far back as 1988–in operative hysteroscopy that provided us the skill necessary to progress to the point where we could safely offer UGRHS.
2. 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 in 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.
3. We have assembled a “team” that includes one R. N, a nurse practitioner, and 3 highly trained operating room technicians that have worked together for many years.
4. 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.
5. 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, 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.

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 if FAR less than the incidence of complications that are associated with all forms of hysterectomy.
4. It is effective in avoiding hysterectomy in approximately 85-89% of women. To be clear it’s not perfect and doesn’t guarantee you’ll never have a hysterectomy. 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 as far south as Florida, as far east as West Germany and even from 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.

Okay. I want to learn more. What’s next?

Here are some suggestions if you are have experienced an endometrial ablation failure and you’d like to learn more.

1. Click here to read peer-reviewed articles by Dr. Wortman. These articles cover a wide range of publications by Dr. Wortman but focus on the ones that include Reoperative Hysteroscopic Surgery for Endometrial Ablation Failures and Late-Onset Endometrial Ablation Failures.
2. Go to one of the many on-line Patient Review websites such as www.healthgrades.com or www.vitals.com. This will give you an opportunity to see how other patients judge us. You can find additional information under our Facebook Page and under our Blogs.
3. If you’re still interested and live within a 2-3 hour driving radius of our office consider making a consultation appointment. These generally are 1-hour appointments. Prior to these appointments we request that you fill out a Patient Information Form and email it to rpw@cmdrc.com.
4. In addition, please provide us with the following:
   • A copy of your most recent ultrasound examination report—we don’t require the actual ultrasound images.
   • A copy of your operative report or some documentation of the date of your procedure and the type of endometrial ablation procedure you had. If an operative report is available please have that copied for our records.
   • A copy of any pathology report such as an endometrial biopsy that may have been performed prior to or since your endometrial ablation.
   • Don’t worry if you can’t locate all of this information. We can assist you in retrieving it.

Finally, if you’re interested in arranging a consultation call our office at (585) 473-8770. If you live more than 2-3 hours away from our office please contact Ms. Marcia Weston or Ms. Christina Cinanni and they will help arrange for a 20-30 phone interview with me.

After I review your information and conduct a preliminary interview we’ll be able to decide whether or not this is an option worth pursuing for you.