Women : Need Relief from Heavy Bleeding? Endometrial Ablation to the Rescue!


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Overly heavy bleeding is more than just an inconvenience – it can affect your day to day life. Some women deal with prolonged and excessive bleeding with each period, but aren’t ready for or do not want a hysterectomy. Dr. Richard Eden discusses this procedure that can lighten up your month.

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  • Bone loss with depo provera is about 3-5% for 2-4 yrs of use. It returns to baseline bone density within 24-30 months. Pregnancy is associated with a 2-8% bone loss. Breast feeding is associated with 3-5% bone loss rare as well. In teenage years bone lose is about 3% for a 2 yr period.
  • Endometrial biopsy is a safe, relatively simple procedure that can be performed during the initial office visit. It is widely used for excluding endometrial cancer, especially in peri- and postmenopausal women. A biopsy may also be used to determine if the bleeding is ovulatory or anovulatory. A drawback to the utility of endometrial biopsy is that it is not a sensitive technique for detecting structural abnormalities, such as polyps or fibroids. Several techniques may be used to obtain endometrial samples. Unfortunately, hospital-based D&C is still performed—even though it should be discouraged. It is no longer considered the gold standard for evaluation of abnormal bleeding, except in patients who have had a miscarriage. A diagnostic D&C is highly inaccurate, resulting in missed diagnoses and incomplete removal of intracavitary pathologic tissue, and is associated with a high false-negative rate. A recently reported retrospective study demonstrated that D&C failed to detect intrauterine disorders in 248 of 397 (62.5%) women. Office-based sampling techniques have been shown to be at least equivalent to D&C in sensitivity and rate of positive diagnosis/effectiveness, while being less intrusive and more cost-effective. Several sampling devices are available for office-based endometrial biopsy, including disposable devices (eg, Pipelle, Tis-u-Trap, Accurette, Z-sampler) and reusable instruments (eg, Novak Curette, Randall Curette, Vabra Aspirator).
  • TVS is inexpensive, noninvasive, and a convenient technique for indirectly visualizing the endometrial cavity, myometrium, and adnexa, and measuring endometrial thickness. It may be used to identify possible abnormal endometrial conditions, such as atrophy, hyperplasia, cancer, leiomyomas, and polyps. Normally, the postmenopausal endometrial echo measures less than 5 mm. Fewer than 0.5% of women with an endometrial echo less than 5 mm will have endometrial cancer. Thicknesses greater than 5 mm are associated with endometrial hyperplasia, polyps, submucosal fibroids, and endometrial cancer. Even through the endometrium is thicker in women receiving HRT, a thin endometrial echo has high negative predictive value for endometrial cancer. Limitations of TVS may include problems associated with poor body habitus, skill of the operator, low signal-to-noise ratio, and lack of tissue-characterization. TVS may not always distinguish among a submucosal fibroid, endometrial polyp, or adenomyosis.
  • This slide shows a TVS image of a posterior fibroid. Slide courtesy of Linda Darlene Bradley, MD.
  • Saline infusion sonography (SIS) is a relatively new technique that involves the infusion of saline into the endometrial cavity to enhance the detection of abnormalities. This technique is very useful for the evaluation of abnormal bleeding in pre-, peri-, and postmenopausal women. It has been reported that SIS is superior to TVS alone for evaluating the uterine cavity in patients with abnormal uterine bleeding. When used in conjunction with endometrial biopsy for the evaluation of postmenopausal women with abnormal uterine bleeding, SIS may have a sensitivity of 95% to 96.2% and a specificity of 65.7% to 98% for the detection of abnormal endometrial tissue. A reported disadvantage of SIS is that small irregularities caused by blood clots or endometrial protrusions have been frequently misinterpreted as polyps.
  • This slide shows a SIS image of a posterior Class 3 fibroid abutting the posterior endometrium. Slide courtesy of Linda Darlene Bradley, MD.
  • This slide shows a transvaginal saline infusion sonography (SIS) of a submucosal fibroid. The fibroid can be clearly delineated and seen to be protruding into the endometrial cavity.
  • This slide shows an SIS image of endometrial polyps. Slide courtesy of Linda Darlene Bradley, MD.
  • Hysteroscopy with biopsy allows visualization of the endometrial cavity, and this technique has been regarded as the “gold standard” for endometrial assessment. Most hysteroscopies are performed to evaluate abnormal uterine bleeding—up to 60% in one author’s experience. Diagnostic hysteroscopy can now be performed easily in an office setting, requires minimal anesthesia or sedation, and allows detection of endometrial myomas, polyps, and other lesions that may cause bleeding. Diagnostic hysteroscopy is particularly useful in the diagnosis of intrauterine lesions in women of reproductive age with ovulatory AUB. Office-based diagnostic hysteroscopy has been associated with a low ( <1%) incidence of complications when performed by physicians skilled in the technique. Complications may include uterine perforation, infections, excessive bleeding, and complications related to the distending medium (eg, CO 2 embolus). The major disadvantages of office-based hysteroscopy include the cost and maintenance of expensive equipment (eg, camera, insufflator, hysteroscope, video equipment), the skill and training required to perform the procedure, and the cost of the procedure.
  • This slide shows a hysteroscopic image of the endometrial polyps seen on the SIS in the previous slide. Slide courtesy of Linda Darlene Bradley, MD.
  • This slide shows multifocal endometrial hyperplasia. Slide courtesy of Linda Darlene Bradley, MD.
  • If myometrium is < 10 mm thick then increased risk of transmural thermal injury to intraabdominal organs.
  • Some important things to know about hysterectomy are that it’s the most common surgical procedure performed on women. This is because it is the definitive solution for many types of common gynecologic conditions. About 650,000 hysterectomies are performed annually in the United States alone. Most of these are still performed through abdominal incisions, either up and down between the belly button and the pubic bone or across, what many women refer to as a bikini incision. Due to recent advances in minimally invasive approaches to hysterectomy, more and more gynecologic surgeons are performing these types of procedures either vaginally or using what’s called a laparoscopic approach.
  • Now that we have talked about some common gynecologic conditions and their various treatment options, let’s discuss some of the approaches that are available when surgery is needed. As I alluded to earlier, if you need a hysterectomy, it can be done with a traditional approach, an open abdominal incision; this incision maybe vertical or transverse. Now, however, many physicians are offering minimally invasive surgery for hysterectomy. A minimally invasive approach could be vaginal with conventional laparoscopy or robotically with the da Vinci Surgical System.
  • There are many advantages to minimally invasive surgery. These include reduced blood loss, fewer complications, a shorter stay in the hospital, a faster recovery, and less scarring.
  • Vaginal surgery maybe appropriate for you for certain gynecologic problems. The pros of vaginal surgery include that it is less invasive. There is no scar on the abdomen and often you spend only one night in the hospital. There is also significantly less pain with a vaginal approach than there is with an abdominal hysterectomy. Cons to vaginal surgery are that it can be difficult to perform. The physician may not be able to see as well and it may be difficult to control bleeding from the vascular tissues that give blood supply to the pelvic organs. In addition, vaginal surgery may not be indicated for certain types of patients. If you have never had children or have large fibroids or other types of large masses, you may not be able to have the surgery performed vaginally. Cancer operations are rarely performed vaginally as they usually require much more extensive surgery than a vaginal approach could offer. Finally, if you have significant adhesions or scar tissue from endometriosis or prior surgeries, this could make vaginal surgery unfeasible.
  • On the other hand, laparoscopic surgery is performed through very small keyhole incisions in the abdomen rather than one long continuous incision. One advantage to laparoscopic surgery is that the surgeon’s view is magnified. Laparoscopic surgery begins with the surgeon inserting a video telescope or camera through a small incision, usually in the belly button. This camera will often magnify the areas that the surgeon is examining and provide better visualization than open surgery. With conventional laparoscopic surgery, after the surgeon has placed the camera, several additional small keyhole incisions are made. Through these small incisions cannulas or trocars are inserted. Through these trocars different types of instruments can be inserted that perform various functions like grasping, cutting or cauterizing.
  • Some of the drawbacks of conventional laparoscopic surgery include that the surgeon is operating while looking at a two-dimensional image usually on a flat screen monitor. The instruments themselves are rigid and can only be moved in a few directions in space. The instruments are controlled at a distance with the surgeon’s hand outside of the patient’s abdomen. This results in reduced dexterity, reduced precision, and reduced control of the instruments. It also results in greater surgeon fatigue. Assistance from the surgeon on the other side of the operating room table can also be difficult to coordinate. With conventional laparoscopic surgery, very complex operations can be quite difficult or impossible to perform. However, conventional laparoscopic surgery is an excellent option for minor or straightforward surgical procedures like tubal ligations or removal of small ovarian cysts.
  • How can we overcome some of these drawbacks of conventional laparoscopic surgery? Many surgeons around the country like myself now have access to the da Vinci Surgical System. This system provides state-of-the-art robotic technology and allows me to be completely in control of the operation. My assistant also has direct access to the patient through traditional laparoscopic trocars or ports.
  • Rather than a two-dimensional flat image, I am immersed in a three-dimensional image of the surgical field.
  • I direct the instruments at all times while controlling the arms on the console. Even small or very precise movements of my hands are transmitted to the instruments inside the patient’s abdomen in real time.
  • Conventional laparoscopic instruments are rigid and do not have the ability to rotate like a human wrist. The EndoWrist instruments, part of the da Vinci Surgical System, move like a human wrist with seven degrees of freedom. This allows me to operate with increased dexterity and precision.
  • These EndoWrist instruments fit through small dime-sized incisions or keyhole incisions. A wide range of instruments are available to perform almost any type of task that might be required.
  • In addition to the number of many benefits to the patient, there are many benefits to me the surgeon as well. These include improved visualization, better control of the instruments, improved surgical dexterity for complex aspects of the operation, easier and faster suturing, and I’m more comfortable while I’m operating.
  • This slide shows a picture of the typical configuration of these small keyhole incisions that might be used for access to perform a robotic-assisted surgery.
  • da Vinci Gynecologic Surgery is not indicated for everybody. It does allow me to perform a broader range of surgeries for different gynecologic conditions and for different patient situations than was ever available before. For example, radical hysterectomy done with conventional laparoscopy has not been widely accepted by gynecologic oncologists. The concern is that the lack of surgical precision results in a less than adequate cancer operation. However, the da Vinci radical hysterectomy is being performed by a small number of gynecologic oncologists around the United States with excellent surgical results. Endometrial cancer has been treated with conventional laparoscopy for sometime now with good surgical results, but it can be technically difficult to perform and quite exhausting for the surgeon. The da Vinci surgical approach offers better ergonomics for the surgeon and better precision. Surgery for vaginal or uterine prolapse can be performed with conventional laparoscopy, but as we discussed before the laparoscopic suturing may not be reliable. da Vinci laparoscopic suturing is reliable and easy. In addition, surgery for endometriosis can be quite complex and the da Vinci System provides the increased precision often required to perform these surgeries safely. Surgery for large uterine fibroids can be difficult or impossible to perform with conventional laparoscopy, but now they can be performed by experienced robotic surgeons. Finally, surgery on obese patients can be difficult for a number of reasons. However, these are the patients that benefit the most from a minimally invasive approach due to a decreased risk of wound infection and decreased risk of wound healing problems. The da Vinci Surgical System allows me to offer minimally invasive surgery to a much greater number of obese patients.
  • Now, let’s talk in more detail about some of the goals of da Vinci Hysterectomy. This allows a minimally invasive approach for hysterectomy. It’s much easier to learn than conventional laparoscopy and enables the gynecologist to perform the surgery for more advanced types of gynecologic problems. Again, the benefits to you include a shorter hospital stay, less pain and scarring, and a quicker return to normal activities.
  • Women : Need Relief from Heavy Bleeding? Endometrial Ablation to the Rescue!

    1. 1. Abnormal Uterine Bleeding What to do about it? Richard Eden, M.D. www.SpringfieldClinic.com
    2. 2. Abnormal Uterine Bleeding Affects… <ul><li>Adolescents </li></ul><ul><li>Women of reproductive age </li></ul><ul><li>Perimenopausal and postmenopausal women </li></ul>
    3. 3. Abnormal Uterine Bleeding Definitions <ul><li>Menorrhagia -heavy or prolonged uterine bleeding that occurs at regular intervals. Usually >7d or >80 ml blood loss. </li></ul><ul><li>Oligomenorrhea -cycle length >35 days </li></ul><ul><li>Polymenorrhea -cycle length < 21days </li></ul><ul><li>Amenorrhea -absence of menstruation for at least 6 months. </li></ul><ul><li>Metrorrhagia -irregular menstrual bleeding or bleeding between periods. Usually normal or reduced flow. </li></ul><ul><li>Menometrorrhagia -irregular menstrual bleeding with excessive volume and duration of flow. </li></ul>
    4. 4. Menorrhagia Excessive Menstrual Bleeding Endometrium Myometrium Cervix <ul><li>Abnormal bleeding is defined by: </li></ul><ul><li>Length of cycle (days) </li></ul><ul><li>Duration of menses (days) </li></ul><ul><li>Amount of blood loss (ml) </li></ul>
    5. 5. Normal Menses <ul><li> Normal Abnormal </li></ul><ul><li>Duration of flow 4-6 days >7days </li></ul><ul><li>Volume of flow 35 ml >80 ml </li></ul><ul><li>Length of cycle 21-35 days </li></ul>
    6. 6. Uterus <ul><li>Hollow, pear-shaped muscular organ, which lies in the pelvic cavity, between the urinary bladder and the rectum </li></ul><ul><li>Functions to prepare for and maintain pregnancy </li></ul>
    7. 7. Laparoscopy-Normal Uterus
    8. 8. Normal Uterus & Right Ovary/Tube
    9. 9. Normal Uterus & Left Ovary/Tube
    10. 10. Abnormal Uterine Bleeding <ul><li>Affects >10 million women in the U.S. </li></ul><ul><li>Impacts daily activities and quality of life </li></ul><ul><li>May cause anxiety </li></ul><ul><li>May lead to iron-deficiency anemia/fatigue </li></ul>
    11. 11. Normal Menstrual Cycle
    12. 12. Abnormal Uterine Bleeding Differential Diagnosis <ul><li>Structural </li></ul><ul><ul><li>-Cervical or vaginal laceration </li></ul></ul><ul><ul><li>-Uterine or cervical polyp </li></ul></ul><ul><ul><li>-Uterine leiomyoma (fibroids) </li></ul></ul><ul><ul><li>-Adenomyosis </li></ul></ul><ul><ul><li>-Cervical stenosis/Asherman’s (hypomenorrhea) </li></ul></ul>
    13. 13. Abnormal Uterine Bleeding Differential Diagnosis <ul><li>Hormonal </li></ul><ul><li>-Anovulatory bleeding (lack of ovulation-decreased progesterone) </li></ul><ul><li>-Hypogonadotropic hypogonadism </li></ul><ul><li>-Pregnancy </li></ul><ul><li>-Hormonal contraception (BCP’s, Depo-Provera) </li></ul><ul><li>Malignancy </li></ul><ul><li>-Uterine or Cervical cancer </li></ul><ul><li>-Endometrial hyperplasia (potentially pre-malignant) </li></ul><ul><li>-Chemotherapy or radiation </li></ul><ul><li>Bleeding Disorders </li></ul><ul><li>-VonWillebrand’s Disease, Hemophilia, ITP, Factor </li></ul><ul><li>deficiencies, platelet disorders. </li></ul>
    14. 14. Abnormal Uterine Bleeding Workup <ul><li>History </li></ul><ul><li> -Timing of bleeding, quantity of bleeding, menstrual history, associated symptoms. </li></ul><ul><li>Family history of bleeding disorders. Excessive psychological stress, exercise, or weight loss. </li></ul><ul><li>Physical Exam </li></ul><ul><li>-pap smear (rule out cervical cancer) </li></ul><ul><li>-endometrial biopsy (rule out uterine cancer) </li></ul><ul><li>-excessive facial hair growth, obesity (BMI>25) (polycystic ovarian disease 6-10% of women) </li></ul><ul><li>-abnormal breast discharge (prolactin disorders) </li></ul><ul><li>-anorexia signs (hypothalamic dysfunction) </li></ul><ul><li>-goiter, weight loss or gain (thyroid disease) </li></ul><ul><li>-other disease states (leukemia, hypersplenism, chemo, radiation) </li></ul><ul><li>Labs </li></ul><ul><li>-Pregnancy test </li></ul><ul><li>-FSH, LH, Estradiol </li></ul><ul><li>-TSH, Prolactin, DHEA-S, Testosterone </li></ul><ul><li>Imaging </li></ul><ul><li>-Pelvic ultrasound (transvaginal) </li></ul><ul><li>-Sonohystogram (saline infusion ultrasound) or hysterosalpingogram (x-ray) </li></ul><ul><li>-MRI (better for adenomyosis dx than U/S) </li></ul><ul><li>Surgical </li></ul><ul><li>-Hysteroscopy </li></ul><ul><li>-D&C </li></ul>
    15. 15. Medical Treatment of Abnormal Uterine Bleeding <ul><li>Iron </li></ul><ul><li>NSAID’s </li></ul><ul><li>Combined Contraceptives (estrogen and progesterone) </li></ul><ul><li>Progesterone only methods </li></ul><ul><li>IV Estrogen </li></ul><ul><li>GnRH agonists </li></ul><ul><li>Androgens </li></ul><ul><li>Antiprogestational agents </li></ul>
    16. 16. Iron <ul><li>Menstrual volume > 60 ml- iron deficiency anemia </li></ul><ul><li>Primary symptom is fatigue </li></ul><ul><li>Daily doses of 60-180 mg of iron needed for anemia Rx </li></ul><ul><li>May be the only treatment necessary </li></ul>
    17. 17. NSAID’s <ul><li>Nonsteroidal Anti-inflammatory Drugs </li></ul><ul><li>Can decrease bleeding by 30-40% </li></ul><ul><li>Motrin (ibuprofen) 400mg every 4 hrs </li></ul><ul><li>Anaprox (Naproxen) 550 mg every 12 hrs </li></ul>
    18. 18. Combined Contraceptives <ul><li>Contain both estrogen & progesterone </li></ul><ul><li>Birth control pills (daily) </li></ul><ul><li>Birth control patch Ortho Evra (weekly) </li></ul><ul><li>Contraceptive ring Nuvaring (monthly) </li></ul>
    19. 19. NuvaRing
    20. 20. Progesterone only Methods <ul><li>Mini-pill -often used in breastfeeding moms, useful in patients who cannot take estrogen containing pills (Hx of strokes, DVT’s, breast cancer). </li></ul><ul><li>Depo-Provera -3 month birth control, high amenorrhea rate, causes weight gain, causes increased bone loss. </li></ul><ul><li>Progesterone sub dermal implants (Implanon) -3 year birth control. High irregular bleeding rates during the first few months. </li></ul><ul><li>Progesterone IUD (Mirena) -5 year birth control, 70-80% reduction in blood loss, 99.8% effective contraception, 3-5 minute office procedure. Same bleeding rate control as ablations after 2-3 years of use. </li></ul>
    21. 21. Implanon
    22. 22. Mirena IUD
    23. 23. Other treatments <ul><li>IV Estrogen —stops bleeding acutely (71% bleeding cessation vs. 38% placebo), usually within 24-48 hrs, given in hospital setting. Premarin 25 mg IV q 4 hrs x 24 hrs. </li></ul><ul><li>Lupron (GnRH agonist) —induces amenorrhea in 40-60% of patients by shrinking total uterine volume. Limited use due to cost and “menopause-like” side effects. Mostly used for fibroid related bleeding prior to surgery. </li></ul><ul><li>Androgens (Danazol) —synthetic testosterone derivative, reduces bleeding volume 50% in women with ovulatory bleeding. Side effects make long term treatment undesirable. </li></ul><ul><li>Antiprogestational Agents (Mifepristone 50 mg/day) —reduces the number of progesterone receptors in the uterus. Reported to induce amenorrhea in women with fibroids. </li></ul>
    24. 24. Endometrial Ablation <ul><li>Surgical procedure-outpatient surgical setting, usually general anesthesia. </li></ul><ul><li>Indicated for the treatment of menorrhagia or perceived heavy menstrual bleeding in premenopausal women (usually< age 50). </li></ul><ul><li>Presence of anemia or failed medical therapy are other indications for endometrial ablations. </li></ul><ul><li>Goal is to normalize menstrual blood flow. </li></ul><ul><li>Contraindicated in postmenopausal bleeding patients. </li></ul><ul><li>Not a contraceptive method. </li></ul><ul><li>Must be done with childbearing (previous tubal or vasectomy). </li></ul><ul><li>Tubal ligation can be done the same day as the ablation surgery. </li></ul>
    25. 25. Ablation Preoperative Evaluation <ul><li>Pap smear -used to exclude cervical cancer </li></ul><ul><li>Endometrial biopsy -used to exclude uterine cancer or uterine hyperplasia. </li></ul><ul><li>Transvaginal U/S -used to look for anatomic causes of bleeding such as uterine fibroids, uterine polyps, cervical polyps, or congenital malformations of the uterus (septate uterus). Often combined with saline infusion sonography (SIS). </li></ul><ul><li>Hysteroscopy -using a camera to look “inside” the uterine cavity. </li></ul><ul><li>D&C –dilation & curettage-scrapping uterine lining. </li></ul>
    26. 26. Endometrial Biopsy <ul><li>Safe, relatively simple procedure useful in perimenopausal or high risk women </li></ul><ul><li>Not sensitive for detecting structural abnormalities (eg, polyps or fibroids) </li></ul><ul><li>Office-based techniques (gold standard replacing D&C) </li></ul><ul><ul><li>Disposable devices (eg, Pipelle, Tis-u-Trap, Accurette, Z-sampler) </li></ul></ul><ul><ul><li>Reusable instruments (eg, Novak Curette, Randall Curette, Vabra Aspirator) </li></ul></ul>
    27. 27. Transvaginal Ultrasonography (TVS) <ul><ul><li>Inexpensive, noninvasive, and convenient </li></ul></ul><ul><li>Indirect visualization of the endometrial cavity, myometrium, and adnexa </li></ul><ul><li>Measurement of endometrial thickness ( <5 mm vs. >5 mm) </li></ul><ul><li>May be used to increase index of suspicion for endometrial atrophy, hyperplasia, cancer, leiomyomas, and polyps </li></ul><ul><li>May not always distinguish among submucosal fibroid, polyp, or adenomyosis </li></ul>
    28. 28. Posterior Fibroid Slide courtesy of Linda Bradley,MD.
    29. 29. Saline Infusion Sonography (SIS) <ul><li>Relatively new technique </li></ul><ul><li>Very useful for evaluation of AUB in pre-, peri-, and postmenopausal women </li></ul><ul><li>May be superior to TVS alone (94.1% vs. 23.5% for detection of focal intrauterine pathology) </li></ul><ul><li>SIS + biopsy: 96.2% sensitivity and 98% specificity </li></ul><ul><li>Disadvantage: small irregularities may be misinterpreted as polyps </li></ul><ul><li>Able to determine penetration depth of uterine fibroids </li></ul>
    30. 30. Saline Infusion Sonography
    31. 31. Posterior Fibroid Slide courtesy of Linda Darlene Bradley, MD.
    32. 32. Submucosal Fibroid Slide courtesy of Linda Darlene Bradley, M.D.
    33. 33. Endometrial Polyps Slide courtesy of Linda Darlene Bradley, MD.
    34. 34. Hysteroscopy <ul><li>Hysteroscopy + biopsy = “gold standard” </li></ul><ul><li>Most are performed to evaluate AUB </li></ul><ul><li>Diagnostic hysteroscopy easily performed in the office setting—although it requires skill </li></ul><ul><li>Particularly useful in the diagnosis of intrauterine lesions in women of reproductive age with ovulatory AUB </li></ul><ul><li>Complications ( <1%) may include uterine perforation, infections, excessive bleeding, and those related to distending medium </li></ul>
    35. 35. Hysteroscopy = Uterine Camera
    36. 36. Flexible hysteroscope
    37. 37. Normal Uterine Cavity
    38. 38. Uterine septum
    39. 39. Endometrial Polyps Slide courtesy of Linda Darlene Bradley, MD.
    40. 40. Vascular endometrial polyp
    41. 41. Uterine Polyp
    42. 42. Uterine Polyp
    43. 43. Large Uterine Polyp
    44. 44. Uterine Cavity Post Resection of Polyp
    45. 45. Uterine Polyps
    46. 46. Endometrial Hyperplasia r S Slide Courtesy of Linda Darlene Bradley, MD.
    47. 47. Uterine Submucosal Fibroid
    48. 48. Resection of uterine fibroid
    49. 49. Ablation Devices <ul><li>Novasure —uses radiofrequency electricity with a bipolar gold mesh electrode. The device is passed through the cervix and into the uterine cavity. </li></ul><ul><li>Ablation cycle takes 80-90 seconds. Very fast. </li></ul><ul><li>78% Success rate </li></ul><ul><li>35-41% amenorrhea rate </li></ul><ul><li>92% patient satisfaction rate at 1 year </li></ul>
    50. 50. Step 1 After slightly dilating your cervix and inserting a slender wand, your doctor will extend a triangular mesh device into your uterus.
    51. 51. Step 2 The mesh device gently expands, conforming to the dimensions of your uterine cavity.
    52. 52. Step 3 Electrical energy is delivered through the mesh for approximately 90 seconds.
    53. 53. Step 4 The mesh device is retracted back into the wand and both are removed from your uterus.
    54. 54. Novasure Endometrial Ablation
    55. 55. Thermachoice Endometrial Balloon
    56. 56. ThermaChoice Balloon
    57. 57. Ablation Devices <ul><li>Thermachoice —balloon tipped catheter is positioned into the uterine cavity and filled with fluid that is heated to 87 degrees centigrade. </li></ul><ul><li>Ablation cycle takes 8 minutes. </li></ul><ul><li>May be better suited for fibroid uterus. </li></ul><ul><li>Reported to decrease menstrual cramps better. </li></ul><ul><li>80 % success rate </li></ul><ul><li>37% amenorrhea rate at one year </li></ul><ul><li>96% patient satisfaction rate </li></ul>
    58. 58. Ablation Complications <ul><li>UTI 0.8-3 % </li></ul><ul><li>Vaginal infection 0.6-2.3% </li></ul><ul><li>Fever 1.4% </li></ul><ul><li>Endometritis 1-2.8 % </li></ul><ul><li>Abdominal pain/cramps 0.6-3.2% </li></ul><ul><li>Hematometra 0.6 % </li></ul><ul><li>Bacteremia 0.5% </li></ul><ul><li>Uterine perforations 1.4% </li></ul><ul><li>Fluid overload 0.2% </li></ul><ul><li>Postablation tubal ligation syndrome 1-10% </li></ul><ul><li>Electrolyte imbalance </li></ul><ul><li>Cervical laceration </li></ul>
    59. 59. Contraindicatons to Ablation <ul><li>Large uterus > 12 wks size </li></ul><ul><li>Uterine fibroids > 3 cm </li></ul><ul><li>Uterine cancer or uterine hyperplasia </li></ul><ul><li>Postmenopausal females </li></ul><ul><li>Recent pregnancy (must be at least 6 wks postpartum) </li></ul><ul><li>Desire for future pregnancy </li></ul><ul><li>Active or recent uterine infection (PID) </li></ul><ul><li>Previous uterine surgery (C/S or myomectomy) </li></ul><ul><li>Anatomic distortion (congenital uterine malformations—bicornuate uterus, etc.) </li></ul>
    60. 60. Effectiveness of Ablation <ul><li>>90 % patient satisfaction at 1 year </li></ul><ul><li>37-41% amenorrhea rate </li></ul><ul><li>About 10% dissatisfaction rate at one year </li></ul><ul><li>2-3 % have repeat ablations after one year </li></ul><ul><li>6-10% will have subsequent hysterectomy after one year </li></ul><ul><li>Some studies report 8% to 24% subsequent hysterectomy rates at 7 years post ablation </li></ul>
    61. 61. Endometrial Ablation Summary <ul><li>Endometrial ablations are effective treatment for abnormal uterine bleeding </li></ul><ul><li>Outpatient procedure </li></ul><ul><li>>90% patient satisfaction rate </li></ul><ul><li>High amenorrhea rate </li></ul><ul><li>Estimated that endometrial ablations will replace 30% of all hysterectomies done in U.S. </li></ul>
    62. 62. Hysterectomy Facts <ul><li>Most common female surgery </li></ul><ul><li>Definitive solution for many uterine conditions </li></ul><ul><li>650,000 procedures annually </li></ul><ul><ul><li>Most performed through abdominal (open) incision </li></ul></ul><ul><li>Advances in minimally invasive surgery (MIS) for hysterectomy </li></ul><ul><ul><li>More GYN surgeons performing MIS for hysterectomy </li></ul></ul>
    63. 63. Hysterectomy <ul><li>Total abdominal hysterectomy (TAH) </li></ul><ul><li>Vaginal hysterectomy </li></ul><ul><li>Laparoscopic assisted vaginal hysterectomy (LAVH) </li></ul><ul><li>Laparoscopic supracervical hysterectomy (LSH) </li></ul><ul><li>Total laparoscopic hysterectomy (TLH) </li></ul>
    64. 64. <ul><li>Open (abdominal) surgery </li></ul><ul><li>Minimally invasive surgery (MIS) </li></ul><ul><ul><li>Vaginal surgery </li></ul></ul><ul><ul><li>Conventional laparoscopic surgery </li></ul></ul><ul><ul><li>da Vinci ® Hysterectomy (robot-assisted surgery) </li></ul></ul>Surgical Approaches to Hysterectomy
    65. 65. Minimally Invasive Surgery (MIS) <ul><li>Reduced blood loss </li></ul><ul><li>Fewer complications </li></ul><ul><li>Shorter Hospital stay </li></ul><ul><li>Faster recovery </li></ul><ul><li>Less scarring </li></ul>Circa. 1991
    66. 66. Vaginal Surgery <ul><li>Pros </li></ul><ul><li>Minimally invasive </li></ul><ul><ul><li>Minimal scarring </li></ul></ul><ul><ul><li>Short hospital stay </li></ul></ul><ul><ul><li>Less pain compared to abdominal hysterectomy </li></ul></ul><ul><li>Cons </li></ul><ul><li>Difficult to perform </li></ul><ul><li>Reduced visualization </li></ul><ul><li>Not indicated for many patients </li></ul><ul><ul><li>Nulliparious (women who have not given birth) </li></ul></ul><ul><ul><li>Multiple fibroids (or large masses) </li></ul></ul><ul><ul><li>Cancer </li></ul></ul><ul><ul><li>Adhesions, e.g., endometriosis, prior pelvic surgery </li></ul></ul>
    67. 67. Laparoscopic Surgery <ul><li>Minimally invasive </li></ul><ul><ul><li>Ability to operate through small, keyhole incisions </li></ul></ul><ul><li>Better visualization than open surgery </li></ul>Open Vertical Incision Open Transverse Incision Laparoscopic or da Vinci ® Incision
    68. 68. Drawbacks with Conventional Laparoscopic Surgery <ul><li>Surgeon operates from a 2D image </li></ul><ul><li>Rigid instruments </li></ul><ul><li>Instruments controlled at a distance </li></ul><ul><li>Reduced dexterity, precision & control </li></ul><ul><li>Greater surgeon fatigue </li></ul><ul><li>Surgical assistance is limited </li></ul><ul><li>Makes complex operations more difficult to perform </li></ul>
    69. 69. How can we overcome these drawbacks? <ul><li>da Vinci ® Surgical System </li></ul><ul><li>State-of-the-art robotic technology </li></ul><ul><li>Surgeon in control </li></ul><ul><li>Assistant has direct access </li></ul>
    70. 70. Vision System Surgeon immersed in 3D image of the surgical field
    71. 71. <ul><li>Surgeon directs precise movements of the instruments using Console controls </li></ul>The Surgeon Directs the Instruments
    72. 72. <ul><li>Conventional minimally invasive instruments are rigid with no wrists </li></ul><ul><li>EndoWrist ® Instrument tips move like a human wrist </li></ul><ul><li>Allows surgeon to operate with increased dexterity & precision </li></ul>Wrist and Finger Movement
    73. 73. <ul><li>EndoWrist ® Instruments fit through dime-sized incisions </li></ul><ul><li>A wide range of instruments are available </li></ul>Small Instruments, Small Incisions
    74. 74. da Vinci ® Surgery <ul><li>Surgeon has… </li></ul><ul><li>Improved visualization </li></ul><ul><li>Better instrumentation, surgical control & precision </li></ul><ul><li>Better surgical dexterity for complex aspects of procedure </li></ul><ul><li>Easier & faster suturing </li></ul><ul><li>Better ergonomics </li></ul>Double-click to view video
    75. 75. Robot-Assisted Surgery Access Open Vertical Incision Open Transverse Incision da Vinci ® Surgical Incision
    76. 76. da Vinci ® Gynecologic Surgery Indications <ul><li>da Vinci ® Surgery appropriate for a broader range of gynecologic conditions & patient situations compared to conventional laparoscopy </li></ul><ul><ul><li>Cervical cancer </li></ul></ul><ul><ul><ul><li>Conventional laparoscopy not widely accepted </li></ul></ul></ul><ul><ul><li>Endometrial cancer </li></ul></ul><ul><ul><ul><li>Conventional laparoscopy accepted, but technically difficult to perform </li></ul></ul></ul><ul><ul><li>Vaginal or uterine prolapse </li></ul></ul><ul><ul><ul><li>Conventional laparoscopic suturing not reliable </li></ul></ul></ul><ul><ul><li>Endometriosis </li></ul></ul><ul><ul><li>Uterine fibroids </li></ul></ul><ul><ul><li>Obese patients </li></ul></ul>
    77. 77. Goals of da Vinci ® Hysterectomy <ul><li>Enable minimally invasive surgery (MIS) approach </li></ul><ul><ul><li>Easier to learn & perform compared to conventional laparoscopic surgery </li></ul></ul><ul><ul><li>da Vinci (robotic-assisted) Surgery will enable: </li></ul></ul><ul><ul><ul><li>More Gynecologists to perform minimally invasive surgery </li></ul></ul></ul><ul><ul><ul><li>Gynecologists to perform more advanced operations & more types of procedures using a minimally invasive approach </li></ul></ul></ul><ul><li>Provide benefits of MIS to hysterectomy candidates </li></ul><ul><ul><li>Short hospital stay </li></ul></ul><ul><ul><li>Minimal pain & scarring </li></ul></ul><ul><ul><li>Quick recovery & return to normal activities </li></ul></ul>
    78. 78. daVinci Robotic Platform
    79. 79. My Girls
    80. 80. My Girls