TCRE or hot ballon -- where and how should be use

3.  when blood lose
is more than 80 ml
per menstrual cycle

4. Endometrium

9.  destroy the endometrial lining of the uterus
upto basal layer

12.  uterine size <12 weeks gestation or
 uterine cavity length <12 cm,
 no cancerous or precancerous lesions of the
endometrium or cervix,
 completion of childbearing,
 no acute genital tract infection,
 no fibroids greater than 5 cm in diameter, and
 no absolute desire for amenorrhea
 (Lessard & Framarin 2002).

13.  the presence of adenomyosis
 Complete septate or bicornuate uterus
 the presence of any uterine sub-mucous
fibroids,

14.  TCRE- First generation endometrial ablative
techniques
 Balloon therapy- Second generation
endometrial ablative techniques

15.  use a hysteroscope and fluid medium,
 require a high level of technical skill.
 They includes-
 Trans-cervical resection
of the endometrium (TCRE),
 Roller-ball endometrial ablation (RB),
 Nd:YAG laser endometrial ablation)

16.  introduced in 1980s.
 use cutting current.
 Uses glycine 1.5%
 10 mm dilatation done & loop resection started from
above downwards and Endometrium is shaved in small
strips superficially from the surface systemically till
basal layer is reached.

17.  “Endometrial ablation techniques in the
treatment of dysfunctional uterine bleeding”
 Lessard and Framarin reviewed and
summarized first- and second-generation EA
techniques to treat DUB in Quebec.
 According to AETMIS, TCRE is an accepted
technique.

18.  safe,
 Effective with
 reproducible results.
 yields a high level of satisfaction.

19.  Electrosurgical burns
 Uterine perforation and visceral injuries
 Cervical lacerations
 Hemorrhage
 Infection
 Fluid overload (congestive heart failure,
hypertension, hemolysis, pulmonary and brain
edema, coma, and death)
 Electrolyte imbalance due to glycine absorption
in blood

20. How to avoid all these adverse effects???
Need arises of new techniques which are
 Safe and effective
 Easy to use and easy to learn
 Free of all above possible complications
 Less operative time
 May be possible under local anesthesia
 More suitable to office
 Cost effective

21.  In 1990s, second-generation ablation
techniques developed with the aim to
provide
 simpler,
 quicker, and
 more effective treatment compared with first-
generation techniques.

22.  performed on an outpatient basis.
 Easy to use
 not as operator dependent
 rely heavily on the devices to ensure safety and
efficacy.
 usually non-hysteroscopic,
 do not require a fluid medium, and
 require less training to perform.
 Procedural risks are minimal when used in patients
with severe medical disorders

23.  Cavaterm plus System (Wallsten Medical
SA; Morges, Switzerland),
 Thermablate EAS (MDMI Technologies Inc.;
Richmond, BC, Canada),
 Thermachoice Uterine Balloon Therapy
System (Gynecare, A Division of Ethicon
Inc.; Somerville,NJ, United States),
 MenoTreat (Lina Medical) is available in
Europe but is not licensed by Health
Canada.

24.  only TBEA is accepted according to
AETMIS. (out of all of the second-generation
techniques)
 The long-term results of a RCT and of
several other studies indicate that this
technique is
 comparable to TCRE on efficacy and the
reoperation rate.

25.  Insertion and Inflation
 The balloon catheter is inserted vaginally, through the cervix, into the
uterus. Inflation occurs when the catheter is filled with a sterile fluid
solution until the pressure reaches 160 to 170 mm of mercury.
 Ablation and Monitoring
 A heating element inside the balloon raises the temperature to about
87 degrees C and maintains it for about 8 minutes.
 Deflation and Removal
 When the controller signals that treatment is complete, the balloon is
deflated and the catheter is
 withdrawn and discarded.
 Above figures used with permission from Gynecare, a division of
Ethicon Inc. From: http://www.gynecare.com/

27.  What studies says???
 Which is better tech.
TCRE or balloon therapy

28. TCRE BALLON THERAPY
Hysteroscopic Visual technique Non- hystereroscopic non Visual
Operator dependent, needs
considerable surgical skills
More dependent on machine
Needs GA to perform Can be done in local anesthesia
In patient only Can be done on out patient basis
Needs cervical dilation No such need
Needs glycine to operate Not needed
Longer operating time average 30min 15min
provides endometrium sampling for
HPE
NA
destroys 4-5 mm endometrium and
forms uterine synechiae
UBT destroys 6mm of endometrium.

30. TCRE Balloon therapy
Complications of GA No GA, only local aneasthesia
Cervical lacerations No cervical dialation
Blunt uterine perforations[14.7 per 1000
procedures]
nil
Uterine perforations by active electrode nil
Thermal visceral injuries May be possible
May needs emergency laparotomy Rare
May need emergency hysterectomy[6.6
per 1000 procedures ]
rare
Fluid overload and Electrolyte imbalance No use of fluid or glycine
No pain Pt. may feel pain due to balloon
distension

31.  TBEA had significantly shorter operating and
theatre times (P < .05, < .01, and .0001).
 TBEA had fewer intraoperative adverse
effects (e.g., reported rates of uterine
perforation with TCRE: from 1% to 5%;
TBEA: 0%;
 rates of cervical laceration with RB: 2% to
5%; TBEA 0%).

33. TCRE more incidence of Balloon therapy[ TBEA]
endometritis Pain
hematometra nausea
fever headache
Urinary tract infection
hemorrhage
hydrosalpinx

34.  Reduction in blood loss after treatment
 amenorrhea
 Dysmenorrhea
 Quality of life
 Satisfaction
 Need of hysterectomy in future

41. Reduction in blood loss after treatment No significant difference
amenorrhea No significant difference
Dysmenorrhea No significant difference
Quality of life No significant difference
Satisfaction with treatment after
surgery
Favored balloons
Need of hysterectomy in future No significant difference
Less costlier then hysterectomy Overall cost is less then TCRE

42.  Which technique is more cost effective???

45.  For TBEA compared with TCRE, costs were
lower with TBEA
 Compared with hysterectomy, TBEA costs
moderately.

46.  The economic model suggests that second-
generation techniques are more cost-
effective than first-generation techniques of
EA for HMB.
 TBEA appears to be less costly than
hysterectomy,

47.  The Cochrane review conducted by Lethaby and
Hickey (2004 and 2002) compared the efficacy,
safety and acceptability of methods used to destroy
the endometrium.
 The review compares first-generation techniques to
second generation techniques.
 And conclude that there is sufficient evidence to
confirm that, on average, second-generation
techniques are technically simpler and quicker to
perform than first generation techniques, while
satisfaction rates and reductions in heavy
menstrual bleeding are similar.

48.  TBEA is effective, safe & cost-effective.
 TBEA is a better alternative to first-
generation techniques,
 because it is associated with fewer
intraoperative adverse effects.
[Thermal Balloon Endometrial Ablation - Ontario Health Technology
Assessment Series 2004; Vol. 4, No. 11]

50.  Further research is suggested to make direct
comparisons of second-generation EA
techniques,
 Should we think about any third generation
technique??

51. Wishing to all ladies to
have a happy uterus