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Endometrial ablation or resection: Resectoscopic techniques

Endometrial ablation or resection: Resectoscopic techniques
Literature review current through: Jan 2024.
This topic last updated: Nov 08, 2022.

INTRODUCTION — Endometrial ablation is a minimally invasive option for the treatment of abnormal uterine bleeding. Resectoscopic endometrial ablation (REA) techniques are performed under hysteroscopic visualization, using resectoscopic instruments to ablate or resect the endometrium. These techniques are also referred to as standard or first-generation ablation. Non-resectoscopic endometrial ablation (NREA), also referred to as second-generation ablation, is performed with a device that is inserted into the uterine cavity and delivers energy in an attempt to uniformly destroy the uterine lining.

REA techniques for endometrial ablation will be reviewed here. Other related content is discussed separately and includes:

General principles of endometrial ablation (see "Overview of endometrial ablation")

Techniques for NREA (see "Endometrial ablation: Non-resectoscopic techniques")

Alternate management options for abnormal uterine bleeding (see "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management")

TECHNIQUES — There are two main REA techniques [1-3]; all methods desiccate the endometrium to the level of the basalis (figure 1):

Endometrial desiccation with an electrosurgical rollerball or rollerbarrel (picture 1 and picture 2).

These devices use thermal energy for heating the tissue to a temperature between 60 to 90°C, which desiccates and destroys the tissue. No tissue is removed.

Resection with a monopolar or bipolar loop electrode (picture 1 and picture 3).

Thermal energy is also used with these electrodes; the loop electrodes resect the endometrium beyond the basalis layer to the myometrium. The resected tissue is sent to pathology for histologic diagnosis.

Less commonly used techniques include laser vaporization (high energy is used to rapidly heat the intracellular water to 100°C, causing vaporization of tissue; no tissue is removed) and radiofrequency vaporization (rare) [4].

METHOD SELECTION — How to choose between REA and NREA techniques is discussed in detail separately (algorithm 1). (See "Overview of endometrial ablation", section on 'Choosing the type of ablation'.)

For most patients undergoing REA, we suggest rollerball endometrial ablation rather than resection or vaporization. Rollerball is the most-used REA method as it requires less advanced hysteroscopic skills than wire loop endomyometrial resection [5] and is less costly than laser vaporization. Ultimately, the choice is often individualized and based on the surgeon's familiarity with the various devices. However, no tissue is removed with rollerball ablation. Thus, for patients in whom histologic examination of the resected tissue is needed, resection with a wire loop is required.

The best available data regarding REA techniques were presented in a 2019 meta-analysis of randomized trials comparing rollerball, vaporizing electrode, and laser methods with endomyometrial resection [6]. One limitation of this meta-analysis was that most of the evidence was low to moderate quality and was downgraded because of inadequate concealment and lack of blinding in many trials. Major findings included:

Rates of reduced menstrual bleeding, amenorrhea, satisfaction at six months or one year of follow-up, and subsequent hysterectomy were similar between groups. Because some patients will not have amenorrhea, reduction in volume of uterine bleeding rather than amenorrhea may be a better marker of treatment success.

The study with the longest follow-up was a randomized trial (not included in the meta-analysis) including 120 patients assigned to either rollerball ablation or wire loop resection [7]. At 10-year follow-up, 93 percent of patients in the study were amenorrheic. Patients treated with rollerball compared with resection had higher rates of repeat ablation (13 versus 8 percent) and hysterectomy (25 versus 19 percent); however, tests of significance were not reported. Most patients with endometrial ablation will not have amenorrhea, and reduction in volume of uterine bleeding rather than amenorrhea may be a better marker of treatment success.

Some, but not all, trials found that ablation took longer than resection (mean difference 9.15 minutes, 95% CI 7.2 to 11.1; 386 patients; two studies) [6]; this increased duration may not be clinically significant.

Rates of complications were overall similar between groups; one study found an increase in irrigation fluid deficit (an additional 258 mL) with endomyometrial resection with a wire loop compared with vaporizing electrode [6]. By contrast, other studies have demonstrated higher rates of uterine perforation with wire loop resection [8,9].

General outcomes of REA and NREA are discussed separately. (See "Overview of endometrial ablation", section on 'Outcomes'.)

PREOPERATIVE PLANNING AND PREPARATION — General principles of endometrial ablation, including indications, contraindications, preoperative issues (eg, endometrial sampling, uterine assessment, endometrial preparation), as well as how to choose between REA and NREA, are discussed in detail separately. (See "Overview of endometrial ablation".)

REA is performed under hysteroscopic visualization and requires the use of a resectoscope (picture 4). Positioning, sterile preparation, and cervical dilation are the same as for hysteroscopy. In our practice, we use a zero-degree hysteroscope to provide a panoramic view of the uterine cavity. (See "Overview of hysteroscopy".)

ROLLERBALL OR ROLLERBARREL OPERATIVE TECHNIQUE

Instrumentation — Rollerball (or rollerbarrel) endometrial ablation may be performed using monopolar or bipolar electrical energy. Typically, the radiofrequency generator is set to 50 to 80 watts of coagulation or cutting current in order to desiccate the endometrium. We prefer cutting current, since coagulation current may result in vaginal burns caused by arcing and capacitive coupling [10]. A 3- or 5-mm rollerball is typically used.

The advantage of a bipolar system is that saline, rather than electrolyte-free hypoconductive fluid, is used to reduce the risk of fluid overload. Excessive absorption of hypoconductive fluids (eg, glycine) may result in hyponatremia. (See "Hyponatremia following transurethral resection, hysteroscopy, or other procedures involving electrolyte-free irrigation".)

Procedure

Insert the resectoscope through the appropriately dilated cervix (see 'Preoperative planning and preparation' above), distend the uterus with fluid, and inspect the uterine cavity.

Position the rollerball at one of the uterine cornu. It is helpful to start the desiccation at the cornua and then move to the anterior fundal wall due to bubble formation in the uterine cavity. Complete the ablation on the posterior wall since the bubbles formed will be anterior. Activate the current and slowly bring the rollerball towards the surgeon until small bubbles are visualized at the leading edge. To avoid injury, it is important to keep the rollerball in view at all times and activate it only when moving it towards the operator. Desiccating the endometrium to a depth of 5 to 6 mm ensures the endometrium is destroyed to the level of the basalis (figure 1) and is unlikely to regenerate in the presence of reproductive hormones. A thin endometrium will be quickly desiccated to this level. When the myometrium is reached, the surgeon will note small bubbles forming around the leading edge of the rollerball. Avoid desiccation of the cervico-uterine junction since this may result in cervical stenosis or uterine occlusion.

Repeat this motion until the entire surface of the endometrium has been desiccated.

RESECTOSCOPIC (WIRE LOOP) OPERATIVE TECHNIQUE

Instrumentation — Endometrial ablation with resection is performed using monopolar or bipolar electrical energy. When a monopolar resectoscope is used, the radiofrequency generator is set to 80 to 100 watts of cutting current or blend 1. In our practice, we prefer cutting current and set it to 80 watts.

As with rollerball ablation (see 'Rollerball or rollerbarrel operative technique' above), bipolar resectoscopes are also available, allowing for the use of saline as a distending medium and reducing the risk of fluid overload. Bipolar resectoscopes are available in 8.5 mm (26 French) and 7 mm (22 French) outer diameter sizes. When a bipolar resectoscopic procedure is performed, a generator produces a high initial voltage arc that converts the sodium chloride solution into a vapor, causing rupture of the cell membrane which creates a cutting effect with the loop electrode. This is accomplished with a setting of approximately 130 watts.

Cutting loops are available in different sizes, ranging from 4 to 8 mm. We use a 6 mm diameter cutting loop which, when inserted to its full radius, will resect 3 mm of tissue, though some surgeons prefer an 8 mm loop which removes 4 mm of tissue. Though the 4 mm loop may decrease the risk of damage, it requires longer resection times. We prefer the 6 mm loop as a good balance of speed and safety.

Procedure

Insert the resectoscope through the appropriately dilated cervix (see 'Preoperative planning and preparation' above), distend the uterus with fluid, and inspect the uterine cavity.

Position the resection loop at the uterine fundus. It is helpful to start at the midline of the fundus, and we avoid resection at the cornua. We prefer to ablate the cornua with a rollerball to decrease the risk of perforation at this vulnerable region of the uterus. Complete the resection on the posterior wall since the bubbles formed will be anterior. Activate the current and bring the loop toward the surgeon. To avoid injury, it is important to keep the loop in view at all times and activate it only when moving it toward the operator. Holding the loop just off the tissue will create a steam layer on which the electrode glides easily across the tissue; dragging the electrode in direct contact with tissue may cause sticking and inefficient resection.

Repeat this motion until the entire surface of the endometrium has been resected, with the exception of the region of the cornua.

LESS COMMONLY USED TECHNIQUES — Neodymium:yttrium-aluminum-garnet (Nd-YAG) laser endometrial ablation is a less commonly used technique in which an Nd-YAG laser in flexible quartz fibers is directed at the endometrium. The quartz fibers come in variable diameters from 600 to 1200 micrometers. The 600-micrometer fiber is used most commonly at 50 to 75 watts. The Nd-YAG laser penetrates to a depth of 4 to 6 mm. The procedure is performed as follows:

Insert the resectoscope through the cervix, distend the uterus with fluid, and inspect the uterine cavity.

Position the Nd-YAG laser at the uterine fundus. A bare fiber is used with approximately 5 to 10 mm of the end protruding through the distal end of the hysteroscope. This tip should be visualized at all times during activation. Parallel furrows are produced in the endometrium by dragging the fiber along the surface of the endometrium; this way, it is easier to differentiate treated versus nontreated areas.

Repeat this motion until the entire surface of the endometrium has been ablated.

Laser vaporization is another technique that is rarely used.

COMPLICATIONS — Complications associated with endometrial ablation include uterine perforation, hemorrhage, hematometra, fluid overload, and pelvic infection. Overall, complications are similar for the various REA techniques, with the exception of uterine perforation and fluid overload, which may be higher in those undergoing wire loop resection. (See 'Method selection' above.)

General complications of REA and NREA are discussed separately. (See "Overview of endometrial ablation", section on 'Complications'.)

SPECIAL POPULATIONS

Patients with leiomyomas or polyps — For patients with submucosal leiomyomas, REA can be performed following hysteroscopic myomectomy. When concurrently performed, the procedure is limited by the amount of irrigation fluid absorbed. It is uncertain whether this procedure is more effective at improving uterine bleeding symptoms than myomectomy alone. These issues are discussed in detail separately. (See "Hyponatremia following transurethral resection, hysteroscopy, or other procedures involving electrolyte-free irrigation" and "Uterine fibroids (leiomyomas): Hysteroscopic myomectomy", section on 'Concomitant procedures' and "Overview of endometrial ablation", section on 'Hysteroscopic myomectomy'.)

Endometrial polyps can also be removed prior to endometrial ablation. (See "Endometrial polyps".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Ectopic pregnancy".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Endometrial ablation (The Basics)")

SUMMARY AND RECOMMENDATIONS

Terminology – Resectoscopic endometrial ablation (REA) is a treatment for abnormal uterine bleeding that is performed under hysteroscopic visualization, using resectoscopic instruments to ablate or resect the endometrium. (See 'Introduction' above.)

Techniques – REA uses one of two main techniques: endometrial desiccation with an electrosurgical rollerball or rollerbarrel (picture 1 and picture 2), and resection with a monopolar or bipolar loop electrode (picture 1 and picture 3). Rollerball endometrial ablation is the most used REA method. Less commonly used techniques include laser vaporization and radiofrequency vaporization (rare). All methods attempt to desiccate the endometrium to the level of the basalis (figure 1). (See 'Techniques' above and 'Method selection' above.)

Method selection How to choose between REA and non-resectoscopic endometrial ablation (NREA) techniques is discussed in detail separately (algorithm 1). (See "Overview of endometrial ablation", section on 'Choosing the type of ablation'.)

For those undergoing REA:

For most patients undergoing REA, we suggest rollerball endometrial ablation rather than wire loop resection or vaporization (Grade 2C). Rollerball ablation requires less advanced hysteroscopic skills than wire loop resection and is less costly than laser vaporization. (See 'Method selection' above.)

For patients in whom tissue is needed for histologic evaluation, resection with a wire loop is required. (See 'Method selection' above.)

Preoperative preparation

REA is performed under hysteroscopic visualization and requires the use of a resectoscope (picture 4). Positioning, sterile preparation, and cervical dilation are the same as for hysteroscopy. (See 'Preoperative planning and preparation' above and "Overview of hysteroscopy".)

Other preoperative issues (eg, endometrial sampling, uterine assessment, endometrial preparation) are discussed in detail separately. (See 'Preoperative planning and preparation' above and "Overview of endometrial ablation".)

Instrumentation

Rollerball or rollerbarrel – Rollerball or rollerbarrel ablation is typically performed with a monopolar resectoscope. The radiofrequency generator is set to 50 to 80 watts of coagulation or cutting current; we prefer cutting current, since coagulation may result in vaginal burns. Alternatively, a bipolar resectoscope can be used. (See 'Rollerball or rollerbarrel operative technique' above.)

Resection (wire loop) – Resectoscopic (wire loop) ablation is performed using monopolar or bipolar electrical energy. Typically, the radiofrequency generator is set to 80 to 100 watts of cutting current or blend 1; in our practice, we prefer cutting current on 80 watts. Cutting loops are available in different sizes; we prefer the 6 mm loop as a good balance of speed and safety. (See 'Resectoscopic (wire loop) operative technique' above.)

Complications – All methods of REA appear to have similar rates of complications, though rates of bleeding, uterine perforation, and fluid overload may be higher in those undergoing wire loop resection. General complications of REA are discussed separately. (See 'Complications' above and "Overview of endometrial ablation", section on 'Complications'.)

Patients with leiomyomas and polyps – For patients with submucosal leiomyomas, REA can be performed following hysteroscopic myomectomy. It is uncertain whether this procedure is more effective at improving uterine bleeding symptoms than myomectomy alone. Endometrial polyps can also be removed prior to ablation. (See 'Patients with leiomyomas or polyps' above.)

  1. Munro MG. Endometrial ablation: where have we been? Where are we going? Clin Obstet Gynecol 2006; 49:736.
  2. Vancaillie TG. Electrocoagulation of the endometrium with the ball-end resectoscope. Obstet Gynecol 1989; 74:425.
  3. DeCherney A, Polan ML. Hysteroscopic management of intrauterine lesions and intractable uterine bleeding. Obstet Gynecol 1983; 61:392.
  4. Goldrath MH, Fuller TA, Segal S. Laser photovaporization of endometrium for the treatment of menorrhagia. Am J Obstet Gynecol 1981; 140:14.
  5. Papadopoulos NP, Magos A. First-generation endometrial ablation: roller-ball vs loop vs laser. Best Pract Res Clin Obstet Gynaecol 2007; 21:915.
  6. Bofill Rodriguez M, Lethaby A, Grigore M, et al. Endometrial resection and ablation techniques for heavy menstrual bleeding. Cochrane Database Syst Rev 2019; 1:CD001501.
  7. Fürst SN, Philipsen T, Joergensen JC. Ten-year follow-up of endometrial ablation. Acta Obstet Gynecol Scand 2007; 86:334.
  8. Overton C, Hargreaves J, Maresh M. A national survey of the complications of endometrial destruction for menstrual disorders: the MISTLETOE study. Minimally Invasive Surgical Techniques--Laser, EndoThermal or Endorescetion. Br J Obstet Gynaecol 1997; 104:1351.
  9. Bhattacharya S, Cameron IM, Parkin DE, et al. A pragmatic randomised comparison of transcervical resection of the endometrium with endometrial laser ablation for the treatment of menorrhagia. Br J Obstet Gynaecol 1997; 104:601.
  10. Munro MG. Mechanisms of thermal injury to the lower genital tract with radiofrequency resectoscopic surgery. J Minim Invasive Gynecol 2006; 13:36.
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