new development in surgical treatment of uterus ...intra-uterine balloon therapy: a novel ultrasound...

New Development

in Surgical Treatment of

Uterus & Endometrial

Pathology

Prof TC Li

Chinese University of Hong Kong

December 2017

Outline

Asherman Syndrome

Intramural fibroid or adenomyoma

Asherman Syndrome

New studies

New focus

New techniques

Asherman Syndrome

What is already known

Asherman syndrome is a common

problem

Surgical treatment is a challenge

Recurrence frequently occurs after

treatment

Not much new knowledge over the years

due to a lack of well planned clinical

studies

2017 is a turning point

Publications

Cohort study 2

Review

Meta-analysis

Guideline

3

RCT 4

Postop Estrogen therapy

Dose

2 to 12mg daily of estradiol or equivalent

Duration

2 weeks to 4 months

Pattern

Continuous or cyclical

No consensus

Prospective RCT

Fuxing Hospital, Beijing J Guo, TC Li, Y Liu, E Xia, Yu X, S Yang

RBM on line 2017

2 mg and 6 mg Estradiol; no difference

Postop Estrogen Therapy

Contrary to earlier belief, high dose

postoperative estrogen therapy is no

more effective than low dose

It remains to be seen whether low

dose E2 therapy is of any benefit.

Fresh Amnion Graft

Does it reduce recurrence?

Significantly reduced incidence of adhesion

recurrence at third look hysteroscopy

from 49 to 30%

Dried Amnion Graft

Efficacy of freeze-dried amnion graft

following hysteroscopic adhesiolysis of

severe intrauterine adhesions. Gan L, Duan H,Sun FQ, Xu Q, TangYQ, Wang S.

International J gynae Obstet 2017 137:116-122

RCT, 44 subjects each arm

Graft Beneficial

A Prospective, randomized, controlled trial

comparing three different durations of

intrauterine Cook balloon (1, 2 and 4 weeks)

therapy in preventing adhesion reformation

after hysteroscopic adhesiolysis

Xue Yang, Yu-Huan Liu, En-Lan Xia, Yu Xiao,

Dong-Mei Song, Qiao-Yun Zhou, Jun Guo, TC Li

Fuxing Hospital, Beijing, Submitted

Postop intra-uterine Balloon How long should it stay in situ?

IUA scores Group A: 1 week

Group B: 2 weeks

Group C: 4 weeks

Asherman Syndrome

New studies

New focus

New techniques

Prevention

Secondary : prevents recurrence

Primary : prevents occurrence

RCT primary prevention Surgical Evacuation for miscarriage

Gel reduced

incidence of

adhesion by ~50%

Additional important primary

preventive measures (other than adjuvants)

20

Recommendation 1

Avoid surgery

Avoid curettage of the

gravid uterus

21

Recommendation 2

Perform intra-uterine surgery

with minimal tissue damage

Use the minimal amount of energy (mechanical or electrical) necessary to

reduce tissue injury

Gentle surgery

Recommendation 3

Precision surgery

Stop the surgery

when the cavity is

empty

There is no need to do check curettage

What is new?

New studies

New focus

New techniques

Choosing different techniques

Methods Special value

Hot wire

(diathermy)

Traditional methods

Good for dense adhesions

Requires anesthetics Cold steel

(scissors)

Balloon therapy

Invisible Knife

Intra-uterine balloon therapy:

A novel ultrasound guided treatment

for intrauterine adhesions

Gynaeology Surgery (2016)

S Saravelos & TC Li

New techniques

(1) Balloon therapy

Gradual dilatation: 3 ,4, 5 ml

After Balloon Therapy

After Balloon Therapy

After Balloon Therapy

Ultrasound-guided Balloon Dilatation

to prevent recurrence of IUA

32

RCT: Intermittent Balloon therapy

Fuxing Hospital

IUA , n=100 each arm

2 week - balloon

6 week - balloon

4 week - Second look 4 week - Second look

8 week -Third look 8 week - Third look

RCT: Intermittent Balloon therapy

Fuxing Hospital

IUA , n=100 each arm

2 week - balloon

6 week - balloon

4 week - Second look 4 week - Second look

8 week -Third look 8 week - Third look

New Surgical Techniques

(2) The invisible knife

The invisible knife

200 mm HG pressure (safe)

Atraumatic, hardly any bleed

Particularly useful for newly formed

or mild-moderate adhesions

Outpatients procedure

No analgesics required in vast

majority of cases

The invisible knife

with Lignocaine gel

Choosing different techniques

Methods Special value

Hot wire

(diathermy)

Traditional methods

Good for dense adhesions

Requires anesthetics Cold steel

(scissors)

Balloon therapy Suitable for mild to moderately

or newly formed adhesions or

during second look

No anesthetics Invisible Knife

Outline

Asherman Syndrome

Intramural fibroid or adenomyoma

laparoscopic Hysteroscopic

Cystic adenomyoma

Surgical Tips

• Careful preoperative assessment including

measurement of safety margin & 3D imaging

Cystic adenomyoma

Surgical Tips

• Careful preoperative assessment including

measurement of safety margin & 3D imaging

• Pre-op GnRH downregulation

• Cervical priming

• Use lowest effective filling pressure

Surgical Tips

• Careful preoperative assessment including

measurement of safety margin & 3D imaging

• Pre-op GnRH downregulation

• Cervical priming

• Use lowest effective filling pressure

• Intraoperative ultrasound monitoring – the

safety margin may change

Surgical Tips

• Careful preoperative assessment including

measurement of safety margin & 3D imaging

• Pre-op GnRH downregulation

• Cervical priming

• Use lowest effective filling pressure

• Intraoperative ultrasound monitoring – the

safety margin may change

• Stimulate uterus to contract

• Be prepared to complete in 2-stages

Stimulating uterus to contract

Manual Massage

Loop diathermy massage

Vasopressin

Summary

There are new approaches and

techniques used to treat uterine and

endometrial pathology

The preservation of endometrial function

and the avoidance of long term

complications such as scar rupture remain

two most important goals of uterine

surgery

Thank You