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