Techniques of hysteroscopic endometrial ablation

A complete description of the various techniques of endometrial ab­lation is beyond the scope of this chapter; however, briefly there are two types: electrosurgical and laser methods.

There are two different types of electrosurgical treatment: roller­ball endometrial ablation and loop endometrial resection.

Rollerball endometrial ablation

This technique involves using a ball electrode to treat the endomet­rial lining. It has become popular because of its relative simplicity and cost advantage compared with laser ablation (26, 27).

It is a safe and effective technique, having also the advantage of being quick to perform (28). The safety and efficacy of the technique have been well demonstrated by several studies which have 2-year follow-up on 200 patients, which reported a success rate of 90% and a repeat procedure rate of 4% with 5% of women ultimately under­going hysterectomy (29).

Rollerball endometrial ablation has the following advantages and disadvantages:

Advantages

• Easier to learn and perform than resection.

• Less risk of uterine perforation, fluid reabsorption, and haemor­rhage than endometrial resection.

• Shorter operating time.

Disadvantages

• No endometrial specimen for histology.

• Cannot treat submucous fibroids.

• Use of monopolar energy which is less safe than bipolar energy.

Loop endometrial resection

TCRE is a technique which has also been shown to be an effective and safe method for treating heavy menstrual bleeding (30-32).

The use of the loop-shaped electrode through a monopolar or bi­polar continuous flow resectoscope produces efficient resection of the endometrium and underlying superficial myometrium—this provides tissue for histological examination.

Bipolar resectoscopes have been introduced which increases the safety of the procedure with respect to fluid overload as uterine distention with normal saline is associated with less electrolyte dis­turbance than is the case with electrolyte-free solutions.

The most important principle of loop resection is to only activate the electrode as it is being pulled towards the cervix—this makes ac­cidental perforation of the uterus less likely. TCRE can be combined easily with hysteroscopic myomectomy in women with heavy men­strual bleeding and submucous fibroids.

TCRE is certainly a proven alternative to hysterectomy with high satisfaction rates ranging between 70% and 94% (31).

Endometrial resection has the following advantages/ disadvantages:

Advantages

• Provides endometrial tissue for histology.

• Submucous fibroids or polyps can be excised at the same time.

• Suitable if endometrium is thick.

Disadvantages

• It is a skill-dependent technique.

• Greatest risk of uterine perforation.

• Need to use electrolyte-free distention media with monopolar resectoscope.