What Is an Endocervical Curettage?
Endometrial ablation is used to treat dysfunctional uterine bleeding. The principle is to remove the entire endometrium and part of the superficial muscle layer by various methods under direct vision.
Endometrial ablation
Right!- Chinese name
- Endometrial ablation
- Object
- Endometrium
- Method
- surgery
- Attend
- Dysfunctional uterine bleeding
- Endometrial ablation is used to treat dysfunctional uterine bleeding. The principle is to remove the entire endometrium and part of the superficial muscle layer by various methods under direct vision.
- Endometrial removal for dysfunctional uterine bleeding is a newer gynecological technique. The basic principle is to remove the entire endometrium and part of the superficial muscle layer in various ways under direct vision to ensure complete removal of the endometrium. Membrane basal glands. If the operation is proficient, the operation is safe and effective, but serious complications have been reported.
Endometrial ablation (ednometrialablation, EA) refers to the destruction of endometrial functional layer, basal layer, and even muscle layer under the guidance of hysteroscopy, resulting in less menstruation and even amenorrhea, so as to achieve treatment of endometrium
Department of Obstetrics and Gynecology, Beijing Tiantan Hospital, Capital Medical University
- At present, there are mainly the following methods.
1. Vaporized endometrial resection (Versapoint):
The device is a hysteroscopic resectoscope with a gasification electrode, a surgical power of 200W, and a destruction depth of 5mm. Gasified EA can not only remove the submucosal fibroids at the same time as an electric knife, but also has the advantages of a safe ball electrode and less absorption of uterine fluid. It is reported that gasified EA treated 40 patients with abnormal uterine bleeding, including 26 patients with submucosal fibroids without complications. After an average follow-up of 203 months, 57.5% of amenorrhea or dripping bleeding, 25% less menstruation, 15% normal menstruation, 2.5% ineffective, 90% satisfaction rate. The clinical effects of 47 cases of EA and 44 cases of TCRE were also randomly compared. The average operation time was about 10 minutes in both groups. The former was considered to be easier to operate, and the amount of uterine fluid absorbed by the body was about one third of the latter. At 1 year postoperative follow-up, amenorrhea, menstruation, or dripping bleeding, normal and excessive menstruation, the gasification EA group was 36%, 43%, 21%, and 0, respectively, and the TCRE group was 48%, 32% , 16% and 5%. It can be seen that the effects of gasification EA and TCRE are similar, but the safety of gasification EA is high.
Shi Yongpeng and others used a bipolar vaporization system, 0.9% physiological saline was dilated uterine fluid, dilated pressure was 25-30 Kpa, and the effective rate was 97.7%. Bipolar vaporization has similar cutting and hemostatic effects as unipolar resection. Because it uses physiological saline as the perfusate, the incidence of dilute hyponatremia caused by the perfusate absorption is extremely low, which is a safe and effective endometrium. Removal method.
2. Hot water circulation endometrial removal (Hydrothermo-ablation, HTA)
In 1995, Baggish designed a device using low-pressure thermosaline circulation to perform hot-water circulation endometrial removal. The safety of this method has been proven. Its principle is to inject 0.9% physiological saline heated to 90 ° into the uterine cavity through a hysteroscope to destroy the endometrium. The depth of endometrial thermal injury is 4-5mm, and the basal layer is not injured. The cervical temperature is 42 ° during operation. On the one hand, the normal diastolic pressure of the fallopian tube is not less than 70mmHg. When the pressure in the uterine cavity is between 45-55mmHg, the liquid cannot flow into the fallopian tube. On the other hand, the stimulation of hot water causes the uterine horn to contract, closing the fallopian tube opening, and hot water will not flow. In the abdominal cavity, causing thermal damage to the peritoneum and abdominal organs. Gerson et al. Treated 26 patients with menopause with HTA and followed up for 18 months. The rate of postoperative amenorrhea or menstruation was 77% at 6 months, 88% at 12 months, 87.5% at 18 months, and a successful operation rate of 96.2%. During the operation, laparoscopy was used to monitor the uterus and fallopian tubes. No fluid leaked from the umbrella end of the fallopian tubes. No obvious side effects and complications were found during and after the operation. Romer et al. [9] treated 18 patients with recurrent menstruation with HTA and followed up for 12 months. The postoperative amenorrhea rate was 50% and the successful rate was 94%. Laparoscopic surveillance during the operation also found no leakage of the fallopian tube. It was also reported that there were 60 more menstrual periods in HTA treatment, followed up for 12 months, the postmenopausal rate was 45%, the menorrhagia rate was 38%, and the success rate was 95%.
3. Cryoablation
The device is a cryostat. The size of the ice ball needs to be monitored by ultrasound. The operation is terminated when the freezing thickness reaches 50% of the myometrium. Rutherford et al reported that 50% of amenorrhea occurred in 15 patients at 22 months after surgery. Dobak et al. Used a new type of freezing device to insert the uterine cavity of 10 patients during hysterectomy. 12mm without necrosis of the whole muscle wall.
Fourth, microwave endometrial ablation (MicrowaveEndomertialAblation, MEA)
MEA was first applied clinically by Sharp in 1995. Microwave energy penetrates into tissue like any other electromagnetic energy, and its wavelength determines the depth of penetration. The endometrium needs a penetration depth of 6mm, which requires high-frequency, short-wavelength microwaves. The selected frequency for endometrial ablation is 9.2GHz, and the output power is 30W. In order to allow the microwave generator to safely enter the cervix through the cervix to release energy, waveguide technology needs to be applied to determine that the maximum diameter of the waveguide does not exceed 8 mm. The waveguide uses a ceramic rod as the dielectric substance to effectively compress the microwave. It is extended in the middle, its round end releases microwaves into the tissue in a hemispherical manner, and its energy is controlled by a foot pedal. The energy in the uterine cavity can reach 1.5-9.3KJ and the temperature can reach 80-95 ° C.
Cooper reported 263 randomized cases, of which 129 received MEA and 134 received TCRE. After 1 year of follow-up, the satisfaction rate was 77% in the MEA group, 75% in the TCRE group, and the menopause rates were 50% and 40%. The operative time and postoperative recovery time were better in the MEA group than in the TCRE group. Parkin summarized the safety study data of 1,433 MEA in 13 medical units in 5 years. The complications included 14 cases of endometritis (9.77 ), 4 cases of uterine perforation (2.79 ), and only 1 case had serious complications, namely the small intestine. Perforation (0.70 ), this patient is a person with a history of two cesarean sections. After timely treatment, the patient recovered well. There were no cases of acute uterine perforation and death in 1,433 cases. Hysteroscopy of MEA showed that the endometrium was fragmented and the uterine cavity was flattened after the fragment was removed. MEA treats excessive menstrual blood, with quick results, short operation time, fast recovery, and high satisfaction rate. There is no need to use hysteroscopy, and heat feedback temperature is used to monitor the surgical process. Compared with TCRE, the operation is simple and the complications are few. It is suitable for cases of uterine malformation and abnormal uterine cavity, and even uterine fibroids less than 5cm can be treated.
V. Hot-bulb Endometrial Removal (UterineBalloonThermo-Ablation, Ubt)
The uterine hot bulb system is based on the principle of hot scalding, which destroys the functional layer of the endometrium, the glandular epithelium of the basal layer and the superficial smooth muscle tissue below the basal layer, making it degenerative and necrotic. It is used to treat menstruation and does not require fertility. Women to achieve the goal of no menstruation, less menstruation or normal menstruation. This method does not require special training and experience in hysteroscopic surgery, and is a safe and effective option for women with menstrual disorders.
The hot-ball endometrial peeling system includes a 16cm long, 3.5mm diameter guide rod, and a balloon with a heater mounted on the tip. The other end of the rod has a balloon-injectable solution interface and is connected to a controller to monitor and control the temperature, pressure and treatment time in the balloon. During operation, the hot-ball guide rod is inserted from the vagina, placed into the uterine cavity through the cervix, and then the balloon is injected with 5% glucose. The pressure in the balloon gradually increases to 160mm-180mmHg, so that the balloon can be shaped according to the shape of the uterus. The thermal element inside the capsule raises the liquid temperature to 87 ° C and maintains this treatment temperature for 8 minutes. At this time, the endometrium is heated and coagulated to a depth of about 5 mm. The controller continuously monitors and displays the pressure of the guide rod, adjusts the temperature of the liquid, and controls the treatment time during the entire treatment process. When the controller sends out a signal to end the treatment, the fluid in the capsule will be drawn out, and the guide rod will be removed from the uterus.
Its indications are menstrual disorders that do not require women to reproduce, including: dysfunction, uterine fibroids (non-submucosal), myasthenia, post-mucosal myomectomy, and thrombocytopenic purpura. Sampling of endometrial tissue from all patients excluded cancer or precancerous diagnosis. Ultrasound and / or hysteroscopy were also negative. Patients with submucosal fibroids, multiple large polyps, or a uterine cavity deeper than 12 cm are excluded from treatment. Patients who wish to continue fertility or are allergic to latex (because the balloon is a latex product) are excluded. No treatment is required for hospitalization.
Uterine heat bulb treatment only burns the endometrium and superficial muscle layer, and does not damage deep smooth muscle tissue and adjacent organs of the uterus. The initial pressure of the hot ball, the heating time and the thickness of the endometrium are the main factors affecting the efficacy.
The endometrial functional layer and basal layer glandular epithelium showed only edema after heating for 4 minutes; the heating of the functional layer glandular epithelium degeneration and necrosis, and basal layer glandular epithelial edema; heating for 12 minutes was basically similar to the pathological change of heating for 8 minutes. But after heating for 12 minutes, the temperature of the uterine serosa had reached 38.7 , exceeding the temperature of the body cavity. Therefore, a heating time of 8 minutes is considered most appropriate. Because the pressure and volume in the capsule reflect the degree of anastomosis between the hot bulb and the uterine patch, low pressure, rapid pressure drop, or large amplitude indicates that the hot bulb is not tightly attached to the uterine cavity and affects the depth of the hot bulb thermal burn. When Dr. Vilos of Canada used an initial pressure of 80-150mmHg, the treatment success rate reached 62%, and then he switched to an initial pressure of 150-180mmHg, and the treatment success rate was 90%. This shows that a slightly higher initial pressure and pressure stabilization during heating have a great impact on the treatment effect. From the uterine pathological section of the hot bulb test, it is believed that the thickness of the endometrium has an effect on the treatment effect. The hot ball treatment time should be in the period of curettage or menstruation, and the hot ball treatment should be performed under the condition of thin endometrium, which can make the basal layer glandular epithelium and superficial muscle layer degeneration and necrosis to achieve no menstruation, The effect of reducing menstrual flow. Bongers and other studies have also confirmed that its efficacy is related to patient age, balloon temperature, preoperative abnormal bleeding and dysmenorrhea, uterine size and flexion.
The success rate of the uterine heat bulb treatment system to reduce menstruation to a normal amount, a small amount or menopause is 87%, with very low complications. Among them, 25% showed menopause or slight menstruation, 33% were small, 28% were normal, and only 13% were still too much. The total mild complication rate was 2.6%, including: uterine hemorrhage, postoperative fever, cystitis, and abdominal pain due to spasm after treatment, but it can be controlled with normal amount of pain medication. Cervical stenosis has also been reported in 0.77% of patients. Dusan et al reported that 70 patients underwent UBT, followed up for 3 years, 25.7% amenorrhea, 45.7% had less menstrual periods, and 21.4% had normal menstruation. Compared with drug therapy and surgical therapy, uterine hot bulb therapy does not require anesthesia, thereby avoiding the dangers caused by it, and the device has a safety system, which makes the patient less likely to be injured. It is also difficult for the balloon to rupture and the subsequent flow of hydrothermal fluid into the uterine cavity, because the sudden loss of pressure will make the heater inoperable, and so far no balloon rupture has occurred. Short treatment time, no need for hospitalization, short recovery period, simple operation, no special technical training and experience in using hysteroscopy. For women who do not want to retain fertility, the uterine heat bulb treatment system is a feasible treatment system. A new type of balloon therapy instrument for the treatment of the principle of scalding is ThermablateTM endometrial therapy instrument, referred to as the TB type endometrial therapy instrument. It also uses thermal energy to treat the endometrium. The thermal controller is used as a heat source for the cavity. The treatment liquid in the medicine is heated, and the positive and negative pressure generated by the micro air pump is used to make the treatment liquid cycle periodically between the liquid cavity and the balloon on the disposable cartridge, and the balloon and the uterus The contact time of the endometrium in each cycle does not exceed 5 seconds. The entire treatment process takes 128 seconds and is divided into 14 cycles. The entire process is automatically completed under the control of a single-chip microcomputer. Within this time, 4-5mm can be obtained. Treatment depth.
The principle of heat treatment is to expand the balloon placed in the uterine cavity by heating the medium to bring it into contact with the endometrium. The action of high temperature causes the endometrial tissue cell protein to coagulate, necrotize, peel, and fibrosis to achieve endometrial removal. Effect. The characteristics of the therapeutic device: 1. The heating medium is an oily therapeutic liquid, and the characteristics of the oily substance are high, the heat is large, and the heat is uniform. This is the key factor for the short treatment time of the therapeutic device. 2. Simple structure, small size and light weight. Its main part is two parts. The disposable treatment cartridge includes a balloon at the treatment end, a guide rod with a uterine depth scale, and a cartridge end filled with a treatment solution. There is a diaphragm bag inside. , Outsourcing aluminum shell, vacuum sterilized independent packaging. The treatment control unit includes a heating cavity placed in the end of the cartridge, a heating device, heating, an active control device for the treatment process, and a visual display screen for instructions for heating process, and data indication. Make it easier and more convenient to operate. 3. The design procedure of the treatment device is reasonable. In order to ensure the uniformity of the temperature on the surface of the hot ball, the built-in control device exchanges the medium in the hot ball with the medium in the cartridge in the heating chamber of the treatment control unit. During the 128s treatment, it was repeated 14 times, which effectively ensured the treatment temperature of the balloon.
The main reaction during the treatment of TB endometrial therapy device is abdominal pain. In severe cases, it can be accompanied by nausea, vomiting, cold sweat, etc. Most of them disappear after treatment, which may be caused by local thermal reaction. The use of anesthesia during surgery can significantly reduce this. One response. No signs of damage to adjacent organs (such as hematuria, intestinal perforation, peritonitis, etc.). After treatment, all patients had different levels and lengths of vaginal bleeding and water, which can be improved by the application of antibiotics and hemostatic drugs, and can prevent secondary infections. After thermal injury, the coagulated and necrotic tissues fall off, which is a kind of body reaction. After the treatment of thermal endometrium, vaginal bleeding and running water appear, indicating that the endometrium has been thermally damaged and detached, which can be a manifestation of achieving the therapeutic purpose. However, it is important to pay attention to prevent infection and major bleeding.