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Study Objective: To assess the efficacy of repeat transcervical resection of the endometrium (TCRE) in patients with dysfunctional uterine bleeding and myomas in whom primary resection failed., Design: Retrospective analysis (Canadian Task Force classification III)., Setting: University hospital endoscopic unit., Patients: Six hundred sixty-eight women., Intervention: Repeat TCRE or transcervical resection of a myoma (TCRM)., Measurements and Main Results: Of 668 patients, 118 (17%) required repeat resection for the following reasons: pain (52, 44%), menorrhagia (39, 31%), myomas (15, 13%), perforation at the primary TCRE (6, 5%), and large fluid deficit during the procedure (6, 5%). Of 118 women undergoing repeat TCRE or TCRM, 33 (28%) eventually required hysterectomy due to pain (17, 48%), persistent bleeding (7, 27%), pain and bleeding (3, 10%), regrowth of myomas (3, 14%), and other reasons (3, 14%)., Conclusion: Repeat resection is an option after failed primary hysteroscopic operation and may reduce the hysterectomy rate.

Successful implantation occurred after embryo transfer in the presence of an extensive endometrial defect after hysteroscopic resection of residual trophoblastic tissue 15 months after cesarean section. At the end of hysteroscopic surgery the anterior uterine wall seemed smooth, although ultimately no endometrium was left in that part and in parts of the fundus. Thus implantation is possible even with extensive endometrial defects. Interesting facts in this case were, first, the long symptom-free period with residual trophoblastic tissue in the uterus, and, second, successful implantation, pregnancy, and delivery despite at least 30% of endometrial surface being irreversibly destroyed. We suggest hysteroscopic resection as the method of choice for exact and minimally traumatic removal of especially older residual trophoblastic tissue.

Study Objective: To evaluate the role of the resectoscope in the diagnosis and treatment of women with abnormal uterine bleeding (AUB) and atypical endometrial hyperplasia., Design: Retrospective case series (Canadian Task Force classification III-3)., Setting: University-affiliated teaching hospital., Patients: Ten women. Intervention. Hysteroscopic evaluation after preoperative endometrial biopsy indicated simple hyperplasia without atypia, complex hyperplasia with atypia, or inadequate specimen., Measurements and Main Results: Atypical hyperplasia was confirmed in eight patients after total endomyometrial resection. Hysterectomy was offered to all patients but accepted by only two: one for bilateral ovarian serous cystadenomas and the second for a granulosa cell ovarian tumor. No residual endometrium was found in hysterectomy specimens. Seven women were amenorrheic and well 1 to 9 years after resection. An additional patient with amenorrhea died from colon cancer 2 years after resection., Conclusion: Resectoscopic surgery confirmed or detected atypical endometrial hyperplasia in eight women and excluded it in two patients with AUB and a previous diagnosis of simple hyperplasia, atypical hyperplasia, or inadequate specimen. Skillful resectoscopic surgery may be an alternative to hysterectomy in selected patients with atypical hyperplasia who are compliant with regular and long-term follow-up.

Study Objective: To evaluate the role of resectoscopic surgery in the diagnosis and treatment of women with abnormal uterine bleeding and endometrial hyperplasia without atypia., Design: Retrospective analysis (Canadian Task Force classification II-2)., Setting: University-affiliated teaching hospital., Patients: Twenty-five women with simple and seven with complex hyperplasia., Intervention: Hysteroscopic endometrial ablation., Measurements and Main Results: In patients with simple hyperplasia, average age, parity, body mass index, and mean arterial pressure were 53.2 years, 2.4 pregnancies, 30 kg/m2, and 99.5 mm Hg, respectively; in those with complex hyperplasia corresponding figures were 48 years, 2 pregnancies, 36 kg/m2, and 100 mm Hg. Nineteen of 32 women had postmenopausal bleeding, 9 of whom were taking combined hormone replacement therapy. Two had subsequent hysterectomies, one for pain and the other for incomplete resection due to an enlarged uterus. Resection could not be completed in one morbidly obese woman. One patient died from heart disease. During the follow-up of 1 to 8 years (mean 4 yrs) all patients remained amenorrheic with no evidence of recurrent disease or progression to cancer., Conclusion: Resectoscopic surgery by experienced hysteroscopists may be effective therapy for endometrial hyperplasia without atypia, especially in women at high risk for medical therapy or hysterectomy. Patient surveillance is mandatory for early detection and management of recurrent disease and progression to cancer.

Study Objective: To evaluate the efficacy and safety of hysteroscopic resection of endometrial hyperplasia without atypia., Design: Pilot feasibility study (Canadian Task Force classification II-1)., Setting: Department of gynecology at a general hospital., Patients: Seventy-three women. Intervention. Transcervical hysteroscopic endometrial resection under general or spinal anesthesia., Measurements and Main Results: Efficacy of treatment was based on hysteroscopic and histologic regression of endometrial hyperplasia and subjectively assessed uterine bleeding. Safety was evaluated by adverse events. Forty-four cycling women experienced complete remission of uterine bleeding and none had persistence of endometrial hyperplasia during follow-up; four underwent hysterectomy. Atrophic endometrium was present in 24 menopausal women, one of whom underwent hysterectomy., Conclusion: Endometrial resection was effective in achieving regression of endometrial hyperplasia and preventing its recurrence. (J Am Assoc Gynecol Laparosc 6(2):151-154, 1999)

The masking or development of endometrial cancer after endometrial ablation is a concern often alluded to in discussions of complications of endometrial ablation. It is necessary to look for a common factor when this complication occurs. Six cases published in peer-reviewed literature were collected to establish a link between the development of endometrial cancer and endometrial ablation. Preexisting endometrial hyperplasia seems to be the common denominator, and should be considered a contraindication to endometrial ablation until more data are collected.

Study Objective: To determine the effectiveness of transcervical endometrial ablation or endomyometrial resection for treating refractory postmenopausal uterine bleeding induced by hormone replacement therapy (HRT)., Design: Prospective observational study., Setting: Community, teaching, and proprietary hospitals., Patients: Twenty-nine postmenopausal women experiencing troublesome uterine bleeding while taking hormones., Interventions: Hormone manipulation, office hysteroscopy or sonohysterography, endometrial curettage, and transcervical endometrial ablation or endomyometrial resection were performed in all 29 patients., Measurements and Main Results: Twenty-seven women (93.1%) who continued HRT became amenorrheic within 2 months of surgery. The two who did not have irregular, intermittent spotting, but neither one required or desired further surgical intervention. Five women discontinued HRT from 3 to 53 months postoperatively (mean 12.5 +/- 8.2 mo) because of apprehension about developing breast cancer and for personal reasons. The 24 (82.8%) who continued HRT were observed for as long as 99 months (mean 36.4 +/- 5.5 mo); 22 (91.6%) of them remained amenorrheic. Pathologic examination of tissue specimens revealed atrophic endometrium in 4 patients, adenomyosis in 7, simple hyperplasia in 4, submucous leiomyomas in 11, endometrial polyps in 4, and proliferative endometrium in 1. There were no perioperative complications., Conclusion: Endometrial ablation or endomyometrial resection was an effective alternative to discontinuing HRT for these postmenopausal women whose uterine bleeding was unrelieved by modification of their sex steroid regimens.

The use of the Laparosonic Coagulating Shears (LCS) for laparoscopic-assisted vaginal hysterectomy (LAVH) was evaluated in three women. The indications for surgery included chronic pelvic pain, adhesions, endometriosis, symptomatic uterine fibroids, and abnormal bleeding. The entire laparoscopic portion of the LAVH was performed with the LCS. All three patients had an uneventful postoperative course, and continue to do well one year postoperatively. The harmonic scalpel produces surgical incisions with concomitant hemostasis. With the introduction of the LCS, larger vessels can be managed safely. The LCS produces less charring and less thermal tissue injury, reduces postoperative adhesions, and promotes faster healing. The cavitational effect facilitates dissection, and the minimal heat production and absence of current through the patient contribute to safety. Ultrasonic activated technology is easy to use, cost effective, and affords the surgeon a greater margin of safety. This is only a preliminary report, and further study is needed, but the benefits of ultrasonically activated technology and the LCS are readily apparent.

Study Objective: To evaluate the classic intrafascial SEMM (serrated-edge macromorcellated) hysterectomy (CISH) performed by pelviscopy and by laparotomy, and determine the histologic features of the procedures., Design: The first 253 women who required hysterectomy were assigned to undergo the procedure by pelviscopy or laparotomy based on uterine size., Patients: One hundred fifty-two women underwent CISH by pelviscopy and 101 by laparotomy., Interventions: Between September 1991 and December 1993, the patients underwent the two procedures. Uterine leiomyomas with menstrual disorders and pressure symptoms were the principal indications (61%)., Measurements and Main Results: Histologic findings were in agreement with indications for the procedures. Leiomyomas and leiomyomas with adenomyosis were the most frequent findings. Histologic analysis revealed that the squamocolumnar transformation zone was totally removed in all cases, and all cervical glands were excised in 92%., Conclusion: Cervical dysplasia is not a contraindication to CISH, but emphasizes the importance of adequate preoperative screening. This is a conservative operation that my protect against some cervical cancers.