AbnormaluterinebleedinginfertileageMinimallyinvasivesurgicalsolution

ProfessorGrigorisF.Grimbizis

Head,1stDeptObstet&Gynecol,AristotleUniversityofThessaloniki

ESGEChairElect

DeclarationofInterests

➢ None(commercial)

➢ ESGEChairElect

➢ ESHREPastMemberoftheExecutiveCommittee

➢ HellenicSocietyforEndoscopicSurgeryVicePresident

AbnormalUterineBleeding:Definition/Comments

AbnormalUterineBleedingisdefinedasbleedingfromtheuterinecorpusthatisabnormalinvolume,regularityand/ortimingwithanestimatedbloodloss>80mlperperiod➢ Theterm“dysfunctional”uterinebleedingisabandoned➢ Life-timeprevalence~30%➢ Substantialimpactonwomen’sphysical,emotional,socialand

materialqualityoflife

➢ Associatedwithlossofproductivity,andmajorhealthcarecosts

Frequency(days)

Infrequent(>38days)

Normal(24-38days)

Frequent(<24days)

Regularity(12movariaton)

Absent(-)

Regular(±2-20days)

Irregular(>20days)

Duration(days)

Shortened(<4,5days)

Normal(4,5-8,0days)

Prolonged(>8days)

Volume(monthly/ml)

Light(<5ml)

Normal(5-80ml)

Heavy(>80ml)

Menstrualparameters

Munro,RevEndocrMetabDisorders,13:223-234,2012

AbnormalUterineBleeding(AUB)• Acute• Intermittent• Chronic

FIGOClassificationofAUB

PALM(Structural)

Polyps

Adenomyosis

Leiomyomas

Malignancy

COEINCoa

gulopathy

Ovulatory

Endometrial

Iatrogenic

NotClassified

Whatisconsideredasminimallyinvasivesurgery?

Hysteroscopy

Diagnostic

Operative

Laparoscopy

Diagnostic

Operative

WhereistheplaceofminimallyinvasivesurgeryinthemanagementofAUB?

ConfirmationofAUB(basedonsymptoms)DiagnosticWork-up(etiological

investigation)

Treatment(basedondiagnosis)

ManagementofAUBpatient

Ishysteroscopicinvestigationnecessaryincasesofpolyps?Whyhysteroscopy?

• Rationaleforhysteroscopicpolypectomy• Histology(malignancy,premalignant)

• BlindD&C,evenunderultrasoundcontrol,nolongerrecommended(success<50%/traumaticforendometrium)

• “Seeandtreat”• Bleedingcontrol(improvement75-100%ofcases)

Isthereaplaceforexpectantmanagement?

• Whenpolypssizeis<1cm• Whenthediagnosisofpolyp

shouldnotbeconsideredasdefinite• polypoidprotrusionsoftheendometrium/hyperechoicendometrialareas

• Re-evaluationofsymptomsandimagingfindingsafter3menstruations• “naturalcurettage”

FIGOP(ALM)-Endometrialpolyps

HysteroscopicinvestigationincasesofAUB&infertility

Non-diagnosticfindings Septum&polyps

Atypicalpolypoidadenomyoma Endometrialadenocarcinoma

AtypicalpolypoidadenomyomaEndometrial

adenocarcinomaHysteroscopicfindings

Atypicalpolypoidadenomyomas

HysteroscopicviewNocleardifferencefromnon-

adenomyoticpolyps!!!

UltrasoundimageNodifferencefromendometrial

polyps!!!

0

3

6

9

12

EndometrialHyperplasia EndometrialAdenocarcinoma

8,8%(12/136cases)

Heatley,Histopathology,48:605-626,2006

8,8%(12/136cases)

6,6%withinthepolyp2,2%intheadjacentendometrium

Atypicalpolypoidadenomyomas:Riskofendometrialcarcinoma

➢ SamplingofendometrialtissueisanimportantapproachinfertileagewomenwithAUB

➢ AlthoughendometrialmalignancyisfoundrarelyamongfertileagewomenwithAUB,itmustbeexcludedpriortoanysurgicalintervention

➢ AmbulatoryhysteroscopycandiagnosediffuseorfocalendometrialhyperplasiaormalignancyandaidblindordirectedEndometrialBiopsy

Copperetal,2015

FIGOPAL(M)-Malignancy/Premalignantconditions

Distributionofageinwomenwithendometrialcomplexhyperplasiaorcancer

Agecut-offforbiopsywasremoved

itisnolongerrelevant

Shoulddiagnosisbebasedonlyinhysteroscopicfindingswithouthistologicalconfirmation?

• The pre-test probability of endometrial cancer was 3.9% (95% CI 3.7%-4.2%)

• A positive hysteroscopy result increased the probability of cancer to 71.8% (95% CI 67%-76.6%)

• A negative hysteroscopy result decreased the probability of cancer to 0.6% (95% CI 0.5%-0.8%)

• The overall accuracy for the diagnosis of endometrial disease was moderate compared to that of cancer

Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic review

Conclusion: hysteroscopic investigation should always be completed with guided histological examination

Clarketal,JAMA,288:1610,2002

Isthereaplaceforminimally

invasive(hysteroscopic)investigation?

COEIN

Coagulopathy

Ovulatory

Endometrial

Iatrogenic

NotClassified

Focallydisorderedproliferativeendometrium

Hysteroscopic“currettage”Removalofthefunctional

endometriallayer

41yearsold-Heavymenstruation/spotting-Noultrasoundfindings

DiagnostichysteroscopyAdhesion(non-significant)/

Normalappearingendometrium/protrusion?

FIGOCO(E)IN–Endometrial

FIGOCOEI(N)–

Hysteroscopicimagessuggestiveofadenomyosis

AUBPatient:diagnosticwork-up

Imaging

Confirmationofdiagnosis

Leiomyomas

Adenomyosis

Iatrogenic(Niches)

Findingsneededhistology

Polyps

Suspectedendometrialpathology

Nofindings

Exclusionofendometrialpathology

Isthereaplaceforminimally

invasiveinvestigation?

Hysteroscopy

Persistent• intermenstrualbleeding

• Irregularuterinebleeding

• infrequentheavybleeding

Heavymenstrualbleedingnotrespondingtomedication

Tamoxifenintake

Obese(BMI>30) PCOS

ConsiderhysteroscopicguidedendometrialbiopsyNICE2018

MinimallyinvasivesurgicalsolutioninthetreatmentofAUB?

“Causative”

treatmentSymptom

atictreatment

Minimallyinvasive/Invasive

Medical/Non-surgical

FIGOP(ALM)-Polyps(atypicalpolypoidadenomyomas)

InitialStepResectionofpolypin

healthybordersPathologyofthelesion!!!

Resectionofendometriumaroundthelesion

Resectionofmyometriumunderthelesion

Multiplerandombiopsiesoftheendometrium

DiSpiezioSardoetal,FertilSteril,89:456,2008

Recurren

cera

tes

0

10

20

30

40

TypicalPolypoidAdenomyomas

RecurrenceratesaftertreatmentofpolypoidadenomyomasPooledresultsofhysteroscopicandD&Ctreatment

4/21reportedcases

37,5%

Mikos&Grimbizis,unpublisheddata,2017

54/144reportedcases

19%

Recurren

cera

tes

0

12,5

25

37,5

50

HysteroscopicPolypectomy D&C

RecurrenceratesofatypicalpolypoidadenomyomasHysteroscopicvsD&Ctreatment

6/28reportedcases

41,4%

48/116reportedcases

23,7%

Mikos&Grimbizis,unpublisheddata,2014

FIGO(P)A(LM)-Adenomyosis

Non-surgicalmedicaland/orinterventional• Hormonaltreatment:GnRH-a/LNG-IUS• Uterinearteryembolization• MagneticResonanceguidedFocused

UltrasoundSurgery(MRgFUS)

Uterussparingminimallyinvasivetreatment• Adenomyomectomy(laparoscopicor

hysteroscopic)• Thermalablationofmyometrium• Endometrialablation

FIGO(P)A(LM)-Adenomyosis

Diffuseadenomyosis• Medicaltreatment(LNG-IUD)

Focaladenomyosis• Minimallyinvasivesurgicaltreatment(adenomyomectomy)

Polypoidadenomyosis• Minimallyinvasivesurgicaltreatment(hysteroscopic)

Sub-serouslayer5to10mmcouldbeusuallypreservedduringlesionexcisionsinceitisrarelyaffectedbythedisease

FIGO(P)A(LM)-AdenomyosisConservativeexcisionalsurgery

Reduc^onofPain Reduc^onofBleeding

N=83

Grimbizisetal,FertilSteril,101:472-487,2014

Adenomyomectomy:post-operativeresultsReductionofpainandbleeding

N=385

FIGO(PA)L(M)-Leiomyomas

Classical FIGO

Submucosal:myomasthatdistorttheuterinecavity

SubmucosalType0 100%intra-cavitary Type0

SubmucosalTypeI >50%intra-cavitary Type1

SubmucosalTypeII <50%intra-cavitary Type2

Intramural:myomaswithinthemyometriumthatdonotdistorttheuterinecavity

Intramural Incontactwiththeendometrium(JZmyomas) Type3

Intramural 100%intramural Type4

Intramural Intramuralbut<50%subserosal Type5

Subserosal:myomaswith>50%extensionoutoftheserosalsurface

Subserosal Subserosalbut<50%intramural Type6

Subserosal Pedunculated Type7

FIGO(PA)L(M)-Leiomyomas

AbnormalUterine

Bleeding:+• Submucosal

• (FIGOTypes0,1&2)

AbnormalUterine

Bleeding:+/-• Intramural

• (FIGOTypes3,4

&2-5)

AbnormalUterine

Bleeding:-• Subserosal

• (FIGOTypes5,6,7)

HysteroscopicMyomectomy

LaparoscopicMyomectomy

Expectantmanagement

FIGOCOE(I)N–Iatrogenic/Niches

Hysteroscopicnicheresection

LaparoscopicnicherepairGubbinietal,JMIG,18:234-237,2011&vanderVoetetal,BJOG,121:145-156,2014

• AsEndometrialAblation(EA)ischaracterizedanymethodthatdestroystheliningoftheuterinecavity(endometrium)

• Itisa“symptomatic”surgicalsolution➢ Target➢ ControlofAbnormalUterineBleeding(AUB)

➢ Minimallyinvasivealternativeto:➢ Medicalmanagement(ifineffective)➢ Hysterectomy

Isendometrialablation/resectionaminimallyinvasivesolution?

1.Endometriallaserablation

2.Trans-cervicalresectionoftheendometrium

3.EndometrialrollerballAblation

FirstGeneration:HysteroscopicTechniques

1.Fluid-filledthermalballoonendometrialablation

2.Radiofrequency(thermo-regulated)balloonendometrialablation

3.Hydrothermalendometrialablation

4.MicrowaveEA(MEA)andimpedance-controlledbipolarradiofrequencyablation

SecondGeneration:Non-HysteroscopicTechniques

EndometrialAblationEfficacy:primaryandsecondaryoutcomes

➢Post-ablationamenorrhea➢ Range:14-55%

➢Post-ablationsatisfactionrate➢ Themostimportantparameterbecausecontrolof

bleedingandnotamenorrheaistherequiredeffect

0

5

10

15

Hysterectomy 1stGeneraron 2ndGeneraron

10,612,3

5,3

Un-Sa^sfac^onrates

Un-satisfactionratescomparedtohysterectomy

7%higherRR:2.4P<0.001

Battacharyaetal,HealthTechnologyAssessment15:No.19,2011

5,3%higherRR:2.3P<0.001

0

5

10

15

20

25

Mirena 1stGeneraron 2ndGeneraron

2018,317,2

Un-Sarsfacronrates

Un-satisfactionratescomparedtoMirena

NS

Battacharyaetal,HealthTechnologyAssessment15:No.19,2011

NS

EndometrialAblationComplications

➢ Fluidoverload&Perforation(1stgenerationTechniques)➢ Infection:early(within3days)orlate(upto50days)

➢ endometritis(1.4–2.0%)

➢ myometritis(0–0.9%)

➢ pelvicinflammatorydisease(1.1%)

➢ Tubo-ovarian,pelvicandcornualabscessorpyometra(0–1.1%)/sepsis

➢ Prevention:antibioticprophylaxis(althoughnotroutinelyrecommended)ortherapywhensuspected

➢ Treatment:hysterectomyanddrainage

Sharp,AJOG,2012

EndometrialAblationComplications:Postablationpainsyndrome

➢ Post-ablationpainsyndrome(bloodblockedwithinclosedcavities)

➢ Contractureandscarring(duetotissuenecrosisandnon-microbialinflammation)inthepresenceofresidualendometriumcanresultinobstructedegressofmenses

➢ Manifestedashematocavitieswithinthebodyoftheuterinecavity(centralhematometra)oratacornualregion

➢ Clinicalsymptom:cyclicorpersistentpelvicpain

➢ Prevention:avoiddestructionofcervicalcanal,“partial”ablation

➢ Treatment:hysterectomyorhysteroscopicadhesiolysis

Sharp,AJOG,2012

AbnormalUterineBleeding(AUB)Complications:Inefficientpost-ablationsampling

Inabilitytosampleendometrialcavityincasesofrecurrentbleedingcouldmaskendometrialcancer

➢ Ablationdoesnotincreasetheriskofendometrialcancer

➢ Absolutecontra-indications:Endometrialhyperplasiaanendometrialcancer

➢ Unknownimportanceofriskfactorsforcancerdevelopment➢ Nulliparity&chronicanovulation➢ Obesity&diabetesmellitus➢ tamoxifentherapy➢ hereditarynon-polyposiscolorectalcancer

Sharp,AJOG,2012

Incidenceofendometrialcancerafterendometrialablationcomparedtothatofgeneralpopulation

Doodetal,JMIG,2014

EndometrialAblation“Complication”:Post-ablationpregnancy

➢Wishingfuturefertilityisacontra-indicationforendometrialablation

➢ Endometrialablationcouldnotbeconsideredasaformofcontraception

➢ Post-ablationpregnancieshavehigherriskfor➢ ectopicimplantation(reportedincidence2-6%)➢ miscarriages,➢ Pretermdelivery(~30%)andpretermprematureruptureof

membranes(~15%)➢ Abnormalplacentation/placentaaccretapercreta(~25%)leading

inobstetricalhysterectomy(~60%)

Sharp,AJOG,2012

WhereistheplaceofminimallyinvasivesurgeryinthemanagementofAUB?

ConfirmationofAUB(basedonsymptoms)

DiagnosticWork-up(etiologicalinvestigation)

Treatment(basedondiagnosis)

HysteroscopicEvaluation➢Imagingfindingsneededhistology➢Polyps➢Suspectedendometrialpathology

➢Nofindings➢Biopsyundervision

WhereistheplaceofminimallyinvasivesurgeryinthemanagementofAUB?

ConfirmationofAUB(basedonsymptoms)

DiagnosticWork-up(etiologicalinvestigation)

Treatment(basedondiagnosis)

Hysteroscopictreatment➢Polyps➢Leiomyomas(Type0-2)➢Adenomyoticcysts➢Noplaceforablation➢NichesLaparoscopictreatment

➢Leiomyomas➢Adenomyosis(mainlyfocal)➢Niches

THESSALONIKI-GREECE6TH-9THOCTOBER2019

ESGE28THANNUALCONGRESS