THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 8, NO.2, 1995

Transcervical endometrial resectionwhen hysterectomy is dangerousN. CHACKO, L. SESHADRI, S. NINAN

ABSTRACTSevere blood loss from dysfunctional uterine bleeding maybe refractory to medical therapy and hysterectomy the onlyoption.

In two young women with severe bleeding wheremedical measures were ineffective and hysterectomywas a hazardous option, we performed a transcervicalendometrial resection. In both of them the bleeding stoppedimmediately and no further treatment was required for dys-functional uterine bleeding. They have had amenorrhea nowfor over six months.

Transcervical endometrial resection is an option whenhysterectomy is hazardous and the bleeding is refractoryto medical treatment.Natl Med J India 1995;8:63-4

INTRODUCTIONTranscervical endometrial resection (TCER) has becomean acceptable alternative to elective hysterectomy in manypatients with dysfunctional uterine bleeding (DUB).!-4

However, it is likely to be especially useful in theemergency management of patients with severe bleedingdue to DUB, who have not responded to medical treatment,and have other complicating medical factors that makehysterectomy hazardous. >-7

We report two such cases where this technique helpedstop severe life threatening uterine bleeding.

CASE 1A 35-year-old multipara presented 6 months after renaltransplantation with severe bleeding per vaginam which hadbeen present for one month. In spite of transfusions herhaemoglobin level had dropped from 14.8 g/dl to 7.2 g/dlover a 48-hour period. A fractional curettage showed cystichyperplasia of the endometrium. As the patient was oncyclosporin, hormonal treatment could not be used. Therewas some concern about the safety of a hysterectomy. TCERcompletely and promptly stopped the blood loss. She hasbeen amenorrheic during a follow up of one year.

CASE 2A 39-year-old multipara with chloramphenicol-inducedaplastic anaemia developed severe bleeding per vaginam. Herplatelet counts were consistently below 10000 per cmm andthe haemoglobin was 5 g/dl in spite of multiple blood trans-fusions and platelet concentrates. She had received 15 units

Christian Medical College, Vellore 632004, Tamil Nadu, IndiaN. CHACKO Department of UrologyL. S. SESHADRI, S. NINAN Department of Obstetrics and

Gynaecology

Correspondence to N. CHACKO

© The National Medical Journal of India 1995

63

of platelet concentrates and 9 units of whole blood in the7 days prior to resection. The uterine bleeding showed noresponse to hormones or platelet transfusions. TCER wasperformed under cover of platelet transfusions. Bleedingwas controlled promptly. Six months later, though herplatelet count was 5000 per cmm she remained amenorrheic.

TECHNIQUEFor both patients a similar technique was followed. We useda 26F continuous flow resectoscope (used for transurethralresection), with 1.5% glycine as the irrigant. The cervicalos was found to be widely dilated and allowed irrigant andclots to flow out freely. The irrigant outflow was monitoredto look for absorption and its sequelae. We used a 24Furological loop. The cornual openings were first sealed byfulguration with coagulating current. The endometrium wasthen resected using pure cutting current. The resection wascontinued till the fibres of the myometrium were seen. At thispoint bleeding stopped. This technique is similar to thatdescribed by Magos et al.8

In both women the procedure was completed within30 minutes. There was no evidence of fluid overload orammonia toxicity. Neither patient required a transfusion,during or after the procedure, other than the platelet concen-trates giveri for Case 2. Though the bleeding during resectionwas more in Case 2 than in Case 1, it stopped once theendometrium had been resected.

Both resections were carried out under general anaes-thesia with ketamine supplemented with oxygen by mask.Cessation of blood loss was immediate and there was noneed for any further medical or surgical intervention.Histopathology confirmed the absence of any malignancy.The amenorrhoea has been sustained and has lasted for theduration of follow up, 12 months and 6 months respectively.In the second instance this was in spite of the fact that theaplastic anaemia had not responded to therapy.

DISCUSSIONTCER has been shown to be a satisfactory! and cost-effective" alternative to hysterectomy. With the increasedincidence of premature ovarian failure.? risk of cardio-vascular disease'? and of psychosexual dysfunction!'following hysterectomy, TCER is likely to be preferred byyounger patients. This would also be appropriate for thosewho may want a child later.F

However, such resections have been done mostly onotherwise healthy individuals.I-' In 1983 Def.herney"reported on his initial experience with TCER for intractablebleeding in women who were considered medically unfit fora hysterectomy. By 1987 his series" had grown to animpressive 21, of whom only 4 were patients who refusedhysterectomy. The rest included 6 with leukaemia, 4 withaplastic anaemia, 2 with thalassaemia and 2 with idiopathicthrombocytopenic purpura. Eighteen of the 19 wereamenorrheic for 6 months. Lockwood? reported on 4 youngwomen who had TCER as hysterectomy was medically ortechnically contraindicated. There is the added advantageof being able to perform TCER under sedoanalgesiaaugmented by paracervical blocks, if required." There wereno procedure related deaths. The outcome in this group isall the more impressive as hysterectomy would have beenextremely dangerous.

64

TCER is technically similar to transurethral resection ofthe prostate and of bladder tumours. We have used the sameeq uipment. The complications are also similar, viz. bleed-ing," perforation.I-!" fluid intravasation and transuretheralresection syndrome.':'! obturator nerve reflex!" and missedmalignancy. 13 Glycine absorption is reduced by minimizingthe height from which the irrigant is delivered, balancingthe outflow, using a continuous flow sheath, minimizing theresection time, initial sealing of the cornual opening byfulguration and having a maximally dilated cervical os tofurther reduce build up of fluid pressure in the uterine cavity.

Hysteroscopic surgery is technically different fromlaparoscopy and expertise with the latter is no guarantee ofsuccess with the former. 15

Both our patients had not responded to conservativemeasures and hysterectomy would have been risky. Therewas an urgent need to stop the intractable haemorrhage,which TCER achieved with immediate effect. Both havehad the added bonus of being amenorrheic since.

REFERENCESColtart TM, Smith RNJ. Problems with endometrial resection. Lancet 1991;338:312.

2 Gannon MJ, Holt EM, Fairbank J, Fitzgerald M, Milne MA, Crystal AM,

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 8, NO, 2, 1995

et al. A randomized trial comparing endometrial resection and abdominalhysterectomyfor the treatment of menorrhagia. BMII99I;303:1362-4.

3 Magos AL, Baumann R, Lockwood GM, Turnbull AC. Experience with thefirst 250 endometrial resections for menorrhagia. Lancet 1991;337:1074-8.

4 Dwyer N, Hutton J, Stirrat GM. Randomized controlled trial comparingendometrial resection with abdominal hysterectomy for the surgical treatmentof menorrhagia. Br I Obstet Gynaecoll993;lOO:237-43.

5 DeCherney AH, Polan ML. Hysteroscopic management of intrauterinelesions and intractable uterine bleeding. Obstet Gynecoll983;61:392-7.

6 DeCherney AH, Diamond MP, Lavy G, Polan ML. Endometrial ablationfor intractable uterine bleeding: Hysteroscopic resection. Obstet GynecolI987;70:66l'r-70.

7 Lockwood GM, Magos AL, Baumann R, Turnbull AC. Endometrial resectionwhen hysterectomy is undesirable, dangerous or impossible. Br J ObstetGynaecoll990;97:656-8.

8 Magos AL, Baumann R, Turnbull AC. Transcervical resection of endometriumin women with menorrhagia. BMI 1989;298:1209-12.

9 Siddle N, Sarrel P, Whitehead MI. The effect of hysterectomy on the age ofovarian failure: Identification of a sub group of women with premature lossof ovarian function and literature review. Fertil SterilI987;47:94-IOO.

10 Centerwall BS. Premenopausal hysterectomy and cardiovascular disease.Am I Obstet GynecoI1981;139:5&-{i1.

II Richards DH. A post hysterectomy syndrome. Lancet 1974;2:983-5.12 Mongelli JM, Evans AJ. Pregnancy aftertranscervical endometrial resection.

Lancet 1991;338:578--9.13 Slade RJ, Ahmed AIH, Gillman MDU. Problems with endometrial resection.

Lancet 1991;338:310.14 Pittrof R, Darwish DH, Shabib G. Near-fatal perforation during transcervical

endometrial resection. Lancet 1991;338:197-8.IS Magos AL. Endometrial ablation for menorrhagia. In: Stud J (ed). Progress

in obstetrics and gynaecology. Volume 9. London:Churchill Livingstone,1991:375--95.

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All India Institute of Medical SciencesNew Delhi 110029

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Dr S. NundyIndian citizenDepartment of Gastrointestinal SurgeryAll India Institute of Medical SciencesNew Delhi 110029

Dr S. NundyIndian citizenDepartment of Gastrointestinal SurgeryAll India Institute of Medical SciencesNew Delhi 110029

Dr S. NundyIndian citizenDepartment of Gastrointestinal SurgeryAll India Institute of Medical SciencesNew Delhi 110029

All India Institute of Medical SceincesNew Delhi 110029

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