Joseph R. Feste, MD

 is generally used to describe a condition of pelvic discomfort not solely associated with menstruation, of more than 6 month's duration, and of a severity sufficient to cause disability in some form. Chronic pelvic pain

 (CPP) is one of the most common problems in gynecology, accounting for approximately 1 of 10 outpatients visits. Forty percent of all laparoscopies are done for chronic pelvic pain. The responsibility for these women is challenging and often very frustrating to the clinician. In many aspects the complaints by their very nature are biased and difficult to quantify; the objective tests are often unsuitable and correlate poorly with symptoms; and patients are often apprehensive, depressed, and distrustful of the medical profession. Several likely etiologies may be unveiled, and the role each plays in the origin of the pain may be difficult to determine. Likewise, common therapies, both medical and surgical, may be associated with significant morbidity, and yet are often of limited or unproved benefit. A paradigm for workup of the CPP patient can be very helpful in fulfilling the treatment of this difficult problem.
 
 

A patient presenting with CPP would have to be defined as one who has experienced pain for 6 months or longer in its prevailing form. There are considered to be six common features for CPP: (1) altered family roles, (2)duration of 6 months or longer, (3) significantly impaired function at home or work; (4) incomplete relief with most treatments; (5) signs of depression, such as early morning awakening, weight loss, or anorexia; and (6) pain out of proportion to pathology. No one of these lineaments is an absolute prerequisite for the diagnosis for CPP, but when identified, they can be used as guidelines to strengthen the clinical impression. Rather, the diagnosis is made based on the overall clinical picture.
 
 It is essential when evaluating the woman with CPP to consider the various known causes that may be contributing to the symptoms. For this purpose the Renaeer classification is of value. This scheme classifies etiologies of CPP as episodic and continuous. (Table 1) Due to the complexity of the carious CPP syndromes and their significant psychological component, thorough evaluation often requires a multidisciplinary approach with a gynecologist, mental health professional and possibly a gastroenterologist, urologist and anesthesiologist.
 
 


 
 It is of upmost importance for a thorough history and physical examination to be undertaken. An open interview allows the patient to present her concerns and their interpretations. The chief complaint should be stated in the patients own words and exactly why she has sought are at the specific time. The description of pain should include its site, character, duration, fluctuations, and aggravating or alleviating factors including changes in relation to gastrointestinal and urinary functions. The questions or review of systems asked can evolve around the etiology of pelvic pain

, whether gynecological, urological, gastrointestinal, musculoskeletal, biochemical, neurological or psychological (table 2). The menstrual history and the association of pain with each part of the menstrual cycle is crucial. A detailed history of past surgical procedures and medical ailments must be taken. The result of the treatment must be reviewed as to whether the medical treatment or surgery worsened or improved the pain.
 
 A history of the illness may be augmented by measures quantifying the severity of pain and its effect on subsequent evaluations and assessment of the effects of therapy. The McGill Pain Questionnaires is composed of four parts designed to identify where the pain is located, how it changes over time, what it feels like qualitatively, and its intensity.
 
 A complete physical examination should be performed. This should include a careful examination of each system with particular attention being made to the location of any pathology, the depth of the pain and the severity of the pain. In order to evaluate the patient’s pain, the standard pain stimulus, subjective pain may be assessed with a verbal rating scale using descriptive categories (no pain >severe pain) or numbers. Also effective are several available visual analog and graphic rating scales. Therefore a scale of 0 to 10 (10 being the worst) is obtained from the patient with a notation as to whether the pain was elicited superficially or deeply. A grade deployment of information can be helpful for comparison and future reference. (table 2) A similar process of grading can be applied to the vaginal examination while the speculum is in place. Touching various quadrants of the vagina with a "Q" tip may be able to map out the location and severity. Not only should a bimanual examination be performed but a rectal-vaginal examination should be instituted especially for diagnosing endometriosis or a frozen pelvis. Occasionally, local anesthesia can be injected into the area at the time of the examination to see if the pain will be ameliorated.. This is especially helpful in evaluation dysmenorrhea with injection of the utero-sacral ligaments as a pre-operative evaluation for a LUNA or Presacral-neurectomy.
 
 


 
 The necessity of further studies depends on the findings at the initial physical examination. A complete blood count with differential should be done in patients with recent worsening symptoms of abdominal or pelvic pain. A routine urinalysis is extremely important to rule out urological problems of CPP. Cultures of urine should be limited to those cases where standard treatment of the urinary tract infection fails. Other pertinent studies used to help identify the etiology of CPP include GC, CT and Chlamydia cultures or titers, wet preps of the vagina, ultrasound, MRI, CT scan, office hysteroscopy, endometrial biopsy or microlaparoscopy under conscious sedation local anesthesia. 
 
 The conscious sedation local anesthetic micro-laparoscopy can be very beneficial in pain mapping. It is somewhat counter productive to put a patient to sleep to determine the location of the pain when under local anesthesia the exact location can be determined. Pathologic findings are typically observed in more than 50% of laparoscopies. 5 Table 3 lists the laparoscopic findings reported by Howard. Thirty-nine percent had no visible pathology, 28 % had endometriosis and 25% had adhesions. The remaining 8% was divided amongst several other pathologies. What was extremely interesting is the 39% with no pathology. It would certainly be cost effective if all the laparoscopies for pelvic pain were performed under local anesthesia in a minor procedure room rather than in a operating suite. Both endometriosis and pelvic adhesions are known as potential causes of CPP. Howard found that these two abnormalities are found in 61% of women with and 28% of women without CPP. The use of contrast ultrasound has been very beneficial and relatively inexpensive method to evaluate the endometrial cavity. The choice of any one of these studies should be carefully weighed against the chances that the study may not be of any help in the diagnosis. We must be sensitive to the cost of medical care and use only those studies that are warranted.
 
 


 
 Medical therapy being readily available is the first choice for the treatment of CPP. This initial therapy poses little or not acute risk and is very beneficial when the etiology of the pain may be psychological or psychosomatic. The medical therapy may be directly related to the relief of pain or to treatment of the underlying disorder. For instance, dysmenorrhea should first be treated with analgesics such as NSAIDs. Should this regime not work, the next best treatment is the use of oral conceptives. The value of NSAIDs has been established in 51 trials involving 1649 women. The use of this category of medication was associated with significant pain relief in 71% of patients. Placebo response was observed in 15% of patients. Pelvic pain, even in the absence of positive chlymadia cultures, should be treated with 10 days of doxycycline that is actually less expensive that the laboratory studies.
 
 Since endometriosis may account for one third of the patient with CPP, the treatment with various medical therapies can be very cost effective. However, the empirical treatment with GnRH analogs or Danazol has been controversial. However, in the presence of typical nodules, symptoms of dysmenorrhea, pelvic pain, and dyspareunia, the diagnosis is extremely likely without an endoscopic procedure. If one can eliminate other non surgical, non-gynecological etiologies with ultrasound, etc., an empirical treatment many be indicated. Waller has shown that patients with known endometriosis stage I and II, the relief of pain without surgery using 6 months of GnRH agonist was over 53% after five years. If there is no relief of the pain within the first three months, the possibility of adhesions must be entertained. Other medications including danazol, continuous oral contraceptives, medroxyprogesterone and megesrol acetate have all been reported to be beneficial for the treatment of many patients with endometriosis. However, in most series, the pain returned 6 months after treatment to the same level as that documented before treatment. 
 
 Pelvic congestion syndrome with venous congestion has been found as an etiology for CPP in some patients. These patients usually experience deep dyspareunia and deep, dull pain exacerbated by postural changes. The treatment of PCS should first be aimed at the treatment of any chronic cervicitis. I have found that chronic cervicitis will increase the vascularity of the uterus manifested by the "four poster" sign with decrease run-off on uterine phlebography. Those patients without chronic cervicitis, the use of dihydroergotalmine and medroxyprogesterone have proven to be somewhat helpful. In one series, significant improvement of pain was observed in 73% of patients treated with medroxyprogesterone acetate 50 mg/day. In contrast, the placebo and placebo plus psychotherapy had 38% and 29% relief of pain respectively.
 
 Initially, any patient with pelvic pain should be tried on a course of NSAIDs. These non-steriodal agents will many times help the pain and in some instances the pain may not recur. When chronic pain is associated with terminal illnesses, opioids are obviously indicated. The use of local anesthesia for treated trigger points on the skin may be very helpful in treating some types of pelvic pain. The use of electrical stimulation of nerves as with the transcutaneous electrical nerve stimulation instruments (TENS) has been proven to be very helpful. However, the use of these modalities would be limited to cyclic, repeated and predictable pain such as dysmenorrhea.
 
 


 
 Surgical Treatment is primarily used either to remove the pathology causing CPP or interrupting the nerves that transmit the pain impulses. In the last several years, the goals for surgical treatment have been primarily that of endoscopic treatment over laparotomy and hysterectomy. The minimally invasive techniques are not only less painful, but obviously cost effective, less invasive, and associated with faster recovery. The diagnosis of CPP is even better served by local anesthesia conscious sedation microlaparoscopy. This even less invasive technique can be a useful tool in the diagnosis and minimal surgical treatment of CPP. It is obvious that one cannot diagnose CPP under general anesthesia when it would be preferred to have the patient be awake and tell you where the pain is located. This is the distinct advantage of conscious sedation local anesthesia microlaparoscopy. The smaller laparoscopes require smaller trocars thereby decreasing the likelihood of injury to normal tissues upon insertion. Adhesiolysis is very appropriate when the adhesions are extensive and their location correlates with the location of CPP. This is the main reason for pain mapping with microlaparoscopy. There has been a significant amount of controversy as the likelihood of adhesion causing pelvic pain. Peter et al did demonstrate a significant long-term improvement 9 to 12 months after surgery in patients with severe vascular, and dense adhesions involving the bowel. However, after treating the adhesions, measures must be taken to prevent the recurrence. Meticulous handling of tissue, impeccable hemostasis, the liberal use of irrigation and the application of barrier grafts such as Interceede or Gortex can be very effective. However the most effective method of decreasing adhesions is the liberal use of the "second Look"; laparoscope. Because of the expense, this procedure has become more difficult to have approved in a managed health care environment. To solve this problem, others as well as myself, have used a Tenckoft dialysis catheter at the time of the extensive adhesiolysis. The catheter is inserted in the umbilicus after the surgery, cut off a few centimeters beneath the peritoneal surface and the outside taped to the abdomen. In one week, the patient is brought back into the office, the catheter is used to insufflate carbon dioxide and the patient has a second look laparoscopy with a 3mm microlaparoscope. Those patients who have recurrent adhesions that are extensive, are justified to be brought back for a procedure in the operating room.. Those with minimal adhesions can easily be lysed using local anesthesia. Those patients with no significant adhesions, would have been spared a general anesthetic laparoscopy by having a microlaparoscopy being performed
 
 The treatment of the most common cause of CPP, endometriosis, can in most cases be treated laparoscopically. There are many studies that reveal the significance of surgical treatment of endometriosis. It is recommended that patients with suspected endometriosis have a bowel preparation prior to their surgery. Rectal probes and vaginal probes can be used to delineate theses structures when dissecting out the cul-de-sac of Douglas. It is usually best to resect all the deep lesions and vaporize the superficial ones. Those cases with extensive bowel involvement may require a laparotomy should bowel resection be necessary. Obvious regard for the ureters, bladder greater vessels and bowel must always be considered. The ovaries are the most likely structures to require adhesion prevention since the capsule is the least vascular structure in the pelvis. The need for hemostasis is critical as well as the need not to use sutures to close the ovary.
 
 Myomectomy has become a questionable treatment for CPP. The myomas may cause pressure especially on the bladder and rectum. It is critical that the myoma be considered to be causing CPP before removing the tumor. Without the concomitant association of bleeding, the myomas are rarely a cause of CPP. Intracavitary and submucous myomas are best removed by hysteroscopy while intramural fibroids should be removed by laparotomy especially if the patient is considering pregnancy in the future. Other ways of treating these intramural fibroids would be a minilap to close the myometrium after a laparoscopic excision. In many instances, however, the time it takes to remove the myoma and potential risks, may make a simple laparotomy a better treatment for these tumors.
 
 Adnexal masses are a cause of CPP when they are involved with adhesions. Rarely, unless the mass is very large will it cause CPP by itself. Those that are deemed a cause of CPP can usually be removed at laparoscopy. The liberal use of "bags" can prevent the spill of malignant tumors.
 
 The two procedures suggested for the treatment of interrupting the nerve supply to the pelvis are the LUNA procedure and presacral neurectomy. The LUNA procedure, of previously called laser neurectomy, has met with less success because of the development of collateral nerve regeneration and incomplete severing of the sensory nerves. There is approximately as 50% recurrence of dysmenorrhea after LUNA within two years of the procedure. However, with presacral neurectomy the likelihood of long term relief of midline dysmenorrhea is about 85% in most reported series. There are many excellent prospective studies that have documented these data. The ability to perform this procedure by laparoscopy has made the treatment of intractable dysmenorrhea very effective. The skill of the surgeon is the main concern in the treatment of intractable dysmenorrhea by laparoscopy.
 
 


 
 Chronic pelvic pain has always been a difficult problem for gynecologist in the past. It is extremely important for one to consider all other etiologies before reverting to surgery. At the same time one must consider the expense of unnecessary studies as well as the cost of consultants necessary to diagnose the etiology of CPP. Ultimately, laparoscopy or even better, conscious sedation local anesthetic microlaparoscopy may be the best tool to diagnosis patients with CPP. In this way only those patients with demonstrable pathology will have to be taken to the operating room for definitive surgical therapy. This local anesthetic microlaparoscopy will direct the attention toward the right treatment if there are no surgical pathologies found.


 
 Episodic Chronic Pain Continuous Chronic Pain
 
 Dyspareunia Adhesions
 
 Mittleschmerz Chronic infection
 
 Primary dysmenorrhea Residual ovary syndrome
 
 Secondary dysmenorrhea Pelvic tumors
 
 Adenomyosis Genital prolapse
 
 Endometriosis Endometriosis
 
 Chronic pain without pathology
 
 Pelvic congestion syndrome
 
 
 


 
 * Gynecological
 
 * Urological
 
 * Gastrointestinal
 
 * Musculoskeletal
 
 * Biochemical
 
 * Neurological
 
 * Psychosocial
 
 
 

Laparoscopic Findings in 1,318 Women with Chronic Pelvic Pain


 
 No visible pathology 39% (516)
 
 Endometriosis 28% (364)
 
 Adhesion 25% (331)
 
 Chronic PID 6% (85)
 
 Ovarian cysts 3% (39)
 
 Pelvic varicosities <1% (5)
 
 Leiomyomata <1% (10)
 
 Other 4% (57)

1. Renaer M, Guzinski G; Pain in gynecologic practice. Pain 5:305-331, 1987.

2. Steege J; Evaluation and treatment of pelvic pain. In Gynecology and Obstetrics.Edited by J Sciarra. Philadelphia, Harper & Row, 1984, pp 1-10.

3. Melzack R.: The McGill pain questionnaire: Major properties and scoring methods.Pain 1:277-299, 1975

4. Martin DC, Hubert GD, Vander Awaag R. et al: Laparoscopic appearance of peritonealendometriosis. Fertil Steril 51:63-67, 1989.

5. Dulgi AM, Miller JD, Knittle J: Lupron depot (leprolide acetate for depot suspension)in the treatment of endometriosis: A randomized, placebo-controlled, double-blindstudy Fertil Steril 54:419-427, 1990.

6. Owen PR: Prostaglandin synthetase inhibitors in the treatment of primarydysmenorrhea. Am J Obstet Gynecol 148:96-103, 1984.

7. Slocumb JC: Neurological factors in chronic pelvic pain; Trigger points and theabdominal pelvic pain syndrome. Am J Obstet Gynecol 149:536-543, 1984

8. Wolf SL: Perspectives on cnetral nervous system responsiveness to transcutaneouselectrical nerve stimulation. Phy Ther 58:1443-1449, 1978

9. Rapkin AJ: Adhesions and pelvic pain: A retrospective study. Obstet Gynecol 68:13-14,1986.

10. Buttram VC Jr. Reiter RC: Uterine leiomyomata: Etiology, symptomatology, andmanagement. Fertil Steril 36:433-445, 1981.

11. Polan ML, DeCherney A. Presacral neurectomy for pelvic pain in infertility. FertilSteril 34:557-560, 1980.

12. Lichten EM, Bombard J: Surgical treatment of primary dysmenorrhea withlaparoscopic uterine nerve ablation. J Reprod Med 32:37-41, 1987

13.Tjaden B. Schlaff WD, Kimball A, et al: The efficacy of presacral neurectomy for therelief of midline dysmenorrhea. Obstet Gynecol 76:89-91, 1990.

14. Sekiba K: Use of Interceed (TC7) absorbable adhesion barrier to reduce portoperativeadhesion formation in infertility and endometriosis surgery. Prog Clin Biiol Res38:221-233, 1993.

Articles

Chronic pelvic pain is generally used to describe a condition of pelvic discomfort not solely associated with menstruation, of more than 6 month's duration, and of a severity sufficient to cause disability in some form.

Chronic Pelvic Pain: Which Approach? Surgical Versus Medical

Since the first laparoscopy was performed in humans by Jacobaeus in 1910, great 			strides have been made by surgeons in utilizing this valuable tool.

 Unfortunately, the expense of performing even 			diagnostic laparoscopy has become prohibitive. With the high cost of medical care, measures must be taken to decrease 			this monumental problem. For years, laparoscopy has been performed under local anesthesia with minimal reported 			complications. 

 In most of the reported cases, a 10 mm trocar was used, especially for tubal sterilization.             

 Complications were reported 			to be minimal. With this vast experience reported in the literature, a method of simple diagnostic laparoscopy 			has been proposed. The first few procedures containing a bundle of image fibers 6 microns in diameter were performed 			with a prototype 1.8mm outer diameter micro-laparoscope developed by Medical Dynamics             Inc. (Englewood, Colorado). 			A more advanced catheter called, "Pixie" microendoscope was provided by Origin Medsystems, Inc., (Menlo 			Park, Calif.) The depth of field with the Origin Pixie microendoscope is 150mm compared to approximately 25mm with 			the Medical Dynamics microlaparoscope. The greater depth of field is similar to the field of vision of a diagnostic 			laparoscope 5 to 10mm in outer diameter. The microendoscope was attached to a video camera with a light source 			and monitor. A third microendoscopic device, the "Microlaparoscope" (Imagyn Medical, New Jersey), has 			a depth of field of 100mm, an external diameter of 1.98 mm and resolution similar to a 5mm diagnostic laparoscope. 			The eye piece of this microlaparoscope can be attached to any video camera system. (see in the instrument section) 			A fourth microendoscope has been manufactured by Olympus. this instrument has an outer diameter of 3 mm and a custom 			trocar made by Ethicon. In the last 4 years, every major endoscope company has a line of microlaparoscope and accessory 			instrumentation. The technology is becoming demanded by physicians, patients and managed health care providers.

Because of the lesser expense of local anesthesia and in-office procedures, the 			indications for microlaparoscopy can be expanded to cover many circumstances.

Candidates 			for second-look laparoscopy for adhesion assessment

: In those patients who 			have had Stage IV endometriosis or adhesive disease treated by laparoscopy or laparotomy, the incidence of postoperative 			adhesions is extremely high, in the range of at least 90%. Yet, 34% with insignificant or so called "friendly" 			adhesions would have to undergo an unnecessary laparoscopy if one were to laparoscope all these patients. By using 			the microlaparoscope in the office, only those patients who need a second look laparoscopy would be required to 			go to surgery for a more expensive procedure. 

Suspected 			endometriosis with minimal or no physical findings

: Frequently, one may 			suspect endometriosis but have minimal or no physical findings. Rather than proceed with an diagnostic laparoscopy 			under general anesthesia, the mircolaparoscope can stage the disease adequately and allow a patient to be treated 			with medical therapy for minimal or mild endometriosis when the complaint is infertility or pelvic pain.

Chronic pelvic pain without positive physical findings

: Often, a patient presents with chronic pelvic pain but no demonstrable physical and ultrasound findings.

 In these 				patients, the mircolaparoscope will prevent a very unnecessary laparoscopy when the incidence of physical evidence 				is so unlikely. At the time of the procedure, one can use a microforcep to either touch or pull on adhesions or 				tissue to minic the pain the patient is having. If the pain can be duplicated, the source of the pain can then 				be identified. In these cases, the least amount of analgesic used the better. Otherwise the pain localization may 				not be successful.

Patients with pelvic 				pain of unknown etiology can have local anesthetic micro-laparoscopy with the intent of mapping out the area of 				pain. Touching or grasping areas within the location of the patient’s pain will allow documentation by duplication 				and demonstrate the potential etiology of the pain.

: 			One of the more controversial diagnosis to differentiate is that of PID vs. appendicitis. A simple out-patient, 			local anesthetic procedure can very well remove the doubt as to the proper diagnosis.

6. Questionable bleeding ectopic pregnancy in conjunction with or without methotrexate 			therapy:

 Fluctuating HCG levels many times are very confusing and may not 			match the ultra-sound findings. Also, patients receiving methotrexate will commonly have pain in the adnexa secondary 			to necrosis of villi rather than rupture of the ectopic. The mircolaparoscope prevents intervening with a diagnostic 			laparoscopy, compelling removal of the ectopic when continued observation is in order.

Post-operative 			evaluation of neosalpingostomy prior to IVF

: The only less invasive method 			we presently have to evaluate our surgical results of neosalpingostomy is by a hysterosalpingogram. Unfortunately, 			the hysterosalpingogram will not show the size or degree of opening in the newly created tubal ostium. A small 			pin point opening frequently can allow as much dye through as a normal ostium. Yet, the prognosis for pregnancy 			is poor and the success of more surgery on the tube would be limited. This patient would probably have better chance 			of pregnancy with in vitro fertilization.

8. Monitor hysteroscopic resection of submucous fibroids and septate uterus

 as well as ablation of the endometrium: On occasion, there may not be a need for a more 			extensive classic laparoscopy when treating these conditions, therefore, simple mircolaparoscope monitoring during 			the general anesthetic would be adequate. This observation will able the surgeon to find any ancillary pathology 			as well as monitor the procedure for possible perforation.

Monitor 			medical therapy for various pelvic diseases

: Because of the expense of general 			anesthesia, there has been no reported sequential monitoring of medical therapy for conditions such as endometriosis, 			pelvic inflammatory disease or postoperative adhesion formation. Feasibly, the mircolaparoscope could be of extreme 			benefit in following the treatment of these conditions under specific protocols.

: 			Unless there is a surgical need to perform a laparoscopy at the time of a Gift or Zift procedure, both of these 			procedures could be done through an mircolaparoscope, using another micro trocar needle to transfer the gametes 			or embryos.

: Too often, a patient is taken to surgery for 			a laparoscopy suspecting a ruptured cyst. The majority of the time, this process is self limiting and would not 			require even a laparoscopy. The use of the mircolaparoscope could prevent an needless laparoscopy when there is 			only a small amount of blood in the pelvis or no significant active bleeding.

: There are thousands of cases reported on tubal sterilization 			under local anesthesia. A smaller endoscope would obviously decrease the likelihood of complications as well as 			provide more than adequate vision for tubal coagulation or other methods of sterilization.

: In those patients with filmy or moderate adhesion where a 			simple lysis can be performed using local anesthesia on the adjacent structures, a successful adhesiolysis can 			eliminate a general anesthetic procedure for five times the cost and recovery time.

: Using a microneedle and three 5 mm punctures, in 			selected cases, the distal hydrosalpinx can be opened and sutured back with 4-0 or 5-0 suture utilizing local anesthesia. 			As stated above, proper patient selection is necessary since many cases of hydrosalpinx are associated with extensive 			adhesions. Attempting a major salpingolysis in an office setting many be stepping over the boundaries of safety 			to the patient.

: Although the outcomes of laparoscopic tubal anastomosis have 			been reported to be less than that of anastomosis at laparotomy, the main obstacle has been the instrumentation 			and video enhancement. With the use of 3-D camera, specialized microlaparoscopy instruments, the feasibility of 			this procedure being successful has become more of a reality. However, only in the hands of experienced microlaparoscopists 			should this procedure be performed. The use of the microlaparoscope and micro instruments under general anesthesia 			would seem more practical and acceptable than performing the procedure under local anesthesia. The endoscopic approach 			alone would be difficult, timely and costly enough where very few surgeons would have the talents to anastomosis 			tubes by laparoscopy.

Most contraindications for the use of the mircolaparoscope would be the same as 			those for routine laparoscopy with only a few exceptions.

. Contraindications, whether medical 			or surgical, as applied to routine laparoscopy.

 Enlarged uterus over 12-14 weeks size: 			Because of the placement of the microlaparoscope in the midline between the symphysis and umbilicus is the most 			desirable, a large uterus would feasibly get in the way of examination of the adnexa and cul-de-sac. Tubal patency 			could be evaluated by hysterosalpingogram but the assessment of adhesions could be difficult with the enlarged 			uterus

 Obesity: Due to the limited length 			of the mircolaparoscope, it is obvious that the thickness of the abdominal wall would limit its use.

. Multiple abdominal incisions: In those 			patients with multiple abdominal incisions where an open laparoscopy would ordinarily be chosen, an mircolaparoscope 			inserted in a closed fashion could feasibly be unsafe. In these cases, the 3mm trocar is inserted beneath the 11 			or 12

 rib in the midclavicular 			line with the patient tilted to her right. This is a safe area of access since the spleen rarely is enlarged. If 			the umbilical area is clear, the large trocar can be inserted. Otherwise, the adhesion can be taken down first 			then the large trocar inserted.

. Already planned operative laparoscopy: 			Any patient on whom one already plans to perform a laparoscopy under general anesthesia, an             microlaparoscope would 			not be indicated since you are planning an operative laparoscopy.

In my practice, the procedure is performed in an outpatient setting either in the 			hospital minor procedure room or office treatment room. The equipment needed to perform the procedure is the following:

1. Mircolaparoscope system to including a video camera, light source and monitor

4. Microlaparoscope verres needle with trocar

5. CO2 insufflator (nitrous oxide is preferred except for sterilization)

7. Heplock (18-22 gauge) for injection of IV Versed or valium

9. Cohen cannula (any uterine manipulator)

12. 2mm and 5mm trocars for ancillary instruments (Step Trocar)

14. Microlaparoscopy instruments
 			
 			The selection of the proper local anesthetic is based on the procedure to be performed. Since microlaparoscopy 			is generally a short procedure, one needs to use a drug that is fast acting, mild to moderate potency, and a selection 			that will allow a significant volume safely. In the above chart and next chart, nesacaine appears to be the best 			choice. However, if the procedure is potentially longer than usual, one might select marcaine which has a much 			longer lasting effect. Unfortunately, on can only use up to 200 mgm for the entire procedure. Injecting three or 			four puncture sites plus adding local within the pelvic cavity may quickly use up the allotted amount of drug. 			In all cases except for evaluation of pelvic pain one can use more ancillary medication to promote pain relief 			and use less local anesthetic.

These more potent local anesthetics can be useful for pain relief, but one must 			watch the maximum amount of drug used. In obese patients or in patients where multiple trocar sites will be used 			or the anticipation of local anesthesia within the pelvic cavity, the total dose must be carefully monitored. The 			injections of these anesthetics have to be properly monitored with no intravenous injection allowed. Only a small 			amount of drug given intravenously can be catastrophic.

The prevention of adverse reactions is primarily related to the dose of the local 			anesthetic used. As shown in the previous slide, the maximum dose of each anesthetic must be monitored carefully. 			This factor is, however, potentially tainted by a varied tolerance in each individual. For the most part, it would 			be best to hedge on a maximum dose of 80% of the recommended dose for injection. The other important factor is 			that of inadvertent vascular injection. For this reason, it is imperative that one pull back on the syringe prior 			to injecting any local any where in the body. If blood is obtained, redirect the needle in a different direction. 			Merely pulling back a few mm still might allow for intravenous contamination of the local anesthetic. If central 			nervous system symptoms develop, the first sign is usually restlessness, followed by dizziness, tinnitus and blurred 			vision. In more advanced cases of adverse reactions, the patient will begin to tremor and even convulse with respiratory 			arrest. These adverse reactions are obviously very uncommon. However, one must have a "crash cart" available 			in the near vicinity of the minor procedure room if such a complication foes occur.

Equally as uncommon, but a severe reaction, is that relating to the cardiovascular 			system. One of the first symptoms of cardiovascualr side effects would be that of depression of the myocardium. 			This would be manifested immediately with the development of hypotension, bradycardia and ventricular arrhythmia. 			In the more severe cases, cardiac arrest would follow. It is both the cardiovascular and central nervous system 			adverse reaction potential that requires the use of a pulse oximeter and blood pressure cuff on all patients treated 			with local anesthetics. This constant monitoring will give one a good deal of comfort in preventing either complication 			from occurring to a point of respiratory or cardiac arrest. This is also a good reason to have in the near vicinity 			a "crash cart" available for use. We find that this precaution is mandatory for any office procedure 			including hysteroscopy, leep procedure, laser of the cervix, colposcopy with cervical biopsies, endometrial biopsy 			or amniocentesis.

The patient is asked to empty her bladder then she is placed on the table in as 			deep of Trendelenburg as she can tolerate. A blood pressure cuff and pulse oximeter is attached to the patient's 			arm and finger. An 21 gauge heplock is inserted into her arm for IV medication. Ten mgm of IM valium is given 15 			minutes before the procedure and .4mgm of atropine to prevent a vagal reaction. In most cases, I use Versed 2-6 			mg IV titrated prior to making the incision for insertion of the verres needle. Additional valium , Demerol or 			Versed can be administered as needed. A paracervical block is performed and a Cohen canula in inserted to allow 			manipulation of the uterus. To prevent injury to the left common iliac vein and for ideal evaluation of the pelvis 			for diagnosis, pain, or infertility, the Mircrolaparoscope verres needle can be placed midway between the umbilicus 			and symphysis. This approach would be recommended for those performing the procedure for the first time or in an 			office setting a significant distance from a hospital. However, when one is comfortable with the procedure, the 			umbilical placement of the verres needle is preferred. The local anesthesia is injected with a 25 gauge needle 			down through all layers of the abdomen. A small nick is made in the skin and the verres needle within the mircotrocar 			sheath is introduced into the abdominal cavity at a 45 degree angle with the uterus being held down by the Cohen 			cannula. The verres needle is removed from the plastic sheath and a gas extension tube is connected to the carbon 			dioxide insufflator. Approximately 500-600 cc of carbon dioxide or nitrous oxide, is instilled into the peritoneal 			cavity. Nitrous oxide for diagnostic procedures because it is less irritating to the peritoneal surfaces and is 			absorbed rapidly. The pelvic cavity is inspected from one infundibulo-pelvic ligament to the other. One may inspect 			both anterior and posterior cul-de-sac, appendix and upper abdomen. Photographs can be taken.

Another 2 mm trocar or 5mm "Step Trocar"( InnerDyne, Sunnyvale, CA) may 			be inserted to aspirate fluid, manipulate viscera perform sterilization with a Kleppinger forcep, lyse adhesions 			or take cultures or biopsies. The ancillary port can be used to insert a 100 micron laser fiber or button bipolar 			cautery to incise minimal adhesions or vaporize minimal endometrial implants. For those patients with pelvic pain, 			the area of the pain can be either touched or pulled on with a microforcep to attempt to duplicate the patients 			pain. If the pain is duplicated by pulling on an adhesion, the adhesion can be lysed. Following the procedure, 			the gas is removed before taking the patient out of Trendelenburg and steri-strips are placed over the incision. 			The patient is allowed to sit up and should be watched for a period of 30 to 45 minutes prior to going home.

Those patients who are candidates for second look laparoscopy can uniquely be evaluated 			without having to insert a trocar and be laparoscoped in the office. This is made possible by the surgeon inserting 			a Tenckhoff dialysis catheter into the umbilicus after the initial surgery either by laparoscopy or laparotomy. 			The catheter is taped on the abdomen with water proof tape and the inside portion of the tubing is cut off two 			inches below the peritoneal surface. The patient is brought back into the minor procedure room one week later, 			N instilled into the peritoneal cavity and the microlaparoscope inserted. If the patient needs to be brought back 			for an operative second-look laparoscope the decision is made at this time. The catheter is removed and the patient 			is sent home. Local anesthesia is used around the catheter before manipulation and for the paracervical block.

Since the first laparoscopy was performed in humans by Jacobaeus in 1910, great strides have been made by surgeons in utilizing this valuable tool.1 Unfortunately, the expense of performing even diagnostic laparoscopy has become prohibitive. With the high cost of medical care, measures must be taken to decrease this monumental problem. For years, laparoscopy has been performed under local anesthesia with minimal reported complications.

The Use Of Microendoscopy For Diagnostic And Therapeutic Office Laparoscopy Under Local Anesthesia

Reported in the literature are more than 100 different kinds of surgical treatments for stress urinary incontinence in women, including anterior colporrhaphy (Kelly plication),

 retropubic urethropexy (Marshall-Marchetti-Krantz procedure,

 Furthermore, among these procedures are many modifications, all of which present a somewhat confusing picture for the practicing surgeon in choosing a proper surgical procedure for incontinent patients. However, with better understanding of the pathophysiology of genuine stress urinary incontinence and with more published data available, there seems to be a consensus, especially among gynecologists that retropubic colposuspension (Burch procedure) is the surgical treatment of choice for genuine stress urinary incontinence in patients who have intact urethral sphincteric mechanism but with poor urethral support and displaced urethrovesical junction.

 However, the abdominal Burch procedure requires patients to undergo laparotomy; and the poor visibility of the retropubic space complicates the dissection of space of Retzius and mobilization of the bladder and tends to incur more blood loss. Additional disadvantages include prolonged operating time and increased surgical morbidity. On the other hand, the various kinds of needle urethropexy can be performed easily with a short operating time and hospital stay. However, most reports in the literature indicate that the long term results do not appear to be as effective as retropubic colposuspension.

 In our own experience with laparoscopic retropubic colposuspension there has been minimal blood loss, low morbidity and shortened hospital stay and postoperative recovery. This procedure can conveniently be performed with a laparoscopic hysterectomy when the patient presents with both uterine problems and urinary stress incontinence.

The diagnosis of genuine stress incontinence must first be confirmed and detrusor instability excluded. The pre-operative evaluation includes a complete history and physical examination with particular emphasis on neurological history and details of current medication. The office incontinence questionnaires and patient's urinary voiding diary (urolog) can add valuable information. Pelvic examination and lower neurological examination with emphasis on the sensory and motor dermatome pattern of S2, S3, and S4, are also necessary. The examination is supplemented by office investigations including urinalysis and urine culture, a stress test and a Q-tip test as well as a simple office cystometry

 and measurement of residual urine. If there is any abnormality in these tests or if the patient has had previous failed incontinence surgery, she should undergo more sophisticated multi-channel electronic urodynamic studies before any treatment is selected.

Under general anesthesia with endotracheal intubation, the patient is placed in a low lithotomy position with legs supported in Allen's Stirrups (Allen Medical, Mayfield, Ohio, U.S.A.). A #20 French sized Foley catheter with a 30ml balloon tip is then inserted into the bladder, and 50ml concentrated indigocarmine dye is instilled into the bladder. The Foley catheter is then clamped. Inadvertent penetration of the bladder during the procedure will immediately be revealed by the escape of blue dye. A 10mm laparoscope is inserted through a vertical intraumbilical incision, and four 5mm puncture sites are made in the abdomen (Figure 1). The lower pair of puncture sites is made lateral to the deep inferior epigastric vessels, and the upper pair is placed lateral to the rectus muscle at about the umbilical level. Careful inspection is made of the internal viscus after which the patient is then placed in 20 degree Trendelenberg position, and the pelvic organs are then meticulously examined. All visible pathologies such as adhesions and endometriosis are excised as described in the previous chapter and the uterus with or without the ovaries are laparoscopically removed as described in chapter 

. After the vaginal cuff has been closed the pelvic area is irrigated with copius amounts of Ringer's lactate solution. Underwater examination of the surgical sites is performed to ensure satisfactory hemostasis. The cul-de-sac is then obliterated using 2-0 permanent sutures with either the Halban or Moschcowitz procedure through the laparoscope. The Halban procedure

 consists of placing several sagittal sutures within the cul-de-sac, and the Moschcowitz procedure

 involves placing one or more purse-string sutures to obliterate the cul-de-sac. It is important to obliterate the channels on either side of the sigmoid colon in both procedures. Either procedure, if properly executed, can prevent future enterocele formation.

1) The laparoscopic retropubic colposuspension proper begins with an incision made about 1 inch above the symphysis pubis in the anterior wall peritoneum. This should be made laparoscopically between the two obliterated bladder folds with laparoscopic scissors.

2) The anterior peritoneum is dissected away from the anterior abdominal wall and the retropubic space is entered.

3) The bladder is mobilized and paravaginal tissue is identified. The fatty tissue around the paravaginal areas is removed and hemostasis achieved with bipolar forceps. No dissection is performed within 2-2.5cms of the urethra.

4) Two sutures of non-absorbable material are used to raise and pull the anterior vaginal wall forward to the Cooper's ligament. The pair of sutures are inserted at the level of the mid-urethra and the urethrovesical junction. The sutures are inserted at lease 2cms from the urethra. A double bite of the whole thickness of the vagina avoiding the vaginal cavity is taken and is then passed through the Cooper's ligament on the ipsilateral side at a level immediately above the location in the anterior vaginal wall. During the insertion of this suture the assistant places his middle and index fingers at the level of the urethrovesical junction. Tenting of the anterior vaginal wall in this manner facilitates the correct placement of the sutures. Once the suture has been correctly placed, it can be tied using the extracorporeal technique with the Clark-Reich knot pusher 18 previously described. Tying is facilitated if the assistant pushes the fingers in the vagina up towards the Cooper's ligament. The procedure is then repeated on the contralateral side.  During the tying of the knots, particular care must be taken to avoid compressing or kinking the urethra. It is not necessary to have the vaginal wall in direct contact with Cooper's ligament and adequate support will be obtained if the sutures are snugly tied without undue tension. Excessive tension will produce necrosis at the suture sites and may result in suture release and surgical failure.

5) The retropubic space is then irrigated with copious amounts of Ringer's lactate solution. Any bleeders are coagulated with bipolar forceps.

6) A suprapubic catheter is inserted into the bladder under direct visualization. The peritoneal defect is closed with 2-0 absorbable suture.

7) Cystoscopic examination is then performed to ensure that no suture material penetrated the bladder wall. 5ml of indigocarmine eye and 20mgs of Furosemide (Lasix) may then be injected intravenously to confirm the integrity of the ureters.

1. Kelly, H.A. and Dumm, W.M.; Urinary incontinence in women without manifest injury to the bladder: A report of cases. Surg. Gynec. & Obstet., 1914;18:444.

2. Marshall, V.F.; Marchetti, A.A., and Krantz, K.E.: The correction of stress incontinence by simple vesicourethral suspension, Surg., Gynecol & Obstet., 1949;88:590.

3. Burch, J.C.: Urethrovaginal fixation to Cooper's ligament for correction of stress incontinence, cystocele and prolapse, Amer. J. Obstet., Gynec., 1961;81:281.

4. Richardson A.C., Edmonds, P.B., Williams N.L.: Treatment of stress urinary incontinence due to paravaginal fascia defect. Obstet. Gynecol., 1981;57:357-362.

5. Pereyra, A.J. and Lebherz, T.B.: Combined urethrovesical suspension and vaginourethroplasty for correction of urinary stress incontinence: Obstet., Gynecol., 1967;30:537.

6. RAZ, S.: Modified bladder neck suspension for female stress incontinence: Urology 1981;17:82.

7. McGuire, E.J. and Lyton, B.: Pubovaginal sling procedure for stress incontinence. Surg., Gynec. & Obst., 1973;136:547.

8. Gittes, R.F., and Loughlin, K.R.: No-incision pubovaginal suspension for stress incontinence. J. Urol., 1987;138:568.

9. Hohnfellner, R., Petrie E. Sling procedures in surgery, In: Stanton, S.L., Tanagho, E. Rds., Surgery of female incontinence, 2nded. Berlin: Springer-Verlag, 1986:105-113.

10. Bergman, A., Ballard, C., Koonings, P.: Primary stress urinary incontinence and pelvic relaxation: prospective randomized comparison of three different operations. Am. J. Obstet., Gynecol., 1989;161:97-101.

11. Bergman, A., Ballard, C., Koonings, P.: Comparison of three different surgical procedures for genuine stress incontinence: prospective randomized study. Am. J. Obstet., Gynecol., 1989:160:1102-6.

12. Karram, M. M., Bhatia, N. N.: Transvaginal needle bladder neck suspension procedures for stress urinary incontinence: A comprehensive review. Obstet., Gynecol., 1989;73:906-914.

13. Bhatia, N.N., Bergman, A.: A modified Burch versus pereyra retropubic urethropexy for stress urinary incontinence. Obstet., Gynecol., 1980;66:255.

14. Mundy, A.R.: A trail comparing the stamey bladder neck suspension procedure with colposuspension for the treatment of stress incontinence. Br. J. Urol., 1983;55:687-690.

15. Green, D.F., McGuire, E.J., Lytton, B.: A comparison of endoscopic suspension of the vesical neck versus anterior urethropexy for the treatment of stress urinary incontinence. J. Urol., 1986;136:1205-1207.

16. Walters, M., Shields, L.; The diagnostic value of history, physical examination and the Q-Tip cotton swab test in women with urinary incontinence. Am. J. Obstet., Gynecol., 1988;159:145-9.

17. Halban, J.: Gynakologische Operationslehre. Berlinand, Vienna: Urban & Schwarzenberg: 1932.

18. Moschcowitz, A.V.: The pathogenesis, anatomy, and cure of prolapse of the rectum. Saxgynecol., Obstet., 1912;15:7-21.

19. Reich H., Clark, C. A simple method for ligating with straight and curved needles in operative laparoscopy. Obstet. & Gynecol., 1992;79:143-7.

20. Tanagho, E.A.: Colpocystourethropexy: The way we do it. J. Urol., 1976;116:751-753.

Reported in the literature are more than 100 different kinds of surgical treatments for stress urinary incontinence in women, including anterior colporrhaphy (Kelly plication), retropubic urethropexy (Marshall-Marchetti-Krantz procedure, Burch procedure, ), paravaginal suspension, various kinds of needle urethropexy, and suburethral sling procedure.

Laparoscopic Retropubic Colposuspension The Burch Procedure

It has been reported that approximately 670,000 hysterectomies are performed each year in the United States. 	Close to one third (more than 200,000) of these operations are done because of intractable menorrhagia not responsive 	to medical therapy or to dilation and curettage. The Nd:YAG laser was first used by Goldrath and colleagues showing 	that this laser can photocoagulate the endometrium and the menstrual flow reduced to little or none. They reported 	their findings with 22 patients and currently have personal experience with more than 380 patients. Their experience 	has been supplemented by additional cases reported by Lomano and Loffer, with more than 550 cases now reported 	and followed up.

DeCherney and Polan have described the use of the resectoscope for ablation of the endometrium. Townsend, and 	Vancailllie all reported like results by using electrocoagulation , and some instances resection of the endometrium, 	to induce hypomenorrhea or amenorrhea. Whether using laser or electrosurgery, the advantages are that the patient 	can avoid major surgery, maintain ovarian function, and can have permanent reduction and hopefully elimination 	of menstrual bleeding after appropriately applied energy.

With all the experience gained in performing this procedure, we have now been able to define the indications 	without any difficulty. Clearly, the foremost indication is intractable menorrhagia that has failed to respond 	to standard therapy, i.e., hormone replacement therapy and dilatation and curettage (D&C). It is also of utmost 	importance that there are not other pathologies such as polyps or submucous fibroids that would be solely responsible 	for the menorrhagia. However, if a patient has polyps or submucous fibroids as has no desire for further children, 	one may perform an ablation in addition to treating the pathology. Since there could be a chance the patient would 	have persistent menorrhagia following the removal of the pathology, a concomitant ablation would prevent the need 	for any additional surgery. The procedure is contraindicated in any patient with a premalignant or malignant endometrium. 	Lastly, the patient must realize that she will be infertile.

It is extremely important to counsel the patients regarding the possibility hypomenorrhea and not total amenorrhea 	as an end point. Also, there are some failures, especially in patients with adenomyosis. Therefore, if a patient 	is complaining of menorrhagia and dysmenorrhea and physical findings of a boggy, tender uterus, it is very likely 	this patient has adenomyosis and may not respond totally to the ablation. If there are submucous fibroids rather 	than intra-cavitary fibroids, an ablation may not completely cure the menorrhagia. These patients may opt for a 	hysterectomy as a definitive therapy. Another important consideration is the fact that this procedure may not prevent 	pregnancy. There have been reported pregnancies, both intrauterine and ectopic. Therefore, one should consider 	sterilization on patients who are at risk for pregnancy.

An important preoperative consideration is that of suppression of the endometrium to ensure successful destruction 	of the basalis membrane. The objective of the ablation is to cause thermal damage to the basalis layer of the endometrium 	to prevent regrowth. Because the unprepared endometrium is on the average of 10 mm or more in thickness, it is 	difficult, especially for the inexperienced hysteroscopist to destroy the total thickness of the endometrium, down 	through the basalis layer. This can be accomplished by using one of several methods. There is a definite marked 	atrophy and thinning of the endometrium with GnRH analog therapy more than with danazol, medroxyprogestrerone acetate 	or progestin therapy. Several articles have been written concerning the use of these preoperative preparations. 	The most successful are the GnRH analogs because of the marked decrease in estradiol, which produces excellent 	atrophy. Serdan and Brooks adequately proved that the pre-operative use of the GnRH analog Lupron produced significantly 	higher rates of amenorrhea following the procedure, more so than danazol or no preparation. The progestins were 	discontinued in their study because of the high rate of side effects.

The article by Gimpelson and Kaigh suggested that mechanical preparation with a suction curette was equally 	effective as preparation with various drugs. However, Gimpelson's failures were mostly those patients early in 	his series. Those patients with atrophy or anovulation had the best results, a fact he did not acknowledge. It 	is difficult to explain the total amenorrhea in those patients with atrophy while the patients placed on the GnRH 	analogs who develop the same atrophy had not as good of a result. Mixing different methods of treatment and different 	anatomical problems make his conclusions marginal at most. The decreased fluid absorption and operating times as 	well as success rates in the mechanically prepared were further swayed by the improved skill of the operator after 	several years of experience as well as the use on continuous flow irrigation. It is supported in the literature 	that preoperative analogs are the treatment of choice for preoperative preparation. This is especially important 	for those hysteroscopist not familiar with the procedure.

I have found that preoperative office hysteroscopy and endometrial biopsy will provide the best evaluation of 	the endometrium prior to starting the patient on Lupron-depot. GnRH analog therapy is particularly helpful, if 	the patient is anemic, by allowing the hemoglobin to build up during the two months she is not having a menstrual 	period. The dose I recommend is 3.75 during the 3rd week of the cycle followed by a second dose 4 weeks later, 	operating two weeks after the last injection. This gives the patient another two weeks of atrophy postoperatively 	which presumably will enhance the scarring in the uterus.

It is equally important to have patients screened by an internist if they have any medical problems such a cardiovascular 	or kidney dysfunction as fluid overload is a potential complication.

The necessary equipment for endometrial ablation rather performed with a laser or electrosurgery, includes a 	good light source, a video camera, (either with a direct coupler or beam splitter, depending on the preference 	of the operator ), and a fluid infusion system. The distention media preferred by most gynecologist is glycine 	(1.5-% solution) or 3% sorbitol urologic irrigation solution, both allowing the use of either cautery or Yag lasers. 	Hyskon (32% Dextran- 70 ) can be used, particularly if bleeding is a problem. If Hyscon is used, volumes greater 	than 300 cc should be avoided because of the problems associated with overload on the circulatory system. Careful 	monitoring of the patient's circulatory system and pulmonary status during the anesthesia is an important safety 	measure with all procedures and with all irrigating solutions.

In patients undergoing endometrial ablation with the Nd:Yag laser the use of a four-channel hysteroscope is 	preferred. This allows constant infusion of distending media and constant drainage of fluid. A fourth channel is 	used to introduce the 600-um ND:Yag fiber. With the Nd:Yag laser, an eye filter should be used at all times to 	protect the operator. If it is desired to perform an elective sterilization procedure or laparoscopy for other 	indications, simultaneous laparoscopy could be helpful when first beginning endometrial ablation.

Instrumentation used for electrosurgery includes a rectoscope, usually 8 mm in outer diameter with a roller 	bar or ball, to perform the ablation. Wire loops have been used by some gynecologist who are experienced hysteroscopist. 	A newer technique using the OperaStar resectoscope and morcellator, allows the resection of the endometrium and 	the chips are morcellated thereby preventing passing the instruments in and out of the cervix. The electric generator 	must deliver at least 150 watts for excision and 150 watts for coagulation in a blended current.

A foley catheter is used to keep the bladder empty as well as measure urinary output. A system for accurately 	measuring all the fluid used for uterine cavity distension must be used. With constant monitoring of the intake 	and output, the exact amount of fluid absorbed can be determined. Several fluid measuring devises are on the market. 	One of the most dependable is the FlowStat manufactured by FemRx. Intravenous diuretics can be given after consultation 	with the anesthesiologist, either electively before surgery or intraoperatively if fluid absorption is high.

The preoperative preparation with GnRH analogs provides several potential benefits especially when endoscopic 	surgery is proposed. The analog may reduce uterine bleeding and allow for a normalization of hemoglobin by the 	time of surgery in patients who are anemic. GnRH analogs, secondly, decrease the uterine volume and the size of 	myomas, which may allow them to be removed more easily. Thirdly, uterine blood flow has been shown to decrease 	with GnRH analog treatment. This effect would logically seem to decrease the blood loss at the time of surgery. 	If preoperative suppression of fibroids is chosen for medical therapy, one should treat for 3 months before surgery. 	Most studies have shown maximum reduction in size is achieved after three months of treatment. GnRH analog therapy 	may be particularly useful in patients who have an intracavitary or submucous myoma where the most difficult step 	is to bring the resected myoma out thought the cervix.

Several studies have proven that treatment of women with GnRH will result in a decrease in mean uterine volume 	by 40% to 60%. Reduction in individual fibroid size is variable, ranging from 0% to 100%, and is probably the result 	of heterogeneity of leiomyoma composition. Maximal reduction in uterine volume is usually noted after 3 months 	of treatment. The amount of reduction in uterine volume has been negatively correlated with both week 12 serum 	estradiol concentrations and the patient's weight.

Friedman reported in a randomized double-blind, placebo-controlled study, eighteen premenopausal women with 	uterine leiomyomata given intramuscular depot leuprolide acetate, 3.75 mg every 4 weeks for 24 weeks, while twenty 	women received IM placebo with the same injection schedule. Patients receiving depot leuprolide acetate had a mean 	reduction in pretreatment uterine volume from 505 +\- 93cm3 to 305 +\- 57 cm3 after 12 weeks on drug therapy and 	to 307 +\_ 57 cm3 after 24 weeks with no drug therapy. No significant change in uterine volume occurred in the 	placebo-treated women.

The effects of GnRH on uterine size and menstrual cyclically are reversible. Mean uterine volume returned to 	88% of the pretreatment size within 3 months of cessation of leuprolide depot therapy. Return on menses occurred 	within 3-24 weeks (mean: 6-10 weeks) of treatment cessation. The ultimate benefit of analog therapy would be to 	prevent a decrease in blood loss and decrease in fibroid size, facilitating the removal of the fibroids at laparoscopy, 	laparotomy or hysteroscopy. In addition, it may be possible to treat selected fibroid patients (perimenopausal 	women, high surgical/anesthetic risk women) with combined GnRh/estrogen/progestin therapy, thus potentially avoiding 	the need for surgery.

Even though the Nd:Yag laser is being used less frequently than the electrosurgical technique, it is important 	to discuss this method, especially in relation to its safety and method of application. Under direct hysteroscopic 	view the 600 um Nd:Yag fiber is used to photocoagulate around each tubal ostia. The anterior fundus is coagulated 	next due to the fact that as the process of coagulation continues, bubbles formed during the ablation tend to accumulate 	at the anterior fundus making visualization in this area somewhat difficult. The posterior fundus and uterine sidewalls 	are coagulated last.

If visibility is obscured because of bleeding, the intrauterine pressure can be raised by temporarily blocking 	off the outflow of the glycine or by increasing pressure on the infusion bag. The goal is to have the intrauterine 	pressure of glycine equal the vascular pressure of the myometrium, so that blood flow is stopped in the basalis 	layer of the endometrium. This pressure gradient has been well described by Garry et al. They contend that if the 	intrauterine pressure is controlled at a satisfactory level, neither the size of the cavity, the duration of the 	procedure, nor the structural state of the endometrium appears to affect the volume of fluid absorbed. This seems 	to be in the range of 100 mm of mercury.

There are two schools of thought as to how to coagulate the endometrium, the dragging technique and the near 	contact technique. Neither technique has actually been proven to be better. The skill of the surgeon and proper 	patient selection probably have as much to do with the results as any other factor. In either technique , it is 	important for the surgeon to overlap the areas or coagulation to prevent missing active endometrial tissue. Adequate 	preoperative preparation will also be a factor in the amount of ablation success in the end.

Electrosurgical Technique (Roller Ball or Barrel)

The technique and set-up for resectoscope is similar to that of the Yag technique. The only difference is that 	the cervix usually has to be dilated a bit more because of the larger diameter of the resectoscope. The continuous 	flow is required to give adequate visualization. The newer hysteroscope has the continuous inflow of clean, distending 	media in front of the lens and outflow of media from the uterine cavity. (figure 3)

Those surgeons using the wire loops should have a laparoscope in the abdominal cavity to visualize the external 	uterine surface since it is difficult to judge the depth of penetration accurately with the wire loops electrode. 	If one uses the roller bar or ball, laparoscopy is not routinely performed as the roller bar merely rolls along 	the surface of the endometrium. The use of 75 to 100 watts on cutting current, blend 2, adequately treats the endometrium 	to the basalis membrane and spares the myometrium. The coagulation with the roller ball is continued in the same 	fashion as the Yag laser fiber, being extra careful when coagulating the cornu since this is the thinnest portion 	of the uterine wall and the most likely area to perforate. The rows of coagulation should overlap each other to 	avoid skip areas. The electrode must be cleaned occasionally to remove tissue debris. A clean electrode will transmit 	energy more effectively.

First described in 1983 by DeCherney et al, the use of the resectoscope-cutting loop to perform endometrial 	ablation is an attractive addition or alternative to ablation. The technique is performed by systematically resecting 	the full thickness of the endometrium, including the underlying superficial myometrium to the level of the internal 	os. A blended electrosurgical waveform is typically chosen to more efficiently coagulate transected blood vessels 	and to destroy missed areas of endometrium. Many clinicians preserve a rim of untreated endometrium above the internal 	os to help prevent the formation of a hematometria. Resected chips of tissue are periodically removed or evacuated 	at the end of the procedure by mechanical means such as curettes or suction catheters. A rollerball electrode can 	then be used to coagulate bleeding points and destroy any untreated areas of the cavity. The shape and size of 	the rollerball provides the operator a more controlled access to the cornu, where the thin myometrium makes perforation 	with the loop electrode more unlikely, and can be used to ablate the lower uterine segment where the nearby large 	isthmic vessels may appropriately restrict use of the cutting loop. The more innovative technique for ablation 	is the use of the OperaStar, which allows continuous morcellation of the chips thereby decreasing the operating 	time by one third to half the time. The convenience of the morcellator prevents the need to remove the chips mechanically 	and increase the likelihood of bleeding within the endometrial cavity.

Postoperative hysteroscopic evaluation of the uterine cavity after endometrial resection has demonstrated a 	spectrum of residual effects ranging from a patent cavity to complete obliteration and marked fundal fibrosis. 	Amenorrhea after endometrial resection does not necessarily reflect total resection of endometrial tissue. In one 	study, postoperative endometrial sampling demonstrated islands of viable endometrium in 25% of amenorrheic patients.

Those who advocate endometrial resection or resection/ablation believe these techniques have several advantages 	over using the rollerball electrode alone. The endometrium is extensively sampled and histopathologically evaluated, 	lessening the risk of concealing undiagnosed endometrial hyperplasia or malignant neoplasia. Hormonal preparation 	of the endometrium may be less important, obviating the expense, necessary delay for therapy, and side effects 	suffered by some patients from these medications. Because -part of the myometrium is resected, superficial endometriosis 	may be treated. For patients desirous of continued menses, a small area of endometrium can be carefully preserved 	at the lower uterine segment. furthermore, submucous myomata and polyps, commonly encountered in patients with 	abnormal bleeding, can be simultaneously resected without the need to change instrumentation or to abort the procedure.

However, there are some disadvantages to the technique. The use of a cutting loop to deeply resect the endometrium 	requires greater hysteroscopic skills and an extensive understanding of uterine anatomy. Uterine perforation causing 	intraoperative hemorrhage is more likely to occur and direct thermal injury to adjacent structures (treat pelvic 	vessels, the ureter) has been reported more often than for ablation. This danger is greatest at the isthmus and 	cornu where the thickness of the myometrium leaves little margin for error. Used alone, resection is more likely 	to result in incomplete treatment at the fundus and cornua, where the size and angle of the cutting loop make it 	difficult to correctly conform to the uterine cavity. Such an effect risks the entrapment of endometrial tissue 	by postoperative synechiae, potentially leading to a symptomatic hematometra. The likelihood of intravascular absorption 	of distention media and intraoperative hemorrhage are potentially increased by the extensive transection of superficial 	vessels as the endometrium is systematically shaved. Collectively, these concerns have lead to the misconception 	that electrosurgical loop resection of the endometrium is more difficult to perform and potentially more dangerous 	than the ablative techniques.

Hysteroscopic Resection of Submucous Fibroids

The methods of treating submucous or intracavitary leiomyomata hysteroscopically has become the gold standard. 	It must be emphasized that for both intracavitary and most submucous fibroids, hysteroscopic resection should be 	considered the sole method of treatment. Gynecologists that do not perform operative hysteroscopy should develop 	the skills to perform hysteroscopic resection of submucous fibroids. Even though these can be removed by laparotomy, 	there is rarely an indication for such an approach. Occasionally one may find a submucous fibroid that will be 	through and through all three layers of the uterus. This type of fibroid can usually be delineated on ultrasound. 	and inevitability be removed by a laparotomy approach. As far as the instrument of choice, I prefer to use a OperaStar 	with a cutting current at 150 watts. Even though there have been several articles written using the yag laser for 	resection, the electrosurgical, loop excision is faster and easier to work with within the uterine cavity. I would 	also recommend monitoring the hysteroscopic resection by laparoscopy, particularly if the fibroid is submucous 	or located in the cornua area. Even though perforation is unlikely, the consequences of bowel injury would be so 	grave, monitoring laparoscopically would be extremely beneficial.

Nonhysteroscopic Methods for Endometrial Ablation

The use of nonhysteroscopically guided techniques for several investigators have reported destruction 	of the endometrium. Because they have the potential for office or clinic use, these techniques are extraordinarily 	attractive. In addition, they may minimize the risk of uterine perforation and completely avoid the chance of fluid 	overload from absorption of uterine distention media. Compared to hysteroscopic ablation and resection, less training 	is required and the procedures are considerably faster to perform. A variety of methods have been proposed and 	demonstrated including electrosurgical technique, thermal transfer, hyperthermia, and photosensitizers, the properties 	of which may be exploited to destroy the endometrium.

Ablation of the endometrium with the energy from radiofrequency alternating current applied using an intrauterine 	probe electrode was first described by Phipps et al in 1990. In preliminary study, 33 patients underwent this procedure, 	lasting for 10 to 20 minutes, and were followed for 4 to 10 months after surgery. In early follow-up studies, a 	significant reduction in menses was achieved in 85% of patients including 30% with amenorrhea and 55% with satisfactory 	reduction in flow. Postoperatively hysteroscopic examinations revealed patent cavities lined by fibrous scar in 	those patients with amenorrhea, and islands of endometrium at the cornu in those patients with persistent but controlled 	menses. Two patients ultimately underwent hysterectomy for persistent bleeding. Both were found to have adenomyosis. 	In two grossly obese patients, high vesicovaginal fistulae developed secondary to heating of redundant vagina that 	presumably contacted the conductive probe. The authors subsequently designed a nylon thermal guard to completely 	retract the vagina.

Further experience with this technique was gathered from several centers in the United Kingdom. Two hundred 	nineteen women were treated and followed for 4 to 14 months. Satisfactory reduction in menses was achieved in 93%, 	including 42% with amenorrhea and 51% with reduced menses. Postoperative hysteroscopy revealed a spectrum of findings 	from no scarring to complete obliteration of the cavity. Despite the newly designed vaginal guard, another patient 	suffered a vesicovaginal fistula, and two electorsurgical burns occurred a sites of an electrocardiograph electrode 	and a pulse oximeter sensor, events that should be preventable with suitably designed electrosurgical generators.

Other electrosurgical designs include those that incorporate a series of parallel electrodes on the surface 	of a balloon that, in turn, can be inflated pressing the electrodes against the endometrial surface. The exact 	role of these approaches for the treatment of menorrhagia awaits confirmation by long-term follow-up and further 	refinements of instrumentation and technique.

In 1994, Singer et al reported their preliminary experience with thermal ablation system incorporating an intrauterine 	balloon to treat women with intractable menorrhagia. The latex balloon is filled with a solution of sterile dextrose 	and water that is heated just below the boiling point of water (about 83’C). The resulting heat is transmitted 	to the endometrium for 7 to 9 minutes, resulting in thermal injury. Eighteen patients underwent the procedure without 	complications and were followed for up to 34 months. A significant reduction of menses or amenorrhea occurred in 	83% including 44% with spotting or amenorrhea and 39% with light bleeding. Two patients ultimately underwent hysterectomy 	including one for persistent bleeding at 9 months, who was found to have a normal cavity with residual endometrium, 	and the other for worsening pelvic pain at 34 months who was found to have significant synechiae without endometrial 	tissue. One patient underwent a hysteroscopic loop resection at 9 months for persistent bleeding when both extensive 	scarring and endometrium was visualized.

The use of ultrasound and microwaves to induce hyperthermia is tissue models has been disappointing due to asymmetric 	heating and damage to adjacent structures. The application of low power ND: YAG laser light has been shown to be 	safer and more predictable. Using a modified quartz fiber tip to symmetrically distribute ND: YAG light to the 	endometrium, Judd and coworkers successfully produced controlled and symmetric endometrial destruction in the rabbit 	uterine horn by using overlapping treatments at 2 watts. It has been suggested that a similar technique using an 	appropriate fiber tip could be passed into the uterine cavity without cervical dilation under ultrasound guidance.

The potential application of photodynamic therapy for the treatment of menorrhagia is being evaluated by a number 	of investigators. Successful destruction of endometrium with photosensitive agents has been reported in both rat 	and rabbit models. The systemic or local pretreatment of target tissues such as endometrium with agents activated 	by monochromic light can produce a local cytotoxic effect. For each photosynthesizer molecule, a specific wavelength 	(usually laser light), accurately matched to the absorption peak, must be used in order to produce local tissue 	necrosis. The activated photosensitizer molecule is thought to react with tissue oxygen producing singlet oxygen, 	which is cytotoxic. Further studies are needed in animals to determine safety of this technique for nontarget tissues 	that bind the photosensitizer molecules and whether endometrial regeneration will be prevented.

It has been reported that approximately 670,000 hysterectomies are performed each year in the United States. Close to one third (more than 200,000) of these operations are done because of intractable menorrhagia not responsive to medical therapy or to dilation and curettage. The Nd:YAG laser was first used by Goldrath and colleagues showing that this laser can photocoagulate the endometrium and the menstrual flow reduced to little or none.

Joseph R. Feste, MD

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