The development of the intrauterine resection of submucous fibroids by Neuwirth in 1978 was the first use of the urologic resectoscope in the uterine cavity and led to its adaptation to treat the whole endometrial cavity with what is commonly referred to as transcervical resection of the endometrium (TCRE). 1 Although Neuwirth extended the procedure to electrocoagulation of the endometrium, 2 it was DeCherney who, in 1983, 2 years after Goldrath's seminal paper on laser endometrial ablation, first formally described burning the entire endometrial cavity hysteroscopically using the loop electrode in women with intractable menorrhagia who were unfit for hysterectomy. 3 The subsequent history of the technique is a little unclear, but at some stage the endometrium began to be resected rather than electrocoagulated, and rather than using a single-flow resectoscope with Hyskon (dextran 70) for uterine distention, continuous-flow resectoscopes with low-viscosity fluids for uterine distention (e.g. 1.5% glycine) became more popular. Indeed, the first gynecologic resectoscope sold by Karl Storz was just such an instrument designed by the urologist Jean-Pierre Hallez, who used it to perform hysteroscopic myomectomy. 4 What is known is that the technique of TCRE was introduced into Europe by the famous Parisian gynecologist, Jacques Hamou, who advocated what has become known as ‘partial TCRE’, while Adam Magos et al. in Oxford described ‘total TCRE’ in 1989. 5
Whatever the exact history, hysteroscopic methods of endometrial ablation soon became established as an effective alternative to more invasive surgery such as hysterectomy, and studies have since shown that around three-quarters of women with abnormal uterine bleeding can avoid hysterectomy with these techniques. 6 The Royal College of Obstetricians and Gynaecologists (RCOG) in London recognized the role of these procedures in an evidence-based guideline published in 1999, stating that, ‘endometrial ablative procedures are effective in treating menorrhagia’. 7
As a result of the success of these hysteroscopic interventions (endometrial resection, rollerball ablation, and
laser ablation), now referred to as first-generation ablation techniques, they are still considered as the gold standard by which the newer, less skill-dependent second-generation endometrial ablation methods (e.g. thermal balloon, radiofrequency, cryotherapy, etc.), must be judged. 8,9
Not all women with menorrhagia are suitable for TCRE and, as with all the ablation procedures, certain criteria have to be met; these are outlined in Table 16.1. TCRE has been shown to be effective in cases of dysfunctional uterine bleeding, and even if the uterus is slightly enlarged with small fibroids. Conversely, concurrent pathologies such as uterovaginal prolapse or endometriosis, to take but two examples, are better treated by more radical surgery. Similarly, malignant or premalignant changes in the endometrium are considered by most surgeons to be absolute contraindications to TCRE, although the opposite view is held by some. 10 Pregnancies have been reported after endometrial ablation as it does not guarantee sterility, but it is universally agreed that the procedure should not be contemplated in those women who may want to become pregnant in the future because of a much higher incidence of pregnancy complications (see later).