Ablation Procedures

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Dr. Togas Tulandi: "Good afternoon, I'm Togas Tulandi with OBGYN.net. I am a professor of obstetrics and gynecology and the Milton Leong Chair in Reproductive Medicine at McGill University.  I have with me Dr. Milton Goldrath who is the father of endometrial ablation."

Dr. Milton Goldrath:  “That just means that I’m old.”

Dr. Togas Tulandi:  “Dr. Goldrath, you started endometrial ablation years back before anybody else was doing it.  Now we have second generation of endometrial ablation techniques: microwave, balloon, and others.  Could you tell us what you think about it?”

Dr. Milton Goldrath:  “I think there’s really a big need for this second generation, basically, not because the others didn’t work but the biggest problem is they’re so skilled dependent and with this great dependency on operative skill, there are not enough physicians who will perform the procedures.  As a result, many women are still getting hysterectomies that could be treated by ablative methods.  The second generations offer some hope for that to be accomplished, however, there are many drawbacks in that so many of them are blind procedures rather than the ones that to my mind have a capacity to view the procedure hysteroscopically.”

Dr. Togas Tulandi:  “Which one do you think is the safest technique nowadays?”

Dr. Milton Goldrath:  “I’ll have to say the one that I’m interested in.”

Dr. Togas Tulandi:  “Could you mention it?”

Dr. Milton Goldrath:  “Yes, it’s called a ‘hydrothermal ablator’ and it is a device that uses direct application of heated normal saline solution through an insulated hysteroscope to truly globally destroy the endometrium because the fluid will form and go into all areas of the uterine cavity.  It has the advantage of using a medium of normal saline, which is very available, it is cheap, and you can see through it as a distending medium so you can actually see what you are destroying.  If the instrument is outside of the uterus, you will see that it is outside.  In addition, the electronics in the instrument preclude you from losing any large amount of saline, and it will turn off after 10 cc’s are lost, therefore, obviating damage from the solution either being absorbed or the heat that is contained.”

Dr. Togas Tulandi:  “Is there any concern of the fluid going into the fallopian tube and then into the abdominal cavity?”

Dr. Milton Goldrath:  “That was the initial concern of me and everybody else, however, data has shown that the tubes open at 70 mm of mercury uterine pressure, this device operates at 50 mm of mercury intrauterine pressure, and we have had no episodes of tubal spill in over 1,000 cases.  In addition, if there were a rare case where that fluid could go through the tube, limiting it to 10 cc’s obviates any damage from a heated solution going out through the tubes.”

Dr. Togas Tulandi:  “Now with the second generation methods, most of them do not use hysteroscopy.  What do you think, will it affect the teaching for residents?”

Dr. Milton Goldrath:  “I do not think they will be taught, if they just put something blindly into the uterus there’s great hazard to patients.  I am more interested in residents learning hysteroscopy.  I think a gynecologist who doesn’t do hysteroscopy is well behind his time, and this provides safety and a learning experience for many gynecologists.”

Dr. Togas Tulandi:  “Could you mention what the future for endometrial ablation is?”

Dr. Milton Goldrath:  “I think the future may be here, there may be new modalities, but whatever the future is, I would hope that if somebody is using any kind of a power source, it’s something where we must see where we’re applying that power.  Will there be a pharmacologic way to do this – perhaps, but there’s a great reluctance of physicians to keep their patients on drugs for long periods of time and there is a great reluctance of patients to use medications over a long period of time.”

Dr. Togas Tulandi:  “I think the visualization is the key.  It’s still the key in the past and it’s still the key in the future.”

Dr. Milton Goldrath:  “I have to agree, it is my first love, I am a hysteroscopist primarily.”

Dr. Togas Tulandi:  “Thank you very much, Dr. Goldrath.”

Dr. Milton Goldrath:  “Thank you very much too.”