|Year : 2017 | Volume
| Issue : 2 | Page : 61-65
Transcervical resection of endometrium: A novel mode of management of patients with abnormal uterine bleeding with chronic kidney disease and renal transplant recipients
Vineet V Mishra, Shaheen Hokabaj, Priyankur Roy, Sumesh Choudhary, Ruchika Verneker, Khushali Gandhi
Department of Obstetrics and Gynaecology, IKDRC, Ahmedabad, Gujarat, India
|Date of Web Publication||12-Sep-2017|
Vineet V Mishra
Department of Obstetrics and Gynaecology, IKDRC, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
Objective: Abnormal uterine bleeding (AUB), especially in cases with chronic kidney diseases (CKDs) have a significant impact on physical, social, economic, and material quality of life of women. The objective of this study was to evaluate the efficacy, change in menstrual pattern, and patient satisfaction after transcervical resection of endometrium (TCRE) in women with AUB and CKD who underwent or were awaiting renal transplant and nonrespondents to medical management. Materials and Methodology: Eleven women with CKD (either underwent renal transplant or on dialysis) and AUB who did not respond to medical management underwent TCRE. The study period was 5 years. The main outcome measures were change in menstrual status, level of satisfaction with the procedure, and the need for repeat TCRE or hysterectomy. Results: The average age of the patients was 44.9 years. Out of the 22 women enrolled, 11 responded to medical management and only the remaining 11 women required TCRE. All 11 women underwent hysteroscopic-guided biopsy, and their histopathological reports revealed nonmalignant status. The average operating time for TCRE was 21.5 ± 8.02 min. Postoperatively 9 (81.81%) women had achieved amenorrhea while 2 (18.18%) developed oligomenorrhea. The duration from TCRE to amenorrhea ranges between 7 and 60 days with an average of 31.54 days. None of the women required hysterectomy. Conclusion: TCRE is clinically and cost effective alternative to medical management or hysterectomy in women with AUB and CKD. The cost-effectiveness, work performance, rapid convalescence, and improved the quality of life provide TCRE a “distinct edge” over the definitive management – hysterectomy.
Keywords: Abnormal uterine bleeding, chronic kidney disease, hysterectomy, renal transplant, transcervical resection of endometrium
|How to cite this article:|
Mishra VV, Hokabaj S, Roy P, Choudhary S, Verneker R, Gandhi K. Transcervical resection of endometrium: A novel mode of management of patients with abnormal uterine bleeding with chronic kidney disease and renal transplant recipients. Indian J Transplant 2017;11:61-5
|How to cite this URL:|
Mishra VV, Hokabaj S, Roy P, Choudhary S, Verneker R, Gandhi K. Transcervical resection of endometrium: A novel mode of management of patients with abnormal uterine bleeding with chronic kidney disease and renal transplant recipients. Indian J Transplant [serial online] 2017 [cited 2020 Feb 26];11:61-5. Available from: http://www.ijtonline.in/text.asp?2017/11/2/61/214387
| Introduction|| |
Abnormal uterine bleeding (AUB) is an irregular uterine bleeding as a result of disruption in the normal cyclic pattern of ovulatory hormonal stimulation to the endometrial lining. It is unpredictable in terms of amount, duration, and frequency of bleeding. Chronic kidney disease (CKD) is defined as kidney damage with or without decreased glomerular filtration rate (GFR), manifested as either pathologic abnormalities or abnormalities in markers of kidney damage, including the composition of blood or urine, renal imaging findings, and a GFR <60 ml/min. Approximately, 17.2% of the Indian population have CKD.
Some female allograft recipients frequently present with AUB that concern both the patient and the gynecologist. Renal transplant patients are 3–4 times more prone for premalignant and malignant lesion because of chronic immunosuppressive therapy, higher vulnerability to viral infections, and secondary morbidities. An increased rate of endometrial hyperplasia, an estrogen-dependent premalignant lesion of the endometrium, has been observed among kidney allograft recipients. Hence, all transplant and CKD patients must undergo strict clinical surveillance for premalignant and malignant lesions of sex organs and breast.
Menstrual dilemmas such as menorrhagia, oligomenorrhea, and amenorrhea are common gynecological problem among women with CKD. This may be partly because of abnormal bleeding time due to platelet dysfunction and partly result of failure to ovulate or adequately maintain corpus luteum. Heavy menstrual bleeding (HMB) is of major concern in such patients as it deteriorates the chronic anemia of renal disease and may require blood transfusion. The majority of these premalignant lesions regress after conservative treatment with progestagens. However, cases of persistent and recurrent endometrial hyperplasia require operative management. Hysterectomy is being offered as last resort, but it increases risk of infection, anemia, hemorrhage in CKD patients with AUB who underwent or are awaiting renal transplant because of prolonged operating time, exposure to prolong anesthesia and postoperative recovery.
Transcervical resection of endometrium (TCRE) has become an increasingly popular treatment for AUB since its introduction in 1983. It is an innovative, simple, less operating time, faster postoperative convalescence, relatively safe, and less invasive surgical technique in which uterus is preserved and provide tissue for histopathological examination as compared to surgical procedures like hysterectomy. There are no studies in past which had specifically focused on role of TCRE in patients post or awaiting renal transplant. Hence, this study aims to evaluate the change in menstrual pattern, patient satisfaction, long-term efficacy, and safety of TCRE in women with AUB and CKD who underwent or are awaiting renal transplantation.
| Materials And Methodology|| |
Between March 2012 and February 2017, after obtaining written informed consent, 22 patients with CKD who underwent or were awaiting renal transplant and referred to the Department of Obstetrics and Gynaecology at a tertiary care center with complaints of AUB were recruited in the study. Institutional Ethical Committee Clearance was obtained before starting the study. Those patients who had uterovaginal descent were desirous of conserving fertility, pelvic infection, thyroid disorders, bleeding disorders, any evidence of malignancy, or those refusing consent were excluded from the study.
Detailed gynecological history, diagnosis, and status of renal disease and treatment received were entered in a pro forma. All the women underwent gynecological examination including cervical smear. Complete blood count, renal function test, coagulation profile, serum electrolytes, thyroid function test, and transvaginal ultrasonography were done in all patients.
All the patients were offered medical management– mainly progesterone treatment. Those who were not willing, nonresponsive and those intolerant to medical treatment underwent hysteroscopic-guided endometrial biopsy. After histopathological confirmation of nonmalignant endometrial biopsy or simple hyperplasia or cystoglandular hyperplasia, women were offered TCRE as an alternative option to hysterectomy.
Preanesthesia checkup, nephrologist preoperative fitness, and preoperative investigations were done. Four patients who had CKD and were awaiting transplant underwent preoperative hemodialysis with one unit of packed cell volume transfusion the day before TCRE. The surgical procedure was performed under general anesthesia according to standard resection technique using bipolar loop resectoscope with normal saline solution as distension medium. Postoperatively, three doses of GnRH agonist, Inj. Leupride Acetate were given at 28 days interval and were advice to continue their renal treatment.
Patients were called for follow-up over a period of 1 year. Patients were asked to describe the change in menstrual status both before and following TCRE; the need for repeat TCRE, hysterectomy, interval between TCRE and further surgeries. The women were also invited to comment on the procedure, their satisfaction for the procedure and on any benefit or disadvantage they could perceived. Statistical analysis of the data was done the software use is SPSS version 20.0 developed by IBM Inc., Bangaluru, India.
| Results|| |
The year-wise distribution of women undergoing TCRE is illustrated in [Table 1]. Totally, 22 patients referred with AUB were carefully evaluated. Eighteen women were postrenal transplant patients, and 12 women were known case of CKD (awaiting renal transplant). The average age of the patients undergoing TCRE was 44.9 years with the range of 37–54 years [Graph 1]. Characteristics of the study population are described in [Table 2]. All 22 patients had taken medical treatment for 3 months. Out of the 22 patients, 11 (50%) women responded to medical treatment alone. Rest of the 11 (50%) patients needed further operative management.
Out of 11 patients, 10 (90.92%) had a normal delivery, and 1 (9.08%) underwent lower segment cesarean section. All the patients had presented with complaints of menorrhagia, the duration is illustrated in [Graph 2]. Severe dysmenorrhea was present in 3 (27.27%) patients. All 11 patients underwent hysteroscopic-guided biopsy, and their histopathological report is mentioned in [Table 3]. The average operating time for TCRE was 21.5 ± 8.02 min. In two patients, intraoperative hemorrhage developed which was controlled using an inflated balloon of a Foley's catheter as uterine tamponade for 6–8 h postsurgery. Postoperatively, serum electrolytes were done for all women which were within normal limits. Eight (72.72%) women were discharged after 24 h of surgery while 3 (27.27%) women went home after 72 h following surgery due to pain and minimal bleeding.
All 11 (100%) women had improvement in their menstrual pattern. Nine (81.81%) women had achieved amenorrhea while 2 (18.18%) developed oligomennorrhoea [Graph 3]. The duration from TCRE to amenorrhea ranged between 7 and 60 days with an average of 31.54 days. One (9.09%) woman had persistent white discharge per vaginum postoperatively. One (9.09%) patient developed hematometra after 2 months of TCRE, for which hysteroscopic-guided cervical dilatation and repeat TCRE was done. None of the women needed to go for hysterectomy. All women were satisfied with the outcome of the procedure.
| Discussion|| |
Women with CKD are usually stoical and rarely complain about gynecological problems which may seem trivial in comparison to their renal ailment. They suffer from many unrecognized gynecological problem which are often caused or exacerbated by the renal disease or its treatment. Menorrhagia is of immense and immediate concern because HMB worsens the chronic anemia of renal disease which may necessitate blood transfusion. This, in turn, is associated with the development of atypical and cytotoxic antibodies which reduce the chances of successful matching, an important consideration for women with CKD on dialysis awaiting a renal transplant.
Renal transplantation has become universally accepted treatment for end-stage renal disease which is followed by increasing number of immunosuppressive therapy to prevent graft rejection. This immunosuppressive therapy increases the chances of infection, premalignant, and malignant lesions. Renal transplanted women form a specific group of patients. The function of the hypothalamus-pituitary-ovarian axis and hence menstrual function is usually restored along with renal function after successful renal transplant. However, high level of estrogen due to impaired metabolism of steroid hormones along with low levels of progesterone in luteal phase and normal level of gonadotropin have also been reported in some female graft recipients. Hence, AUB is a common gynecological problem in women with CKD and in renal allograft recipients.
Menorrhagia secondary to CKD is often refractory to medical management with cyclical progestogens while prostaglandin synthetase inhibitors are contraindicated in CKD because they constrict the renal artery and have a direct adverse effect on glomerular function. Hysterectomy which is last resort for the management of AUB is associated with increased risk of infection, gastrointestinal complication, longer hospital stay, and need for blood transfusion in kidney transplant patients as compared to nonkidney transplant patients as found in a study by Heisler et al. and DiBrito et al.,
TCRE is a clinically effective, minimally invasive and safe method for the management of AUB especially in women with comorbidities. It is superior to hysterectomy in terms of intra- and post-operative morbidity in experienced hands. It has the advantages of rapid recovery, early resumption of normal activities, shorter duration of the procedure, and stay in the hospital.
All women who underwent TCRE in our study was primarily due to menorrhagia. The majority of the women had symptoms for more than 6 months. These patients were initially treated with progestogens but were nonresponsive and hence planned for further operative management.
As TCRE has the advantage of shorter duration of the procedure, rapid convalescence and less complications as compared to hysterectomy, it can be a good alternative in patients with CKD and renal allograft recipients who are unfit for the prolonged surgery and prolonged anesthesia exposure. All these women underwent hysteroscopic-guided biopsy and their histopathological examination revealed the majority of women had endometrial hyperplasia without atypia. Bobrowska et al. in their study found that out of 45, 31 (69%) patients had endometrial hyperplasia without atypia which is believed to be associated with inappropriate estrogen stimulation of endometrial tissue and chronic immunosuppressive therapy.
With advanced technology, careful control of infusion pressure of fluid by hysteromat and shorter time for the procedure achieved by experienced surgeons limits the risk of fluid overload. No cases of fluid overload were noted in this study.
Intraoperative excessive uterine bleeding was found in two patients which was managed easily by using inflated Foley's catheter as uterine tamponade. Anemia, platelet dysfunction, dialysis, the accumulation of medications due to poor renal clearance and anticoagulation used during dialysis contributes in causing impaired hemostasis in end-stage renal disease patients. Uterine perforation, false passage, and postpartum endometritis are though rare yet recognized complications seen while performing TCRE.
Postoperatively, 1 (9.09%) woman had chronic white discharge per vaginum. Another woman developed hematometra for which she underwent repeat hysteroscopic-guided dilatation and TCRE after 2 months which was in concordance with a study by Chandel et al.
The success of TCRE depended on improvement in menstrual patterns. The results of TCRE were overwhelming; all 11 (100%) women had improvement in their menstrual cycle which gave immense satisfaction to the women. Nine women had amenorrhea, and two women had spotting per vaginum every month for 1 day. This protects immunocompromised CKD and kidney graft recipients from heavy bleeding, severe anemia, and from endometrial cancer development. The average duration of achieving amenorrhea was 31.54 days. This results were in consistent with other studies. None of the women needed more radical treatment like hysterectomy.
Thus, TCRE in experienced hands is a safe and effective alternative to medical or more radical surgical treatment in women with AUB in a known case of CKD and postrenal transplant recipients.
| Conclusion|| |
Hysteroscopic TCRE is clinically and cost-effective modality which avoids unnecessary hysterectomies in the perimenopausal women. The cost-effectiveness, improvement in the quality of life, safety, less complications, and better work performance provides TCRE an edge over the “conventional” hysterectomy in high-risk patients such as CKD and renal transplant recipients.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Khrouf M, Terras K. Diagnosis and management of formerly called “Dysfunctional uterine bleeding” according to PALM-COEIN FIGO classification and the new guidelines. J Obstet Gynaecol India 2014;64:388-93.
Vanrenterghem Y, Ponticelli C, Morales JM, Abramowicz D, Baboolal K, Eklund B, et al.
Prevalence and management of anemia in renal transplant recipients: A European survey. Am J Transplant 2003;3:835-45.
Durai G, Kumar S, Ganesan M. A study on anemia in post renal transplant patients. Int J Curr Med Appl Sci 2017;13:179-84.
Kaminski P, Bobrowska K, Pietrzak B, Bablok L, Wielgos M. Gynecological issues after organ transplantation. Neuro Endocrinol Lett 2008;29:852-6.
Bobrowska K, Kaminski P, Cyganek A, Pietrzak B, Jabiry-Zieniewicz Z, Durlik M, et al.
High rate of endometrial hyperplasia in renal transplanted women. Transplant Proc 2006;38:177-9.
Amina AA, Mohammad EM, Khidr N. Evaluation of gynecological problems among hemodialysis women. IOSR J Nurs Health Sci 2015;4:82-91.
Chandel NP, Bhat VV, Bhat RS, Chandel RS. Treatment analysis of transcervical resection of endometrium (TCRE) in heavy menstrual bleeding (HMB): A prospective multicentre theraupetic study in Indian scenario. JOGI 2015;2:28-35.
Cochrane R, Regan L. Undetected gynaecological disorders in women with renal disease. Hum Reprod 1997;12:667-70.
Rajski D, Bobrowska K, Pietrzak B, Wielgos M, Kaminski P. Endometrial polyps in female allograft recipients with abnormal bleedings. Prz Menopauzalny 2014;13:194-7.
Heisler CA, Casiano ER, Gebhart JB. Hysterectomy and perioperative morbidity in women who have undergone renal transplantation. Am J Obstet Gynecol 2010;202:314.e1-4.
Kaw D, Malhotra D. Hematology: Issues in the dialysis patient: Platelet dysfunction and end-stage renal disease. Semin Dial 2006;19:317-22.
Stamatellos I, Koutsougeras G, Karamanidis D, Stamatopoulos P, Timpanidis I, Bontis J, et al.
Results after hysteroscopic management of premenopausal patients with dysfunctional uterine bleeding or intrauterine lesions. Clin Exp Obstet Gynecol 2007;34:35-8.
[Table 1], [Table 2], [Table 3]