Nonresectoscopic Endometrial Ablation in High-Risk Surgical Patients: A Cohort Study

Study Objective: To evaluate the use of nonresectoscopic endometrial ablation in women with high anesthetic and surgical risk compared with low-risk women based on the American Society of Anesthesia (ASA) physical status stratification. Design: This is a cohort study of women who were classified as high-risk (HR) or low-risk (LR) cohorts based on ASA physical status stratification. The ASA classification includes 6 grades: ASAP1, a normal healthy person; ASAP2, mild systemic disease; ASAP3, severe systemic disease; ASAP4, severe systemic disease that is a constant threat to life; ASAP5, a critically ill patient who is not expected to survive without the operation; and ASAP6, declared brain-dead patient whose organs are being removed for donor purposes. Baseline characteristics including comorbidities were obtained. Outcome measures included amenorrhea, treatment failure, and operative complications. The time to treatment failure was compared using Kaplan-Meier analysis. Risk adjustments were performed using regression models. Setting: Academic medical center in the Upper Midwest. Patients: Seven-hundred eleven women underwent nonresectoscopic endometrial ablation at our institution between January 1998 and December2005. Interventions: Bipolar radiofrequency was used in 448 women and thermal balloon ablation in 263 women. Measurements and Main Results: The HR cohort had a higher proportion of women with cardiac disease (27.1% vs 6.7%, p < .001) and more women with nongynecologic cancer (12.3% vs 2.9%, Fisher exact test, p < .001). Nonetheless, endometrial ablation had comparable efficacy in both the HR and LR cohorts with 5-year failure rates of 11.7% and 14.8% (p = .659), respectively. Amenorrhea rates were also similar in both cohorts (29.7% vs 27.2%, p = .645). After adjusting for known confounders including age, parity, dysmenorrhea, previous tubal ligation, uterine length, and the type of the procedure, the calculated hazard ratio for failure in the HR cohort was 0.80 (95% confidence interval; 0.31-1.74, p = .607), and the adjusted odds ratio for amenorrhea was 1.27 (95% confidence interval, 0.71-2.20; p = .411). Complications were rare in both groups. The mortality rate in the HR cohort was significantly higher compared with the LR cohort (7.9% vs <1%, p < .001), but this was not related to the ablation procedures. Conclusion: For women who are high anesthetic and surgical risks because of serious underlying comorbidities, nonresectoscopic endometrial ablation can provide minimally invasive, safe, and effective therapy for menorrhagia.