Simon Rochelle A, Quddus M Ruhul, Lawrence W Dwayne, Sung C James
Department of Pathology, Warren Alpert Medical School, Brown University, Women & Infants Hospital, Rhode Island.
Int J Gynecol Pathol. 2015 May;34(3):245-52. doi: 10.1097/PGP.0000000000000147.
Endometrial ablation is a minimally invasive alternative to hysterectomy for abnormal uterine bleeding. Although the failure rate is low, continued bleeding or development of pelvic pain after ablation does occur. We analyzed the clinicopathologic features of 164 hysterectomy specimens after endometrial ablation, 19 of which were performed for indications other than failed ablation (control cases). Pathologic findings included: dense fibrosis and hyalinization of the endometrial surface ablative necrosis within the uterine cavity and adherent to the endometrial surface, persistent months after ablation; uterine cavity lined by superficial, large, congested, patent blood vessels with atherosis; ablation changes present only in the lower uterine segment; and residual endometrium present in the cornual regions. Patients with ablative necrosis underwent subsequent hysterectomy sooner than those without such debris (median of 5 vs. 23 mo, respectively). Patients with superficial abnormal vessels were also more likely to have a shorter ablation-hysterectomy interval than those without (median of 2 vs. 18 mo, respectively). Patients with associated adenomyosis or prior tubal ligation were significantly more likely to have continued bleeding. Possible sources of continued abnormal bleeding or pelvic pain include: the presence of ablative necrosis or superficial abnormal blood vessels, although the association did not reach statistical significance in this study; incomplete ablation, affecting only the lower uterine segment or sparing the cornual region; tubal endometriosis after ligation; and endometrial regeneration via adenomyosis.
子宫内膜消融术是子宫切除术治疗异常子宫出血的一种微创替代方法。尽管失败率较低，但消融术后仍会出现持续出血或盆腔疼痛。我们分析了164例子宫内膜消融术后子宫切除标本的临床病理特征，其中19例因消融失败以外的指征进行手术（对照病例）。病理结果包括：子宫内膜表面致密纤维化和玻璃样变，子宫腔内有与子宫内膜表面粘连的消融性坏死，消融后持续数月；子宫腔表面有粗大、充血、通畅且伴有动脉粥样硬化的血管；消融改变仅见于子宫下段；宫角区域存在残留子宫内膜。有消融性坏死的患者比没有这种坏死组织的患者更早接受子宫切除术（中位时间分别为5个月和23个月）。有浅表异常血管的患者消融至子宫切除的间隔时间也比没有的患者更短（中位时间分别为2个月和18个月）。合并子宫腺肌病或既往输卵管结扎的患者持续出血的可能性显著更高。持续异常出血或盆腔疼痛的可能原因包括：存在消融性坏死或浅表异常血管，尽管本研究中这种关联未达到统计学意义；消融不完全，仅累及子宫下段或未累及宫角区域；结扎后输卵管子宫内膜异位；以及通过子宫腺肌病实现子宫内膜再生。
