Study Objective. To determine the effectiveness of endometrial cryoablation in comparison with rollerball electroablation.Design. Prospective, randomized study (Canadian Task Force classification I).Setting. Ten university and private medical centers in the United States.Patients. Two hundred seventy-nine women with menorrhagia due to benign causes.Intervention. Endometrial ablation using a Her Option cryoablation device in 193 women and rollerball electroablation in 86.Measurements and Main Results. Women treated by cryoablation received significantly less general anesthesia (46%) than those treated by electroablation (92%). Subjects maintained menstrual diaries for at least one cycle before and for 12 months after the procedure. Success was defined as reduction of menstrual bleeding to a score of 75 or less in the absence of retreatment. Success rates in the cryoablation and electroablation groups were 77.3% and 83.8%, respectively. Bleeding declined by 92% and 94%, respectively. Both procedures led to significant improvements in a broad range of symptoms including menses-related pain, mood, and overall improvement in quality of life.Conclusion. Endometrial cryoablation is a safe and effective procedure in treatment of dysfunctional uterine bleeding. Its advantages include technical ease of performance, direct ultrasonographic view of depth of ablation, little anesthetic, and avoidance of potential complications related to distention media.

After observing Melvin Cohen perform laparoscopy in Chicago, Illinois, during the late 1960s, Jordan M. Phillips performed this revolutionary operation in Downey, California, with enthusiasm. By 1971 he envisioned the need for an independent organization to devote its efforts to promoting this method of surgery through education and training. With the aid of his wife, Eleanor (Ellie), the American Association of Gynecological Laparoscopists (AAGL; a name to be changed slightly later) was incorporated as a not-forprofit entity that year. Based on an exhaustive search of the literature in the United States and Europe, he selected 30 physicians to speak about their experiences at the first meeting held at the Stardust Hotel in Las Vegas, Nevada, in November 1972. Because the AAGL was yet to become an organization of members, the first meeting was appropriately called an annual symposium. It was personally organized, managed, and funded by the Phillips. When one reviews the original program, the 23 speakers and 19 subjects plus 17 luncheon roundtable discussions expose a history lesson in the state of the art of laparoscopy. The keynote speaker was Patrick Steptoe from England, then the author of the only English-language monograph on laparoscopy. Hans Frangenheim of Konstanz, West Germany, a leader in laparoscopic creativity, was the luncheon speaker. As evidenced by a standing ovation, none would argue that the highlight of the meeting was a laparoscopic movie of human ovulation taken by Professor Frangenheim using time-framed 16mm movie film. Anesthesia, basic techniques, and sterilization by laparoscopy were pivotal subjects discussed or presented on film. The potential for infertility investigation was explored, including early operative maneuvers in the form of ovarian biopsy.

Study Objective. To compare a distensible multielectrode balloon for endometrial ablation with electrosurgical ablation performed by a combined resection-coagulation technique.Design. Randomized prospective trial (Canadian Task Force classification 1).Setting. Eight centers.Patients. Women with menorrhagia validated with a standardized pictorial blood loss assessment chart (PBAC), without intracavitary organic uterine disease, who failed or poorly tolerated medical therapy.Intervention. Results in 122 patients treated by Vesta and 112 treated surgically, evaluable at 1 year, were compared, with success defined as monthly blood loss of less than 80 ml and avoidance of additional therapy.Measurements and Main Results. Pretreatment PBAC scores for patients treated by Vesta and resection or roller-ball were 535 +/- 612 and 445 +/- 313, respectively; at 1 year they were 18 +/- 37 and 28 +/- 60, respectively. With PBAC below 75 as the definition of success, 86.9% of Vesta-treated patients were successful compared with 83.0% treated by rollerball or resection. Total amenorrhea, defined as no visible bleeding and no use of protective products, was 31.1% and 34.8%, respectively. None of the outcome comparisons between treatments showed statistical difference. Complications in both groups were few and minor. Most(86.6%) Vesta procedures were carried out with paracervical block with or without intra venous sedation in an office or outpatient setting, compared with 79.7% epidural or general anesthesia for rollerball or resection.Conclusion. The Vesta system of endometrial ablation is equally effective and safe as classic resectoscopic methods. Potential advantages include avoidance of fluid and electrolyte disturbance associated with intravasation of distending media, and ability to perform the procedure under local anesthesia in an office setting with less total operating time.

Study Objective. To compare results of endometrial ablation using the Vesta system compared with resection and rollerball.Design. Multicenter, prospective, randomized, controlled study (Canadian Task Force classification I).Setting. Private practice and academic center.Patients. Women with menorrhagia documented by menstrual diaries who failed or refused hormonal therapy and who had no major uterine organic lesions.Interventions. Vesta endometrial ablation or traditional endometrial resection and rollerball ablation.Measurements and Main Results. Both groups achieved excellent control of menorrhagia.Conclusion. Vesta is an attractive alternative to traditional methods of endometrial ablation.

Editorial Comment: More reports are beginning to appear with m a r d to the treatment of a distal ureteral stone in pregnant women with ureteroscopy and intracorporeal lithotripsy or direct stone extraction. Notably, the authors performd 3 of the procedures with O d Y topical anesthesia and no fluoroscopy. In each case they reported successful treatment of the stone and an uneventful convalescence with delivery of a healthy child. Ulvik et al have also repofid successful ureteroscopy in 24 pregnant women without any complications.' However, as the authors and others have noted, the standard of care in these patients remains ureteral stent placement or percutaneous nephrostomy, with ureteroscopy currently held in reserve should either of these former methods fail. Given the advent of the smaller 6.9F rigid and 7.6F flexible ureteroscopes, I would expect even more articles to appear on ureter~scopy as a primary modality in these patients. However, until further data are available in a larger number of ureteroscopic cases in which fluoroscopy or postoperative ureteral stents have not been used, this approach during pregnancy must be considered under advisement. Ralph V. Clayman, M.D. 1. Ulvik, N. M., Bakke, A. and Hoiseter, P. k: Ureteroscopy and pregnancy. J. Ud., 154: 1660,1996.

The VestaBlate system uses a multielectrode intrauterine balloon as a device to create effective and safe endometrial ablation (EA). The surface of the distensible balloon is impregnated with thermistors and thin, platelike electrodes. It is designed to deliver low-power electroenergy to the endometrium. Unlike the resectoscope techniques that require nonelectrolytic fluids for uterine distention, moving electrodes at high power outputs, and other variables that are operator dependent, the VestaBlate is computer controlled using a standard type electrosurgical generator. A respiratory enzyme stain, nitroblue tetrazoleum, was used to determine the extent and depth of tissue necrosis to a myometrial depth of 2 to 4 mm with uniform destruction of tissue with power setting at 45 W for a 4-minute application of energy. Sixty-nine patients have been treated, with 45 followed for at least 3 to 9 months. The amenorrhea rate is 40%; the oligomenorhea-hypomenorrhea rate is 49%.

OBJECTIVE:To alert gynecologic surgeons to the risk of room air embolism during endoscopy.DESIGN:Case reports.SETTING:Medico-legal consultations.PATIENTS:Five women having endoscopic procedures.INTERVENTIONS:Endoscopy followed by emergency resuscitative measures.RESULTS:Morbidity and mortality.CONCLUSIONS:The risk of room air embolism may be lessened by attention to the operative technique and by monitoring the end tidal carbon dioxide levels.

Despite the fact that electrophysics and its application to surgery, in particular endoscopic surgery, is a discreet science, there is little attention paid to the applied principles of the physics involved when surgeons receive their formal training in the technical aspects of surgery. Most training programs consider the discipline of electrosurgery as a skill that is left to the 'hands on' exposure of the student, and that the skills and knowledge of the average professor have been awarded through a 'grandfather' process of credentials. As a result, many myths have been perpetuated over the past decades since William Bovie introduced the first electrosurgical diathermy machine using high frequency radio waves instead of heated instruments (cautery) to destroy human tissue. Electrogenerators, today, have become finely tuned instruments that offer many versatile variables for the contemporary surgeon to harness and deliver, in either a discreet or broad manner, to tissue to obtain a desired effect and outcome.

There is growing interest in using the urologic resectoscope for endometrial ablation, but the actual depth of tissue destruction is unknown. A preliminary in vitro study measured the depth of visible coagulation produced when various waveforms of high-frequency current were applied to tissue using the "rollerball" electrode of the resectoscope. Tissue necrosis caused by high-frequency electrical energy is not immediately apparent: several days must elapse before the true extent of the damage can be seen. To study it, the uterus from a woman who was planning to undergo a hysterectomy was treated with the resectoscope four days prior to surgery. The depth of tissue destruction caused by 19 and 59 W of "cutting" current and by 28 and 57 W of "coagulating" current was 1.5, 2.7, 6.1 and 1.8 mm, respectively. A second patient underwent a hysterectomy 48 hours after resectoscopic endometrial ablation. There was no endometrium remaining, and coagulation extended 2-3 mm into the myometrium. Visual effects on the surface do not predict actual tissue destruction, so further in vivo studies will be necessary in order to obtain consistent clinical results.

The results of a survey on various aspects of laparoscopy in the U.S. and Canada are presented for the period July 1 1972-June 30 1973. The following information was surveyed: the number of diagnostic and operative laparoscopies performed laparotomies performed due to a variety of laparoscopic complications known pregnancies at the time of surgery or following sterilization deaths associated with laparoscopy other complications requiring hospitalization cardiac arrest and failed laparoscopies. In addition a discussion is presented concerning training certification for laparoscopists and the need for informational brochures to accompany laparoscopy equipment.