Treatment of Postoperative Uterine Adhesions
The recommended treatment for postoperative uterine adhesions includes hysteroscopic adhesiolysis followed by placement of physical barriers such as intrauterine devices combined with a Foley catheter balloon, along with hormonal therapy to prevent recurrence. 1
Pathophysiology and Impact
- Postoperative uterine adhesions (intrauterine adhesions or IUAs) are fibrous tissue bands that form in the endometrial cavity following surgical trauma, leading to abnormal menstruation, recurrent pregnancy loss, secondary infertility, and pregnancy complications 2
- These adhesions commonly develop after myomectomy and are a major risk of the procedure, resulting from surgical trauma to the endometrium 3, 4
- Adhesions can significantly reduce subsequent fertility and may cause other complications such as bowel obstruction 3
Primary Treatment Approach
Hysteroscopic Adhesiolysis
- Hysteroscopic transcervical resection of adhesion (TCRA) is the principal initial therapy for intrauterine adhesions 5
- The procedure should be performed by experienced endoscopic surgeons to minimize additional trauma to the endometrium 3
- Bipolar resection techniques may help reduce adhesion formation compared to other methods 4
Prevention of Recurrence
Physical Barriers
- Combination approaches show superior outcomes to single interventions 1:
- Intrauterine device (IUD) placement post-adhesiolysis provides mechanical separation of uterine walls 1
- Foley catheter balloon combined with IUD is more effective than IUD alone in preventing re-adhesion 1
- For moderate adhesions, extended placement of Foley balloon (1 month) plus IUD significantly improves pregnancy rates compared to shorter duration or IUD alone 1
Adhesion Prevention Barriers
- Several materials are used as adhesion prevention barriers 3:
- Oxidized regenerated cellulose (degraded by leukocytes)
- Polytetrafluoroethylene (a permanent material typically removed after an appropriate interval)
- Hydrolyzable combination of hyaluronic acid and carboxymethylcellulose
- Barrier gels may be useful but require stronger evidence 4
Hormonal Therapy
- Sequential estrogen and progesterone therapy should be initiated on the day of operation 1
- Postoperative estradiol may help prevent adhesion recurrence by promoting endometrial regeneration 4
Treatment Considerations Based on Adhesion Severity
Moderate Adhesions
- Foley catheter balloon for 1 month combined with IUD placement and hormonal therapy shows the best outcomes 1
- This approach significantly improves pregnancy rates compared to shorter duration balloon placement or IUD alone 1
Severe Adhesions
- Extended Foley balloon placement does not show significantly better outcomes for severe adhesions 1
- More aggressive approaches may be needed, including consideration of advanced tissue engineering methods 5
Emerging Therapeutic Strategies
- Bioactive scaffolds combined with tissue engineering technology show promising results for endometrial repair 5
- Stem cell therapy has demonstrated promising efficacy in pre-clinical and initial clinical studies 2
- Combination strategies using physical barriers as delivery carriers for therapeutics may provide new alternatives for adhesion prevention 2
Follow-up Protocol
- Second-look hysteroscopy should be performed at 1 and 3 months after treatment to assess uterine cavity healing and potential re-adhesion 1
- Monitoring should include evaluation of:
- Uterine cavity appearance
- Endometrial thickness
- Menstrual pattern
- Fertility outcomes 1
Surgical Technique Considerations
- Minimize surgical trauma during the initial procedure that may lead to adhesions 3
- Confine incisions to the anterior uterine surface to protect bowel and adnexal structures 3
- For myomectomy procedures, careful attention to surgical blood loss using techniques such as vasopressin injection can reduce complications 3
- Endoscopic surgery reduces de novo adhesion rates in other parts of the pelvis, though not necessarily at the surgical site 3