Hysteroscopic local anaesthetic intrauterine cornual ‘focal local’ block before endometrial ablation with direct cervical block in an outpatient setting: a feasibility study Vinod Kumar a , Janesh Kumar Gupta b, * a University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK b Birmingham Women’s NHS Foundation Trust, Birmingham, UK 1. Introduction Outpatient endometrial ablation (EA) using local anaesthetic has gained wider acceptance in the last decade as it avoids the risk of general anaesthesia and reduces the duration of hospital stay and recovery [1–3]. Pain experienced during the procedure, however, can be a disincentive and is the commonest reason for failure to complete the procedure [4]. The best approach to provide complete uterine anaesthesia during EA has yet to be determined [5,6]. The most commonly used local anaesthetic method during EA is a cervical block only, such as the direct or paracervical block [7–9]. It is well recognised, however, that by this method alone it is difficult to achieve complete uterine anaesthesia, especially of the uterine fundus [5,6,10,11]. The uterus has complex innervations (Fig. 1). The cervix and lower two-thirds of the body of the uterus are primarily innervated from the uterovaginal plexus, largely derived from the parasym- pathetic sacral S1–4 nerve roots [12], whereas the upper one-third is innervated from the thoracic nerves, largely derived from the sympathetic fibres of the superior hypogastric plexus T8–T10 and L1 roots [13]. These latter nerve supplies enter the uterus along the infundibulopelvic ligament and the path of the ovarian arteries [14]. Therefore specific targeting of this nerve pathway with an intrauterine cornual block may result in improved anaesthesia during EA. Recently Skensved found that a combination of an ostial and fundal block with a paracervical block was more effective in relieving pain than a sole paracervical block during EA [15]. Understanding the anatomy of the nerve pathways (Fig. 1) suggests that a more lateral block to the fundus, specifically targeting the concentrations of the nerve plexus around the cornua of the uterus, would be more effective in achieving complete uterine anaesthesia when combined with a direct cervical block. The objective of this study was therefore to evaluate the safety, feasibility and efficacy of a hysteroscopic intrauterine cornual block (ICOB) along with direct cervical block (DCB) on women’s perception of pain during outpatient Thermachoice endometrial ablation (TEA). European Journal of Obstetrics & Gynecology and Reproductive Biology 170 (2013) 222–224 A R T I C L E I N F O Article history: Received 12 March 2013 Received in revised form 1 May 2013 Accepted 3 June 2013 Keywords: Endometrial ablation Thermachoice ablation Local anaesthesia Direct cervical block Intrauterine cornual block A B S T R A C T Objective: To evaluate the safety, feasibility and efficacy of a hysteroscopic local anaesthetic intrauterine cornual block (ICOB) on women’s perception of pain during outpatient Thermachoice endometrial ablation (TEA). Study design: Pre-menopausal women with heavy menstrual bleeding undergoing TEA were included in the study. The intervention used, ICOB, was a hysteroscopic injection of local anaesthetic into the myometrium just medial to each tubal ostium. The women also had a traditional direct cervical block (DCB). We measured the acceptability of ICOB and the pain score (visual analogue score scale) immediately after the procedure. Results: We treated 30 patients (mean age 41 years, SD 6; BMI 29 Æ 7) between January 2012 and December 2012. All patients had a successful ICOB block and found TEA with ICOB acceptable. The mean VAS score was 3.5 Æ 2.7, which was two points lower compared to our earlier prospective cohort of patients undergoing TEA with only a DCB (mean 5.8 Æ 2.7, n = 102). No serious complications occurred during the procedure or postoperatively. Three patients experienced a vasovagal response which resolved spontaneously. Conclusion: ICOB with DCB is a safe, feasible and efficacious method of pain control during TEA. There is however a need to evaluate efficacy of ICOB in a randomised placebo controlled trial. ß 2013 Elsevier Ireland Ltd. All rights reserved. * Corresponding author at: Birmingham Women’s Hospital, Edgbaston, Birming- ham B15 2TG, UK. Tel.: +44 121 607 4751; fax: +44 121 627 2667. E-mail address: j.k.gupta@bham.ac.uk (J.K. Gupta). Contents lists available at SciVerse ScienceDirect European Journal of Obstetrics & Gynecology and Reproductive Biology jou r nal h o mep ag e: w ww .elsevier .co m /loc ate/ejo g rb 0301-2115/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejogrb.2013.06.010