SCF: 30-31, SECTOR-11, HUDA, URBAN ESTATE, Panipat, Haryana 132103 SCF: 30-31, SECTOR-11, HUDA, URBAN ESTATE, Panipat, Haryana 132103A minimally invasive hysteroscopic approach-Transcervical resection of the endometrium (TCRE) was introduced and accepted in the management of abnormal uterine bleeding (AUB), especially in postmenopausal women, over the past 3 decades as an effective alternative to hysterectomy with lower morbidity and a shorter length of stay and recovery time.
Although TCRE has shown success over the years, recurrence of bleeding, imperfect endometrial removal, and need for retreatment in some select patients persist as challenging aspects.
New technology such as bipolar electrosurgery systems, real-time fluid management, AI-guided hysteroscopy, improved visualisation technologies, etc have proven to be effective in enhancing the safety and outcomes.
We review here the principles, indications, procedure, advantages and limitations, technological advancement in recent years and future directions of TCRE.
Hysteroscopic surgery changed the treatment of AUB, facilitating conservative, uterine-preserving interventions. Of the techniques that evolved, Transcervical Resection of the Endometrium (TCRE), a first-generation endometrial ablation, is perhaps the best-established procedure.
TCRE involves resecting the lining of the uterus with a hysteroscopic, electro- surgical loop that is inserted through the hysteroscope and resectoscope. TCRE provides the ability to visualise and directly resect the endometrium instead of the less targeted blind curettage. Myometrial preservation during the TCRE is possible. This hysteroscopic procedure can effectively treat AUB in the infertile woman who has failed medical therapy.
Studies have reported an 80% or higher rate of patient satisfaction with the procedures, with associated improvement in menstrual blood loss. With recent advancements in instrumentation, TCRE continues to evolve and is an established procedure, performed in the outpatient setting.
The TCRE procedure is also a less aggressive alternative to hysterectomy. It is a surgical technique that utilizes a hot wire loop to destroy the endometrial lining and reduce or abolish bleeding or provide the definitive cure of the menstrual loss in about 85% of patients with this symptom who have failed treatment and do not desire to conceive in the future (after TCRE pregnancy is not advised as it will cause damage to the unborn child, although there is no guarantee of this).
Heavy menstrual bleeding (HMB) / Menorrhagia– Unacceptable impact on quality of life from continuous excessive bleeding. Failure of medical therapy (e.g., tranexamic acid, NSAIDs, hormones, levonorgestrel-releasing IUD).
Abnormal uterine bleeding (AUB) in premenopausal women after all structural lesions not suitable for operative hysteroscopy have been ruled out or are amenable to operative hysteroscopy.
Complete family– Those who are finished having children and do not plan to get pregnant in the future, since this may still occur with other major complications after endometrial ablation/resection.
Benign uterine cavity– Normal or not distorted endometrial cavity. Small submucosal fibroids (generally FIGO type 0 or 1, size typically <3 cm) or endometrial polyps are treatable by operative hysteroscopy.
The procedure TCRE should not be performed in cases with,
The patient is put under general or regional anaesthesia. The patient is in the lithotomy position. Empty the bladder and prepare the operative area aseptically.
The cervix is dilated with cervical dilators to enable the insertion of a resectoscope inside the uterus. Insertion of the Hysteroscope. The resectoscope is inserted inside the uterus through the cervix. The uterus cavity is distended with the help of the fluid.
Inspect the endometrial cavity through direct hysteroscopic vision, visualising the endometrium and any pathologies.
Endometrium and adjacent myometrium of 3-5 mm thickness are resected with an electrosurgical loop starting from the fundus down to the uterine body.
All bleeding points are electrocauterized. Resected material removed. Cavity reinspected.
Observe the patient for bleeding, pain, fluid overload and vaginal discharge.
Minimally Invasive– TCRE is performed through the hysteroscope, and no cuts or holes are made to the abdomen. This translates to less discomfort and a faster recovery.
Controls Heavy Menstrual Bleeding– The process can either minimise or eliminate excessive bleeding during menstruation. For many women, symptoms are drastically reduced or eliminated.
Uterus Preserved– The uterus remains in place after the surgery. TCRE can be a beneficial option for many women instead of a hysterectomy.
Short Hospital Stay– The surgery typically takes one day. Patients are normally sent home on the same day they undergo the procedure.
Quick Recovery- Patients may be able to resume normal daily activities within just a couple of days after their surgery. Compared to a hysterectomy, it involves a much quicker recuperation period.
Lower Morbidity– There is less loss of blood and fewer complications compared with a hysterectomy. TCRE procedures are generally considered safe when conducted by a qualified medical professional.
TCRE is still a cornerstone in minimally invasive management for postmenopausal dysfunctional uterine bleeding, with favourable symptom relief and minimal risk compared with hysterectomy, supported by continuing technological innovations (bipolar energy sources, AI-enhanced hysteroscopy, and augmented intraoperative imaging).
However, symptoms recur, and the long-term effectiveness is heterogeneous, demanding a precise selection of patients and systematic follow-up. In the future, precise medicine strategies, multi-centric randomised controlled trials, machine learning, and economic assessment would further optimise this modality.
