- Email: [email protected]
2944 Transgluteal Pudendal Neurolysis
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231
S179
Jorgensen EM,1,* Modest AM,2 Awtrey CS,2 King LP2. 1Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; 2OB/GYN, Beth Israel Deaconess Medical Center, Boston, MA *Corresponding author.
work-up including renal functions tests and pelvic imaging. Ureteral reimplantation for severe distal disease must be considered.
Study Objective: Presence of endometriosis is commonly believed to make surgery more complex; however, there is a paucity of data to support and elaborate upon this idea. We aim to describe the incidence of endometriosis among patients undergoing total laparoscopic hysterectomy (TLH), as well as the impact of endometriosis on surgical complications and reimbursement. Design: Retrospective cohort. Setting: 147 academic or community-based hospitals in the United States participating in the American College of Surgeons National Surgical Quality Improvement Program. Patients or Participants: Patients undergoing TLH for benign indications from 2014 to 2017. Interventions: Presence or absence of endometriosis was determined by chart and operative note review by trained research assistants, rather than reliance on diagnosis codes. Measurements and Main Results: A total 29,243 TLH’s were identified. Endometriosis was noted in 16.5% of all patients undergoing TLH for benign indications. Though more prevalent among white patients, endometriosis is common among black patients undergoing TLH (16.7% white versus 12.8% black, p<0.001). Only 10.5% of patients with endometriosis documented at the time of hysterectomy underwent concomitant excision or ablation of endometriosis. Perioperative complications were more common among patients with endometriosis (5.1% versus 4.4%, p=0.04). Hysterectomies in patients with endometriosis noted intraoperatively earned a lower average number of work relative value units (wRVU’s) compared to hysterectomies in patients without endometriosis (16.1 versus 16.3, p<0.001). Conclusion: Endometriosis is a common finding at the time of benign TLH; however, peritoneal endometriosis is rarely treated at the time of hysterectomy. Though patients with endometriosis are more likely to have surgical complications, their surgeries earn fewer wRVU’s than surgeries in patients without endometriosis. Given its prevalence, endometriosis should be well-understood by all practicing benign gynecologic surgeons.
10:10 AM: STATION C
Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM) 10:10 AM: STATION B 3034 Robotic-Assisted Ureteroneocystostomy and Psoas Hitch for Ureteral Endometriosis Awosogba TP,1,* Jan A,2 Zaid H3. 1Gynecology, Lahey Hospital and Medical Center, Boston, MA; 2Gynecology, Beth Israel Lahey Health, Burlington, MA; 3Urology, Lahey Hospital and Medical Center, Burlington, MA *Corresponding author. Video Objective: We present a case of extrinsic urethral endometriosis. We review the peri-operative management with renal function testing, preoperative imaging and stent placement. The patient had a robotic-assisted ureteroneocystostomy with psoas hitch for her severe disease. The goal of this video is to review peri-operative management of urinary tract endometriosis and to demonstrate the surgical technique of ureterolysis in extrinsic ureteral endometriosis and ureteroneocystostomy with psoas hitch. Setting: the patient was managed in the outpatient setting as well as the inpatient surgical suite. Interventions: Surgical: ureteroneocystostomy with psoas hitch. Conclusion: Ureteral endometriosis is a rare manifestation of pelvic endometriosis that can be managed with appropriately with a peri-operative
Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM)
2426 Sliding Sign Testing Could be a Potential Alternative to Laparoscopy to Predict Endometriosis Fertility Index (EFI) in Endometriosis Associated Infertility Alfaraj SA,1,* Bedaiwy M,2 Yong PJ,2 Allaire C,2 Williams C,2 Lisonkova S,3 Noga H4. 1Obstetric and Gynecology, Reproductive Endocrinology and Infertility, University of British Columbia, Vancouver, BC, Canada, Vancouver, BC, Canada; 2Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada; 3Obstetric and gynecology, University of British Columbia, Vancouver, BC, Canada; 4 Obstetric and Gynecology, Reproductive Endocrinology and Infertility, University of British Columbia, Vancouver, BC, Canada *Corresponding author. Study Objective: EFI is a robust tool to predict pregnancy rate in endometriosis patients who attempt non-in vitro fertilization conception. However, EFI calculation requires laparoscopy. Sliding sign is a newly established technique that can predict Pouch of Douglas (POD) obliteration with a high degree of accuracy. The objective of this study is to investigate the relationship between sliding sign and the EFI, and to explore the practicality of using sliding sign to predict EFI score less than seven. Design: Observational study from a prospective registry (Endometriosis Pelvic Pain Interdisciplinary Cohort (EPPIC), ClinicalTrials.gov#NCT 02911090). Analyzed data was captured from December 2013 to June 2017. Setting: Tertiary referral center at British Columbia Women’s Hospital. Patients or Participants: Eighty-six women who are less than 40 years old. Interventions: Dynamic ultrasonography for the sliding sign testing and EFI calculation during laparoscopic surgery. Measurements and Main Results: Patients with a negative sliding sign (N=26,Group I) were older, had stage IV endometriosis, and a lower median EFI score than patients who had a positive sliding sign (N=60, Group II).Patients in group I had significantly lower surgical factor scores, Regarding the EFI historical factors, group I participants had a longer duration of infertility with no significant difference in parity or age compared to group II. Logistic regression showed that an EFI score < 7 can be predicted with a high sensitivity of 87.9% and specificity of 81.1% with a negative sliding sign and EFI historical factors score. The area under the curve (AUC) was 0.93 (95% CI 0.85−0.99). Conclusion: The sliding sign could be a potential alternative to the EFI surgical factors, and it could be used in combination with EFI historical factors to predict an EFI score < 7 for patients who are not scheduled for immediate surgery. Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM) 10:10 AM: STATION D 2944 Transgluteal Pudendal Neurolysis Reinert AE,* Hibner M, Castellanos ME. OB/GYN, St Joseph’s Hospital and Medical Center, Phoenix, AZ *Corresponding author. Video Objective: To describe the surgical technique of pudendal neurolysis via a transgluteal route as performed at St Joseph’s Hospital and Medical Center in Phoenix, Arizona.
S180
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231
Setting: 68 year old woman with right-sided pudendal neuralgia persistent despite non-surgical treatment. Interventions: Right-sided transgluteal surgery for pudendal nerve entrapment. Conclusion: Several modifications to the procedure originally described by Dr. Robert Roger may improve post-operative pain and function, and reduce risk of surgical complication.
p-value 0.193), BMI (26.9 kg/m2 vs. 29.3 kg/m2 p-value 0.157), history of chronic pain (25% vs. 46.7%, p-value 0.163), smoking history (never smokers 66.7% vs. 66.7%, p-value 0.713), or post-operative IV narcotic use (morphine milligram equivalents) prior to discharge (23.3 mg vs. 31.2 mg p-value 0.187). There were no pain related post-operative clinic visits. Conclusion: Providing dual narcotic prescriptions after gynecologic surgery can decrease the number of opioids obtained by patients postoperatively. Patient characteristics cannot be used to predict who fills the second prescription. This strategy was not associated with pain related post-operative visits.
Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM) 10:10 AM: STATION E 1425 Robotic Resection of Full Thickness Bladder Wall Endometriosis Fogelson N,1,* Christianson LA2. 1Northwest Endometriosis and Pelvic Surgery, Portland, OR; 2Minimally Invasive Gynecologic Surgery, Legacy Health Systems, Portland, OR *Corresponding author. Video Objective: To demonstrate a case of invasive endometriosis of the bladder wall, with preoperative images and description of operative technique for thorough removal and bladder wall closure. Setting: Private practice specialized in endometriosis care. Interventions: A 27 year old woman with stage IV endometriosis presented with infertility and pelvic pain. Pre-operative evaluation and MRI demonstrated bladder wall disease, as well as disease of the sigmoid colon and cecum. Complex robotic surgery was performed including ureteral catheter placement, resection of pelvic endometriosis, shave resection of colon, ileocecectomy, and full thickness bladder wall resection. This video focuses on removal of bladder disease, including preoperative workup and technique. The patient did well postoperatively with no complication and significant improvement in symptoms. Conclusion: Bladder wall endometriosis in the dome of the bladder is readily resectable using laparoscopic or robotic techniques. Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM) 10:10 AM: STATION F 1725 Dual-Opioid Post-Operative Prescription Model in Gynecologic Surgery − A Pilot Study Islam MR,* Cornella J, Wasson MN. Mayo Clinic Arizona, Phoenix, AZ *Corresponding author. Study Objective: Determine if providing two opioid prescriptions postoperatively is an effective strategy to decrease total number of opioids obtained. Design: Retrospective descriptive study. Setting: Tertiary care academic institution. Patients or Participants: Thirty-nine patients undergoing gynecologic surgery. Interventions: Two oral narcotic prescriptions were provided post-operatively. Patients were instructed to initially fill the first prescription with 10 pills. If the patient continued to have opioid requirement for pain control, she was instructed to fill the second prescription with an additional 20 pills. Opioids obtained within 6 weeks post-operatively were confirmed utilizing the Arizona Board of Pharmacy Controlled Substance Monitoring Program. Measurements and Main Results: Thirty-nine patients underwent gynecologic surgery via laparoscopy or robotics (N=26), laparotomy (N=3), or vaginal routes (N=10). In the post-operative period, 24 patients (61.5%) filled only 10 pills and 15 patients (38.4%) filled the additional 20 pills (CI 44.62%-76.64% p-value 0.15). Patients filling only one prescription versus two prescriptions were not affected by age (49.6 years vs. 43.2 years,
Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM) 10:10 AM: STATION G 1957 Robotic Assisted Mesh Removal: Posterior Vaginal Mesh Kit and Perivesical Mesh Invading Obturator Internus Sticco PL,* Ladanyi C, Furr RS. Minimally Invasive Gynecologic Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN *Corresponding author. Video Objective: This video depicts a surgical approach in a patient with both a complicated and unclear surgical history, with inability to obtain complete surgical record. It demonstrates a robotic assisted laparoscopic approach to removal of mesh in a patient with persistent pelvic pain with an unclear or unknown mesh location. Setting: This is a 60 year old woman with a remote history of hysterectomy for benign indications. Per patient, she subsequently developed symptomatic prolapse for which she underwent a “bladder sling” and two “hernia repairs” which necessitated suprapubic catheter post-operatively. She then experienced worsening pelvic pain since that time, now years later, and with constant rectal pressure and more recent post-coital bleeding. The patient is adamant on complete mesh removal. This was performed as an ambulatory surgery within a hospital setting. Interventions: Pelvic examination revealed noticeable tenderness of anterior vaginal wall, with no exposed mesh or bleeding. The video itself depicts a robotic assisted laparoscopic removal of bilateral posterior vaginal mesh kit and left perivesical mesh invading obturator internus. Careful surgical technique involving bladder dissection off vaginal cuff, ureterolysis, and dissection throughout the space of Retzius down to the obturator internus muscle is carried out with complete removal of multiple mesh components. Conclusion: Avoiding transection of the mesh along with meticulous dissection aides in traction and greatest chance of complete removal. Maintenance of hemostasis is critical for adequate visualization, especially within the space of Retzius. Knowledge of pelvic anatomy is paramount, as scarring, fibrosis, and mesh migration can distort normal anatomical planes. Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM) 10:10 AM: STATION H 2413 Appendiceal Endometriosis: Laparoscopic Endoloop Appendectomy Vigueras Smith A,* Sumak R, Kulkarni N, Pinto Rosario D, Ferreira H. Gynecology, Centro Hospitalar Universit ario do Porto, Porto, Portugal *Corresponding author. Video Objective: To demonstrate the surgical steps of the laparoscopic appendectomy for a deep endometriosis nodule using endoloops.
S179
Jorgensen EM,1,* Modest AM,2 Awtrey CS,2 King LP2. 1Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; 2OB/GYN, Beth Israel Deaconess Medical Center, Boston, MA *Corresponding author.
work-up including renal functions tests and pelvic imaging. Ureteral reimplantation for severe distal disease must be considered.
Study Objective: Presence of endometriosis is commonly believed to make surgery more complex; however, there is a paucity of data to support and elaborate upon this idea. We aim to describe the incidence of endometriosis among patients undergoing total laparoscopic hysterectomy (TLH), as well as the impact of endometriosis on surgical complications and reimbursement. Design: Retrospective cohort. Setting: 147 academic or community-based hospitals in the United States participating in the American College of Surgeons National Surgical Quality Improvement Program. Patients or Participants: Patients undergoing TLH for benign indications from 2014 to 2017. Interventions: Presence or absence of endometriosis was determined by chart and operative note review by trained research assistants, rather than reliance on diagnosis codes. Measurements and Main Results: A total 29,243 TLH’s were identified. Endometriosis was noted in 16.5% of all patients undergoing TLH for benign indications. Though more prevalent among white patients, endometriosis is common among black patients undergoing TLH (16.7% white versus 12.8% black, p<0.001). Only 10.5% of patients with endometriosis documented at the time of hysterectomy underwent concomitant excision or ablation of endometriosis. Perioperative complications were more common among patients with endometriosis (5.1% versus 4.4%, p=0.04). Hysterectomies in patients with endometriosis noted intraoperatively earned a lower average number of work relative value units (wRVU’s) compared to hysterectomies in patients without endometriosis (16.1 versus 16.3, p<0.001). Conclusion: Endometriosis is a common finding at the time of benign TLH; however, peritoneal endometriosis is rarely treated at the time of hysterectomy. Though patients with endometriosis are more likely to have surgical complications, their surgeries earn fewer wRVU’s than surgeries in patients without endometriosis. Given its prevalence, endometriosis should be well-understood by all practicing benign gynecologic surgeons.
10:10 AM: STATION C
Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM) 10:10 AM: STATION B 3034 Robotic-Assisted Ureteroneocystostomy and Psoas Hitch for Ureteral Endometriosis Awosogba TP,1,* Jan A,2 Zaid H3. 1Gynecology, Lahey Hospital and Medical Center, Boston, MA; 2Gynecology, Beth Israel Lahey Health, Burlington, MA; 3Urology, Lahey Hospital and Medical Center, Burlington, MA *Corresponding author. Video Objective: We present a case of extrinsic urethral endometriosis. We review the peri-operative management with renal function testing, preoperative imaging and stent placement. The patient had a robotic-assisted ureteroneocystostomy with psoas hitch for her severe disease. The goal of this video is to review peri-operative management of urinary tract endometriosis and to demonstrate the surgical technique of ureterolysis in extrinsic ureteral endometriosis and ureteroneocystostomy with psoas hitch. Setting: the patient was managed in the outpatient setting as well as the inpatient surgical suite. Interventions: Surgical: ureteroneocystostomy with psoas hitch. Conclusion: Ureteral endometriosis is a rare manifestation of pelvic endometriosis that can be managed with appropriately with a peri-operative
Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM)
2426 Sliding Sign Testing Could be a Potential Alternative to Laparoscopy to Predict Endometriosis Fertility Index (EFI) in Endometriosis Associated Infertility Alfaraj SA,1,* Bedaiwy M,2 Yong PJ,2 Allaire C,2 Williams C,2 Lisonkova S,3 Noga H4. 1Obstetric and Gynecology, Reproductive Endocrinology and Infertility, University of British Columbia, Vancouver, BC, Canada, Vancouver, BC, Canada; 2Obstetrics & Gynaecology, University of British Columbia, Vancouver, BC, Canada; 3Obstetric and gynecology, University of British Columbia, Vancouver, BC, Canada; 4 Obstetric and Gynecology, Reproductive Endocrinology and Infertility, University of British Columbia, Vancouver, BC, Canada *Corresponding author. Study Objective: EFI is a robust tool to predict pregnancy rate in endometriosis patients who attempt non-in vitro fertilization conception. However, EFI calculation requires laparoscopy. Sliding sign is a newly established technique that can predict Pouch of Douglas (POD) obliteration with a high degree of accuracy. The objective of this study is to investigate the relationship between sliding sign and the EFI, and to explore the practicality of using sliding sign to predict EFI score less than seven. Design: Observational study from a prospective registry (Endometriosis Pelvic Pain Interdisciplinary Cohort (EPPIC), ClinicalTrials.gov#NCT 02911090). Analyzed data was captured from December 2013 to June 2017. Setting: Tertiary referral center at British Columbia Women’s Hospital. Patients or Participants: Eighty-six women who are less than 40 years old. Interventions: Dynamic ultrasonography for the sliding sign testing and EFI calculation during laparoscopic surgery. Measurements and Main Results: Patients with a negative sliding sign (N=26,Group I) were older, had stage IV endometriosis, and a lower median EFI score than patients who had a positive sliding sign (N=60, Group II).Patients in group I had significantly lower surgical factor scores, Regarding the EFI historical factors, group I participants had a longer duration of infertility with no significant difference in parity or age compared to group II. Logistic regression showed that an EFI score < 7 can be predicted with a high sensitivity of 87.9% and specificity of 81.1% with a negative sliding sign and EFI historical factors score. The area under the curve (AUC) was 0.93 (95% CI 0.85−0.99). Conclusion: The sliding sign could be a potential alternative to the EFI surgical factors, and it could be used in combination with EFI historical factors to predict an EFI score < 7 for patients who are not scheduled for immediate surgery. Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM) 10:10 AM: STATION D 2944 Transgluteal Pudendal Neurolysis Reinert AE,* Hibner M, Castellanos ME. OB/GYN, St Joseph’s Hospital and Medical Center, Phoenix, AZ *Corresponding author. Video Objective: To describe the surgical technique of pudendal neurolysis via a transgluteal route as performed at St Joseph’s Hospital and Medical Center in Phoenix, Arizona.
S180
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231
Setting: 68 year old woman with right-sided pudendal neuralgia persistent despite non-surgical treatment. Interventions: Right-sided transgluteal surgery for pudendal nerve entrapment. Conclusion: Several modifications to the procedure originally described by Dr. Robert Roger may improve post-operative pain and function, and reduce risk of surgical complication.
p-value 0.193), BMI (26.9 kg/m2 vs. 29.3 kg/m2 p-value 0.157), history of chronic pain (25% vs. 46.7%, p-value 0.163), smoking history (never smokers 66.7% vs. 66.7%, p-value 0.713), or post-operative IV narcotic use (morphine milligram equivalents) prior to discharge (23.3 mg vs. 31.2 mg p-value 0.187). There were no pain related post-operative clinic visits. Conclusion: Providing dual narcotic prescriptions after gynecologic surgery can decrease the number of opioids obtained by patients postoperatively. Patient characteristics cannot be used to predict who fills the second prescription. This strategy was not associated with pain related post-operative visits.
Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM) 10:10 AM: STATION E 1425 Robotic Resection of Full Thickness Bladder Wall Endometriosis Fogelson N,1,* Christianson LA2. 1Northwest Endometriosis and Pelvic Surgery, Portland, OR; 2Minimally Invasive Gynecologic Surgery, Legacy Health Systems, Portland, OR *Corresponding author. Video Objective: To demonstrate a case of invasive endometriosis of the bladder wall, with preoperative images and description of operative technique for thorough removal and bladder wall closure. Setting: Private practice specialized in endometriosis care. Interventions: A 27 year old woman with stage IV endometriosis presented with infertility and pelvic pain. Pre-operative evaluation and MRI demonstrated bladder wall disease, as well as disease of the sigmoid colon and cecum. Complex robotic surgery was performed including ureteral catheter placement, resection of pelvic endometriosis, shave resection of colon, ileocecectomy, and full thickness bladder wall resection. This video focuses on removal of bladder disease, including preoperative workup and technique. The patient did well postoperatively with no complication and significant improvement in symptoms. Conclusion: Bladder wall endometriosis in the dome of the bladder is readily resectable using laparoscopic or robotic techniques. Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM) 10:10 AM: STATION F 1725 Dual-Opioid Post-Operative Prescription Model in Gynecologic Surgery − A Pilot Study Islam MR,* Cornella J, Wasson MN. Mayo Clinic Arizona, Phoenix, AZ *Corresponding author. Study Objective: Determine if providing two opioid prescriptions postoperatively is an effective strategy to decrease total number of opioids obtained. Design: Retrospective descriptive study. Setting: Tertiary care academic institution. Patients or Participants: Thirty-nine patients undergoing gynecologic surgery. Interventions: Two oral narcotic prescriptions were provided post-operatively. Patients were instructed to initially fill the first prescription with 10 pills. If the patient continued to have opioid requirement for pain control, she was instructed to fill the second prescription with an additional 20 pills. Opioids obtained within 6 weeks post-operatively were confirmed utilizing the Arizona Board of Pharmacy Controlled Substance Monitoring Program. Measurements and Main Results: Thirty-nine patients underwent gynecologic surgery via laparoscopy or robotics (N=26), laparotomy (N=3), or vaginal routes (N=10). In the post-operative period, 24 patients (61.5%) filled only 10 pills and 15 patients (38.4%) filled the additional 20 pills (CI 44.62%-76.64% p-value 0.15). Patients filling only one prescription versus two prescriptions were not affected by age (49.6 years vs. 43.2 years,
Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM) 10:10 AM: STATION G 1957 Robotic Assisted Mesh Removal: Posterior Vaginal Mesh Kit and Perivesical Mesh Invading Obturator Internus Sticco PL,* Ladanyi C, Furr RS. Minimally Invasive Gynecologic Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN *Corresponding author. Video Objective: This video depicts a surgical approach in a patient with both a complicated and unclear surgical history, with inability to obtain complete surgical record. It demonstrates a robotic assisted laparoscopic approach to removal of mesh in a patient with persistent pelvic pain with an unclear or unknown mesh location. Setting: This is a 60 year old woman with a remote history of hysterectomy for benign indications. Per patient, she subsequently developed symptomatic prolapse for which she underwent a “bladder sling” and two “hernia repairs” which necessitated suprapubic catheter post-operatively. She then experienced worsening pelvic pain since that time, now years later, and with constant rectal pressure and more recent post-coital bleeding. The patient is adamant on complete mesh removal. This was performed as an ambulatory surgery within a hospital setting. Interventions: Pelvic examination revealed noticeable tenderness of anterior vaginal wall, with no exposed mesh or bleeding. The video itself depicts a robotic assisted laparoscopic removal of bilateral posterior vaginal mesh kit and left perivesical mesh invading obturator internus. Careful surgical technique involving bladder dissection off vaginal cuff, ureterolysis, and dissection throughout the space of Retzius down to the obturator internus muscle is carried out with complete removal of multiple mesh components. Conclusion: Avoiding transection of the mesh along with meticulous dissection aides in traction and greatest chance of complete removal. Maintenance of hemostasis is critical for adequate visualization, especially within the space of Retzius. Knowledge of pelvic anatomy is paramount, as scarring, fibrosis, and mesh migration can distort normal anatomical planes. Virtual Poster Session 3: Endometriosis (10:10 AM − 10:20 AM) 10:10 AM: STATION H 2413 Appendiceal Endometriosis: Laparoscopic Endoloop Appendectomy Vigueras Smith A,* Sumak R, Kulkarni N, Pinto Rosario D, Ferreira H. Gynecology, Centro Hospitalar Universit ario do Porto, Porto, Portugal *Corresponding author. Video Objective: To demonstrate the surgical steps of the laparoscopic appendectomy for a deep endometriosis nodule using endoloops.