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Endometrioma Excision Utilizing Plasma Energy
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S91–S135 301
Open Communications 16 - New Instruments (3:09 PM - 3:14 PM)
Vaginal Ultrasound-Directed Myolysis: Preclinical Testing on Fibroids after Hysterectomy Hurst BS,1 Merriam KS,2 DeVita J,3 Elliot M.1 1Obstetrics and Gynecology, Carolinas HealthCare System, Charlotte, North Carolina; 2 University of Norh Carolina Medical School - Charlotte Campus, Charlotte, North Carolina; 3Medical University of South Carolina, Charleston, South Carolina Study Objective: To determine if a final prototype vaginal myolysis device can be used for uterine fibroids with a currently available vaginal probe ultrasound machine, needle guides, and standard electrosurgical generator. Design: Prospective observational preclinical study. Setting: Outpatient surgical center. Patients: Women undergoing abdominal, vaginal, or laparoscopy assisted vaginal hysterectomy for uterine fibroids. Intervention: The uterus was removed from the operative field and placed on a grounding pad. A vaginal ultrasound probe with needle guide was placed on the uterus and fibroid identified. An insulated monopolar device connected to an electrosurgical generator was passed through the needle guide, advanced to the fibroid/pseudocapsule interface, and 20 watts current activated for approximately 5 seconds. The myolysis device has an echogenic tip, and is designed to shut off the electrical current if the uterus is perforated. Measurements and Main Results: Visualization of the fibroids and the myolysis device was good. Monopolar activation resulted in an echogenic pattern consistent with generation of water vapor, and this hyperechoic area quickly spread along the fibroid pseudocapsule. When testing the shut-off mechanism, the current shut off each time the uterus was intentionally punctured. Conclusion: The final prototype devices functioned properly in this preclinical study. The myolysis needle is engineered to be used with standard electrosurgical generators, vaginal ultrasounds, and needle guides. Vaginal ultrasound allows for precise placement at the pseudocapsule, similar to needle placement for oocyte retrieval. Activation of the monopolar device is expected to shrink the myoma by infarction, as has been shown for laparoscopic myolysis. Vaginal ultrasound-directed myolysis (VUM) has the potential to be a simple, and cost-effective, new outpatient treatment for women with uterine fibroids.
302
Video Session 9 - Endometriosis (2:15 PM - 2:21 PM)
Complete Excision of Full-Thickness Bladder Endometriosis Cook AS, Hopton EN. Vital Health Institute, Los Gatos, California This video demonstrates the safe and complete resection of a fullthickness endometriotic nodule of the left superior posterior dome of the bladder. A 35-year-old nulligravida Caucasian female presents with a history of severe, chronic bladder pain, nocturia, cyclic dysuria and macroscopic hematuria, and the bladder is found to be tender on exam. During cystoscopy a nodule measuring approximately 4cm in diameter is visualized, with evident infiltration of the bladder mucosa. At laparoscopy the nodule is circumscribed and carefully excised using the Carbon 13 CO2 laser, inevitably leading into the lumen of the bladder. Histopathology performed on the biopsied nodule confirms the diagnosis of full-thickness bladder endometriosis. The surgical techniques involved in demarcating the margins between diseased and healthy tissue and carefully maintaining hemostasis are described. Following removal of the nodule, bladder closure is demonstrated. Post-operative follow-up reveals a 95% improvement in the patient’s previous symptoms.
303
S91
Video Session 9 - Endometriosis (2:22 PM - 2:28 PM)
Transvaginal Ultrasound with Bowel Prep: A Technique to Evaluate the Presence of Deep Endometriosis Billow M,1 Young S,2 Magrina J,1 Kho R.1 1Gynecologic Surgery, Mayo Clinic Arizona, Phoenix, Arizona; 2Radiology, Mayo Clinic Arizona, Phoenix, Arizona The purpose of our video is to describe the technique of transvaginal ultrasound with bowel preparation in the diagnosis of deep infiltrating endometriosis. Deep infiltrating endometriosis affects approximately 20% of women and impairs a women’s quality of life more than superficial or ovarian endometriosis. Surgical resection of these lesions often eradicates symptoms. For this reason, it is imperative that a technique to preoperatively diagnose these lesions is available to provide optimal surgical planning. The transvaginal ultrasound with bowel preparation is useful to thoroughly evaluate the presence of these lesions. Our experience with this technique suggests this can be incorporated into the treatment algorithm of patients with endometriosis and chronic pelvic pain. 304
Video Session 9 - Endometriosis (2:29 PM - 2:35 PM)
Obliterated Cul-de-Sac Dissection, Endometrioma Excision and Endometriotic Nodule Excision Around Ureter While Sparing Hypogastric and Splanchnic Nerves Turkgeldi E, Taskiran C, Celik S, Oktem O, Urman B. Obstetrics and Gynecology, American Hospital, Istanbul, Turkey Deep pelvic endometriosis can infiltrate all the structures in the pelvis. It can distort the pelvic anatomy severely, puzzling even the experienced surgeon. While struggling to solve this puzzle, it is not uncommon to damage some of the pelvic autonomic nerves. Studies suggest that this damage may cause bowel, bladder, or sexual dysfunction. Therefore, nerve-sparing endometriosis surgery has been gaining attention. While the concept was recognized in oncology, it was applied to deep pelvic endometriosis only in the mid-2000s. Kavallari, Possover, and Ceccaroni have reported less bowel, urinary, and sexual problems after nerve-sparing endometriosis surgery. They declared it to be feasible, while emphasizing that it is only for the advanced laparoscopic surgeon. In this presentation, we aimed to share a case of deep pelvic endometriosis with obliterated cul-de-sac, endometrioma, endometriotic nodule around left ureter and pelvic splanchnic and hypogastric nerves, in which the nerves were spared. 305
Video Session 9 - Endometriosis (2:36 PM - 2:42 PM)
Endometrioma Excision Utilizing Plasma Energy Uy-Kroh MJS, Falcone T. Women’s Health Institute, Obstetrics & Gynecology, Cleveland Clinic, Cleveland, Ohio Optimal endometrioma treatment in reproductive age women weighs inadvertent follicle destruction against endometrioma recurrence. Current endometrioma surgical management is largely influenced by a Cochrane review that reported endometriomas greater than 3cm have a higher recurrence rate when ablated with bipolar energy versus cyst excision. Recent investigation by Roman et al, however, suggests that cyst fenestration and plasma vaporization may preserve antral follicles without compromising cyst recurrence or subsequent pregnancy rates. While we await randomized, prospective investigation that confirms this claim surgeons must re-consider their techniques to balance adequate treatment of symptomatic disease against unintentional reduction of the very fertility they wish to preserve. With this in mind, we demonstrate a safe and highly reproducible technique of endometrioma cystectomy utilizing versatile plasma energy.
Open Communications 16 - New Instruments (3:09 PM - 3:14 PM)
Vaginal Ultrasound-Directed Myolysis: Preclinical Testing on Fibroids after Hysterectomy Hurst BS,1 Merriam KS,2 DeVita J,3 Elliot M.1 1Obstetrics and Gynecology, Carolinas HealthCare System, Charlotte, North Carolina; 2 University of Norh Carolina Medical School - Charlotte Campus, Charlotte, North Carolina; 3Medical University of South Carolina, Charleston, South Carolina Study Objective: To determine if a final prototype vaginal myolysis device can be used for uterine fibroids with a currently available vaginal probe ultrasound machine, needle guides, and standard electrosurgical generator. Design: Prospective observational preclinical study. Setting: Outpatient surgical center. Patients: Women undergoing abdominal, vaginal, or laparoscopy assisted vaginal hysterectomy for uterine fibroids. Intervention: The uterus was removed from the operative field and placed on a grounding pad. A vaginal ultrasound probe with needle guide was placed on the uterus and fibroid identified. An insulated monopolar device connected to an electrosurgical generator was passed through the needle guide, advanced to the fibroid/pseudocapsule interface, and 20 watts current activated for approximately 5 seconds. The myolysis device has an echogenic tip, and is designed to shut off the electrical current if the uterus is perforated. Measurements and Main Results: Visualization of the fibroids and the myolysis device was good. Monopolar activation resulted in an echogenic pattern consistent with generation of water vapor, and this hyperechoic area quickly spread along the fibroid pseudocapsule. When testing the shut-off mechanism, the current shut off each time the uterus was intentionally punctured. Conclusion: The final prototype devices functioned properly in this preclinical study. The myolysis needle is engineered to be used with standard electrosurgical generators, vaginal ultrasounds, and needle guides. Vaginal ultrasound allows for precise placement at the pseudocapsule, similar to needle placement for oocyte retrieval. Activation of the monopolar device is expected to shrink the myoma by infarction, as has been shown for laparoscopic myolysis. Vaginal ultrasound-directed myolysis (VUM) has the potential to be a simple, and cost-effective, new outpatient treatment for women with uterine fibroids.
302
Video Session 9 - Endometriosis (2:15 PM - 2:21 PM)
Complete Excision of Full-Thickness Bladder Endometriosis Cook AS, Hopton EN. Vital Health Institute, Los Gatos, California This video demonstrates the safe and complete resection of a fullthickness endometriotic nodule of the left superior posterior dome of the bladder. A 35-year-old nulligravida Caucasian female presents with a history of severe, chronic bladder pain, nocturia, cyclic dysuria and macroscopic hematuria, and the bladder is found to be tender on exam. During cystoscopy a nodule measuring approximately 4cm in diameter is visualized, with evident infiltration of the bladder mucosa. At laparoscopy the nodule is circumscribed and carefully excised using the Carbon 13 CO2 laser, inevitably leading into the lumen of the bladder. Histopathology performed on the biopsied nodule confirms the diagnosis of full-thickness bladder endometriosis. The surgical techniques involved in demarcating the margins between diseased and healthy tissue and carefully maintaining hemostasis are described. Following removal of the nodule, bladder closure is demonstrated. Post-operative follow-up reveals a 95% improvement in the patient’s previous symptoms.
303
S91
Video Session 9 - Endometriosis (2:22 PM - 2:28 PM)
Transvaginal Ultrasound with Bowel Prep: A Technique to Evaluate the Presence of Deep Endometriosis Billow M,1 Young S,2 Magrina J,1 Kho R.1 1Gynecologic Surgery, Mayo Clinic Arizona, Phoenix, Arizona; 2Radiology, Mayo Clinic Arizona, Phoenix, Arizona The purpose of our video is to describe the technique of transvaginal ultrasound with bowel preparation in the diagnosis of deep infiltrating endometriosis. Deep infiltrating endometriosis affects approximately 20% of women and impairs a women’s quality of life more than superficial or ovarian endometriosis. Surgical resection of these lesions often eradicates symptoms. For this reason, it is imperative that a technique to preoperatively diagnose these lesions is available to provide optimal surgical planning. The transvaginal ultrasound with bowel preparation is useful to thoroughly evaluate the presence of these lesions. Our experience with this technique suggests this can be incorporated into the treatment algorithm of patients with endometriosis and chronic pelvic pain. 304
Video Session 9 - Endometriosis (2:29 PM - 2:35 PM)
Obliterated Cul-de-Sac Dissection, Endometrioma Excision and Endometriotic Nodule Excision Around Ureter While Sparing Hypogastric and Splanchnic Nerves Turkgeldi E, Taskiran C, Celik S, Oktem O, Urman B. Obstetrics and Gynecology, American Hospital, Istanbul, Turkey Deep pelvic endometriosis can infiltrate all the structures in the pelvis. It can distort the pelvic anatomy severely, puzzling even the experienced surgeon. While struggling to solve this puzzle, it is not uncommon to damage some of the pelvic autonomic nerves. Studies suggest that this damage may cause bowel, bladder, or sexual dysfunction. Therefore, nerve-sparing endometriosis surgery has been gaining attention. While the concept was recognized in oncology, it was applied to deep pelvic endometriosis only in the mid-2000s. Kavallari, Possover, and Ceccaroni have reported less bowel, urinary, and sexual problems after nerve-sparing endometriosis surgery. They declared it to be feasible, while emphasizing that it is only for the advanced laparoscopic surgeon. In this presentation, we aimed to share a case of deep pelvic endometriosis with obliterated cul-de-sac, endometrioma, endometriotic nodule around left ureter and pelvic splanchnic and hypogastric nerves, in which the nerves were spared. 305
Video Session 9 - Endometriosis (2:36 PM - 2:42 PM)
Endometrioma Excision Utilizing Plasma Energy Uy-Kroh MJS, Falcone T. Women’s Health Institute, Obstetrics & Gynecology, Cleveland Clinic, Cleveland, Ohio Optimal endometrioma treatment in reproductive age women weighs inadvertent follicle destruction against endometrioma recurrence. Current endometrioma surgical management is largely influenced by a Cochrane review that reported endometriomas greater than 3cm have a higher recurrence rate when ablated with bipolar energy versus cyst excision. Recent investigation by Roman et al, however, suggests that cyst fenestration and plasma vaporization may preserve antral follicles without compromising cyst recurrence or subsequent pregnancy rates. While we await randomized, prospective investigation that confirms this claim surgeons must re-consider their techniques to balance adequate treatment of symptomatic disease against unintentional reduction of the very fertility they wish to preserve. With this in mind, we demonstrate a safe and highly reproducible technique of endometrioma cystectomy utilizing versatile plasma energy.