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Obstetric Outcomes after Robotic-Assisted Laparoscopic Repair of Cesarean Scar Defect
Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S191–S227 Study Objective: To assess whether adhesions formed by laparoscopic myomectomy (LM) influence postoperative spontaneous pregnancy. Design: Retrospective study. Setting: University hospital. Patients: Patients who underwent LM between January 2000 and December 2012. Intervention: Laparoscopy, myomectomy, second-look laparoscopy (SLL). Measurements and Main Results: Adhesions were evaluated by SLL after six months of LM for patients who desired pregnancy in the future. The association between the postoperative status and the spontaneous pregnancy rate was assessed in 591 patients who desired pregnancy immediately after SLL. There were three degree classifications (D0: no adhesion; D1: filmy adhesion; D2: dense to cohesive adhesion), and four extensities (E0: no adhesion; E1: portion of uterine surface; E2: whole posterior or anterior uterine surface)for uterine adhesions. The cumulative pregnancy rate at 24 months after SLL did not significantly differ between patients without and with adhesions (44.1% vs. 33.1%, p=0.14); however, cox regression analysis revealed that the age and extensity of the adhesions were significantly associated with postoperative spontaneous pregnancy (odds ratio: 0.96 and 0.36; p=0.04 and p=0.02). In terms of the extensities, the pregnancy rate of patients with E2 adhesions were significantly lower in comparison with that of patients with E0 and E1 adhesions. According to logistic regression analysis, the E2 adhesion formation was significantly correlated to the number of enucleated myomas, the diameter of the largest myoma, and the coexistence of stage III-IV endometriosis at initial LM (odds ratio: 1.13, 1.02, and 3.96; p\0.001, p=0.04, and p=0.001). Conclusion: Our data suggests that the postoperative spontaneous pregnancy rate potentially declines due to extensive adhesions formed after LM. 624 Hystroscopic Correction of the T-Shaped, Narrow, Infantile and Arcuate Cavities in Infertile Women and Women with Recurrent ICSI/IVF Failure, Significant Results Regarding Both Spontaneous or Assisted Pregnancies Mounir MS,1 Zayed LH,2 Soliman E,1 Fathy AO.1 1Obstetrics and Gynecology, ART, Agial Hospital for Infertility, Endoscopy and Women Health, Alexandria, Roushdy, Egypt; 2Obstetrics and Gynecology, Alexandria University, Alexandria, El Shatby, Egypt Study Objective: Hystroscopic correction of T-shaped, narrow, infantile and arcuate endometrial cavities in women suffering from infertility and IVF/ICSI failure, to develop a chance of pregnancy. Design: Prospective cohort study. Setting: 2D and 3D vaginal U/S revealed narrow endometrial cavity not exceeding 1.2 cm in the maximum transverse diameter in the sagittal scan. Preoperative preparation included laboratory investigations and anaesthesia assessment. Patients: The study was conducted in the period from June 2009 till January 2014 including 200 women suffering from primary infertility for 3-11 years with exclusion of the male factors, their age ranged between 27 and 38 years 120 of them had previous single or more ICSI failure. Intervention: Postmenstrual operative hysteroscope with right angle resectopscope was used in all cases. Hysteroscopic resection of the cavity sides till visualising the osteal orifice from the midcavitary point and resection of the arcuate till the myometrial reserve. Measurements and Main Results: Spontaneous pregnancy: 44 women (22%) had became pregnant within 6 months Spontaneously:, 32 cases (16%) within the next 6 months (76 cases in the first year 38%), 40 women (20%) cases within the 2nd 12 months, Assisted pregnancies: after 1.5-2 years 36 women (18%) had trial of ICSI 21 (58.3% pregnancy rate) of them had success and 11 of them had twin pregnancies. 4 of them had delivered preterm and five full term and the other two are still followed up.
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Lost cases: 11 cases had been lost from the follow up. 43 cases not became pregnant till now. Conclusion: In our study it was clear that, correction of T shaped, narrow infantile and arcuate uterine cavity has marked success in the treatment of infertile women. We recommend hystroscopic assessment preceded by 3D ultrasound should be done for all infertile women either for assisted or for spontaneous pregnancy as a part of the work up. 625 The Use of Ullipristal Acetate/Esmya in a Clinical Setting Powell MC, Chen B. Outpatient Gynaecology, CIRCLE Treatment Centre on the Queens Medical Campus, Nottingham, Nottinghamshire, United Kingdom Study Objective: Esmya is a recently introduced progesterone receptor modulator. This study is one of the first to report the efficacy and side effects of Esmya for the treatment of fibroids in a clinical setting. Design: A questionnaire covering bleeding pattern and pain severity prior and during taking Esmya based on the numeric rating scale was sent after 3 months. Patients were asked whether they would take Esmya long-term and the effect on their surgical intervention. The side effects of Esmya and a modified daily record to score the premenstrual syndrome before and during the Esmya intake were recorded. Setting: The Gynaecology department at the CIRCLE Treatment Centre on the Queens Medical Centre Campus Nottingham. Patients: 86 patients with symptomatic fibroids took Esmya for 3 months. Intervention: Patients referred with symptomatic fibroids requiring interventions in the form of Transcervical resection, Myomectomies, or Uterine Artery Embolisation were offered Esmya to make surgical intervention simpler and safer and reduce symptoms in the interim. Measurements and Main Results: Our preliminary results show that 80% of the patients showed improvement in their bleeding pattern. 56% became amenorrhoeic within 10 days. Menses returned within 4 weeks of stopping the esmya. 16% had noimprovement at all. 56% improved their pain scores but in 70% the pain had returned within 4 weeks. Hot flushes occurred in 28% compared to 3% in clinical trials. 76% of the patients demonstrated improvement in PMS. However one patient had a worsening PMS with suicidal thoughts despite lower bleeding and pain. 50% would have carried on the Esmya and 25% would change their mind about surgery if allowed to continue with this drug. 2 patients stopped prematurely due to increased bleeding and headaches. Conclusion: Treatment with Esmya is effective to control excessive bleeding and pain with tolerated side effects. This data also showed new evidence of improvements in PMS. 626 Obstetric Outcomes after Robotic-Assisted Laparoscopic Repair of Cesarean Scar Defect Sangha R. Henry Ford Hospital, Detroit, Michigan Study Objective: To describe Obstetric Outcomes after robotic-assisted repair of cesarean scar defect. Design: Case Series-Prospective, consecutive. Setting: Henry Ford Hospital (Detroit, MI), University-affiliated Hospital. Patients: Three consectuive women undergoing robotic-assisted repair of cesarean scar defect. Intervention: Robotic-assisted repair of Cesarean Scar Defect. Measurements and Main Results: A common complication of multiple cesarean deliveries is uterine scar dehiscence. This gives rise to the serious complication of future uterine rupture in pregnancy. Three consecutive cases from 2009-2011 are presented here. Case 1 and 2 were diagnosed by a saline sonogram done prior to embryo transfer during an IVF cycle. This was then confirmed by an MRI. They underwent roboticassisted laparoscopic repair of the uterus with scar revision and diagnostic hysteroscopy. They subsequently became pregnant with embryo transfer 3 months later . They had uncomplicated pregnancies and delivered via repeat c-section at term. Case 3 was diagnosed one week after a VBAC
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Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S191–S227
when she developed severe pain and endometritis. She had a CT scan that revealed a dehiscence of the c-section scar. She was treated with IV antibiotics. She continued to have severe pelvic pain and had a saline sonogram 6 months later. This revealed a defect and was successively confirmed by MRI. She too underwent a robotic-assisted laparoscopic repair of the uterus with scar revision and diagnostic hysteroscopy. She became asymptomatic thereafter and two years later became pregnant and delivered via c-section at term. Conclusion: Robotic-assisted laparoscopic approach is an effective minimally invasive alternative for the repair of cesarean scar defect. Surgical intervention can result in improvement of symptoms and avert the related secondary obstetric complications.
Fibroid produced Prolactin & Increases aromatase which converts Estrone to Estradiol thrice myometrium Laparoscopic myomectomy in Infertility & ART increased 47% Pregnancy rate if no other cause, 50% PR even in Donor Oocyte Pregnancy outcome after Laparoscopic Myomectomy in 3324 cases: Pregnancy Rate 47%, Abortion rate 6% No Scar Rupture, LSCS 69%, Vaginal Delivery 31%, Lost to follow up - 21%, recurrence higher in Laparoscopic vs open myomectomy. Fibroid & IVF-ICSI Intramural fibroid & IVF-ICSI outcome -167 Laparoscopic myomectomy & 302 with no removal . Oocyte –embryo etc was same .Fibroid till 5 cm PR -47% compared without removal of fibroid – 20%.Donor Oocyte with Myomectomy increased Pregnancy Rate Intramural fibroid to 50%.
627 Transvaginal Hydrolaparoscopy – Minimally Invasive Diagnostic and Therapeutic Tool Suciu N,1 Costin AG,2 Suciu ID.1 1UMF Carol Davila, Bucharest, Romania; 2Ob/Gyn, Polizu Hospital, Bucharest, Romania Study Objective: To reevaluate the advantages, risks and limits of the transvaginalhydrolaparoscopy(THL) and to familiarize gynecologists worldwide with this technique. Design: Research of the current literature and studies regarding the impact of THL as a diagnostic and operative tool, mainly in minimally reproductive surgery field. Measurements and Main Results: Transvaginal hydrolaparoscopy (THL) is a modern minimally invasive technique gaining wide popularity especially among gynecologists interested in reproductive surgery. Since it was described by S Gordts, many improvements of the technique and instrumentation led to a large number of studies which confirm the valuable potential, both diagnostic and therapeutic, of the THL. Main advantages over traditional laparoscopy are that no abdominal incision is required and can be performed in outpatient settings with local anestesia. Numerous studies have shown very good concordance between THL and laparoscopy results (>95.5%) and also THL can be combined with chromopertubation and salpingoscopy. THL operative interventions include biopsies (endometriosis), adhesiolisis and ovarian drilling. Conclusion: Despite the low incidence of complications like rectal injury or minor bleeding THL didnt gain enough recongnition and the purpose of this presentation is a reevaluation of the advantages, risks and limits of the technique to familiarize gynecologists worldwide with THL. 628 New Facts and Outcomes of Laparoscopic Myomectomy in Infertility Trivedi PH. Dr. Trivedi’s Total Womens Health Care, Mumbai, Maharashtra, India Study Objective: Though fibroids are common tumors of uterus impact on fertility remains poorly understood. We present to you path breaking facts. Design: 4230 cases of fibroids in 20 years evaluated, Risks, preventive factors , growth and actual sarcomatous changes, Impact on Infertility and ART,laparoscopic removal in 3344 cases, outcome, Rupture uterus. Conclusion: Risks factors: 1st degree female relative has fibroid at more than 45 years than she has 6 times chances of fibroid Red meat eating women 3 times chances of fibroids than vegetarian but fish eater have \ incidence of fibroid. Every 10 kg excess weight had 18%,Diastolic rise in BP by 10 mm has 8 – 10% increased risk of fibroid. Decreases by smoking ,OC pills 50% reduction, parity 5 fold decrease. Laparoscopic myomectomy done in 3324 patients removing 8000 fibroids from different locations with 4 to 17 cms in size and 18 in number with 20 conversion to Laparotomy. Growth/Sarcoma Impact on fertility: Average growth rate is 0.5 cm per year, No myoma turns to Leiomyosarcoma
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Poster Session: Robotics
Comparison of Intraoperative Outcomes of Total Abdominal, Vaginal, Total Laproscopic and Robotically Assisted Hysterectomy Achjian T,1 Kilic GS,1 Mostafa B,1 Baxley SE,1 Alanbay I.2 1Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas; 2 Obstetrics and Gynecology, Gulhane Military Medical Academy, Anakara, Turkey Study Objective: To compare outcomes of estimated blood loss and intraoperative complications between four different routes of hysterectomy:total abdominal, vaginal, total laproscopic and robotically assisted Hysterectomy. Design: Retrospective cohort study. Setting: University teaching hospital. Patients: A cohort of 322 patients who underwent hysterectomy for benign or malignant conditions were studied. Intervention: A retrospective cohort chart review was performed on patients who underwent hysterectomy from February 2009 to March 2013. A total of 322 patients were identified. Patient characteristics compared include preoperative diagnosis (benign or malignant condition), age, BMI, prior abdominal surgeries, route of hysterectomy, intraoperative complications and estimated blood loss (EBL). Measurements and Main Results: Outcome measures included intraoperative complications and estimated blood loss(EBL). There were no statistically significant differences in intraoperative complications when comparing different routes of hysterectomy. However, the EBL was significantly lower in hysterectomies performed in a minimally invasive manner. Conclusion: Minimally invasive hysterectomy seems to be associated with lower intraoperative blood loss. However, further studies are needed to assess this. Moreover, additional studies with more patients are needed to compare intraoperative complications between different routes of hysterectomy. 630 Large Adnexal Masses Managed Robotically Agarwala N. Ob-Gyn, Mount Sinai Roosevelt Hospital, New York, New York Study Objective: Feasibility and technique for robotic handling of large adnexal masses and outcomes. Design: 14 patients with large adnexal masses greater than 13 cm were operated on using the robot. A 3 port technique is described that helps with healing and provides excellent results. Setting: University teaching hospital. Patients: Description of various cases and tips and technique for robotic dissection, tissue extraction and interesting highlights. Intervention: Robotic surgical intervention. Measurements and Main Results: Excellent outcomes. One patient diagnosed with immature teratoma required staging and oopohorectomy. Conclusion: Robotic surgery is feasible and preferred for such cases.
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Lost cases: 11 cases had been lost from the follow up. 43 cases not became pregnant till now. Conclusion: In our study it was clear that, correction of T shaped, narrow infantile and arcuate uterine cavity has marked success in the treatment of infertile women. We recommend hystroscopic assessment preceded by 3D ultrasound should be done for all infertile women either for assisted or for spontaneous pregnancy as a part of the work up. 625 The Use of Ullipristal Acetate/Esmya in a Clinical Setting Powell MC, Chen B. Outpatient Gynaecology, CIRCLE Treatment Centre on the Queens Medical Campus, Nottingham, Nottinghamshire, United Kingdom Study Objective: Esmya is a recently introduced progesterone receptor modulator. This study is one of the first to report the efficacy and side effects of Esmya for the treatment of fibroids in a clinical setting. Design: A questionnaire covering bleeding pattern and pain severity prior and during taking Esmya based on the numeric rating scale was sent after 3 months. Patients were asked whether they would take Esmya long-term and the effect on their surgical intervention. The side effects of Esmya and a modified daily record to score the premenstrual syndrome before and during the Esmya intake were recorded. Setting: The Gynaecology department at the CIRCLE Treatment Centre on the Queens Medical Centre Campus Nottingham. Patients: 86 patients with symptomatic fibroids took Esmya for 3 months. Intervention: Patients referred with symptomatic fibroids requiring interventions in the form of Transcervical resection, Myomectomies, or Uterine Artery Embolisation were offered Esmya to make surgical intervention simpler and safer and reduce symptoms in the interim. Measurements and Main Results: Our preliminary results show that 80% of the patients showed improvement in their bleeding pattern. 56% became amenorrhoeic within 10 days. Menses returned within 4 weeks of stopping the esmya. 16% had noimprovement at all. 56% improved their pain scores but in 70% the pain had returned within 4 weeks. Hot flushes occurred in 28% compared to 3% in clinical trials. 76% of the patients demonstrated improvement in PMS. However one patient had a worsening PMS with suicidal thoughts despite lower bleeding and pain. 50% would have carried on the Esmya and 25% would change their mind about surgery if allowed to continue with this drug. 2 patients stopped prematurely due to increased bleeding and headaches. Conclusion: Treatment with Esmya is effective to control excessive bleeding and pain with tolerated side effects. This data also showed new evidence of improvements in PMS. 626 Obstetric Outcomes after Robotic-Assisted Laparoscopic Repair of Cesarean Scar Defect Sangha R. Henry Ford Hospital, Detroit, Michigan Study Objective: To describe Obstetric Outcomes after robotic-assisted repair of cesarean scar defect. Design: Case Series-Prospective, consecutive. Setting: Henry Ford Hospital (Detroit, MI), University-affiliated Hospital. Patients: Three consectuive women undergoing robotic-assisted repair of cesarean scar defect. Intervention: Robotic-assisted repair of Cesarean Scar Defect. Measurements and Main Results: A common complication of multiple cesarean deliveries is uterine scar dehiscence. This gives rise to the serious complication of future uterine rupture in pregnancy. Three consecutive cases from 2009-2011 are presented here. Case 1 and 2 were diagnosed by a saline sonogram done prior to embryo transfer during an IVF cycle. This was then confirmed by an MRI. They underwent roboticassisted laparoscopic repair of the uterus with scar revision and diagnostic hysteroscopy. They subsequently became pregnant with embryo transfer 3 months later . They had uncomplicated pregnancies and delivered via repeat c-section at term. Case 3 was diagnosed one week after a VBAC
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Abstracts / Journal of Minimally Invasive Gynecology 21 (2014) S191–S227
when she developed severe pain and endometritis. She had a CT scan that revealed a dehiscence of the c-section scar. She was treated with IV antibiotics. She continued to have severe pelvic pain and had a saline sonogram 6 months later. This revealed a defect and was successively confirmed by MRI. She too underwent a robotic-assisted laparoscopic repair of the uterus with scar revision and diagnostic hysteroscopy. She became asymptomatic thereafter and two years later became pregnant and delivered via c-section at term. Conclusion: Robotic-assisted laparoscopic approach is an effective minimally invasive alternative for the repair of cesarean scar defect. Surgical intervention can result in improvement of symptoms and avert the related secondary obstetric complications.
Fibroid produced Prolactin & Increases aromatase which converts Estrone to Estradiol thrice myometrium Laparoscopic myomectomy in Infertility & ART increased 47% Pregnancy rate if no other cause, 50% PR even in Donor Oocyte Pregnancy outcome after Laparoscopic Myomectomy in 3324 cases: Pregnancy Rate 47%, Abortion rate 6% No Scar Rupture, LSCS 69%, Vaginal Delivery 31%, Lost to follow up - 21%, recurrence higher in Laparoscopic vs open myomectomy. Fibroid & IVF-ICSI Intramural fibroid & IVF-ICSI outcome -167 Laparoscopic myomectomy & 302 with no removal . Oocyte –embryo etc was same .Fibroid till 5 cm PR -47% compared without removal of fibroid – 20%.Donor Oocyte with Myomectomy increased Pregnancy Rate Intramural fibroid to 50%.
627 Transvaginal Hydrolaparoscopy – Minimally Invasive Diagnostic and Therapeutic Tool Suciu N,1 Costin AG,2 Suciu ID.1 1UMF Carol Davila, Bucharest, Romania; 2Ob/Gyn, Polizu Hospital, Bucharest, Romania Study Objective: To reevaluate the advantages, risks and limits of the transvaginalhydrolaparoscopy(THL) and to familiarize gynecologists worldwide with this technique. Design: Research of the current literature and studies regarding the impact of THL as a diagnostic and operative tool, mainly in minimally reproductive surgery field. Measurements and Main Results: Transvaginal hydrolaparoscopy (THL) is a modern minimally invasive technique gaining wide popularity especially among gynecologists interested in reproductive surgery. Since it was described by S Gordts, many improvements of the technique and instrumentation led to a large number of studies which confirm the valuable potential, both diagnostic and therapeutic, of the THL. Main advantages over traditional laparoscopy are that no abdominal incision is required and can be performed in outpatient settings with local anestesia. Numerous studies have shown very good concordance between THL and laparoscopy results (>95.5%) and also THL can be combined with chromopertubation and salpingoscopy. THL operative interventions include biopsies (endometriosis), adhesiolisis and ovarian drilling. Conclusion: Despite the low incidence of complications like rectal injury or minor bleeding THL didnt gain enough recongnition and the purpose of this presentation is a reevaluation of the advantages, risks and limits of the technique to familiarize gynecologists worldwide with THL. 628 New Facts and Outcomes of Laparoscopic Myomectomy in Infertility Trivedi PH. Dr. Trivedi’s Total Womens Health Care, Mumbai, Maharashtra, India Study Objective: Though fibroids are common tumors of uterus impact on fertility remains poorly understood. We present to you path breaking facts. Design: 4230 cases of fibroids in 20 years evaluated, Risks, preventive factors , growth and actual sarcomatous changes, Impact on Infertility and ART,laparoscopic removal in 3344 cases, outcome, Rupture uterus. Conclusion: Risks factors: 1st degree female relative has fibroid at more than 45 years than she has 6 times chances of fibroid Red meat eating women 3 times chances of fibroids than vegetarian but fish eater have \ incidence of fibroid. Every 10 kg excess weight had 18%,Diastolic rise in BP by 10 mm has 8 – 10% increased risk of fibroid. Decreases by smoking ,OC pills 50% reduction, parity 5 fold decrease. Laparoscopic myomectomy done in 3324 patients removing 8000 fibroids from different locations with 4 to 17 cms in size and 18 in number with 20 conversion to Laparotomy. Growth/Sarcoma Impact on fertility: Average growth rate is 0.5 cm per year, No myoma turns to Leiomyosarcoma
629
Poster Session: Robotics
Comparison of Intraoperative Outcomes of Total Abdominal, Vaginal, Total Laproscopic and Robotically Assisted Hysterectomy Achjian T,1 Kilic GS,1 Mostafa B,1 Baxley SE,1 Alanbay I.2 1Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas; 2 Obstetrics and Gynecology, Gulhane Military Medical Academy, Anakara, Turkey Study Objective: To compare outcomes of estimated blood loss and intraoperative complications between four different routes of hysterectomy:total abdominal, vaginal, total laproscopic and robotically assisted Hysterectomy. Design: Retrospective cohort study. Setting: University teaching hospital. Patients: A cohort of 322 patients who underwent hysterectomy for benign or malignant conditions were studied. Intervention: A retrospective cohort chart review was performed on patients who underwent hysterectomy from February 2009 to March 2013. A total of 322 patients were identified. Patient characteristics compared include preoperative diagnosis (benign or malignant condition), age, BMI, prior abdominal surgeries, route of hysterectomy, intraoperative complications and estimated blood loss (EBL). Measurements and Main Results: Outcome measures included intraoperative complications and estimated blood loss(EBL). There were no statistically significant differences in intraoperative complications when comparing different routes of hysterectomy. However, the EBL was significantly lower in hysterectomies performed in a minimally invasive manner. Conclusion: Minimally invasive hysterectomy seems to be associated with lower intraoperative blood loss. However, further studies are needed to assess this. Moreover, additional studies with more patients are needed to compare intraoperative complications between different routes of hysterectomy. 630 Large Adnexal Masses Managed Robotically Agarwala N. Ob-Gyn, Mount Sinai Roosevelt Hospital, New York, New York Study Objective: Feasibility and technique for robotic handling of large adnexal masses and outcomes. Design: 14 patients with large adnexal masses greater than 13 cm were operated on using the robot. A 3 port technique is described that helps with healing and provides excellent results. Setting: University teaching hospital. Patients: Description of various cases and tips and technique for robotic dissection, tissue extraction and interesting highlights. Intervention: Robotic surgical intervention. Measurements and Main Results: Excellent outcomes. One patient diagnosed with immature teratoma required staging and oopohorectomy. Conclusion: Robotic surgery is feasible and preferred for such cases.