2: Laparoscopic Management of Ectopic Pregnancy in Obese and Morbidly Obese Women: Safety and Feasibility

Journal of Minimally Invasive Gynecology (2007) 14, November/December Supplement

Oral Presentations 1

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Botox for Recurrent Pelvic Pain: Outcomes at 5 Years Abbott JA. University of New South Wales; Royal Hospital for Women, Sydney, Australia

Laparoscopic Management of Ectopic Pregnancy in Obese and Morbidly Obese Women: Safety and Feasibility 1 Abdallah ME, 1Victory R, 2Miklos JR, 2Alexandrian D. 1 Detroit, Michigan; 2Atlanta Urogynecology Associates, Georgia

Study Objective: To report the 5 year outcomes for women injected with Botox for chronic pelvic pain relating to high pressure pelvic floor dysfunction. Design: A prospective observational study A tertiary referral hospital in Sydney, Australia. Patients: Twenty women enrolled for injections of BOTOX. Intervention: Women with demonstrated spasm in the pelvic floor muscles on palpation and perineometry with associated tenderness and symptoms of pelvic pain were injected with BOTOX 40-100U under conscious sedation. Outcome measures included VAS pain scores, perineometry readings, time to reinjection and quality of life assessments. Measurements and Main Results: Between April 2002 and May 2007, 20 women have been enrolled and together have received 52 injections of BOTOX. Two women have not required any further injections. Three women have declined further injections. For women requiring reinjection, the median number of retreatments is 2 (range 1-11) and the median time to reinjection is 26 weeks (range 6-120 weeks). Median perineometry score is significantly reduced (p⬍.0001) from 54 (range 37-110cm H20) to 34.5 (range 26-65cm H20). For women requiring reinjection, compared with baseline, there is a significant reduction in daily pain (64 vs. 35; p ⬍.001) and in dyspareunia (73 vs. 32; p⬍.001). Ten women have had at least one laparoscopy and endometriosis has been confirmed histologically for 8 of these women. Conclusion: For women with spasm of the pelvic floor muscles and chronic pelvic pain, injection of BOTOX is a good treatment. Time to reinjection is approximately 6 months and response to a subsequent treatment is likely to be as efficacious as the first. Where subsequent treatments confer no improvement or are of short duration, organic disease such as endometriosis should be considered. Treatment of underlying organic disease and concurrent injection of BOTOX is likely to result in decreased pain symptoms. © 2007 AAGL. All rights reserved.

Study Objective: To study the safety and feasibility of laparoscopic management of ectopic pregnancy (EP) in obese and morbidly obese women. Design: Retrospective review between 1/2000 and 2/2005. Setting: Tertiary care university hospital. Patients: Three hundred sixty-eight patients underwent laparoscopy (LSC) for treatment of EP. Cases were divided into 2 groups with a cutoff BMI of 30 kg/m2 for obese (OB) and non-obese (non-OB) cases. For the morbid obesity (MO) sub-analysis, the cutoff BMI was 40 kg/m2. The MO cases were compared with those who had laparotomy as a primary intervention (LAP). Intervention: LSC, LAP or LSC with conversion to laparotomy. Measurements and Main Results: Of the cases, 37.6% were OB, mean BMI 35.9 kg/m2 and 7.9% were MO, mean BMI 44.4 kg/m2. There was no difference in procedure duration, blood loss, intraoperative findings or hospital stay between the OB or MO cases and their respective controls. The OB and non-OB groups differed in American Society of Anesthesiologists (ASA) score (10.2% OB vs. 4.2% non-OB had ASA⫽3, p⫽0.006) and failed methotrexate use (7.7% OB vs. 15.3% non-OB, p⫽0.038) but not in the conversion rate (20% OB vs. 18% non-OB, p⫽0.6) or incidence of complications. MO cases had higher incidence of complications (32.1% MO vs. 9.5% non-MO, p⫽0.001) and ASA score of 3 (29.6% MO vs. 4.3% non-MO, p⬍0.001). Although the difference in conversion rate had trends towards significance (32.1% MO vs. 17.5% non-MO, p⫽0.056), logistic regression showed no correlation between MO and conversion. MO cases had similar incidence of complications in the LSC (32.1%) and LAP (33.3%) groups (P⫽0.94). Conclusion: Neither obesity nor morbid obesity increased the likelihood of laparoscopic failure in EP treatment. Laparoscopy did not seem to increase morbidity in obese women.Morbid obesity was associated with higher incidence of

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Journal of Minimally Invasive Gynecology, Vol 14, No 6, November/December Supplement 2007

complications. Compared to laparotomy, laparoscopy did not seem to increase morbidity in morbidly obese women undergoing surgical EP treatment. 3 Intraoperative Laser Fluorescent Diagnosis of Gynecologic Diseases Adamyan LV, Kiselev S. Moscow State University of Medicine and Dentistry, Reproductive Medicine and Surgery, Moscow, Russia Study Objective: Optimization of early differential diagnosis of gynecologic diseases. Design: Analysis of the 2032 fluorescent spectrums obtained from 102 patients with 157 pathologic conditions. Setting: Department of operative Gynecology, Scientific Center for Obstetrics, Gynecology and perinatology. Patients: One hundred two patients aged 21 – 61 yrs with various gynecologic diseases and their associations (ovarian benign masses and malignant tumors, endometrial hyperplasia and cancer, cervical neoplasm). Intervention: Laser-spectroscopic examination of reproductive organs performed during diagnostic or surgical laparoscopy and hysteroscopy using the device LESA-01Biospec (Russia) 3-8 hours after oral administration of Alasens (preparation based on aminolevuline acid, Russia), followed by pathology investigation of specimens or bioptates. Measurements and Main Results: In patients with malignant ovarian tumors fluorescence intensity was 1.6 times higher than in borderline tumors, while benign ovarian tumors and cysts demonstrated low index of fluorescence. The method was able to reveal ovarian cancer metastasis in omentum and peritoneum. Index of diagnostic contrasting in adenocarcinoma in situ was 2 times higher than in endometrial polyp. Microinvasive, invasive and in situ cervical cancer produced 5.9 times more expressed fluorescence intensity compared to intact tissues. In some patients with endometriosis intensive cumulation of Alasens-induced protoporphirine IX was documented, possibly in cases of high prolifirative activity of the endometriotic foci. Conclusion: Laser fluorescent spectroscopy provides guidelines for choice of adequate operating volume on the basis of intraoperative differential diagnosis of benign and malignant conditions of genitalia. 4 Malformations of Uterus and Vagina: Endoscopy for Disagnosis and Treatment Adamyan LV, Tkachenko E. Scientific Center for Obstetrics, Gynecology and Perinatology, Department of Operative Gynecology, Moscow, Russia Study Objective: Enhancement of diagnosis and treatment of malformations of genitalia.

Design: Analysis of 1380 cases of malformations managed by various surgical approaches. Setting: Department of Operative Gynecology of the Scientific Center for Obst., Gyn. & Perinatology. Patients: One hundred sixteen patients with rudimentary uterine horn, 179 with uterine septum, 7 with bicornuate uterus, 223 with vaginal and uterine aplasia, 33 with vaginal aplasia with functional uterus. Intervention: Rudimentary horns were removed laparoscopically with simultaneous adhesiolysis and removal of endometriosis. Resectoscopy was used either alone for management of uterine septum, or together with laparoscopy for correction of bicornuate uterus. In 27 cases of vaginal aplasia with functional uterus laparoscopic hysterectomy was performed; 6 analogous cases were managed by creation of utero-perineal tunnel. In patients with vaginal and uterine aplasia neovagina was created from pelvic peritoneum by combined perineal-laparoscopic approach. Measurements and Main Results: Metroplasties resulted in complete restoration of endometrium and full-term pregnancy and natural delivery in 56.9% for uterine septum and in 71.4% pregnancy rate with cesarean section for bicornuate uterus. Colpopiesis provided adequate neovagina capacity and normal epithelium morphology. Creation of uteroperineal tunnel in cases of functional uterus and vaginal aplasia allowed to preserve the uterus. Conclusion: Malformations of uterus and vagina should be diagnosed with use of laparoscopy and hysteroscopy. Hysteroresectoscopy is the method of choice for correction of uterine septum, and the important step of combined hysterolaparoscopic metroplasty. In asymmetric anomalies laparoscopy provides minimally invasive approach both for radical and reconstructive treatment. 5 Potentialties of Total Laparoscopic Hysterectomy for Radical Treatment of Uterine Diseases Adamyan LV, Kiselev S, Arakelyan A. Moscow State University of Medicine and Dentistry, Reproductive Medicine and Surgery, Moscow, Russia Study Objective: To evaluate the results of total laparoscopic hysterectomy (TLH) for treatment of benign and malignant diseases. Design: Retrospective analysis of 2270 TLH procedures. Setting: Dept. Operative Gynecology of the Research Centre for Obst., Gyn., & Perinatology. Patients: Patients aged 45.9⫹/⫺4.4 yrs with myoma, adenomyosis and/or recurrent endometrial hyperplasia, squamous cell cervical cancer st.I-II (17 cases), and non-invasive endometrial adenocarcinoma (25 cases). Average uterine size was 14.8 weeks, uterine weight ⫽ 690 g. Intervention: TLH was performed for benign conditions, endometrial cancer and st.IA cervical neoplasm, while 6 women with cervical cancer st.IB-II were submitted for