2170 Vaginoscopy: A Minimally Invasive Approach to Hysteroscopy

Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231 Virtual Poster Session 3: Hysteroscopy (10:30 AM − 10:40 AM) 10:30 AM: STATION L 2935 Cost-Effectiveness of an Outpatient Uterine Assessment and Treatment Unit in Patients with Abnormal Uterine Bleeding: A Modelling Study Bennett A,1 Thavorn K,1 Coyle D,1 Arendas K,2 Singh SS3,*. 1Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada; 2 Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, ON, Canada; 3 Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, ON, Canada *Corresponding author. Study Objective: To assess the cost-effectiveness of a single-visit uterine assessment and treatment unit (UATU) compared with the current standard of care to diagnose and treat women with abnormal uterine bleeding (AUB). Design: A cost-effectiveness analysis using a decision tree model from the perspective of the publicly funded health care system in Canada. Setting: An ambulatory women’s health clinic at a tertiary academic health sciences center (The Shirley E. Greenberg Women’s Health Center at The Ottawa Hospital (TOH)). Patients or Participants: Patients presenting with abnormal uterine bleeding. Interventions: Non-interventional. Methods: We developed a probabilistic decision tree model to simulate the total costs and outcomes of women presenting with AUB receiving diagnosis and treatment at a UATU or usual care over a one-year time horizon. Probabilities, resource use, and time associated with each treatment option were obtained from a retrospective chart review of 200 randomly selected patients presenting with AUB at TOH between April 1st 2014 and March 31st 2017. Results were expressed as overall cost and time savings per patient. A series of sensitivity analyses were conducted to assess the robustness of the study findings. Costs are reported in 2018 Canadian dollars. Measurements and Main Results: Compared to usual care, the UATU was associated with a decrease in overall cost ($1,331.90 [95% CI -1,337 to -1,326.8]) and a decrease in overall time to treatment (-74.50 days [95% CI -74.70 to -74.40]), dominating usual care. The point at which the UATU would no longer be cost-effective is if the cost to maintain and operate the UATU required an additional $1,600 spent per patient. The results of the sensitivity analysis did not impact the conclusions from our base-case analysis. Conclusion: An outpatient UATU is more cost-effective than usual care and should be recommended as the best use of limited health care resources. Virtual Poster Session 3: Hysteroscopy (10:30 AM − 10:40 AM) 10:30 AM: STATION M 1288 Robotic Assisted Ovarian and Fallopian Tube Transposition: A Video Presentation Nicholson K,1,* Holubyeva A,2 Amro O,3 Urh A1. 1Department of OBGYN, Northwell Health, Southside Hospital, Bay Shore, NY; 2Department of OGBYN, Northwell Health, Southside Hospital, Bay Shore, NY; 3Northwell Health, Southside Hospital, Bay Shore, NY *Corresponding author. Video Objective: The objective of this video is to demonstrate the technique of performing an ovarian transposition using robotic assistance in order to preserve ovarian function in a patient who is planning to undergo pelvic radiation therapy. Setting: The patient is a 29 y/o nulligravida with a history of stage 3B rectal adenocarcinoma. She is s/p neoadjuvant chemotherapy using Folfox

S195 and Capecitabine and is planning for pelvic radiation therapy. She elects to undergo a transposition procedure in order to reduce her risk of premature ovarian failure. Interventions: The robotic trocars are placed in the standard gynecologic oncology robotic fashion in order to mobilize the ovaries above the pelvic brim and out of the radiation field. To avoid comprising the ovarian vasculature, retroperitoneal tunnels are created in the pelvic sidewalls bilaterally and the adnexa are pulled through. The ovaries are sutured in place superior to the anterior superior iliac spine and lateral to the psoas muscle. Surgical clips are placed at the border of each ovary for identification during radiation planning. Conclusion: Pelvic radiation therapy is often required in the management of gynecologic and nongynecologic malignancies. The ovaries are extremely radiosensitive and very low doses can be associated with a high risk of ovarian failure. Premature menopause results in long-term deprivation of estrogen and can lead to increased risk of all-cause mortality, cardiovascular risk, and osteoporosis. Research indicates that many female patients diagnosed with cancer do not receive adequate information regarding ovarian preservation. One study reports that 50% of oncologists reported moderate to high confidence in knowledge of female fertility preservation. Laparoscopic ovarian transposition is a great surgical option for reproductive age women undergoing gonadotoxic radiation. Robotic assisted ovarian transposition has the advantage of improved visualization and articulation of wrist movements. Robotics can help to overcome the limitations of laparoscopy, especially in complicated procedures. Virtual Poster Session 3: Hysteroscopy (10:30 AM − 10:40 AM) 10:30 AM: STATION N 2407 Surgical Technique: Posterior Culdotomy Chu A,1,* Seckin SI,2 Seckin TA3. 1OB/GYN, Lenox Hill Hospital, New York, NY; 2Mount Sinai West, New York, NY; 3Lenox Hill Hospital, New York, NY *Corresponding author. Video Objective: The purpose of this video is to demonstrate a posterior culdotomy; this is a simple surgical technique with a number of benefits. Setting: We perform a laparoscopic myomectomy and create a posterior culdotomy for specimen removal. Interventions: N/A. Conclusion: In summary, we urge gynecologists and other surgical subspecialties to strongly consider this method of extraction. Virtual Poster Session 3: Hysteroscopy (10:30 AM − 10:40 AM) 10:30 AM: STATION O 2170 Vaginoscopy: A Minimally Invasive Approach to Hysteroscopy Persenaire C,1,* Duyar S,1 Traylor J,2 Tsai SC,2 Chaudhari A2. 1 Obstetrics & Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL; 2Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL *Corresponding author. Video Objective: To demonstrate the vaginoscopic approach to hysteroscopy. Setting: The patient is a 35-year-old G0 with a history of endometrial polyps previously treated with hysteroscopic resection who presented with recurrent intermenstrual spotting and evidence of endometrial polyp on ultrasound. She presented for hysteroscopic polypectomy in the outpatient setting.

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Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231

Interventions: The patient underwent vaginoscopy with hysteroscopy under monitored anesthesia care using a 5-mm operative hysteroscope. Manual coaptation of the labia allowed for vaginal distention, and the posterior approach was used to locate and enter the external cervical os without the use of a speculum or tenaculum. Full survey of the endometrial cavity was completed and a small area of polypoid tissue was sampled. Conclusion: Vaginoscopy is recommended as the standard approach to hysteroscopy by the Royal College of Obstetricians and Gynecologists and the French College of Gynecologists and Obstetricians because of its many benefits over traditional hysteroscopy, including improved patient comfort and reduced need for anesthesia. Vaginoscopy may allow for hysteroscopic evaluation of patients otherwise thought to be poor candidates because of intolerance of a speculum examination, vaginal atrophy and/or cervical stenosis, as seen in pediatric, virginal and postmenopausal patients. Vaginoscopy may also afford benefits over traditional hysteroscopy by allowing direct inspection of the vagina and cervix, as well as management of cervical stenosis under direct, magnified visualization. Despite these benefits, uptake of this method has not been widespread in the United States, likely because it is not frequently taught. This video demonstrates a vaginoscopic procedure with adequate vaginal distention and a posterior approach to localization of the cervical os with the aim of increasing provider comfort and adoption of this approach.

Mullerian anomalies that could impact a woman’s quality of life and possible reproductive success in the future.

Virtual Poster Session 3: Hysteroscopy (10:30 AM − 10:40 AM) 10:30 AM: STATION P 1329 Surgical Management of Longitudinal Vaginal Septum and Complete Uterine Septum Selter J,1,* Arora C,1 Rackow B2. 1Obstetrics and Gynecology, Columbia University Medical Center, New York, NY; 2Obstetrics and Gynecology, Columbia University Medical Center, NY, NY *Corresponding author. Video Objective: To illustrate the steps for surgical correction of a longitudinal vaginal septum and complete uterine septum using narrative video footage. Setting: A longitudinal vaginal septum and complete uterine septum are anomalies of Mullerian duct development that occur during embryological development. The exact incidence of Mullerian anomalies is difficult to determine, since women with them are often not diagnosed if asymptomatic, but is approximately 2-3%. In women who present with infertility, the incidence of uterine anomalies is often higher, approximately 5-10%. Although some women with vaginal anomalies are asymptomatic, some may note difficulty inserting tampons or dyspareunia. Reproductive outcomes in women with a complete uterine septum include possible decreased chance of implantation, and increased risk of spontaneous abortion and preterm labor/ delivery. Benefits of surgical correction of a uterine septum include possible improved reproductive success and decreased poor obstetric outcomes. Interventions: In this video, we illustrate the key surgical steps of excision of a longitudinal vaginal septum and hysteroscopic metroplasty for a complete uterine septum resection. Key surgical steps include: 1. Exam under anesthesia Lidocaine with epinephrine injection into vaginal septum. 2. Excision of septum with mayo scissors and re-approximation of vaginal mucosal edges. 3. Dilation of one side of cervical canal and placement of pediatric foley catheter to instill methylene blue-dyed fluid. 4. Hysteroscopic incision of septum using bipolar resectoscope until blue dye is visualized. 5. Complete incision of uterine septum. 6. Placement of uterine balloon for endometrial healing. 7. Vaginal packing placed to promote vaginal healing. Conclusion: Surgical management of a longitudinal vaginal septum and complete uterine septum is a minimally invasive procedure to correct these

Virtual Poster Session 3: Hysteroscopy (10:30 AM − 10:40 AM) 10:30 AM: STATION Q 2755 Clinical Manifestations and Reproductive Outcomes of Patients Undergoing Hysteroscopic Resection of Placental Site Nodules Chan CW,1 Shah N,2 Pereira N3,*. 1Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY; 2Obstetrics & Gynecology, Weill Cornell Medicine, New York, NY; 3The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, NY *Corresponding author. Study Objective: To investigate the clinical manifestations and reproductive outcomes of patients undergoing hysteroscopic resection of PSNs. Design: Retrospective chart review. Setting: University-affiliated fertility center. Patients or Participants: Patients with secondary infertility undergoing hysteroscopic polypectomy. The study cohort was compared based on final histopathology i.e., PSN (cases) vs. endometrial polyp (controls). Interventions: Operative hysteroscopy. Measurements and Main Results: Demographics (age, gravidity, parity, BMI) and reproductive history (preceding pregnancy type, number of prior miscarriages, duration of infertility) was compared among the PSN and endometrial polyp groups. Live birth rate after operative hysteroscopy was considered the primary outcome. Of the 2,688 hysteroscopic procedures during the study period, 2036 (75.7%) were excluded due to non-polypectomy diagnoses. Of these, 766 were excluded due to primary infertility. The 477 patients with secondary infertility were divided into PSN (n=34) and endometrial polyp (n=413) groups based on histopathology. The overall prevalence of PSNs in the study cohort was 7.6%. The median (IQR) age, gravidity, parity and BMI of women with PSNs was 38.5 (3.9) years, 2.41 (1.2), 0.9 (0.6) and 24.8 (6.7) kg/m2, respectively. The preceding pregnancy was IVF-conceived in 53% of women; the other 47% were conceived naturally. The median number of miscarriages in women with PSNs was 1.50 (1.1), with a median infertility duration of 18.1 (9.4) months. Women with PSNs were older (38.5 vs. 35.0 years; P<0.001) and had a higher number of miscarriages (1.50 vs. 1; P<0.001) compared to women with endometrial polyps. There was no difference in live birth rates (67.6% vs. 65.1%) after hysteroscopic treatment of PSNs or endometrial polyps. Conclusion: Among women undergoing hysteroscopic polypectomy, PSNs are more commonly observed in women who are older and with a higher number of miscarriages when compared to women with endometrial polyps. The live birth rates after operative hysteroscopy are comparable between the groups.

Virtual Poster Session 3: Hysteroscopy (10:30 AM − 10:40 AM) 10:30 AM: STATION R 2117 Removal of Submucous Myoma with Truclear 8 Tissue Retrieval System Telang MA,* Telang PM, Pattanaik S. Galaxy CARE Laparoscopy Institute Pvt. Ltd, PUNE, India *Corresponding author. Video Objective: This video demonstrates that intracervical injection of dilute vasopressin not only helps in smooth cervical dilatation prior to introduction of Truclear8 device, but also has beneficial hemostatic effect on submucous fibroid during intrauterine morcellation. Setting: 39 year old primary infertility patient with 2 failed IVF cycles, presented with menorrhagia for 6 months. On trans vaginal sonography