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2607 Hysterectomy in Women with Endometriosis
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231
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pathology was identified on standard versus modified pathology, rereviewed the slides and documented the slide set containing the abnormal pathology. Measurements and Main Results: The main outcome measure is detection of appendix endometriosis. Standard analysis identified endometriosis in 7.7% (n=23) of appendix specimens whereas modified analysis identified endometriosis in 9.7% (n=29; OR 1.29, CI 1.05-1.56, p-value 0.01). When all pathology was combined, standard analysis identified abnormal pathology in 9.3% (n=28) of specimens whereas modified analysis identified abnormal pathology in 12% (n=36; OR 1.32, CI 1.09-1.61, p<0.01). Other abnormal appendix pathology identified in this study includes carcinoid, polyp, neuroendocrine tumor, and acute appendicitis. The average number of slides required for standard analysis was 1.6, compared to 4.9 slides for modified analysis. At this institution, the average cost of production for each slide is $4.44. Conclusion: Modified pathologic analysis resulted in a significantly higher diagnosis rate of endometriosis and abnormal pathology in coincidental appendectomy performed during a primary gynecologic procedure. Modified pathologic analysis was found to be affordable in this academic tertiary referral center. Implementation of a modified pathologic protocol should be considered to improve diagnosis rates of abnormal pathology in coincidental appendectomy specimens.
surgical landmarks and a proper technique. It emphasizes mainly that we should start with the endometriosis treatment before the hysterectomy. Conclusion: According to literature, there are no randomized controlled trials for hysterectomy as the treatment for endometriosis. We should only offer hysterectomy with a radical removal of endometriosis and for those women who have completed their families and failed to respond to more conservative treatments.
Virtual Poster Session 3: Endometriosis (10:00 AM − 10:10 AM) 10:00 AM: STATION P 2607 Hysterectomy in Women with Endometriosis Bellelis P*. ObGyn, University of Sao Paulo, Sao Paulo, Brazil *Corresponding author. Video Objective: To demonstrate that hysterectomy is not the ideal treatment for endometriosis and how to perform a hysterectomy in patients with endometriosis. Setting: We describe a case of a 42 years-old woman referred to our center complaining of severe dysmenorrhea, dyspareunia and menorrhagia. The patient had 2 previous cesarean section and with no relevant past medical. The pre-operative investigation involved a transvaginal ultrasonography with bowel preparation that showed an infiltrative endometriotic nodule on the paracervix and posterior vaginal fornix, rectosigmoid and vesicouterine space besides adenomyosis. The patient was in clinical treatment with medroxyprogesterone acetate, without response. We scheduled a surgical procedure for radical eradication of the deep infiltrating endometriosis and hysterectomy. Interventions: A step-by-step surgical video, demonstrating a systematic approach in case of deep infiltrating endometriosis, indicating
Observer 1 2 3 4 5 6 7
Accuracy %/95% CI
Sensitivity %/95% CI
84.4/91.1-98.0 50.0/18.7-81.3 92.5/83.4-97.5 80.0/28.4-99.5 95.3/91.3-97.8 37.5/8.5-75.5 97.3/90.7-99.7 50.0/1.3-98.7 96.5/91.9-98.8 44.4/13.7-78.8 94.3/88.1-97.9 28.6/3.7-71.0 100.0/94.5-100.0 100.0/15.8-100.0
Virtual Poster Session 3: Endometriosis (10:00 AM − 10:10 AM) 10:00 AM: STATION Q 1851 Diagnostic Accuracy and Interrater Agreement of Gynecological Sonographers in Evaluating the Pouch of Douglas for Obliteration Using the Sliding Sign Technique Vanza K,1,* Leonardi M,1,2 Espada M,1 Condous G1,2. 1Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney, NSW, Australia; 2Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia *Corresponding author. Study Objective: Evaluate the accuracy of sonographers in classifying pouch of Douglas (POD) obliteration state and their interrater agreement with the reference standard senior sonologist. Design: Prospective diagnostic accuracy and interrater agreement study. Setting: Gynecology-focused ultrasound practice. Patients or Participants: Seven sonographers of varying experience. Interventions: Sonographer were provided with a short educational program on POD obliteration and the sliding sign technique. None were routinely utilizing the sliding sign in practice prior to study initiation. Over two months, the sonographers prospectively and consecutively performed, recorded, and interpreted the state of the POD as positive, negative or indeterminate. Senior sonologist was blinded to the sonographers’ classification when the reference standard classification was made. Measurements and Main Results: Diagnostic accuracy and interrater agreement using Cohen’s kappa were calculated (Table). 819 patients underwent basic TVS. The reference standard prevalence of a negative sliding sign was 43/819 (5.3%). Conclusion: With a low prevalence of a negative sliding sign, it is difficult to evaluate a sonographers’ ability to correctly classify this abnormal state. However, sonographers were uniformly highly specific in their classification of the POD state. As the awareness of the sliding sign technique spreads, it will be essential to understand how to educate, credential, and monitor performance and interpretation by sonographers, who perform the majority of gynecological scans internationally.
Specificity %/95% CI
Positive predictive value %/95% CI
Negative predictive value %/95% CI
Positive likelihood ratioValue/ 95% CI
98.2/94.7-99.6 93.6/84.3-98.2 97.8/94.5-99.4 98.6/92.6-100.0 100.0/97.2-100.0 99.0/94.5-100.0 100.0/94.3-100.0
62.5/31.6-85.7 50.0/26.0-74.0 42.9/16.7-73.7 50.0/8.4-91.6 100.0 66.7/17.1-95.1 100.0
97.0/94.5-98.4 98.3/90.9-99.7 97.3/95.5-98.4 98.6/94.7-99.7 96.4/93.6-97.9 95.2/92.5-96.9 100.0
27.17/7.55-97.81 12.40/4.36-35.23 17.25/4.61-64.51 36.50/3.35-398.15 N/A 28.29/2.91-275.1 N/A
Negative likelihood ratio Interrateragreement Value/95% CI kappa/p value 0.51/0.27-0.95 0.21/0.04-1.24 0.64/0.37-1.09 0.51/0.13-2.03 0.56/0.31-1.00 0.72/0.45-1.15 0.00
0.531/<0.001 0.576/<0.001 0.376/<0.001 0.486/<0.001 0.600/<0.001 0.375/<0.001 1.000/<0.001
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pathology was identified on standard versus modified pathology, rereviewed the slides and documented the slide set containing the abnormal pathology. Measurements and Main Results: The main outcome measure is detection of appendix endometriosis. Standard analysis identified endometriosis in 7.7% (n=23) of appendix specimens whereas modified analysis identified endometriosis in 9.7% (n=29; OR 1.29, CI 1.05-1.56, p-value 0.01). When all pathology was combined, standard analysis identified abnormal pathology in 9.3% (n=28) of specimens whereas modified analysis identified abnormal pathology in 12% (n=36; OR 1.32, CI 1.09-1.61, p<0.01). Other abnormal appendix pathology identified in this study includes carcinoid, polyp, neuroendocrine tumor, and acute appendicitis. The average number of slides required for standard analysis was 1.6, compared to 4.9 slides for modified analysis. At this institution, the average cost of production for each slide is $4.44. Conclusion: Modified pathologic analysis resulted in a significantly higher diagnosis rate of endometriosis and abnormal pathology in coincidental appendectomy performed during a primary gynecologic procedure. Modified pathologic analysis was found to be affordable in this academic tertiary referral center. Implementation of a modified pathologic protocol should be considered to improve diagnosis rates of abnormal pathology in coincidental appendectomy specimens.
surgical landmarks and a proper technique. It emphasizes mainly that we should start with the endometriosis treatment before the hysterectomy. Conclusion: According to literature, there are no randomized controlled trials for hysterectomy as the treatment for endometriosis. We should only offer hysterectomy with a radical removal of endometriosis and for those women who have completed their families and failed to respond to more conservative treatments.
Virtual Poster Session 3: Endometriosis (10:00 AM − 10:10 AM) 10:00 AM: STATION P 2607 Hysterectomy in Women with Endometriosis Bellelis P*. ObGyn, University of Sao Paulo, Sao Paulo, Brazil *Corresponding author. Video Objective: To demonstrate that hysterectomy is not the ideal treatment for endometriosis and how to perform a hysterectomy in patients with endometriosis. Setting: We describe a case of a 42 years-old woman referred to our center complaining of severe dysmenorrhea, dyspareunia and menorrhagia. The patient had 2 previous cesarean section and with no relevant past medical. The pre-operative investigation involved a transvaginal ultrasonography with bowel preparation that showed an infiltrative endometriotic nodule on the paracervix and posterior vaginal fornix, rectosigmoid and vesicouterine space besides adenomyosis. The patient was in clinical treatment with medroxyprogesterone acetate, without response. We scheduled a surgical procedure for radical eradication of the deep infiltrating endometriosis and hysterectomy. Interventions: A step-by-step surgical video, demonstrating a systematic approach in case of deep infiltrating endometriosis, indicating
Observer 1 2 3 4 5 6 7
Accuracy %/95% CI
Sensitivity %/95% CI
84.4/91.1-98.0 50.0/18.7-81.3 92.5/83.4-97.5 80.0/28.4-99.5 95.3/91.3-97.8 37.5/8.5-75.5 97.3/90.7-99.7 50.0/1.3-98.7 96.5/91.9-98.8 44.4/13.7-78.8 94.3/88.1-97.9 28.6/3.7-71.0 100.0/94.5-100.0 100.0/15.8-100.0
Virtual Poster Session 3: Endometriosis (10:00 AM − 10:10 AM) 10:00 AM: STATION Q 1851 Diagnostic Accuracy and Interrater Agreement of Gynecological Sonographers in Evaluating the Pouch of Douglas for Obliteration Using the Sliding Sign Technique Vanza K,1,* Leonardi M,1,2 Espada M,1 Condous G1,2. 1Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney, NSW, Australia; 2Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia *Corresponding author. Study Objective: Evaluate the accuracy of sonographers in classifying pouch of Douglas (POD) obliteration state and their interrater agreement with the reference standard senior sonologist. Design: Prospective diagnostic accuracy and interrater agreement study. Setting: Gynecology-focused ultrasound practice. Patients or Participants: Seven sonographers of varying experience. Interventions: Sonographer were provided with a short educational program on POD obliteration and the sliding sign technique. None were routinely utilizing the sliding sign in practice prior to study initiation. Over two months, the sonographers prospectively and consecutively performed, recorded, and interpreted the state of the POD as positive, negative or indeterminate. Senior sonologist was blinded to the sonographers’ classification when the reference standard classification was made. Measurements and Main Results: Diagnostic accuracy and interrater agreement using Cohen’s kappa were calculated (Table). 819 patients underwent basic TVS. The reference standard prevalence of a negative sliding sign was 43/819 (5.3%). Conclusion: With a low prevalence of a negative sliding sign, it is difficult to evaluate a sonographers’ ability to correctly classify this abnormal state. However, sonographers were uniformly highly specific in their classification of the POD state. As the awareness of the sliding sign technique spreads, it will be essential to understand how to educate, credential, and monitor performance and interpretation by sonographers, who perform the majority of gynecological scans internationally.
Specificity %/95% CI
Positive predictive value %/95% CI
Negative predictive value %/95% CI
Positive likelihood ratioValue/ 95% CI
98.2/94.7-99.6 93.6/84.3-98.2 97.8/94.5-99.4 98.6/92.6-100.0 100.0/97.2-100.0 99.0/94.5-100.0 100.0/94.3-100.0
62.5/31.6-85.7 50.0/26.0-74.0 42.9/16.7-73.7 50.0/8.4-91.6 100.0 66.7/17.1-95.1 100.0
97.0/94.5-98.4 98.3/90.9-99.7 97.3/95.5-98.4 98.6/94.7-99.7 96.4/93.6-97.9 95.2/92.5-96.9 100.0
27.17/7.55-97.81 12.40/4.36-35.23 17.25/4.61-64.51 36.50/3.35-398.15 N/A 28.29/2.91-275.1 N/A
Negative likelihood ratio Interrateragreement Value/95% CI kappa/p value 0.51/0.27-0.95 0.21/0.04-1.24 0.64/0.37-1.09 0.51/0.13-2.03 0.56/0.31-1.00 0.72/0.45-1.15 0.00
0.531/<0.001 0.576/<0.001 0.376/<0.001 0.486/<0.001 0.600/<0.001 0.375/<0.001 1.000/<0.001