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2948 Prospective, Single-Blinded Pilot Study: Bimanual Pelvic Examination Versus Pelvic Ultrasound Results in Symptomatic Women
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S98−S231
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cavity (73% in published data). We planned to evaluate the prevalence of infectious agents within in the endometrial cavity and endo-cervix when endometriosis is present. Design: Retrospective review of all patients that underwent diagnostic laparoscopy, diagnostic hysteroscopy, and the collection of sterile endometrial/endo-cervical cultures during surgical evaluation for suspected endometriosis and chronic endometritis. Setting: Referral center for reproductive medicine and surgery in an academic medical center. Patients or Participants: All patients diagnosed with endometriosis at the time of laparoscopy who underwent collection of endometrial/endo-cervical cultures from 2016 − 2018 (N=97). Interventions: N/A. Measurements and Main Results: Sterile endometrial/endo-cervical cultures were collected, per standardized protocol, prior to preparation of the vagina. Aerobic/anaerobic cultures; PCR for mycoplasma/ureaplasma/gonorrhea/chlamydia; viral cultures; and yeast cultures were performed. In patients diagnosed with endometriosis at the time of laparoscopy, 70% tested positive for an infectious agent on endometrial/endo-cervical culture. Organisms were found in 65% of individuals diagnosed laparoscopically with mild endometriosis (American Society for Reproductive Medicine Revised Classification of Endometriosis “ASRM Classification” Stage 1-2), and 75% diagnosed with severe endometriosis (ASRM Classification Stage 3-4). Gram positive organisms were the most common infectious agent cultured at 72%, and were primarily E. Faecalis (31%), Lactobacillus (17%), and Group B Strep (15%). Gram negative organisms (18%) were primarily E. coli (10%). Less commonly, yeasts (13%), anaerobes (3%), and ureaplasma (1%) were found. No gonorrhea, chlamydia, mycoplasma, or viruses were detected. No significant correlation was found between severity of endometriosis and prevalence of any single organism. Conclusion: For individuals with endometriosis, regardless of severity, the presence of infectious organisms in the endometrium and endo-cervix is similar to published data on chronic infectious endometritis.
bleeding. While PU indicated adnexal abnormalities in 25% of patients (hydrosalpinx, ovarian cysts or endometrioma), BPE only identified 1 case, for a detection rate of 20%. PU identified myomas in 80% of the cases, while BPE detected only 5 cases, for a detection rate of 31%. Although the size and location of myomas were mostly undetermined by BPE, it did accurately assess uterine size in 80% of the cases. Conclusion: BPE offers little clinical utility in diagnosing gynecologic problems in symptomatic women. A full prospective study of a large number of patients is in progress to further validate these results.
Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION K 2948 Prospective, Single-Blinded Pilot Study: Bimanual Pelvic Examination Versus Pelvic Ultrasound Results in Symptomatic Women Touchan F,1,* Mamik M,2 Sarfoh V,2 Mackoul P,2 Danilyants N,3 van der Does L,1 Haworth L1. 1Research, The Center for Innovative GYN Care, Rockville, MD; 2The Center for Innovative GYN Care, Rockville, MD; 3cigc, Rockville, MD *Corresponding author. Study Objective: To compare the results of bimanual pelvic exam (BPE) to Pelvic Ultrasound (PU) in symptomatic women. The American College of Physicians reported that 35% of women may experience pain, discomfort, embarrassment, or anxiety during a pelvic exam. This may serve as a barrier for women to seek medical care, which could potentially delay diagnosis. While prior studies show lack of evidence for routine BPE in asymptomatic women, its use in symptomatic women may also be limited. Design: Prospective single-blinded pilot study. Setting: Free-standing ambulatory surgery center serving the Washington, DC area. Patients or Participants: Women, 18 years or older, with BMI < 40, presenting for evaluation of symptomatic gynecologic problems. Interventions: BPE was performed by an experienced gynecologist blinded to the patient’s previous ultrasound results. The sonographer was also blinded to BPE results. Measurements and Main Results: A total of 20 patients were evaluated, 45% for abnormal uterine bleeding, 60% for pelvic pain or dysmenorrhea, 25% for infertility or pregnancy losses, and 15% for post-menopausal
Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION L 1901 Obliterated Rectovaginal Space Dissection Gupta N*. Minimally Invasive Gynecologic Surgery, Jackson Madison County General Hospital, Jackson, TN *Corresponding author. Video Objective: Show dissection techniques in a completely obliterated cul-de sac. Setting: Stage 4 Endometriosis patient. Interventions: Robotic assisted excision of endometriosis, hysterectomy and restoration of normal anatomy. Conclusion: Stage 4 Endometriosis causes frozen pelvis and complete distortion of normal anatomy. Restoration of normal anatomy and excision of endometriosis is the goal of surgery in such patients whether or not hysterectomy is performed. It is essential to restore the normal anatomy and identify the key structures before undertaking hysterectomy to avoid inadvertent injuries and also to provide symptomatic relief to the patient. Deeply infiltrative fibrotic endometriosis infiltrates through rectovaginal space and causes complete obliteration of the cul-de sac, displacement of ureters, distorted pelvic side walls and perirectal fossas. The dissection is started by identifying the ureters on each side, develop normal space between the ureter and colon as well as between the rectum and uterosacral ligaments. The instinct is to tackle the midline but a minimally invasive gynecologic surgeon should know that the correct approach is in developing the spaces laterally before dissecting in the midline. Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION M 2133 Bilateral Ureteral Endometriosis - an Indolent, Aggressive and Dangerous Condition Fernandes LFC,1,* Xavier GE,2 Bassi MA3. 1Obstetrics and Gynecology, Faculty of Medicine of University of S~ ao Paulo, S~ ao Paulo, Brazil; 2 Urology, Faculty of Medicine of University of S~ ao Paulo, S~ ao Paulo, Brazil; 3Gynecology, Faculty of Medicine of University of S~ ao Paulo, S~ ao Paulo, Brazil *Corresponding author. Video Objective: Describe an unusual bilateral ureteral reimplantation due to endometriosis and a flowchart of a conservative decision making. Setting: Deep infiltrating endometriosis (DIE) involving the ureter has an incidence of 0.1 − 1%, normally affecting the lower third of its segment, up to 4 cm above the vesicoureteric junction. Bilateral ureteral involvement happens in 9% of the cases. The absence of specific symptoms makes its diagnostic challenging. Lumbar pain takes place when its involvement is complicated by a marked obstruction, with an impaired renal function. Decompressive surgery is mandatory. The necessity of ureteroneocystostomy increases along with the severity of hydronephrosis, accounting for 62% of the ureteral decompressive procedures. Even though, bilateral ureteroneocystostomy is a rare procedure, not trespassing 6% of ureteral reimplantations.
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cavity (73% in published data). We planned to evaluate the prevalence of infectious agents within in the endometrial cavity and endo-cervix when endometriosis is present. Design: Retrospective review of all patients that underwent diagnostic laparoscopy, diagnostic hysteroscopy, and the collection of sterile endometrial/endo-cervical cultures during surgical evaluation for suspected endometriosis and chronic endometritis. Setting: Referral center for reproductive medicine and surgery in an academic medical center. Patients or Participants: All patients diagnosed with endometriosis at the time of laparoscopy who underwent collection of endometrial/endo-cervical cultures from 2016 − 2018 (N=97). Interventions: N/A. Measurements and Main Results: Sterile endometrial/endo-cervical cultures were collected, per standardized protocol, prior to preparation of the vagina. Aerobic/anaerobic cultures; PCR for mycoplasma/ureaplasma/gonorrhea/chlamydia; viral cultures; and yeast cultures were performed. In patients diagnosed with endometriosis at the time of laparoscopy, 70% tested positive for an infectious agent on endometrial/endo-cervical culture. Organisms were found in 65% of individuals diagnosed laparoscopically with mild endometriosis (American Society for Reproductive Medicine Revised Classification of Endometriosis “ASRM Classification” Stage 1-2), and 75% diagnosed with severe endometriosis (ASRM Classification Stage 3-4). Gram positive organisms were the most common infectious agent cultured at 72%, and were primarily E. Faecalis (31%), Lactobacillus (17%), and Group B Strep (15%). Gram negative organisms (18%) were primarily E. coli (10%). Less commonly, yeasts (13%), anaerobes (3%), and ureaplasma (1%) were found. No gonorrhea, chlamydia, mycoplasma, or viruses were detected. No significant correlation was found between severity of endometriosis and prevalence of any single organism. Conclusion: For individuals with endometriosis, regardless of severity, the presence of infectious organisms in the endometrium and endo-cervix is similar to published data on chronic infectious endometritis.
bleeding. While PU indicated adnexal abnormalities in 25% of patients (hydrosalpinx, ovarian cysts or endometrioma), BPE only identified 1 case, for a detection rate of 20%. PU identified myomas in 80% of the cases, while BPE detected only 5 cases, for a detection rate of 31%. Although the size and location of myomas were mostly undetermined by BPE, it did accurately assess uterine size in 80% of the cases. Conclusion: BPE offers little clinical utility in diagnosing gynecologic problems in symptomatic women. A full prospective study of a large number of patients is in progress to further validate these results.
Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION K 2948 Prospective, Single-Blinded Pilot Study: Bimanual Pelvic Examination Versus Pelvic Ultrasound Results in Symptomatic Women Touchan F,1,* Mamik M,2 Sarfoh V,2 Mackoul P,2 Danilyants N,3 van der Does L,1 Haworth L1. 1Research, The Center for Innovative GYN Care, Rockville, MD; 2The Center for Innovative GYN Care, Rockville, MD; 3cigc, Rockville, MD *Corresponding author. Study Objective: To compare the results of bimanual pelvic exam (BPE) to Pelvic Ultrasound (PU) in symptomatic women. The American College of Physicians reported that 35% of women may experience pain, discomfort, embarrassment, or anxiety during a pelvic exam. This may serve as a barrier for women to seek medical care, which could potentially delay diagnosis. While prior studies show lack of evidence for routine BPE in asymptomatic women, its use in symptomatic women may also be limited. Design: Prospective single-blinded pilot study. Setting: Free-standing ambulatory surgery center serving the Washington, DC area. Patients or Participants: Women, 18 years or older, with BMI < 40, presenting for evaluation of symptomatic gynecologic problems. Interventions: BPE was performed by an experienced gynecologist blinded to the patient’s previous ultrasound results. The sonographer was also blinded to BPE results. Measurements and Main Results: A total of 20 patients were evaluated, 45% for abnormal uterine bleeding, 60% for pelvic pain or dysmenorrhea, 25% for infertility or pregnancy losses, and 15% for post-menopausal
Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION L 1901 Obliterated Rectovaginal Space Dissection Gupta N*. Minimally Invasive Gynecologic Surgery, Jackson Madison County General Hospital, Jackson, TN *Corresponding author. Video Objective: Show dissection techniques in a completely obliterated cul-de sac. Setting: Stage 4 Endometriosis patient. Interventions: Robotic assisted excision of endometriosis, hysterectomy and restoration of normal anatomy. Conclusion: Stage 4 Endometriosis causes frozen pelvis and complete distortion of normal anatomy. Restoration of normal anatomy and excision of endometriosis is the goal of surgery in such patients whether or not hysterectomy is performed. It is essential to restore the normal anatomy and identify the key structures before undertaking hysterectomy to avoid inadvertent injuries and also to provide symptomatic relief to the patient. Deeply infiltrative fibrotic endometriosis infiltrates through rectovaginal space and causes complete obliteration of the cul-de sac, displacement of ureters, distorted pelvic side walls and perirectal fossas. The dissection is started by identifying the ureters on each side, develop normal space between the ureter and colon as well as between the rectum and uterosacral ligaments. The instinct is to tackle the midline but a minimally invasive gynecologic surgeon should know that the correct approach is in developing the spaces laterally before dissecting in the midline. Virtual Poster Session 3: Endometriosis (9:50 AM − 10:00 AM) 9:50 AM: STATION M 2133 Bilateral Ureteral Endometriosis - an Indolent, Aggressive and Dangerous Condition Fernandes LFC,1,* Xavier GE,2 Bassi MA3. 1Obstetrics and Gynecology, Faculty of Medicine of University of S~ ao Paulo, S~ ao Paulo, Brazil; 2 Urology, Faculty of Medicine of University of S~ ao Paulo, S~ ao Paulo, Brazil; 3Gynecology, Faculty of Medicine of University of S~ ao Paulo, S~ ao Paulo, Brazil *Corresponding author. Video Objective: Describe an unusual bilateral ureteral reimplantation due to endometriosis and a flowchart of a conservative decision making. Setting: Deep infiltrating endometriosis (DIE) involving the ureter has an incidence of 0.1 − 1%, normally affecting the lower third of its segment, up to 4 cm above the vesicoureteric junction. Bilateral ureteral involvement happens in 9% of the cases. The absence of specific symptoms makes its diagnostic challenging. Lumbar pain takes place when its involvement is complicated by a marked obstruction, with an impaired renal function. Decompressive surgery is mandatory. The necessity of ureteroneocystostomy increases along with the severity of hydronephrosis, accounting for 62% of the ureteral decompressive procedures. Even though, bilateral ureteroneocystostomy is a rare procedure, not trespassing 6% of ureteral reimplantations.