311: Assessment of Changes in Uterine Volume and Vascularity Following Laparoscopic Myomectomy and Ligation of the Uterine Arteries Using Three-Dimensional Power Doppler Ultrasound

Scientific Posters 309 The Effectiveness of an Extended Freeze Regimen using the HerOption Office Cryoablation Therapy for the Treatment of Abnormal Uterine Bleeding (AUB) is Unaffected by the Presence of Fibroids 1 Bruno R, 2Lukes A, 3Herbst S, 4Manjon J, 5Heilbronn D, 6 Roy K, 7Whiteside D. 1Lahey Clinic, Burlington Massachusetts; 2Duke University Medical Center, Women’s Hemostasis and Thrombosis Clinic, Durham, North Carolina; 3Institute for Women’s Health and Body, West Palm Beach, Florida; 4Camp Hill, Pennsylvania; 5 Valley OB/GYN, Saginaw, Michigan; 6Phoenix, Arizona; 7 Center for Endometrial Ablation, Charlotte, North Carolina Study Objective: To evaluate the benefits of extended freeze regimens using the HerOption System for the treatment of AUB. Design: The primary endpoint of this prospective, nonrandomized, multi-center study, conducted under an investigational device exemption, was the 12-month Pictorial Bleeding Assessment Chart (PBAC) score. Additional follow-up in process for 24 and 36 months. Setting: Location was determined at the discretion of the investigators, with 63/82 (77%) of procedures performed in the office. Patients: Subjects were pre-menopausal women ⭌30 years of age with AUB, demonstrated by PBAC scores ⭌150, unresponsive to prior treatments. Myomas ⭌3 cm were exclusionary.Each patient provided informed consent. Intervention: The study permitted midline freeze durations at the fundus ⬉minutes, in the cornua and lower uterine segment ⬉10 minutes. Up to 4 freeze cycles were allowed and were based on previously-determined uterine dimensions. The number of subjects undergoing 2, 3 or 4 freeze cycles was 9 (11%), 50 (61%) and 23 (28%), respectively. Measurements and Main Results: Sixty-five subjects were evaluated at 1-year post-treatment. In a paired data analysis of outcomes, baseline mean PBAC scores were 412 (⫾254) in subjects with fibroids (n⫽29) and 423 (⫾463) in subjects without fibroids (n⫽36). Mean PBAC scores (SD) at 12 months were 31 (⫾46) in subjects with fibroids and 27 (⫾70) in subjects without fibroids. Longer-term evaluations are on-going. Conclusion: Preliminary results suggest that the effectiveness of the HerOption Office Cryoablation Therapy as an office-based treatment of AUB is unaffected by fibroids ⬍3 cm.

S113 Study Objective: To discuss a patient with amenorrhea, Asherman’s syndrome, and persistently elevated HCG levels. Design: Case report. Setting: Infertility clinic. Patient: Thirty-five year old woman. Intervention: Hysterosalpingogram, sonohysterogram, hysteroscopy, laparoscopy. Measurements and Main Results: A 35 year old G1P0 presented with a 5 year history of secondary infertility and amenorrhea. She previously underwent a dilation and curettage (D&C) for a missed abortion. Laboratory values were unremarkable. She had no withdrawal bleed after a trial of medroxyprogesterone acetate. A hysterosalpingogram revealed a fundal filling defect. She later presented at 6⫹5 weeks gestation, and an ultrasound demonstrated a single live intrauterine pregnancy. Unfortunately, a demise occurred at 11 weeks gestation. A D&C was performed, and her HCG levels declined to ⬍4 mIU/ml. Several months later she presented with continued amenorrhea. A sonohysterogram revealed a fundal filling defect. An operative hysteroscopy was performed revealing degenerated and hyalinized immature chorionic villi. Three months later she conceived. HCG levels rose appropriately. At 6 weeks gestation a transvaginal ultrasound revealed heterogeneity in her endometrium and a right adnexal anechoic cyst. An early uterine evacuation was performed. Evaluation by pathology revealed no villi and methotrexate therapy was given. The final pathology reported secretory endometrium and decidua with fibrotic chorionic villi. The patient’s HCG levels following methotrexate injection initially fell appropriately, but then plateaued between 7 to 15 mIU/ml and persisted despite a repeat methotrexate injection. A test for heterophile antibodies was negative. An operative laparoscopy and diagnostic hysteroscopy was performed. Operative findings revealed a right ectopic pregnancy. A right linear salpingotomy was performed. Pathology revealed degenerated fibrotic villi consistent with an ectopic pregnancy. One week later her HCG declined to ⬍ 4 mIU/ml. Conclusion: Methotrexate failure usually involves a lack of decline of HCG at much higher levels than this case report or a need for operative intervention due to clinical findings. 311

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Assessment of Changes in Uterine Volume and Vascularity Following Laparoscopic Myomectomy and Ligation of the Uterine Arteries Using ThreeDimensional Power Doppler Ultrasound Chang WC, Huang S, Sheu B, Torng P, Hsu W, Chang D. National Taiwan University Hospital, Taipei, Taiwan

Persistent Ectopic Pregnancy in a Patient With Amenorrhea, Asherman’s Syndrome, and Chronic Retained Products of Conception Casey CL, Hanson GE, Murray CA. University of Vermont, Burlington, Vermont

Study Objective: To evaluate the hemodynamic changes in uterine perfusion following laparoscopic myomectomy and vascular occlusion of the uterine arteries. Design: Prospective study. Setting: University-affiliated hospital.

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

Patients: Thirty-three patients had laparoscopic myomectomy only (control group) and 44 had additional bilateral uterine artery ligation (study group). Intervention: Three-dimensional power Doppler ultrasound was obtained the day before operation and at 1 week and 3 months postoperatively. Vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were calculated using the VOCAL (Virtual Organ Computeraided AnaLysis) software. Power Doppler ultrasound was also used to evaluate the resistance index (RI), pulsatility index (PI), and peak systolic velocity (PSV) from the flowvelocity waveforms of the right uterine artery. Measurements and Main Results: Both groups were similar in the baseline characteristics, including uterine volume, number of myomas, size and localization of the largest myomas. The weight of extirpated myomas, operative time and duration of hospital stay were comparable between these two groups, whereas the estimated blood loss 50/(50-200) mL, vs. 100/(50800) mL, P ⫽ .001) and frequency of excessive bleeding (0% vs. 12%, P ⫽ .018) were significantly less in patients with concurrent uterine artery ligation. Preoperatively, all the flow parameters including RI, PI, PSV VI, FI and VFI in the study and control groups were comparable. The RI, PI and PSV of the study group became significantly less than those of the control group 1 week after operation, but the significance of difference disappeared 3 months later. The myometrial VI, FI and VFI between these two groups were not different significantly at any time. The VI and VFI decreased progressively after operation but the FI did not change significantly in both groups. Conclusion: The collateral blood supply of the pelvis may resume normal perfusion of the uterus after bilateral uterine artery ligation. 312 A Method to Prevent Bladder Injury in Laparoscopically Assisted Vaginal Hysterectomy (LAVH) for Patients With Vesicocervical Adhesions 1 Chen SY, 2Namgung S, 2Choi J, 2Hwang S. 1Taipei, Taiwan; 2Seoul, Korea Study Objective: A method to prevent bladder injury in laparoscopically assisted vaginal hysterectomy (LAVH) for patients with vesicocervical adhesion after previous cesarean deliveries. Design: A method to prevent bladder injury in laparoscopically assisted vaginal hysterectomy (LAVH) for patients with vesicocervical adhesion after previous cesarean deliveries. Setting: National Taiwan University Hospital. Patients: Fifty women who had given birth by cesarean delivery with vesicocervical adhesion were undergoing LAVH between July 2004 and July 2005. Intervention: Original article. Measurements and Main Results: In these 50 patients, twenty-four (48%) patients had once previous cesarean delivery, twenty-two (44%) had twice and four (8%) had three

times. No bladder injury occurred among them. Also there was no other complication. Conclusion: Transvaginal lateral intervention may be helpful to minimize bladder injuries during LAVH for patients with previous cesarean deliveries. 313 Tubal Pregnancy After Total Hysterectomy Cho HJ, Hwang S. Seoul, Korea Study Objective: Tubal pregnancy after total hysterectomy is reported 39cases past 4 deceases. And 2 of 39 cases was immediately after Hysterectomy. This clinical situation is extremely rare and the delayed diagnosis can resulted in massive bleeding. Patients: 36-year-old multiparous woman presenting dyepnea and whole abdominal pain. She was underwent total abdominal hysterectomy for degenerated leiomyoma uteri 4 weeks before. Her urine HCG was positive and Ultrasound and CT revealed massive intra-abdominal bleeding and 3 cm sized well vascularized mass on Rt adnexae. Laparoscopic salpingectomy was done without any complication. Conclusion: A In reproductive aged group women presenting hemoperitoneum, urin HCG test is essential and possibility of ectopic pregnancy should be keep in mind. 314 Laparoscopic Treatment of a Huge Omental Cyst: A Case Report 1 Choi JH, 2Ahn S. 1Seoul Medical Center, Seoul, Korea; 2 Kangnam St. Mary’s Hospital, Seocho-gu, Seoul, Korea Study Objective: Mesenteric cysts are uncommon, and thery are histopathologically classified as pseudocyst, mesothelial cyst, lymphangioma and omental cyst. We report a case of a 27-year-old female with a huge cystic mass arising from greater omentum. Design: Omental cysts are asymptomatic tumor. The detection of that is difficult because of the rarity of these lesions and the absence of characteristic clinical findings. Complete resection with abdominal exploration has been a treatment of choice for omental cyst. Setting: We report a case of huge omental cyst treated with laparoscopic excision. Patient: A 27-year-old woman complained the symptoms of abdominal distention due to massive ascites and intermittent pelvic discomort. The diagnostic exminations including ultrasonography and computed tomography were performed and identified a huge, intraabodminal cyst. Intervention: Diagnostic laparoscopy was performed. Large amount of serous fluid was observed after insertion of the first trocar, and aspiration of fluid was done for cytologic exmination. Uterus, both ovaries, intestine, iliac vessels and abdominal aorta were all covered with cystic wall. A vascular stalk of cyst was attached to the infracolic omentum