Bowel endometriosis: safe endoscopic excision of deep infiltrating extra-genital endometriosis

Treatment included manual therapy of pelvic floor and abdominal musculature; therapeutic exercises; biofeedback and electrical stimulation . NIH-CPSI questionnaires were collected at initial evaluation, every subsequent 10th visit, and discharge. Higher scores reflect worse symptoms. Previous validation of the modified NIH-CPSI calculated a reduction of 7 points to robustly predict being a treatment responder (sensitivity 100%, specificity 76%) and a change in 4 points to predict modest response. CONCLUSIONS: Male CPPS is difficult to treat and often requires a multimodal approach. Comprehensive pelvic floor physical therapy may be an effective treatment option for select patients. A larger study with a control group is needed to validate the routine use of pelvic floor rehabilitation in men with CPPS and predict characteristics of men who would respond to therapy. V-6 Monday, October 30, 2017 4:45 PM BOWEL ENDOMETRIOSIS: SAFE ENDOSCOPIC EXCISION OF DEEP INFILTRATING EXTRA-GENITAL ENDOMETRIOSIS. R. Falik, A. Li, A. Nezhat, C. Nezhat. Center for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA. OBJECTIVE: The purpose of this film is to demonstrate the various surgical techniques for treatment of bowel endometriosis. METHODOLOGY: Surgery is the cornerstone for treatment of bowel endometriosis in patients who are clinically symptomatic. The laparoscopic approach is the ideal mode of incision as it has been shown to be equally safe as open surgery and results in fewer intra-operative and post-operative complications. Several techniques are employed in particular circumstances and choice of technique varies depending on site of disease and level of bowel lumen involvement. Here, we demonstrate techniques including shaving of the lesion, disc excision of the lesion, segmental bowel resection, and appendectomy. Historically, segmental resection was advocated as the treatment of choice for endometriosis at all levels of the bowel. However, disc resection and the shave technique are safe, minimally-invasive treatment options that should additionally be considered. In addition, we also demonstrate surgical management of multi-organ involvement of deeply infiltrative endometriosis. Examples of foundational surgical techniques, including hydro-dissection and use of the CO2 laser, are shown as well. CONCLUSIONS: Techniques for surgical management of bowel endometriosis include shaving of the lesion, disc excision of the lesion, and segmental bowel resection. Shave excision and disc resection should be advocated whenever possible. V-7 Monday, October 30, 2017 4:54 PM LAPAROSCOPIC APPROACH TO ENDOMETRIOSIS OVERLYING THE URETER. N. C. Llarena,a T. Falcone.b aObstetrics & Gynecology, Cleveland Clinic Foundation, Cleveland, OH; bOb/Gyn, Cleveland Clinic, Cleveland, OH. Endometriosis may affect the urinary tract in up to 6% of cases. This video describes a laparoscopic approach to the excision of endometriosis overlying the ureter. We demonstrate a retroperitoneal pelvic sidewall dissection in a patient with pelvic pain who desired conservative surgical management of her endometriosis. The ureter is identified and followed through its course in the pelvis. Relevant nearby structures, including the umbilical artery, uterine artery, and iliac arteries, are clearly seen. After bilateral ureterolysis, the video features dissection of the pararectal space in the setting of complete posterior cul de sac obliteration due to endometriosis.

and Robotic Surgery, Palo Alto, CA; bSchool of Medicine, University of California, San Francisco, CA. OBJECTIVE: Endometriosis most often affects the pelvic organs, but the most common sites of extragenital endometriosis are the intestine and urinary tract. While bladder endometriosis mimics cystitis in presentation, ureteral endometriosis is usually silent. Rarely, ureteral endometriosis can result in silent kidney loss if stricture reaches a critical level. Medical management of deeply infiltrating lesions of the urinary tract poses a high risk of failure. Laparotomy for treatment of endometriosis is inferior due to decreased visualization and increased morbidity. We consider laparoscopic excision the gold standard for treatment of ureteral endometriosis. In a case involving endometriosis, a gynecologic surgeon should be prepared to proceed at the very least with laparoscopic ureterolysis. METHODOLOGY: In this video, we classify multiple forms of urinary tract endometriosis and describe successful laparoscopic excisional management strategies. First, demonstrating without robotic assistance, we show ureterolysis of extrinsic (superficial) disease of the ureter. Next we demonstrate how to release a ‘‘choked’’ ureter, constricted by endometriosis, and then ureteroureterostomy for intrinsic (deeply invasive) endometriosis necessitating excision of a segment of ureter. Finally we demonstrate ureterolysis and peritoneal stripping with robotic assistance. Throughout the cases, we demonstrate the use and safety of the CO2 laser for excision and vaporization of endometriotic lesions as well as the role of hydro-dissection in protecting the ureter and other vital structures from harm. CONCLUSIONS: This video compilation demonstrates various presentations of ureteral endometriosis and successful laparoscopic management strategies with and without robotic assistance. V-9 Monday, October 30, 2017 5:07 PM CANCER ARISING FROM ENDOMETRIOSIS. E. C. Dun,a K. Davis,b C. Nezhat.c aObstetrics, Gynecology, and Reproductive Science, Yale School of Medicine, New Haven, CT; bSchool of Medicine, Emory University, Atlanta, GA; c Atlanta Center for Minimally Invasive Surgery and, Atlanta, GA. OBJECTIVE: The video presents a 78 year-old G1P1 female with a history of endometriosis who presented with post-coital vaginal bleeding. She had a history of a total abdominal hysterectomy at the age of 46 due to pelvic pain, and later underwent bilateral salpingo-oophorectomy and treatment of endometriosis at the age of 56 due to continued pain. She was on hormonal supplementation with transdermal estrogen. Preoperative examination and imaging revealed a 5 cm friable mass at the vaginal cuff and a smaller pelvic mass in the left pelvic sidewall. METHODOLOGY: The patient underwent small diameter laparoscopy using a multi-puncture technique. The left pelvic sidewall mass near the left ureter was carefully resected and found to be endometriosis on final pathology. The vaginal cuff mass was also resected and determine to be endometriosis juxtaposed with well-differentiated endometrioid adenocarcinoma. CONCLUSIONS: Although not fully elucidated, there is a strong relationship between endometriosis and ovarian cancer. Therefore, among patients with a history of endometriosis, continued regular gynecologic follow up is recommended not only for recurrence but also for possible malignant transformation. V-10 Monday, October 30, 2017 5:13 PM

V-8 Monday, October 30, 2017 5:00 PM

SEGMENTAL BLADDER RESECTION FOR TREATMENT OF BLADDER ENDOMETRIOSIS: WITH AND WITHOUT ROBOTIC ASSISTANCE. R. C. Falik,a D. H. Copeland,a,b A. Li,a A. Nezhat,a C. Nezhat.a aCenter for Special Minimally Invasive and Robotic Surgery, Palo Alto, CA; bSchool of Medicine, University of California, San Francisco, CA.

LAPAROSCOPIC TREATMENT OF URETERAL ENDOMETRIOSIS: WITH AND WITHOUT ROBOTIC ASSISTANCE. R. C. Falik,a D. H. Copeland,a,b A. Li,a A. Nezhat,a C. Nezhat.a aCenter for Special Minimally Invasive

OBJECTIVE: In this video, we demonstrate the presentation, workup, and laparoscopic treatment of deeply infiltrating endometriosis of the bladder. Although advanced laparoscopic management of extensive extragenital endometriosis has been reported by this author’s group since the

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ASRM Abstracts

Vol. 108, No. 3, Supplement, September 2017