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Coaxial robot-assisted single-incision laparoscopic (RA-SIL) myomectomy and adenomyomectomy: technique and outcomes
TABLE 2. Respondents Somewhat or Very Satisfied with Energy Sources (%)
Cost Patient Outcomes Safety Operating Time/Efficiency For Endometriosis For Myomectomy Overall
Electrosurgery
Ultrasonic
Laser
75/52 90/89 77/90 89/52
37/38 68/73 72/75 63/70
16/15 39/40 34/33 29/35
Monopolar: 67; Bipolar 72 Monopolar: 70; Bipolar 63 87/93
60
44
48
13
64/72
30/33
Surgeon Response/Resident and Fellow Response where both groups surveyed; single number where only Surgeon surveyed. P-871 Wednesday, October 16, 2013 FERTILOSCOPY: INITIAL EXPERIENCE IN A U.S. FERTILITY CENTER. B. S. Hurst, P. B. Marshburn, M. L. Matthews, R. S. Usadi. Obstetrics and Gynecology, Carolinas Healthcare System, Charlotte, NC. OBJECTIVE: Fertiloscopy, a minimally invasive transvaginal endoscopy, provides accesses to the adnexae for evaluation and treatment of infertility. The first 39 fertiloscopy cases are reviewed to determine the role of this procedure in a U.S. fertility practice. DESIGN: Retrospective. MATERIALS AND METHODS: Fertiloscopy was performed in a surgical center beginning July 2011. Fertiloscopy is performed by transvaginally filling the posterior cul de sac with saline using a Verres needle, placing a Fertiloscope trocar through the posterior fornix into the cul de sac fluid, and inspecting the adnexae with a 2.9 mm endoscope. Endometriosis and adhesions are treated and ovarian drilling performed using a bipolar twizzle-tip electrode placed through the operating channel. A transcervical tubal catheter is used to open proximally occluded tubes. RESULTS: Fertiloscopy was completed in 34 women. Endometriosis was diagnosed and treated in 11, tubal or ovarian adhesions in 13, and adhesiolysis performed in 12 (9 had adhesions + endometriosis), and ovarian drilling for 4 with PCOS. Tubal cannulation was performed after ruling out distal hydrosalpinges in 3 women with proximal tubal occlusion, and avoided in 2 with hydrosalpinges. Since July 2011, 13 of 33 women under age 40 conceived. The procedure could not be performed for 5, including 1 with a large rectocele (the posterior vaginal wall obscured the cervix after filling the cul de sac with saline) and 2 women with BMI over 40; bowel injury occurred in a woman with BMI > 43. CONCLUSION: Fertiloscopy provides diagnosis and treatment for endometriosis, adnexal adhesions, and ovarian drilling for PCOS. Fertiloscopy allows remarkable visualization of the tubes and ovaries; magnification over 100-fold allows for microscopic inspection of the fimbrial and distal tubal lumen. It is useful to assess the distal tubes for women undergoing tubal cannulation for proximal occlusion. However, the procedure is technically difficult in women with BMI >40 and cannot be recommended for this group.
P-872 Wednesday, October 16, 2013 COAXIAL ROBOT-ASSISTED SINGLE-INCISION LAPAROSCOPIC (RA-SIL) MYOMECTOMY AND ADENOMYOMECTOMY: TECHNIQUE AND OUTCOMES. S. Choussein, S. S. Srouji, A. P. Bailey, A. R. Gargiulo. Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA. OBJECTIVE: To report our preliminary experience with RA-SIL myomectomy and adenomyomectomy. DESIGN: This is a retrospective descriptive study of 8 consecutive patients who underwent RA-SIL myomectomy and/or adenomyomectomy between October 2011 and March 2013. MATERIALS AND METHODS: All patients who underwent robot-assisted SIL myomectomy at our institution during the stated time interval have been included in the study. We employed the da Vinci Si Surgical System
FERTILITY & STERILITYÒ
(Intuitive Surgical) and the GelPOINT multi-access platform (Applied Medical). Our institutional review board established no need for experimental protocol. RESULTS: Eight patients underwent robot-assisted SIL myomectomy. Mean age (SD) was 42.32.3 years and mean BMI was 32.56.0 kg/ m2. Severe menorrhagia, lower abdominal pressure, infertility and urinary symptoms were the main presenting symptoms. In total, 7 intramural, 3 submucosal and 5 subserosal myomas and a focal adenomyoma were removed. Mean operative time was 172.836.8 min (median¼165.5 min, range, 130227 min). Mean diameter of the largest tumor was 5.22.2 cm (median¼5 cm, range, 2.1-8 cm). Mean blood loss was 41.345.6 ml (median¼ 25 ml, range, 5-150 ml). All procedures were successfully completed without conversion to conventional SIL, multi-port laparoscopy or open surgery. No post-operative complications were observed. Patients were discharged home on day of surgery. CONCLUSION: Our coaxial RA-SIL myomectomy is a safe and reproducible technique in obese patients. SIL bears great promise of patient acceptability with advantages of improved cosmesis and less likelihood of injury to superficial nerves or blood vessels. Larger retrospective studies and prospective trials are needed to evaluate cosmetic and postoperative outcomes and to define the patient groups that will most benefit from this novel operation. P-873 Wednesday, October 16, 2013 EFFICACY OF TRANSVAGINAL FALLOPOSCOPIC TUBOPLASTY. K. Kyono,a,b M. Kuchiki,a M. Hattori,a H. Sakai,a a,b b a E. Sakamoto, T. Takeuchi. Kyono ART Clinic, Sendai, Miyagi, Japan; b Kyono ART Clinic Takanawa, Minato-ku, Tokyo, Japan. OBJECTIVE: To examine the efficacy and future tasks of falloposcopic tuboplasty (FT) in patients with tubal obstruction/stenosis near the uterus. DESIGN: Retrospective study. MATERIALS AND METHODS: Subjects were 24 patients who received FT under total anesthesia in Kyono ART Clinic (20 cases) and Kyono ART Clinic Takanawa (4 cases) from June 2012 to January 2013. We assessed the age of the patients, cause of infertility, infertility period, and time to pregnancy after FT. RESULTS: In 24 patients (24/24, 100.0%), cause of infertility was tubal factor (one side or both sides), and 12 patients (12/24, 50.0%) had mild male factor. Mean age of the patients was 32.83.8 years old, mean infertility period was 44.720.7 months, mean operative duration was 22.38.7 minutes. Pregnancy rate was 25% (6/24): 2 cases became pregnant during the treatment cycle (0 month after FT), 3 patients 1 month after FT, and 1 patient 5 months after FT; all pregnancies are ongoing. 4 pregnancies resulted from the timing method (a husband had varicocele surgery in one case), and 2 from intrauterine insemination (IUI). Of these IUI cases, one case was a 43-year-old patient with right tubal obstruction and left tubal stenosis who had a husband with ejaculation disorder. They received IUI after FT and achieved pregnancy. The other case was a 39-year-old patient with right tubal obstruction and left tubal stenosis who received FT and IUI (right follicle development; mild asthenozoospermia) after an operation for breast cancer and 6 cycles of chemotherapy. Even though anti-mullerian hormone (AMH) was very low (<0.1 ng/ml), she became pregnant 1 month after FT. CONCLUSION: Training by a skilled doctor is required before adopting FT. In our clinic, adoption was relatively smooth, although practice is required to locate the orifice of the fallopian tube more quickly. In Japan, FT is covered by national health insurance and it is outpatient surgery. Therefore, FT can be a useful option in infertility treatment before artificial reproductive technology. P-874 Wednesday, October 16, 2013 A STUDY OF SURGICAL INTERVENTION FOR SEPTATE UTERUS AS A CAUSE OF RECURRENT MISCARRIAGE. S. Ono, T. Abe, K. Mine, Y. Kuwabara, S. Akira, T. Takeshita. Obsterics & Gynecology, Nippon Medical School, Bunkyouku, Tokyo, Japan. OBJECTIVE: Septate uterus is considered to be a major cause of recurrent miscarriage.As surgical interventions for septate uterus, both-abdominal (the Jones operation) and hysteroscopic metroplasty (HM) have been utilized. We have introduced laparoscopic approach (laparoscopically-assisted Jones,
S399
Cost Patient Outcomes Safety Operating Time/Efficiency For Endometriosis For Myomectomy Overall
Electrosurgery
Ultrasonic
Laser
75/52 90/89 77/90 89/52
37/38 68/73 72/75 63/70
16/15 39/40 34/33 29/35
Monopolar: 67; Bipolar 72 Monopolar: 70; Bipolar 63 87/93
60
44
48
13
64/72
30/33
Surgeon Response/Resident and Fellow Response where both groups surveyed; single number where only Surgeon surveyed. P-871 Wednesday, October 16, 2013 FERTILOSCOPY: INITIAL EXPERIENCE IN A U.S. FERTILITY CENTER. B. S. Hurst, P. B. Marshburn, M. L. Matthews, R. S. Usadi. Obstetrics and Gynecology, Carolinas Healthcare System, Charlotte, NC. OBJECTIVE: Fertiloscopy, a minimally invasive transvaginal endoscopy, provides accesses to the adnexae for evaluation and treatment of infertility. The first 39 fertiloscopy cases are reviewed to determine the role of this procedure in a U.S. fertility practice. DESIGN: Retrospective. MATERIALS AND METHODS: Fertiloscopy was performed in a surgical center beginning July 2011. Fertiloscopy is performed by transvaginally filling the posterior cul de sac with saline using a Verres needle, placing a Fertiloscope trocar through the posterior fornix into the cul de sac fluid, and inspecting the adnexae with a 2.9 mm endoscope. Endometriosis and adhesions are treated and ovarian drilling performed using a bipolar twizzle-tip electrode placed through the operating channel. A transcervical tubal catheter is used to open proximally occluded tubes. RESULTS: Fertiloscopy was completed in 34 women. Endometriosis was diagnosed and treated in 11, tubal or ovarian adhesions in 13, and adhesiolysis performed in 12 (9 had adhesions + endometriosis), and ovarian drilling for 4 with PCOS. Tubal cannulation was performed after ruling out distal hydrosalpinges in 3 women with proximal tubal occlusion, and avoided in 2 with hydrosalpinges. Since July 2011, 13 of 33 women under age 40 conceived. The procedure could not be performed for 5, including 1 with a large rectocele (the posterior vaginal wall obscured the cervix after filling the cul de sac with saline) and 2 women with BMI over 40; bowel injury occurred in a woman with BMI > 43. CONCLUSION: Fertiloscopy provides diagnosis and treatment for endometriosis, adnexal adhesions, and ovarian drilling for PCOS. Fertiloscopy allows remarkable visualization of the tubes and ovaries; magnification over 100-fold allows for microscopic inspection of the fimbrial and distal tubal lumen. It is useful to assess the distal tubes for women undergoing tubal cannulation for proximal occlusion. However, the procedure is technically difficult in women with BMI >40 and cannot be recommended for this group.
P-872 Wednesday, October 16, 2013 COAXIAL ROBOT-ASSISTED SINGLE-INCISION LAPAROSCOPIC (RA-SIL) MYOMECTOMY AND ADENOMYOMECTOMY: TECHNIQUE AND OUTCOMES. S. Choussein, S. S. Srouji, A. P. Bailey, A. R. Gargiulo. Center for Infertility and Reproductive Surgery, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA. OBJECTIVE: To report our preliminary experience with RA-SIL myomectomy and adenomyomectomy. DESIGN: This is a retrospective descriptive study of 8 consecutive patients who underwent RA-SIL myomectomy and/or adenomyomectomy between October 2011 and March 2013. MATERIALS AND METHODS: All patients who underwent robot-assisted SIL myomectomy at our institution during the stated time interval have been included in the study. We employed the da Vinci Si Surgical System
FERTILITY & STERILITYÒ
(Intuitive Surgical) and the GelPOINT multi-access platform (Applied Medical). Our institutional review board established no need for experimental protocol. RESULTS: Eight patients underwent robot-assisted SIL myomectomy. Mean age (SD) was 42.32.3 years and mean BMI was 32.56.0 kg/ m2. Severe menorrhagia, lower abdominal pressure, infertility and urinary symptoms were the main presenting symptoms. In total, 7 intramural, 3 submucosal and 5 subserosal myomas and a focal adenomyoma were removed. Mean operative time was 172.836.8 min (median¼165.5 min, range, 130227 min). Mean diameter of the largest tumor was 5.22.2 cm (median¼5 cm, range, 2.1-8 cm). Mean blood loss was 41.345.6 ml (median¼ 25 ml, range, 5-150 ml). All procedures were successfully completed without conversion to conventional SIL, multi-port laparoscopy or open surgery. No post-operative complications were observed. Patients were discharged home on day of surgery. CONCLUSION: Our coaxial RA-SIL myomectomy is a safe and reproducible technique in obese patients. SIL bears great promise of patient acceptability with advantages of improved cosmesis and less likelihood of injury to superficial nerves or blood vessels. Larger retrospective studies and prospective trials are needed to evaluate cosmetic and postoperative outcomes and to define the patient groups that will most benefit from this novel operation. P-873 Wednesday, October 16, 2013 EFFICACY OF TRANSVAGINAL FALLOPOSCOPIC TUBOPLASTY. K. Kyono,a,b M. Kuchiki,a M. Hattori,a H. Sakai,a a,b b a E. Sakamoto, T. Takeuchi. Kyono ART Clinic, Sendai, Miyagi, Japan; b Kyono ART Clinic Takanawa, Minato-ku, Tokyo, Japan. OBJECTIVE: To examine the efficacy and future tasks of falloposcopic tuboplasty (FT) in patients with tubal obstruction/stenosis near the uterus. DESIGN: Retrospective study. MATERIALS AND METHODS: Subjects were 24 patients who received FT under total anesthesia in Kyono ART Clinic (20 cases) and Kyono ART Clinic Takanawa (4 cases) from June 2012 to January 2013. We assessed the age of the patients, cause of infertility, infertility period, and time to pregnancy after FT. RESULTS: In 24 patients (24/24, 100.0%), cause of infertility was tubal factor (one side or both sides), and 12 patients (12/24, 50.0%) had mild male factor. Mean age of the patients was 32.83.8 years old, mean infertility period was 44.720.7 months, mean operative duration was 22.38.7 minutes. Pregnancy rate was 25% (6/24): 2 cases became pregnant during the treatment cycle (0 month after FT), 3 patients 1 month after FT, and 1 patient 5 months after FT; all pregnancies are ongoing. 4 pregnancies resulted from the timing method (a husband had varicocele surgery in one case), and 2 from intrauterine insemination (IUI). Of these IUI cases, one case was a 43-year-old patient with right tubal obstruction and left tubal stenosis who had a husband with ejaculation disorder. They received IUI after FT and achieved pregnancy. The other case was a 39-year-old patient with right tubal obstruction and left tubal stenosis who received FT and IUI (right follicle development; mild asthenozoospermia) after an operation for breast cancer and 6 cycles of chemotherapy. Even though anti-mullerian hormone (AMH) was very low (<0.1 ng/ml), she became pregnant 1 month after FT. CONCLUSION: Training by a skilled doctor is required before adopting FT. In our clinic, adoption was relatively smooth, although practice is required to locate the orifice of the fallopian tube more quickly. In Japan, FT is covered by national health insurance and it is outpatient surgery. Therefore, FT can be a useful option in infertility treatment before artificial reproductive technology. P-874 Wednesday, October 16, 2013 A STUDY OF SURGICAL INTERVENTION FOR SEPTATE UTERUS AS A CAUSE OF RECURRENT MISCARRIAGE. S. Ono, T. Abe, K. Mine, Y. Kuwabara, S. Akira, T. Takeshita. Obsterics & Gynecology, Nippon Medical School, Bunkyouku, Tokyo, Japan. OBJECTIVE: Septate uterus is considered to be a major cause of recurrent miscarriage.As surgical interventions for septate uterus, both-abdominal (the Jones operation) and hysteroscopic metroplasty (HM) have been utilized. We have introduced laparoscopic approach (laparoscopically-assisted Jones,
S399