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Combined Transurethral and Laparoscopic Partial Cystectomy and Robot-Assisted Bladder Repair for the Treatment of Bladder Mulerianosis
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
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626 A Modified Technique of Temporary Suspension of the Ovary to the Anterior Abdominal Wall Abuzeid OM,1,2 Hebert J,1,2 Ashraf M,1,2 Abuzeid MI,1,2 Raju R.1,2 1 Ob/Gyn, Hurley Medical Center, Flint, Michigan; 2College of Human Medicine, Michigan State University, Flint, Michigan Study Objective: Our group previously described a technique of temporary suspension of the ovary to the abdominal wall using nylon suture (Abuzeid et al 2002). The aim of this study is to describe a modified simple technique of temporary suspension of the ovary to the fascia of the anterior abdominal wall after operative laparoscopy for advanced stage endometriosis to reduce postoperative adhesion formation. Design: Retrospective cohort study. Setting: Academic affiliated community medical center. Patients: Patients who underwent temporary suspension of one or both ovaries, using 3-0 plain catgut suture, after operative laparoscopy for advanced stage endometriosis (Stage III/IV ASRM classification) between 2006 and 2015. Intervention: Temporary suspension of one or both ovaries to the fascia of the abdominal wall at the conclusion of operative laparoscopy using dissolvable suture (3-0 plain catgut suture). Measurements and Main Results: Forty one infertile patients were studied. A 3-0 plain catgut suture was used to elevate the ovary away from the ovarian fossa towards the abdominal wall . The ends of the sutures were brought out of the peritoneal cavity through a 3 mm skin incision using Endo Close device. The suture was tied over the fascia while allowing CO2 gas out of the peritoneal cavity to ensure that the suture remained under tension and the ovary is well suspended without touching the abdominal wall. Any complications were documented. There was no reported incidence of increased postoperative pain, while in the hospital or after discharge. All patients were discharged home on oral pain medication on the same day of surgery. No postoperative complications were reported as a result of the suspension procedure. All patients had uneventful recovery. Conclusion: This modified approach of temporary ovarian suspension to the fascia of the anterior abdominal wall appears to be simple and safe and easy to learn.
627 Real-Time Transvaginal Elastography of Recto-Sigmoid Endometriotic Nodules: Correlation With Symptoms and Histology Racca A,1 Vellone VG,2 Camerini G,2 Leone Roberti Maggiore U,1 Sozzi F,1 Remorgida V,1 Venturini PL,1 Biscaldi E,3 Ferrero S.1 1 Department of Obstetrics and Gynecology, IRCCS AOU San Martino - IST, University of Genova, Genova, GE, Italy; 2Deparment of Surgical and Diagnostic Sciences, IRCCS AOU San Martino - IST, University of Genova, Genova, GE, Italy; 3Department of Radiology, Galliera Hospital, Genova, GE, Italy
(from S1 to S4) and the disarray of muscle cells (from D0 to D3) were evaluated. Measurements and Main Results: The mean largest diameter of the endometriotic nodule was 29 ( 7 mm); the mean volume of the nodule was 8.4 ( 5.9) cm3. The elasticity score was % 3 in 7 patients, 4 in 8 patients and 5 in 9 patients. The elasticity score was significantly correlated with the intensity of dyschezia (Spearman’s correlation coefficient = 0.836; p \ 0.001) and with the gastrointestinal symptoms score (Spearman’s correlation coefficient = 0.716; p \ 0.001). The elastographic stiffness of the nodules was strongly correlated with the degree of fibrosis (Spearman’s correlation coefficient = 0.798; p \ 0.001) and negatively correlated with the amount of endometrial stroma (Spearman’s correlation coefficient = - 0.656; p \ 0.001). There was a moderate correlation between the elastographic stiffness and the disarray of muscle cells (Spearman’s correlation coefficient = 0.446; p = 0.029). Conclusion: Elastography allows to predict the histological characteristics of recto-sigmoid endometriotic nodules and correlates with intestinal symptoms.
628 Study Objective: To correlate the elastographic characteristics of rectosigmoid endometriotic nodules with symptoms and histology. Design: Prospective study. Setting: University hospital. Patients: This study included 24 patients with recto-sigmoid endometriotic nodules scheduled for laparoscopic colorectal resection. Intervention: Ultrasound imaging was performed with transvaginal probe and software for elastography. The elastograms were classified into 5 patterns according to the elasticity score: from score 1, low stiffness (the entire nodule is evenly shaded green, as is the surrounding normal bowel) to score 5, high stiffness (the entire nodule is evenly shaded blue). A standardized questionnaire was used to assess the gastrointestinal symptoms; a total gastrointestinal symptoms score was calculated. At histology, the depth of infiltration of endometriosis in the intestinal wall, the degree of fibrosis (from G0 to G4), the amount of endometrial stroma
Combined Transurethral and Laparoscopic Partial Cystectomy and Robot-Assisted Bladder Repair for the Treatment of Bladder Mulerianosis Algreisi F,1 Vilos G,1 Oraif A,2 Vilos A,1 Pautler S.1 1The Fertility Clinic, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Western University, London, Ontario, Canada; 2Obstetrics and Gynecology, Faculty of Medicine, King AbdulAziz University, Jeddah, Saudi Arabia Study Objective: To report experience with combined transurethral and laparoscopic partial cystectomy and robot-assisted bladder reconstruction, and clinical outcomes in 7 women with transmural bladder mullerianosis. Design: Case series from 2004-2014. Setting: Tertiary Care University affiliated hospital.
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Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
Patients: Seven nulliparous women, median age and range 25 years (22-40), BMI 25.7 kg/m2 (20.6-28.7) presented with pelvic pain/infertility and/or bladder dysfunction. Investigation by cystoscopy/biopsy in 6 and US/MRI in one identified a bladder tumor. Intervention: After informed consent, pelvic endometriosis was excised/ vaporized with the CO2 laser and the bladder lesion was excised in a combined transurethral and laparoscopic approach using the CO2 laser and electrosurgical instruments. Both ureters had been catheterized and the cystotomy was repaired using the daVinci robot. Measurements and Main Results: There were no perioperative complications. All patients recovered uneventfully and went home in 24-48 hours with Foley catheter for 10 days. Histologically, transmural bladder endometriosis was confirmed in 6 and enocervicosis in 1 woman. At a median follow up of 3 years (0.5-10), one woman conceived spontaneously and had uneventful vaginal delivery. Presently, all women are asymptomatic; one wishing pregnancy, five using oral contraceptives and one LNG-IUS. Conclusion: Endometriosis and endocervicosis of the urinary bladder are rare Mullerian choristomas. Symptomatic lesions can be excised by various surgical techniques, and a collaborative team-based approach is in the patients’ best interest.
629 Endometriosis in Adolescents: Referrals, Diagnosis, Treatment, and Outcomes Dun EC,1 Kho KA,2 Kearney S,3 Nezhat CH.3 1Department of Obstetrics, Gynecology, and Reproductive Science, Yale School of Medicine, New Haven, Connecticut; 2Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas; 3Atlanta Center for Minimally Invasive Surgery & Reproductive Medicine, Atlanta, Georgia Study Objective: Women with endometriosis often report onset of symptoms during adolescence; however, the diagnosis of endometriosis is often delayed. The aim of this study is to describe the experience of adolescent females who underwent laparoscopy for pelvic pain and were diagnosed with endometriosis, specifically the symptoms, time from onset of symptoms to correct diagnosis, number and type of medical professionals seen, diagnosis, treatment, and postoperative outcomes. Design: Case series. Setting: Tertiary referral center. Patients: We reviewed a series of 25 females 21 years and younger diagnosed with endometriosis during laparoscopy for pelvic pain over an 8 year period. They were followed for a period of 1 year after their surgery. Intervention: Laparoscopic surgery and hormonal and non-hormonal adjuvant therapy. Measurements and Main Results: The mean age at the time of surgery was 17.2 (2.4) years; range 10 - 21. The most common complaints were dysmenorrhea (64%), menorrhagia (44%), abnormal/irregular uterine bleeding (60%), R1 gastrointestinal symptom (56%), and R1 genitourinary symptom (52%). The mean time from the onset of symptoms until diagnosis was 22.8 (31.0) months; range 1 – 132. The median number of physicians who evaluated their pain was 3 (2.3); range 1-12. The adolescents had Stage I (68%), Stage II (20%), and Stage III (12%). Atypical endometriosis lesions (figure 1) (figure 2) and were most commonly observed. At 1 year, 64% reported resolved pain, 16% improved pain, 12% continued pain, and 8% recurrent pain. Conclusion: Timely referral to a gynecologist experienced with laparoscopic diagnosis and treatment of endometriosis is critical to expedite care for adolescents with pelvic pain. Once diagnosed and treated, adolescents have favorable outcomes with hormonal and nonhormonal therapy. Figure 1. Hemorrhagic lesion (arrow) involving the pelvic sidewall with a fibrotic lesion (double arrow) immediately over the ureter. Figure 2. Atypical clear lesions (arrow) studding the peritoneum.
630 A Randomised, Single-Blind Clinical Trial to Investigate the Effectiveness of Bipolar Versus Monopolar Diathermy Treatment on Pain Symptoms for Women With Newly Diagnosed Superficial Endometriosis: The Set Study (Superficial Endometriosis Treatment) Hardcastle RJ. Portsmouth Hospital, Portsmouth, Hampshire, United Kingdom Study Objective: To establish if there is Single-blind (participant) parallel group randomised controlled trial of monopolar diathermy versus bipolar diathermy. Any difference between monopolar or bipolar diathermy in the relief of pain symptoms after surgery for superficial endometriosis? Primary Objective: To compare the Visual Analogue Score (VAS) difference in Chronic Pelvic Pain symptoms between patients treated with monopolar vs bipolar diathermy at 4 months post-surgery. Secondary Objectives: To compare the Visual Analogue Score (VAS) difference in Chronic Pelvic Pain symptoms between patients treated with monopolar vs bipolar diathermy at 8 months post-surgery. To compare the change in the average VAS for three individual VAS domains (dyspareunia, chronic pelvic pain, menstrual pelvic pain) between patients treated with monopolar vs bipolar diathermy at 4 and 8 months post-surgery. To compare the change in the three individual VAS domains (dyspareunia, chronic pelvic pain, menstrual pelvic pain) between patients treated with monopolar vs bipolar diathermy at 4 and 8 months post-surgery.
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626 A Modified Technique of Temporary Suspension of the Ovary to the Anterior Abdominal Wall Abuzeid OM,1,2 Hebert J,1,2 Ashraf M,1,2 Abuzeid MI,1,2 Raju R.1,2 1 Ob/Gyn, Hurley Medical Center, Flint, Michigan; 2College of Human Medicine, Michigan State University, Flint, Michigan Study Objective: Our group previously described a technique of temporary suspension of the ovary to the abdominal wall using nylon suture (Abuzeid et al 2002). The aim of this study is to describe a modified simple technique of temporary suspension of the ovary to the fascia of the anterior abdominal wall after operative laparoscopy for advanced stage endometriosis to reduce postoperative adhesion formation. Design: Retrospective cohort study. Setting: Academic affiliated community medical center. Patients: Patients who underwent temporary suspension of one or both ovaries, using 3-0 plain catgut suture, after operative laparoscopy for advanced stage endometriosis (Stage III/IV ASRM classification) between 2006 and 2015. Intervention: Temporary suspension of one or both ovaries to the fascia of the abdominal wall at the conclusion of operative laparoscopy using dissolvable suture (3-0 plain catgut suture). Measurements and Main Results: Forty one infertile patients were studied. A 3-0 plain catgut suture was used to elevate the ovary away from the ovarian fossa towards the abdominal wall . The ends of the sutures were brought out of the peritoneal cavity through a 3 mm skin incision using Endo Close device. The suture was tied over the fascia while allowing CO2 gas out of the peritoneal cavity to ensure that the suture remained under tension and the ovary is well suspended without touching the abdominal wall. Any complications were documented. There was no reported incidence of increased postoperative pain, while in the hospital or after discharge. All patients were discharged home on oral pain medication on the same day of surgery. No postoperative complications were reported as a result of the suspension procedure. All patients had uneventful recovery. Conclusion: This modified approach of temporary ovarian suspension to the fascia of the anterior abdominal wall appears to be simple and safe and easy to learn.
627 Real-Time Transvaginal Elastography of Recto-Sigmoid Endometriotic Nodules: Correlation With Symptoms and Histology Racca A,1 Vellone VG,2 Camerini G,2 Leone Roberti Maggiore U,1 Sozzi F,1 Remorgida V,1 Venturini PL,1 Biscaldi E,3 Ferrero S.1 1 Department of Obstetrics and Gynecology, IRCCS AOU San Martino - IST, University of Genova, Genova, GE, Italy; 2Deparment of Surgical and Diagnostic Sciences, IRCCS AOU San Martino - IST, University of Genova, Genova, GE, Italy; 3Department of Radiology, Galliera Hospital, Genova, GE, Italy
(from S1 to S4) and the disarray of muscle cells (from D0 to D3) were evaluated. Measurements and Main Results: The mean largest diameter of the endometriotic nodule was 29 ( 7 mm); the mean volume of the nodule was 8.4 ( 5.9) cm3. The elasticity score was % 3 in 7 patients, 4 in 8 patients and 5 in 9 patients. The elasticity score was significantly correlated with the intensity of dyschezia (Spearman’s correlation coefficient = 0.836; p \ 0.001) and with the gastrointestinal symptoms score (Spearman’s correlation coefficient = 0.716; p \ 0.001). The elastographic stiffness of the nodules was strongly correlated with the degree of fibrosis (Spearman’s correlation coefficient = 0.798; p \ 0.001) and negatively correlated with the amount of endometrial stroma (Spearman’s correlation coefficient = - 0.656; p \ 0.001). There was a moderate correlation between the elastographic stiffness and the disarray of muscle cells (Spearman’s correlation coefficient = 0.446; p = 0.029). Conclusion: Elastography allows to predict the histological characteristics of recto-sigmoid endometriotic nodules and correlates with intestinal symptoms.
628 Study Objective: To correlate the elastographic characteristics of rectosigmoid endometriotic nodules with symptoms and histology. Design: Prospective study. Setting: University hospital. Patients: This study included 24 patients with recto-sigmoid endometriotic nodules scheduled for laparoscopic colorectal resection. Intervention: Ultrasound imaging was performed with transvaginal probe and software for elastography. The elastograms were classified into 5 patterns according to the elasticity score: from score 1, low stiffness (the entire nodule is evenly shaded green, as is the surrounding normal bowel) to score 5, high stiffness (the entire nodule is evenly shaded blue). A standardized questionnaire was used to assess the gastrointestinal symptoms; a total gastrointestinal symptoms score was calculated. At histology, the depth of infiltration of endometriosis in the intestinal wall, the degree of fibrosis (from G0 to G4), the amount of endometrial stroma
Combined Transurethral and Laparoscopic Partial Cystectomy and Robot-Assisted Bladder Repair for the Treatment of Bladder Mulerianosis Algreisi F,1 Vilos G,1 Oraif A,2 Vilos A,1 Pautler S.1 1The Fertility Clinic, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Western University, London, Ontario, Canada; 2Obstetrics and Gynecology, Faculty of Medicine, King AbdulAziz University, Jeddah, Saudi Arabia Study Objective: To report experience with combined transurethral and laparoscopic partial cystectomy and robot-assisted bladder reconstruction, and clinical outcomes in 7 women with transmural bladder mullerianosis. Design: Case series from 2004-2014. Setting: Tertiary Care University affiliated hospital.
S176
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
Patients: Seven nulliparous women, median age and range 25 years (22-40), BMI 25.7 kg/m2 (20.6-28.7) presented with pelvic pain/infertility and/or bladder dysfunction. Investigation by cystoscopy/biopsy in 6 and US/MRI in one identified a bladder tumor. Intervention: After informed consent, pelvic endometriosis was excised/ vaporized with the CO2 laser and the bladder lesion was excised in a combined transurethral and laparoscopic approach using the CO2 laser and electrosurgical instruments. Both ureters had been catheterized and the cystotomy was repaired using the daVinci robot. Measurements and Main Results: There were no perioperative complications. All patients recovered uneventfully and went home in 24-48 hours with Foley catheter for 10 days. Histologically, transmural bladder endometriosis was confirmed in 6 and enocervicosis in 1 woman. At a median follow up of 3 years (0.5-10), one woman conceived spontaneously and had uneventful vaginal delivery. Presently, all women are asymptomatic; one wishing pregnancy, five using oral contraceptives and one LNG-IUS. Conclusion: Endometriosis and endocervicosis of the urinary bladder are rare Mullerian choristomas. Symptomatic lesions can be excised by various surgical techniques, and a collaborative team-based approach is in the patients’ best interest.
629 Endometriosis in Adolescents: Referrals, Diagnosis, Treatment, and Outcomes Dun EC,1 Kho KA,2 Kearney S,3 Nezhat CH.3 1Department of Obstetrics, Gynecology, and Reproductive Science, Yale School of Medicine, New Haven, Connecticut; 2Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas; 3Atlanta Center for Minimally Invasive Surgery & Reproductive Medicine, Atlanta, Georgia Study Objective: Women with endometriosis often report onset of symptoms during adolescence; however, the diagnosis of endometriosis is often delayed. The aim of this study is to describe the experience of adolescent females who underwent laparoscopy for pelvic pain and were diagnosed with endometriosis, specifically the symptoms, time from onset of symptoms to correct diagnosis, number and type of medical professionals seen, diagnosis, treatment, and postoperative outcomes. Design: Case series. Setting: Tertiary referral center. Patients: We reviewed a series of 25 females 21 years and younger diagnosed with endometriosis during laparoscopy for pelvic pain over an 8 year period. They were followed for a period of 1 year after their surgery. Intervention: Laparoscopic surgery and hormonal and non-hormonal adjuvant therapy. Measurements and Main Results: The mean age at the time of surgery was 17.2 (2.4) years; range 10 - 21. The most common complaints were dysmenorrhea (64%), menorrhagia (44%), abnormal/irregular uterine bleeding (60%), R1 gastrointestinal symptom (56%), and R1 genitourinary symptom (52%). The mean time from the onset of symptoms until diagnosis was 22.8 (31.0) months; range 1 – 132. The median number of physicians who evaluated their pain was 3 (2.3); range 1-12. The adolescents had Stage I (68%), Stage II (20%), and Stage III (12%). Atypical endometriosis lesions (figure 1) (figure 2) and were most commonly observed. At 1 year, 64% reported resolved pain, 16% improved pain, 12% continued pain, and 8% recurrent pain. Conclusion: Timely referral to a gynecologist experienced with laparoscopic diagnosis and treatment of endometriosis is critical to expedite care for adolescents with pelvic pain. Once diagnosed and treated, adolescents have favorable outcomes with hormonal and nonhormonal therapy. Figure 1. Hemorrhagic lesion (arrow) involving the pelvic sidewall with a fibrotic lesion (double arrow) immediately over the ureter. Figure 2. Atypical clear lesions (arrow) studding the peritoneum.
630 A Randomised, Single-Blind Clinical Trial to Investigate the Effectiveness of Bipolar Versus Monopolar Diathermy Treatment on Pain Symptoms for Women With Newly Diagnosed Superficial Endometriosis: The Set Study (Superficial Endometriosis Treatment) Hardcastle RJ. Portsmouth Hospital, Portsmouth, Hampshire, United Kingdom Study Objective: To establish if there is Single-blind (participant) parallel group randomised controlled trial of monopolar diathermy versus bipolar diathermy. Any difference between monopolar or bipolar diathermy in the relief of pain symptoms after surgery for superficial endometriosis? Primary Objective: To compare the Visual Analogue Score (VAS) difference in Chronic Pelvic Pain symptoms between patients treated with monopolar vs bipolar diathermy at 4 months post-surgery. Secondary Objectives: To compare the Visual Analogue Score (VAS) difference in Chronic Pelvic Pain symptoms between patients treated with monopolar vs bipolar diathermy at 8 months post-surgery. To compare the change in the average VAS for three individual VAS domains (dyspareunia, chronic pelvic pain, menstrual pelvic pain) between patients treated with monopolar vs bipolar diathermy at 4 and 8 months post-surgery. To compare the change in the three individual VAS domains (dyspareunia, chronic pelvic pain, menstrual pelvic pain) between patients treated with monopolar vs bipolar diathermy at 4 and 8 months post-surgery.