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Incidence and Predictors of Persistent Pelvic Pain Following Hysterectomy in Women with Chronic Pelvic Pain
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 Fazel A,1,* Sinervo KR,2 Magrina JF,3 Wattiez A,5 Yeung PP, Jr.6 Ceccaroni M,7 Seracchioli R,8 Tulandi T,9 Estrade JP,10 Fernandez H,11 Nisolle M,12 Gordts S,13 Brucker SY,14 Mueller MD,15 Nezhat FR,4 Bouquet de la Jolini ere J,16 Sauvanet E,17 von Theobald P,18 Boukerrou M,19 Benifla JL,20 Sroussi J,21 Smeets M,22 Jansen FW23. 1 Obstetrics and Gynecology, Larboisiere Hospital APHP, Paris, France; 2 Center for Endometriosis Care, Atlanta; 3Mayo Clinic, Phoenix; 4Weill Cornell Medicine, New York; 5Latifa Maternity & Paediatric Hospital, Dubai, United Arab Emirates; 6Saint Louis University Center for Endometriosis, Saint Louis; 7Gynecology and Obstetrics, Gynecologic Oncology, Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy; 8Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), S. Orsola Hospital, University of Bologna, Bologna, Italy; 9Obstetrics and Gynecology, McGill University, Montreal, QC, Canada; 10Surgery Unit, Gynecomarseille, Marseille, France; 11Paris Sud University, Le Kremlin Bicetre, France; 12CHR de Li ege, Liege, Belgium; 13Life Expert Centre/ Heilig Hart Hospitaal, Leuven, Belgium; 14 Universit€ ats-Frauenklinik, T€ ubingen, Germany; 15H^ opital Universitaire opital cantonal, de Berne, Berne, Switzerland; 16HFR Fribourg - H^ Fribourg, Switzerland; 17H^ opital Parisien Saint Joseph, Paris, France; 18 CHU La R eunion Saint Denis, Saint Denis de la R eunion, French eunion Saint Pierre, Saint Pierre de la Southern Territories; 19CHU La R R eunion, French Southern Territories; 20Hopital Lariboisi ere, Paris, France; 21APHP Lariboisi ere Hospital, Paris 75010, France; 22HMC Bronovo, The Hague, Netherlands; 23Leids Universitair Medisch Centrum, Leids, Netherlands *Corresponding author. Study Objective: The aim of our study is to test a combination of biological markers differentially expressed in samples from women with or without endometriosis. Methods Design: ENDOSEARCH is a prospective multicentric international clinical trial registered with Clinical Trial.gov. Setting: 20 renowned specialized centers in Europe, USA, Canada, and the Indian Ocean, granted by the European Union aiming to validate a cluster of biomarkers. Patients or Participants: 1000 patients. The Patient Group includes women between 18 and 45 with suspected endometriosis undergoing laparoscopy. Patients with predominant adenomyosis and/or fibroids diagnosed by imaging, chronic, malignant, infectious, metabolic or endocrine diseases are excluded. The Control Group includes patients of same age group without any endometriosis-related clinical sign, with planned laparoscopic surgery for other indications. Samples of endometriosis lesions and endometrial biopsies for both groups are sent to a unique center (Endodiag, Paris, France) to be tested with the cluster of biomarkers. Interventions: Laparoscopy for endometriosis or benign conditions (Control group). Measurements and Main Results: 40% of the patients recruited in the Endometriosis group have already had at least one and up to 4 previous laparoscopies for endometriosis. Almost 50% of the patients had an AFS score of III or IV. 14% of the patients suspected of endometriosis had negative pathology while 2% of the patients in the control group had severe endometriosis at laparoscopy and were excluded. Conclusion: We present the first large prospective multicentric international clinical trial aiming to test a cluster of biomarkers to diagnose endometriosis by recruiting over 1000 patients all around Europe, the US and Canada. Even in major referral centers almost 14% of the pre-op diagnosis were negative at pathology while 2% of the control group had severe endometriosis. Those preliminary results with others show the necessity of development of accurate biological tests to diagnose endometriosis and avoid unnecessary laparoscopies.
S91 Open Communications 26: Endometriosis (4:10 PM − 5:15 PM) 4:59 PM Roadmap to Safe Vaginal Cuff Revision for Endometriosis Moawad NS,1,* Salem Z2. 1Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics & Gynecology, University of Florida, Gainesville, FL; 2Obstetrics & Gynecology, University of Florida, Gainesville, FL *Corresponding author. Video Objective: This video describes a systematic stepwise approach for vaginal cuff revision associated with vaginal cuff endometriosis and rectovaginal disease. Setting: 39 year-old presented with persistent cyclic vaginal bleeding, pelvic pain and deep dyspareunia following laparoscopic hysterectomy. She was noted to have a 2 cm vaginal cuff nodule with posterior cul de sac obliteration. The patient failed medical management and desired surgical management. Interventions: Laparoscopic vaginal cuff revision was performed using a systematic approach with bilateral ureterolysis, excision of uterosacral ligament fibrosis, opening the rectovaginal space, shaving of rectal endometriosis and resection of the vaginal cuff nodule. Conclusion: This stepwise approach for vaginal cuff revision in patients with symptomatic rectovaginal endometriosis provides a roadmap for the effective and safe excision of vaginal cuff nodules, while minimizing the risks of injury to the bladder, the ureters, the rectum and the risk of vaginal cuff dehiscence, persistent dyspareunia and recurrent endometriosis. Open Communications 26: Endometriosis (4:10 PM − 5:15 PM) 5:06 PM Incidence and Predictors of Persistent Pelvic Pain Following Hysterectomy in Women with Chronic Pelvic Pain As-Sanie S,1,* Till SR,1 Griffith KC,1 Daniel C,2 Brummett CM2. 1 Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; 2 Anesthesiology, University of Michigan, Ann Arbor, MI *Corresponding author. Study Objective: To describe the incidence and risk factors for persistent pelvic pain 6 months following hysterectomy in women with chronic pelvic pain (CPP). Design: Prospective, observational cohort study of women with chronic pelvic pain undergoing hysterectomy. Setting: Academic tertiary care center. Patients or Participants: 126 women with CPP undergoing hysterectomy for benign indications. Interventions: Patients completed validated assessments of pain, anxiety, depression, and centralized pain (using the 2011 fibromyalgia survey criteria, 0-31 points) preoperatively and 6-months after hysterectomy. Demographic information, surgical history, intraoperative findings and surgical pathology were abstracted from the electronic medical record. Preoperative CPP was defined as average pelvic pain ≥3/10 for >3 months. Multivariate logistic regression was used to identify independent predictors of persistent pelvic pain 6 months following hysterectomy, defined as <50% improvement in pelvic pain severity. Measurements and Main Results: Among 176 participants with CPP, 126 (71.6%) were retained at 6-months, and 15 (11.9%) reported persistent pelvic pain. There was no difference in age (p=0.46), race (p=0.55), pain severity (p=0.10) or pain duration (p=0.80) in those with and without persistent pelvic pain. While intraoperative findings of
S92 endometriosis (p=0.045) was associated with a higher incidence of persistent pain, surgical route (p=0.46), uterine fibroids (p=0.34), adenomyosis (p=0.23), pelvic adhesions (0.51), uterine weight (p=0.66) were not related to risk of persistent pain. Higher preoperative centralized pain scores (p=0.01), but not depression (p=0.13) or anxiety (p=0.28) were more common in women with persistent pelvic pain. Multivariate logistic regression controlling for age, anxiety, and endometriosis indicated that every 1-point increase in centralized pain was associated with a 23% increase in odds of persistent pelvic pain (OR 1.23, 95%CI 1.03, 1.48). Conclusion: While the majority of women with CPP report considerable improvement in pain following hysterectomy, higher degrees of centralized pain prior to hysterectomy is a robust predictor of persistent pain, even among women whose score falls below the diagnostic criteria for fibromyalgia.
Open Communications 27: Endometriosis (4:10 PM − 5:10 PM) 4:10 PM Typical Opioid use After Minimally Invasive Hysterectomy Huynh TQ,1,* Makai GE,1 Patel NR,2 Thompson D3. 1Obstetrics and Gynecology, Christiana Care Health Systems, Newark, DE; 2Medical Education, OB/GYN, TriHealth/Good Samaritan Hospital, Cincinnati, OH; 3Washington State Department of Health, Tumwater, WA *Corresponding author. Study Objective: To describe typical narcotic requirements after benign minimally invasive hysterectomy and evaluate patient risk factors for higher narcotic use. Design: In a prospectively collected data set as part of a randomized controlled trial comparing single-dose preoperative gabapentin use to nonusers, women undergoing a benign minimally invasive hysterectomy were assessed for total narcotic use and subjective pain scores at 2 weeks postoperatively via phone. Results from this trial resulted in no difference between groups, therefore the data set was utilized to assess typical narcotic use at 2 weeks postoperative. Total narcotic use was then compared across surgical specialties (generalist, urogynecology, minimally invasive gynecology [MIGS]). Patient demographics and operative details were compared between top quartile users versus regular users. Setting: Single academic affiliated community hospital. Patients or Participants: From June 2016 to June 2017, women undergoing hysterectomy for benign indications via a minimally invasive approach were approached to participate. Inclusion was limited to patients of high volume surgeons (more than 20 hysterectomies annually) within the generalist, MIGS, and urogynecology divisions. Women were excluded if known to have a contraindication to gabapentin, acetaminophen, or celecoxib use, or if their procedure was converted to laparotomy for any indication. Interventions: N/A Measurements and Main Results: A total of 109 women had data at 2 weeks postoperative to be analyzed for cohort analysis. The median oral narcotic requirement was 40 morphine milligram equivalents [MME] (interquartile range 0 − 96). Patients undergoing surgery with MIGS providers required less postoperative narcotics than those with a generalist trained surgeon (15 MME versus 75 MME, p = 0.007). Younger age and prior laparoscopic surgery were also found to be associated with high narcotic utilization after benign hysterectomy. Conclusion: Typical oral narcotic requirements after benign minimally invasive hysterectomy are minimal with median use equivalent to approximately five tablets of oxycodone (5 milligrams).
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 Open Communications 27: Endometriosis (4:10 PM − 5:10 PM) 4:17 PM Superficial Endometriosis can be Seen on Ultrasound: A Pilot Application of Saline-Infusion Sonopodography Leonardi M,1,2,* Espada M,1 Stamatopoulos N,1 Vanza K,1 Condous G1,2. 1 Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney, NSW, Australia; 2Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia *Corresponding author. Study Objective: Saline-infusion sonoPODography (SPG) is a novel ultrasound procedure that involves introducing fluid into the pouch of Douglas (POD) via the uterus and tubes to create an acoustic window and enhanced contrast between tissues in the posterior compartment. We aim to demonstrate that SPG has utility in diagnosing superficial endometriosis (SE) in a non-invasive fashion. Design: Prospective diagnostic accuracy study. Setting: Tertiary healthcare center in Sydney, Australia from September 2018-March 2019. Patients or Participants: Patients with symptoms of endometriosis planned for laparoscopy were recruited. Interventions: SPG was done intra-operatively. Measurements and Main Results: Laparoscopy was initiated to ascertain a reference standard visual diagnosis of endometriosis and to suction free fluid from the pelvis. The single SPG operator was blinded to this part of surgery. If fluid collected in the POD, SE of the posterior compartment was evaluated and compared to laparoscopic findings. SE on TVS was defined relative to peritoneal surfaces: 1) superficial hypoechoic areas, 2) hyperechoic projections, 3) cystic areas, 4) pockets of fluid, 5) filmy, irregular adhesions. 15/19 patients underwent successful SPG. Prevalence of overall endometriosis was 15/19 (79%); deep endometriosis (DE) 5/19 (26%); ovarian endometriomas 3/19 (16%); POD obliteration 2/19 (11%); SE 14/19 (74%). SPG diagnostic accuracy results are depicted in Table 1. Table 1.
Accuracy Prevalence Sensitivity Specificity Positive predictive value Negative predictive value Positive likelihood ratio Negative likelihood ratio
SE
POD SE
73% 80% 67% 100% 100% 43% N/A 0.33
90% 90% 89% 100% 100% 50% N/A 0.11
Conclusion: SPG was successfully completed in the majority of patients. In those without advanced endometriosis (i.e. POD obliteration), SPG is even more achievable and provides a reasonable sensitivity for overall SE and very good sensitivity for POD SE, which is the second most common site of SE. At present, SPG needs to be further evaluated but offers hope for a novel non-invasive diagnostic tool for SE.
Open Communications 27: Endometriosis (4:10 PM − 5:10 PM) 4:24 PM The Role of Shaving Technique in the Treatment of Recto-Vaginal Endometriosis
S91 Open Communications 26: Endometriosis (4:10 PM − 5:15 PM) 4:59 PM Roadmap to Safe Vaginal Cuff Revision for Endometriosis Moawad NS,1,* Salem Z2. 1Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics & Gynecology, University of Florida, Gainesville, FL; 2Obstetrics & Gynecology, University of Florida, Gainesville, FL *Corresponding author. Video Objective: This video describes a systematic stepwise approach for vaginal cuff revision associated with vaginal cuff endometriosis and rectovaginal disease. Setting: 39 year-old presented with persistent cyclic vaginal bleeding, pelvic pain and deep dyspareunia following laparoscopic hysterectomy. She was noted to have a 2 cm vaginal cuff nodule with posterior cul de sac obliteration. The patient failed medical management and desired surgical management. Interventions: Laparoscopic vaginal cuff revision was performed using a systematic approach with bilateral ureterolysis, excision of uterosacral ligament fibrosis, opening the rectovaginal space, shaving of rectal endometriosis and resection of the vaginal cuff nodule. Conclusion: This stepwise approach for vaginal cuff revision in patients with symptomatic rectovaginal endometriosis provides a roadmap for the effective and safe excision of vaginal cuff nodules, while minimizing the risks of injury to the bladder, the ureters, the rectum and the risk of vaginal cuff dehiscence, persistent dyspareunia and recurrent endometriosis. Open Communications 26: Endometriosis (4:10 PM − 5:15 PM) 5:06 PM Incidence and Predictors of Persistent Pelvic Pain Following Hysterectomy in Women with Chronic Pelvic Pain As-Sanie S,1,* Till SR,1 Griffith KC,1 Daniel C,2 Brummett CM2. 1 Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; 2 Anesthesiology, University of Michigan, Ann Arbor, MI *Corresponding author. Study Objective: To describe the incidence and risk factors for persistent pelvic pain 6 months following hysterectomy in women with chronic pelvic pain (CPP). Design: Prospective, observational cohort study of women with chronic pelvic pain undergoing hysterectomy. Setting: Academic tertiary care center. Patients or Participants: 126 women with CPP undergoing hysterectomy for benign indications. Interventions: Patients completed validated assessments of pain, anxiety, depression, and centralized pain (using the 2011 fibromyalgia survey criteria, 0-31 points) preoperatively and 6-months after hysterectomy. Demographic information, surgical history, intraoperative findings and surgical pathology were abstracted from the electronic medical record. Preoperative CPP was defined as average pelvic pain ≥3/10 for >3 months. Multivariate logistic regression was used to identify independent predictors of persistent pelvic pain 6 months following hysterectomy, defined as <50% improvement in pelvic pain severity. Measurements and Main Results: Among 176 participants with CPP, 126 (71.6%) were retained at 6-months, and 15 (11.9%) reported persistent pelvic pain. There was no difference in age (p=0.46), race (p=0.55), pain severity (p=0.10) or pain duration (p=0.80) in those with and without persistent pelvic pain. While intraoperative findings of
S92 endometriosis (p=0.045) was associated with a higher incidence of persistent pain, surgical route (p=0.46), uterine fibroids (p=0.34), adenomyosis (p=0.23), pelvic adhesions (0.51), uterine weight (p=0.66) were not related to risk of persistent pain. Higher preoperative centralized pain scores (p=0.01), but not depression (p=0.13) or anxiety (p=0.28) were more common in women with persistent pelvic pain. Multivariate logistic regression controlling for age, anxiety, and endometriosis indicated that every 1-point increase in centralized pain was associated with a 23% increase in odds of persistent pelvic pain (OR 1.23, 95%CI 1.03, 1.48). Conclusion: While the majority of women with CPP report considerable improvement in pain following hysterectomy, higher degrees of centralized pain prior to hysterectomy is a robust predictor of persistent pain, even among women whose score falls below the diagnostic criteria for fibromyalgia.
Open Communications 27: Endometriosis (4:10 PM − 5:10 PM) 4:10 PM Typical Opioid use After Minimally Invasive Hysterectomy Huynh TQ,1,* Makai GE,1 Patel NR,2 Thompson D3. 1Obstetrics and Gynecology, Christiana Care Health Systems, Newark, DE; 2Medical Education, OB/GYN, TriHealth/Good Samaritan Hospital, Cincinnati, OH; 3Washington State Department of Health, Tumwater, WA *Corresponding author. Study Objective: To describe typical narcotic requirements after benign minimally invasive hysterectomy and evaluate patient risk factors for higher narcotic use. Design: In a prospectively collected data set as part of a randomized controlled trial comparing single-dose preoperative gabapentin use to nonusers, women undergoing a benign minimally invasive hysterectomy were assessed for total narcotic use and subjective pain scores at 2 weeks postoperatively via phone. Results from this trial resulted in no difference between groups, therefore the data set was utilized to assess typical narcotic use at 2 weeks postoperative. Total narcotic use was then compared across surgical specialties (generalist, urogynecology, minimally invasive gynecology [MIGS]). Patient demographics and operative details were compared between top quartile users versus regular users. Setting: Single academic affiliated community hospital. Patients or Participants: From June 2016 to June 2017, women undergoing hysterectomy for benign indications via a minimally invasive approach were approached to participate. Inclusion was limited to patients of high volume surgeons (more than 20 hysterectomies annually) within the generalist, MIGS, and urogynecology divisions. Women were excluded if known to have a contraindication to gabapentin, acetaminophen, or celecoxib use, or if their procedure was converted to laparotomy for any indication. Interventions: N/A Measurements and Main Results: A total of 109 women had data at 2 weeks postoperative to be analyzed for cohort analysis. The median oral narcotic requirement was 40 morphine milligram equivalents [MME] (interquartile range 0 − 96). Patients undergoing surgery with MIGS providers required less postoperative narcotics than those with a generalist trained surgeon (15 MME versus 75 MME, p = 0.007). Younger age and prior laparoscopic surgery were also found to be associated with high narcotic utilization after benign hysterectomy. Conclusion: Typical oral narcotic requirements after benign minimally invasive hysterectomy are minimal with median use equivalent to approximately five tablets of oxycodone (5 milligrams).
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 Open Communications 27: Endometriosis (4:10 PM − 5:10 PM) 4:17 PM Superficial Endometriosis can be Seen on Ultrasound: A Pilot Application of Saline-Infusion Sonopodography Leonardi M,1,2,* Espada M,1 Stamatopoulos N,1 Vanza K,1 Condous G1,2. 1 Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney, NSW, Australia; 2Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia *Corresponding author. Study Objective: Saline-infusion sonoPODography (SPG) is a novel ultrasound procedure that involves introducing fluid into the pouch of Douglas (POD) via the uterus and tubes to create an acoustic window and enhanced contrast between tissues in the posterior compartment. We aim to demonstrate that SPG has utility in diagnosing superficial endometriosis (SE) in a non-invasive fashion. Design: Prospective diagnostic accuracy study. Setting: Tertiary healthcare center in Sydney, Australia from September 2018-March 2019. Patients or Participants: Patients with symptoms of endometriosis planned for laparoscopy were recruited. Interventions: SPG was done intra-operatively. Measurements and Main Results: Laparoscopy was initiated to ascertain a reference standard visual diagnosis of endometriosis and to suction free fluid from the pelvis. The single SPG operator was blinded to this part of surgery. If fluid collected in the POD, SE of the posterior compartment was evaluated and compared to laparoscopic findings. SE on TVS was defined relative to peritoneal surfaces: 1) superficial hypoechoic areas, 2) hyperechoic projections, 3) cystic areas, 4) pockets of fluid, 5) filmy, irregular adhesions. 15/19 patients underwent successful SPG. Prevalence of overall endometriosis was 15/19 (79%); deep endometriosis (DE) 5/19 (26%); ovarian endometriomas 3/19 (16%); POD obliteration 2/19 (11%); SE 14/19 (74%). SPG diagnostic accuracy results are depicted in Table 1. Table 1.
Accuracy Prevalence Sensitivity Specificity Positive predictive value Negative predictive value Positive likelihood ratio Negative likelihood ratio
SE
POD SE
73% 80% 67% 100% 100% 43% N/A 0.33
90% 90% 89% 100% 100% 50% N/A 0.11
Conclusion: SPG was successfully completed in the majority of patients. In those without advanced endometriosis (i.e. POD obliteration), SPG is even more achievable and provides a reasonable sensitivity for overall SE and very good sensitivity for POD SE, which is the second most common site of SE. At present, SPG needs to be further evaluated but offers hope for a novel non-invasive diagnostic tool for SE.
Open Communications 27: Endometriosis (4:10 PM − 5:10 PM) 4:24 PM The Role of Shaving Technique in the Treatment of Recto-Vaginal Endometriosis