- Email: [email protected]
Laparoscopic-Assisted Hysteroscopic Resection of Interstitial Ectopic Pregnancy
S2
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201 ultrasound had a sensitivity of 96%, specificity of 58%, PPV of 94.4%, NPV of 66.6% and accuracy of 91.5%, while hysteroscopy had a sensitivity of 91.8%, specificity of 76.6%, PPV of 96%, NPV of 60.5% and accuracy of 89.7%. In postmenopausal women, ultrasound had a sensitivity of 99%, specificity of 19%, PPV of 96.1%, NPV of 50% and accuracy of 95.3% and hysteroscopy had a sensitivity of 96.7%, specificity of 86.9%, PPV of 99.2%, NPV of 58.8% and accuracy of 96.2%. Conclusion: Ultrasound is an effective method for the diagnosis of endometrial disease especially in postmenopausal women.
4
Plenary 1 – Hysteroscopy (11:00 AM - 12:00 PM) 11:30 AM – GROUP B
The measurement of the area of the defect permitted to classify isthmoceles in 3 grades: 1st grade < 15 mm2, 2nd grade between 16-24 mm2 and 3rd grade > 25 mm2. We found seven 1st grade isthmoceles, six 2nd grade, nineteen 3rd grade. In 24 cases the procedure was performed using a bipolar resectoscope loop, and in 8 patients using bipolar 5Fr electrode, we found no differences between this two techniques. All the patients discharged the same day of the surgery. We had no complications. Follow up was performed one and two months after the surgery. In all cases the abdominal pain had disappeared in the first month after the surgery. In 87.5% of the patients AUB was resolved within the first month, 96.8% in the second month and one needed a second surgery to eliminate the symptoms. Symptoms
AUB Abdominal pain
Symptoms before surgery
1 month after surgery
2 month after surgery
100% (32) 40.6% (13)
12.5% (4) 0
3.1% (1) 0
Conclusion: Hysteroscopic correction of symptomatic isthmoceles seems to be a safe and effective technique for those patients who present AUB and pelvic pain due to the cesarean scar defect.
3
Plenary 1 – Hysteroscopy (11:00 AM - 12:00 PM) 11:20 AM – GROUP A
Comparison between Transvaginal Ultrasound and Hysteroscopy for Endometrial Assessment Oliveira Brito LG, Pini P, Benetti-Pinto CL, Yela DA. Gynecology and Obstetrics, State University of Campinas, Campinas, SP, Brazil Study Objective: To evaluate whether transvaginal ultrasound is an effective method for diagnosis of endometrial alterations, in comparison to hysteroscopy. Design: Retrospective study. Setting: Tertiary, academic hospital. Patients: Seven hundred and fifty-four women were evaluated (256 reproductive-aged women, 498 menopausal women). Intervention: None. Measurements and Main Results: All women had undergone hysteroscopy from January 2011 to December 2013 due to ultrasound findings suggestive of endometrial alterations and/or abnormal bleeding. For statistical analysis, the mean and standard deviation of variables in both groups were used and accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ultrasound and hysteroscopy of endometrial lesions were calculated. Histopathology remains the gold standard. Results: For the detection of endometrial disease in reproductive-aged women,
Pain as an Independent Risk Factor for Failed Second Generation Endometrial Ablation Cramer MS, Klebanoff JS, Hoffman M. Obstetrics, and Gynecology, Christiana Care Health System, Newark, Delaware Study Objective: To determine if pain, as an indication for second generation endometrial ablation, is an independent risk factor for failure. Design: Retrospective cohort study. Setting: Academic affiliated community hospital. Patients: Women undergoing second-generation endometrial ablation for benign indications. Intervention: Women who underwent Radiofrequency Ablation (RFA), Hydrothermablation (HTA), or Uterine Balloon Ablation (UBA) performed between January 2003 and December 2015. Measurements and Main Results: 5,906 women were identified who underwent endometrial ablation at a single institution. Device distribution was as follows: 3,740 RFA (63.3%), 1,838 HTA (31.1%), and 328 balloon ablations (5.6%). Failure was defined as the need for hysterectomy following ablation. The primary outcome of interest was the incidence of failed second generation endometrial ablation when the original indication was related to pain. Of the 5,906 ablations, 439 (7.4%) were done for an indication related to pain (pelvic pain, dysmenorrhea, dyspareunia, lower abdominal pain, endometriosis, and adenomyosis). Pain as an indication for endometrial ablation, compared with all other indications, was a significant risk factor for failed ablation (20.1% failure rate vs. 15.4%, p = 0.01). Consistent with previous studies, women who underwent ablation at an older age were less likely to fail, which holds true even when the indication for ablation is related to pain (OR 0.96, 95% CI 0.95-0.97). Women who underwent ablation for pain with RFA were more likely to fail than women who underwent ablation for pain with HTA or UBA (OR 1.4, 95% CI 1.0-2.0). Conclusion: Pain as an indication for second generation endometrial ablation is an independent risk factor for failure. Consistent with previous studies younger age was a significant risk factor for hysterectomy following endometrial ablation. RFA used for indication of pain was also a significant risk factor for failure.
5
Plenary 1 – Hysteroscopy (11:00 AM - 12:00 PM) 11:40 AM – GROUP B
Laparoscopic-Assisted Hysteroscopic Resection of Interstitial Ectopic Pregnancy Vilkins AL, Awosogba T, Hendessi P, Noel N. Obstetrics & Gynecology, Boston Medical Center, Boston, Massachusetts This video presents a case in which an interstitial ectopic pregnancy was successfully treated with hysteroscopic resection. Due to the overlying thin myometrial layer and vascular anatomy associated with this location, this was performed under direct laparoscopic visualization. As the pregnancy was resected, electrocautery could be seen illuminating through the thin uterine
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201
S3
wall when viewed laparoscopically. This dual set up allowed for immediate laparoscopic treatment of possible complications including uterine perforation or hemorrhage. This technique allowed the patient a shorter recovery time than the traditional wedge resection, as well as allowed her the opportunity to be a candidate for vaginal delivery in future pregnancies. With the use of still images and labels, the purpose of the video is to guide the viewer through an alternate possible management of an interstitial ectopic pregnancy and the anatomical knowledge required to surgically complete a similar case.
6
Plenary 1 – Hysteroscopy (11:00 AM - 12:00 PM) 11:50 AM – GROUP B
Operative Hysteroscopy with an IUD in Place Wright KN, Vogell A. Gynecology, Lahey Hospital and Medical Center, Burlington, Massachusetts We present two cases of operative hysteroscopy where an intrauterine device (IUD) was left in place. In the first case, a patient undergoing hysteroscopic sterilization by Essure presented with a Paragard IUD in place for 5 years. We opted to leave the IUD in place for the coil placement so that she would not have a break in contraception while waiting for her threemonth hysterosalpingogram to confirm tubal occlusion. In the second case, a patient undergoing hysteroscopic myomectomy presented with a Mirena IUD in place for one year. We decided to leave the IUD in place to provide endometrial suppression to optimize visualization for the procedure. Afterwards, the IUD will continue to provide menstrual control. Leaving an IUD in place during operative hysteroscopy is feasible and cost-effective in these two situations.
Regarding 30-day morbidity, we observed 4 postoperative complications that were managed conservatively, including fever (n = 3) and postoperative ileus (n = 1). No severe (grade 3 or more) complication occurred among patients having risk-reduction surgery. Only presence of occult cancer correlated with an increased risk of developing postoperative complications (p = 0.02); basically, due to the adjunctive staging procedures needed. Conclusion: Minimally invasive risk-reducing surgery is a safe and effective strategy to manage BRCA mutation carriers. Patients should have to be counseled about the high prevalence of undiagnosed cancers observed at the time of surgery.
8
Plenary 2 – Oncology (12:10 PM - 1:10 PM) 12:20 PM – GROUP A
TUESDAY, NOVEMBER 14, 2017
7
Plenary 2 – Oncology (12:10 PM - 1:10 PM) 12:10 PM – GROUP A
A Prospective Study on the Risk of Occult Malignancies and 30-Day Morbidity in Women Undergoing Miniamlly Invasive Risk-Reducing Surgery Bogani G, Martinelli F, Ditto A, Signorelli M, Chiappa V, Leone Roberti Maggiore U, Lorusso D, Raspagliesi F. National Cancer Institute, Milan, Italy Study Objective: Assessing the Risk Occult Cancers and 30-day Morbidity in Women Undergoing Risk-Reducing Surgery: A prospective experience. Design: Prospective study (Canadian Task Force classification II-1). Setting: Gynecologic oncology referral center. Patients: BRCA mutation carriers and BRCAX patients (those with strong family history of breast and ovarian cancer). Intervention: Minimally invasive risk-reduction surgery (including bilateral salpingo-oophorectomy with or without hysterectomy). Measurements and Main Results: Overall, 85 women had risk-reducing surgery: 30 (35%) and 55 (75%) women had hysterectomy plus bilateral salpingo-oophorectomy (BSO) and BSO alone, respectively. Overall, 6 (7%) patients were diagnosed with undiagnosed cancers: three early stage ovarian / fallopian tube cancer, two advanced stage ovarian cancer (stage IIIA and IIIB) and one serous endometrial carcinoma. Additionally, 3 (3.6%) patients had incidental diagnosis of serous tubal intraepithelial carcinoma (STIC). A nomogram of predicting factors for the risk of having occult malignancies was built.
Do Fibroids Reduce the Likelihood of Unanticipated Malignancy? Alvi FA, Glaser LM, Tolentino J, Chaudhari A, Milad M, Tsai S. Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois Study Objective: To compare the likelihood of unanticipated malignancy for patients with and without leiomyomata undergoing hysterectomy or myomectomy for benign indications. Design: Retrospective case-control study. Setting: Urban, academic tertiary care center. Patients: All patients undergoing hysterectomy or myomectomy for benign indications between January 1, 2010 and December 31, 2014. Intervention: Charts were reviewed for relevant demographic, clinical, and pathologic data. Measurements and Main Results: A total of 1,569 hysterectomies or myomectomies were included after excluding patients with a known malignant or pre-malignant preoperative condition. Patients with adnexal masses were also included if a separate indication for hysterectomy or myomectomy was reported. We found a total of 30 patients with a confirmed gynecologic malignancy or “borderline” tumor, defined as those not meeting criteria for benign or malignant, including 10 versus 20 patients with and without leiomyoma, respectively. Malignant and borderline tumors in the leiomyoma group included 3 leiomyosarcomas (LMS), 2 endometrioid adenocarcinomas, 2 smooth muscle tumors of uncertain malignant potential (STUMP), 1 endometrial stromal sarcoma (ESS), 1 granulosa tumor, and 1 atypical leiomyoma. None of these specimens were morcellated. The rate of leiomyosarcoma with a preoperative indication of benign symptomatic leiomyoma was 0.26%. A surgical indication of symptomatic leiomyoma was less likely to be associated with a diagnosis of malignancy (OR 0.35; 95% CI, 0.16-0.75; p < .05). When pre-operative uterine size was 15 to 20 weeks, the odds of malignancy were reduced in patients with leiomyoma (OR 0.21; 95% CI, 0.44-5.68; p < .05).
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201 ultrasound had a sensitivity of 96%, specificity of 58%, PPV of 94.4%, NPV of 66.6% and accuracy of 91.5%, while hysteroscopy had a sensitivity of 91.8%, specificity of 76.6%, PPV of 96%, NPV of 60.5% and accuracy of 89.7%. In postmenopausal women, ultrasound had a sensitivity of 99%, specificity of 19%, PPV of 96.1%, NPV of 50% and accuracy of 95.3% and hysteroscopy had a sensitivity of 96.7%, specificity of 86.9%, PPV of 99.2%, NPV of 58.8% and accuracy of 96.2%. Conclusion: Ultrasound is an effective method for the diagnosis of endometrial disease especially in postmenopausal women.
4
Plenary 1 – Hysteroscopy (11:00 AM - 12:00 PM) 11:30 AM – GROUP B
The measurement of the area of the defect permitted to classify isthmoceles in 3 grades: 1st grade < 15 mm2, 2nd grade between 16-24 mm2 and 3rd grade > 25 mm2. We found seven 1st grade isthmoceles, six 2nd grade, nineteen 3rd grade. In 24 cases the procedure was performed using a bipolar resectoscope loop, and in 8 patients using bipolar 5Fr electrode, we found no differences between this two techniques. All the patients discharged the same day of the surgery. We had no complications. Follow up was performed one and two months after the surgery. In all cases the abdominal pain had disappeared in the first month after the surgery. In 87.5% of the patients AUB was resolved within the first month, 96.8% in the second month and one needed a second surgery to eliminate the symptoms. Symptoms
AUB Abdominal pain
Symptoms before surgery
1 month after surgery
2 month after surgery
100% (32) 40.6% (13)
12.5% (4) 0
3.1% (1) 0
Conclusion: Hysteroscopic correction of symptomatic isthmoceles seems to be a safe and effective technique for those patients who present AUB and pelvic pain due to the cesarean scar defect.
3
Plenary 1 – Hysteroscopy (11:00 AM - 12:00 PM) 11:20 AM – GROUP A
Comparison between Transvaginal Ultrasound and Hysteroscopy for Endometrial Assessment Oliveira Brito LG, Pini P, Benetti-Pinto CL, Yela DA. Gynecology and Obstetrics, State University of Campinas, Campinas, SP, Brazil Study Objective: To evaluate whether transvaginal ultrasound is an effective method for diagnosis of endometrial alterations, in comparison to hysteroscopy. Design: Retrospective study. Setting: Tertiary, academic hospital. Patients: Seven hundred and fifty-four women were evaluated (256 reproductive-aged women, 498 menopausal women). Intervention: None. Measurements and Main Results: All women had undergone hysteroscopy from January 2011 to December 2013 due to ultrasound findings suggestive of endometrial alterations and/or abnormal bleeding. For statistical analysis, the mean and standard deviation of variables in both groups were used and accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ultrasound and hysteroscopy of endometrial lesions were calculated. Histopathology remains the gold standard. Results: For the detection of endometrial disease in reproductive-aged women,
Pain as an Independent Risk Factor for Failed Second Generation Endometrial Ablation Cramer MS, Klebanoff JS, Hoffman M. Obstetrics, and Gynecology, Christiana Care Health System, Newark, Delaware Study Objective: To determine if pain, as an indication for second generation endometrial ablation, is an independent risk factor for failure. Design: Retrospective cohort study. Setting: Academic affiliated community hospital. Patients: Women undergoing second-generation endometrial ablation for benign indications. Intervention: Women who underwent Radiofrequency Ablation (RFA), Hydrothermablation (HTA), or Uterine Balloon Ablation (UBA) performed between January 2003 and December 2015. Measurements and Main Results: 5,906 women were identified who underwent endometrial ablation at a single institution. Device distribution was as follows: 3,740 RFA (63.3%), 1,838 HTA (31.1%), and 328 balloon ablations (5.6%). Failure was defined as the need for hysterectomy following ablation. The primary outcome of interest was the incidence of failed second generation endometrial ablation when the original indication was related to pain. Of the 5,906 ablations, 439 (7.4%) were done for an indication related to pain (pelvic pain, dysmenorrhea, dyspareunia, lower abdominal pain, endometriosis, and adenomyosis). Pain as an indication for endometrial ablation, compared with all other indications, was a significant risk factor for failed ablation (20.1% failure rate vs. 15.4%, p = 0.01). Consistent with previous studies, women who underwent ablation at an older age were less likely to fail, which holds true even when the indication for ablation is related to pain (OR 0.96, 95% CI 0.95-0.97). Women who underwent ablation for pain with RFA were more likely to fail than women who underwent ablation for pain with HTA or UBA (OR 1.4, 95% CI 1.0-2.0). Conclusion: Pain as an indication for second generation endometrial ablation is an independent risk factor for failure. Consistent with previous studies younger age was a significant risk factor for hysterectomy following endometrial ablation. RFA used for indication of pain was also a significant risk factor for failure.
5
Plenary 1 – Hysteroscopy (11:00 AM - 12:00 PM) 11:40 AM – GROUP B
Laparoscopic-Assisted Hysteroscopic Resection of Interstitial Ectopic Pregnancy Vilkins AL, Awosogba T, Hendessi P, Noel N. Obstetrics & Gynecology, Boston Medical Center, Boston, Massachusetts This video presents a case in which an interstitial ectopic pregnancy was successfully treated with hysteroscopic resection. Due to the overlying thin myometrial layer and vascular anatomy associated with this location, this was performed under direct laparoscopic visualization. As the pregnancy was resected, electrocautery could be seen illuminating through the thin uterine
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201
S3
wall when viewed laparoscopically. This dual set up allowed for immediate laparoscopic treatment of possible complications including uterine perforation or hemorrhage. This technique allowed the patient a shorter recovery time than the traditional wedge resection, as well as allowed her the opportunity to be a candidate for vaginal delivery in future pregnancies. With the use of still images and labels, the purpose of the video is to guide the viewer through an alternate possible management of an interstitial ectopic pregnancy and the anatomical knowledge required to surgically complete a similar case.
6
Plenary 1 – Hysteroscopy (11:00 AM - 12:00 PM) 11:50 AM – GROUP B
Operative Hysteroscopy with an IUD in Place Wright KN, Vogell A. Gynecology, Lahey Hospital and Medical Center, Burlington, Massachusetts We present two cases of operative hysteroscopy where an intrauterine device (IUD) was left in place. In the first case, a patient undergoing hysteroscopic sterilization by Essure presented with a Paragard IUD in place for 5 years. We opted to leave the IUD in place for the coil placement so that she would not have a break in contraception while waiting for her threemonth hysterosalpingogram to confirm tubal occlusion. In the second case, a patient undergoing hysteroscopic myomectomy presented with a Mirena IUD in place for one year. We decided to leave the IUD in place to provide endometrial suppression to optimize visualization for the procedure. Afterwards, the IUD will continue to provide menstrual control. Leaving an IUD in place during operative hysteroscopy is feasible and cost-effective in these two situations.
Regarding 30-day morbidity, we observed 4 postoperative complications that were managed conservatively, including fever (n = 3) and postoperative ileus (n = 1). No severe (grade 3 or more) complication occurred among patients having risk-reduction surgery. Only presence of occult cancer correlated with an increased risk of developing postoperative complications (p = 0.02); basically, due to the adjunctive staging procedures needed. Conclusion: Minimally invasive risk-reducing surgery is a safe and effective strategy to manage BRCA mutation carriers. Patients should have to be counseled about the high prevalence of undiagnosed cancers observed at the time of surgery.
8
Plenary 2 – Oncology (12:10 PM - 1:10 PM) 12:20 PM – GROUP A
TUESDAY, NOVEMBER 14, 2017
7
Plenary 2 – Oncology (12:10 PM - 1:10 PM) 12:10 PM – GROUP A
A Prospective Study on the Risk of Occult Malignancies and 30-Day Morbidity in Women Undergoing Miniamlly Invasive Risk-Reducing Surgery Bogani G, Martinelli F, Ditto A, Signorelli M, Chiappa V, Leone Roberti Maggiore U, Lorusso D, Raspagliesi F. National Cancer Institute, Milan, Italy Study Objective: Assessing the Risk Occult Cancers and 30-day Morbidity in Women Undergoing Risk-Reducing Surgery: A prospective experience. Design: Prospective study (Canadian Task Force classification II-1). Setting: Gynecologic oncology referral center. Patients: BRCA mutation carriers and BRCAX patients (those with strong family history of breast and ovarian cancer). Intervention: Minimally invasive risk-reduction surgery (including bilateral salpingo-oophorectomy with or without hysterectomy). Measurements and Main Results: Overall, 85 women had risk-reducing surgery: 30 (35%) and 55 (75%) women had hysterectomy plus bilateral salpingo-oophorectomy (BSO) and BSO alone, respectively. Overall, 6 (7%) patients were diagnosed with undiagnosed cancers: three early stage ovarian / fallopian tube cancer, two advanced stage ovarian cancer (stage IIIA and IIIB) and one serous endometrial carcinoma. Additionally, 3 (3.6%) patients had incidental diagnosis of serous tubal intraepithelial carcinoma (STIC). A nomogram of predicting factors for the risk of having occult malignancies was built.
Do Fibroids Reduce the Likelihood of Unanticipated Malignancy? Alvi FA, Glaser LM, Tolentino J, Chaudhari A, Milad M, Tsai S. Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois Study Objective: To compare the likelihood of unanticipated malignancy for patients with and without leiomyomata undergoing hysterectomy or myomectomy for benign indications. Design: Retrospective case-control study. Setting: Urban, academic tertiary care center. Patients: All patients undergoing hysterectomy or myomectomy for benign indications between January 1, 2010 and December 31, 2014. Intervention: Charts were reviewed for relevant demographic, clinical, and pathologic data. Measurements and Main Results: A total of 1,569 hysterectomies or myomectomies were included after excluding patients with a known malignant or pre-malignant preoperative condition. Patients with adnexal masses were also included if a separate indication for hysterectomy or myomectomy was reported. We found a total of 30 patients with a confirmed gynecologic malignancy or “borderline” tumor, defined as those not meeting criteria for benign or malignant, including 10 versus 20 patients with and without leiomyoma, respectively. Malignant and borderline tumors in the leiomyoma group included 3 leiomyosarcomas (LMS), 2 endometrioid adenocarcinomas, 2 smooth muscle tumors of uncertain malignant potential (STUMP), 1 endometrial stromal sarcoma (ESS), 1 granulosa tumor, and 1 atypical leiomyoma. None of these specimens were morcellated. The rate of leiomyosarcoma with a preoperative indication of benign symptomatic leiomyoma was 0.26%. A surgical indication of symptomatic leiomyoma was less likely to be associated with a diagnosis of malignancy (OR 0.35; 95% CI, 0.16-0.75; p < .05). When pre-operative uterine size was 15 to 20 weeks, the odds of malignancy were reduced in patients with leiomyoma (OR 0.21; 95% CI, 0.44-5.68; p < .05).