Laparoscopic Nerve Sparing Anatomical Radical Hysterectomy with Fascia Space Dissection Technique for Early Stage Cervical Cancer: Techniques, Application and Results

Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252 of myoma-myometrium cleavage plane identification, ease of myoma detachment, blood loss during fibroid detachment, myometrial blood loss after fibroid detachment, and myoma consistency. Inter-rater reliability was calculated and scores for UPA-treated patients were compared to those without medical pre-treatment. Measurements and Main Results: 50 myomectomy procedure videos were assessed. There was high agreement between reviewers for the total surgical experience score (intra-class correlation 0.97, p\0.01). Agreement for the six subscales of the tool ranged between 0.80 – 0.98. UPA pre-treatment was used in 25 procedures (50%) compared to 25 (50%) who received no pre-treatment. There was no difference in mean surgical experience score in the UPA group (13.5  2.9) compared to the group without pre-treatment (13.3  2.9), p=0.81. There was also no difference in subscale scores between the two groups. This study was powered to detect a 20% difference in scores between groups (power=0.8, alpha=0.05). Conclusion: The new scale of surgical experience at laparoscopic myomectomy had high inter-rater reliability. There was no difference in surgical experience for myomectomies pre-treated with UPA, compared to those without pre-treatment. 5

Plenary 1 - Laparoscopic Surgeries (11:00 AM - 12:00 PM) 11:40 AM – GROUP B

Laparoscopic Single Incision Supracervical Hysterectomy for Extremely Large Uterus with Bag Tissue Extraction Guan X, Wang Y, Gisseman J. Obstetrics & Gynecology, Baylor College of Medicine, Houston, Texas Background: Single-incision laparoscopic hysterectomy can be difficult because of longer surgery time, steep learning curve, and the need for articulated instruments, but is especially challenging in patients with a uterus larger than 20 cm. However, the advantages of single-site laparoscopic surgery may include less bleeding, infection, pain, and better cosmetic outcome. Objective: To describe the single incision laparoscopic technique with an articulated energy device for uterus larger than 20 cm. Clinical information: A 49 year-old G3P3 female with 24 weeks sized fibroid uterus requested supracervical hysterectomy presented with a 2year history of pelvic pain and menorrhagia. Interventions: Laparoscopic single incision supracervical hysterectomy with contained bag tissue extraction. Results: Rotating between the patient’s right and left side allows the surgeon to access the entire abdomen from a single umbilical port. Single incision laparascopic hysterectomy for larger than 20 cm uterus is not only possible, but leads to better outcomes. 6

Plenary 1 - Laparoscopic Surgeries (11:00 AM - 12:00 PM)

in 27 cases (1.04%). During the study period, no cases needed conversion to laparotomy to repair urinary tract complications. I will present some cases of urinary tract complications and explain how these complications were managed. Conclusions: It is most important that we strive to not cause urinary tract complications in the first place. However, when they do occur, appropriate treatment with manipulation can prevent conversion to laparotomy. 7

Urinary Tract Complications and Repair Strategies in Total Laparoscopic Hysterectomy at Kurashiki Medical Center Nakajima S, Andou M, Kanno K, Shirane A, Yanai S. Obstetrics and Gynecology, Kurashiki Medical Center, Kurashiki, Okayama, Japan Objectives: The aim of this study is to clarify cases with urinary tract injury during TLH, and to review strategies for repairing urinary tract complications. Methods: All 2604 women who underwent TLH in our department from January 2011 to December 2015 were included in this study. Results: The ureter was injured in 8 cases (0.31%), the bladder was perforated in 7 cases (0.27%), and the bladder muscle layer was injured

Plenary 2 - Oncology (12:10 PM - 1:10 PM) 12:10 PM – GROUP A

Practice Changes in Power Morcellation Among Gynecologic-Oncologists Since 2014 Mandelberger AH, Mathews S, Chuang L. Icahn School of Medicine at Mount Sinai, New York, New York Study Objective: To determine attitudes and practice changes among gynecologic oncologists since the 2014 FDA warning on uterine power morcellation. Design: Observational survey study. Setting: In response to media attention surrounding a few cases of disseminated uterine sarcoma after power morcellation in 2013, the FDA issued a statement in April 2014 discouraging use of power morcellation. Several institutions since have placed a moratorium on power morcellators. Patients: Members of the Society of yecologic Oncologists. Intervention: A 34-question survey was sent to all members of SGO. Questions included demographic information, questions regarding practices prior to the FDA warning, practice changes since the warning, institutional changes and regulation, and attitudes. Measurements and Main Results: 199 gyn-oncologists responded to the survey. 65.48% were male and 34.52% female. 47.74% reported they performed laparoscopic supracervical hysterectomies. Since the FDA warning, 12.5% decreased and 38.75% discontinued use of power morcellation. Factors most influential for decreased or discontinued use included patient refusal, FDA statement release and change of institutional policy. Men were more likely than women to decrease or discontinue use (58.46% vs 19.35%, p=.0015). There were no differences in change of use based on region of practice, years in practice, or institution type. 41% report they have changed their surgical technique to minimally invasive without use of power morcellation, and 20.54% report changing to laparotomy. Other changes included more rigorous consent process (38.67%), patient selection (37.5%), and perioperative evaluation (30.14%) with 20.54% report adding preoperative MRI. Conclusion: Although attitudes towards its use are divided, there seems to be an overall consensus that minimally invasive techniques can be sustained without the use of power morcellation. Many gynecologic oncologists continue its use and have made changes in patient selection, perioperative evaluation, and consent process, either by physician discretion or necessitated by institutional policy. 8

11:50 AM – GROUP B

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Plenary 2 - Oncology (12:10 PM - 1:10 PM) 12:20 PM – GROUP A

Laparoscopic Nerve Sparing Anatomical Radical Hysterectomy with Fascia Space Dissection Technique for Early Stage Cervical Cancer: Techniques, Application and Results Wang Y, Chen G, Xu H, Chen Y, Liang Z. Department of Obstetrics and Gynecology, Southwest Hospital, Third Military Medical University, Chongqing, China Study Objective: The objectives of this study were to describe our laparoscopic nerve-sparing anatomical radical hysterectomy (LNSARH) technique and to assess the feasibility and safety of the procedure, as well

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Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252

as its impact on voiding function. We introduce a fascia space dissection technique in order to preserve the pelvic nerve. Design: Data from patients were prospectively collected and compared. Setting: University teaching hospital. Patients: From October 2008 to November 2014, 245 consecutive patients with cervical cancer underwent laparoscopic radical hysterectomy (LRH) and pelvic lymphadenectomy. Intervention: With 118 woman undergoing LNSARH with fascia space dissection technique (LNSARH group) and 127 undergoing LRH (LRH group). Measurements and Main Results: Post-operative assessment of bladder function. The laparoscopic nerve-sparing anatomical radical hysterectomy procedure was completed successfully and was conducted safely in all of the patients. There were no conversions to open surgery in the two groups. The median operative duration in the LNSARH and the LRH groups were 163.52  34.47 min and 132.13  31.42 min, respectively. Blood loss was 142.12  62.38 ml and 187.69  68.63 ml, respectively. The time taken to obtain a post-void residual urine volume of less than 50 ml after removal of the urethral catheter was 7.42  2.35 d (5-18 d) in LNSRH group and was16.75  7.73 d (5-35 d) in LRH group (P \0.05). The bladder void function recovery to Grade 0-I was 76 (92.7%) for the LNSARH group and 59 (72.8%) for the LRH group. A mean follow-up of 52.3 (12-72) months was adhered to. The overall disease-free survival was 95.2% for Ia2, 89.5% for Ib1, and 84.5% for IIa1 respectively. Conclusion: The technique described in this preliminary study appears to be safe, feasible, and easy in our population, with satisfactory recovery of voiding function and oncological outcome. 9

Plenary 2 - Oncology (12:10 PM - 1:10 PM) 12:30 PM – GROUP A

Risk Reducing Surgery for Patients at High Risk of Gynecologic or Breast Cancer: Who, What, When, Where, Why, and How Hill AM, Azodi M. Obstetrics and Gynecology, Yale New Haven Health Bridgeport Hospital, Bridgeport, Connecticut Study Objective: Describe the surgical treatment of patients with elevated risk of breast or gynecologic cancer, including BRCA1/2, Lynch Syndrome, and women with breast cancer. Design: Review. Setting: Literature search. Patients: Women with high risk of gynecologic or breast cancer, including BRCA1/2 mutations, Lynch Syndrome, and patients with breast cancer. Intervention: Literature reviewed to formulate recommendations regarding risk reducing BSO, answering the questions ‘‘Who?’’ (Which patients benefit from prophylactic BSO), ‘‘What?’’ (Role of hysterectomy and staged salpingectomy before oophorectomy), ‘‘Where?’’ (Facilities and resources necessary), ‘‘When?’’ (Timing of surgery), ‘‘How?’’ (Surgical techniques and principles), and ‘‘Why?’’ (Evidence that risk reducing BSO is beneficial). Measurements and Main Results: Who? Women with BRCA1/2 (individualized care for variants of undetermined significance), Lynch Syndrome, and/or hormone receptor positive breast cancer. What? Salpingectomy with interval oophorectomy closer to menopause is acceptable. Hysterectomy for Lynch Syndrome and considered for BRCA and those with breast cancer. Where? Surgery should be performed in a facility with Gyn/Onc backup or by a Gyn-Oncologist. Pathologist must have expertise in processing specimens from high-risk patients to avoid missing occult malignancy. When? Society of Gynecologic Oncology recommends BSO between 35 and 40 years in patients with BRCA1/2 mutations. However, there is a role for fertility preservation in young women. How? Laparoscopy is standard, and single-port laparoscopy may be considered. Peritoneal lavage should be performed. Care should be taken to remove the entire fallopian tube, ovary, and IP ligament. Omental biopsy should be considered.

Why? Risk reducing BSO decreases the risk of ovarian and breast cancer as well as overall mortality in women with BRCA. BSO reduces mortality in breast cancer patients, especially premenopausal. Hormone therapy remains an option in women with BRCA mutations after risk reducing BSO. Conclusion: Bilateral salpingo-oophorectomy is a straightforward procedure, but a standardized approach and impeccable surgical technique are necessary in patients with elevated risk of ovarian cancer. 10

Plenary 2 - Oncology (12:10 PM - 1:10 PM) 12:40 PM – GROUP B

Laparoscopic Hysterectomy with Morcellation versus Abdominal Hysterectomy for Presumed Uterine Leiomyomata: An Updated Decision Analysis Siedhoff MT,1 Doll KM,2 Rutstein SE,2 Wheeler SB,2 Geller EJ,2 Wu JM,2 Clarke-Pearson DL.2 1Obstetrics & Gynecology, Minimally Invasive Gynecologic Surgery, Cedars-Sinai Medical Center, Los Angeles, California; 2Obstetrics & Gynecology, University of North Carolina, Chapel Hill, North Carolina Study Objective: To compare mortality associated with laparoscopic hysterectomy (LH) with morcellation to total abdominal hysterectomy (AH) for an enlarged uterus presumably due to leiomyomata, using updates from the literature following 2014 FDA statements. Design: Decision analytic model with 5-year time horizon. Setting: Women with an enlarged uterus presumed due to leiomyomata undergoing hysterectomy. Patients: Hypothetical cohort of 100,000 women undergoing hysterectomy in the United States. Intervention: LH with morcellation versus AH. Measurements and Main Results: We previously constructed a decision analysis, modeling LH with morcellation compared to AH.* Quality of life and nearly all clinical outcomes (transfusion, wound infection, venous thromboembolism, hernia) favored LH. Using data available in the literature prior to the 2014 FDA statements on morcellation, the risk of occult leiomyosarcoma was estimated at 0.0012. Assuming more deaths due to morcellation in the LH group, overall mortality was still higher in the AH group due to procedure-related mortality. We searched the literature for updated estimates on the risk of occult LMS during hysterectomy published following the 2014 FDA statements. The number of subjects ranged from 808 to 34,728 and LMS rates ranged from zero to 0.0032 (1:314). In total,127 cases of LMS were found among 103,892 surgeries for a weighted average of 0.0012. Thus, mortality still favored LH using an updated base-case estimate. This finding was robust in sensitivity analysis, varying the LMS and procedure death rates, with most scenarios favoring LH