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Reduced port robotic myomectomy: feasibility and safety
immune-response escape. On the other hand, neutralization of PD-L1 might be a novel anti-fibroid immunotherapeutic strategy. Further testing of such strategy in appropriate fibroid animal models is underway in our laboratory. P-259 Tuesday, October 31, 2017 INFLUENCE OF MYOMECTOMY IN PRECONCEPTION PERIOD ON THE COURSE AND OUTCOME OF UPCOMING PREGNANCY IN NULLIPAROUS WOMEN. V. Solskyy,a S. Solskyy.b aInsitute of Pediatrics, Obstetrics and Gynecology Academy of Medical Sciences of Ukraine, Kiev, Ukraine; bChair of OB/GYN #2, National Medical University, Kiev, Ukraine. OBJECTIVE: Taking into consideration strong tendency to increase in the age of primiparous women, the question about tactics to be used in management of women with leiomyoma (especially those of relatively big size) becoming extremely important. Thus, our main objective was to assess influence of myomectomy on the course of upcoming pregnancy in nulliparous women of reproductive age with uterine fibroids. DESIGN: Prospective comparative study. MATERIALS AND METHODS: 53 nulliparous women with leiomyomas (with big size of myomas - 6-12 cm) at the preconception preparation stage were included in the study. All of them were offered myomectomy in combination with GnRH-agonists. 37 patients did agree to suggested treatment option (Group I) and 16 rejected proposed treatment (Group II). Women in Group I were prescribed with GnRH-agonists (triptorelin 3,75 mg) for 4-6 months, followed by myomectomy. In the next 2-3 years after start of the study all women from both groups became pregnant. The course of pregnancy and delivery in both groups were analyzed. RESULTS: Prescription of GnRH-agonists in Group I allowed to decrease volume of fibroids on average by 42,4% (variation from 12,1% to 83,6%) by the time of surgery. Spontaneous pregnancy occurred in 75,67% of women in the Group I and in 81,25% - in Group II. Assisted reproductive technologies (ART) were used in 24,33% and 18,75% of cases respectively. Threatened miscarriage in the first trimester of pregnancy was observed in 10,8% of cases in Group I and in 37,5% of cases in Group II. Miscarriage occurred in 2,7% and 12,5% of cases respectively. Preterm delivery was registered in 2 (5,4%) women in Group I and 3 (18,75%) of women in Group II. Intrauterine growth restriction (IUGR) was diagnosed in 5,4% of cases in Group I and in 12,5% in Group II. 2,7% of women in Group I and 18,75% in Group II did have malpresentation of the fetus. Frequency of Caesarian section was 43,2% in Group I vs 81,25% in Group II (average Caesarian section rate in the clinic is 19,9%). Substantial growth in leiomyoma size was registered during pregnancy in 6 (37,5%) cases in Group II. By the time of delivery they were 18 to 22 cm in size. Myomectomy was performed in all women from Group II who underwent C-section, while in Group I only 2 women did require such intervention. On top of this 2 (12,5%) women from Group II did have myomectomy at W16 and W23 of pregnancy due to fibroids trophic disorders (they both did then have on-time delivery). CONCLUSIONS: It is reasonable to prescribe GnRH-agonists prior to myomectomy in preconception period in order to reduce fibroids volume and limit the surgery burden - in the presence of big size fibroids, myomectomy is an effective method of prophylactics of obstetric complications in upcoming pregnancy.
P-260 Tuesday, October 31, 2017 PREDICTORS OF POST-OPERATIVE ADMISSION FOR MINIMALLY INVASIVE MYOMECTOMIES. H. Young,a E. D. Abi Khalil,a P. Tyan,a D. E. Park,b M. V. Vargas,c C. Q. Marfori,a G. Moawad.a aObstetrics and Gynecology, The George Washington University, Washington, DC; bEpidemiology and Biostatistics, The George Washington University, Washington, DC; cDepartment of Obstetrics and Gynecology, Division, George Washington University Medical Center, Washington, DC. OBJECTIVE: To identify predictors of post-operative admission after minimally invasive myomectomies. DESIGN: Single-center, retrospective cohort study including patients receiving a minimally invasive myomectomy at an urban, academic university. MATERIALS AND METHODS: Pre-operative and operative characteristics, as well as intraoperative and post-operative complications were collected. T-test was used to compare characteristics of cases with overnight
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stay versus cases with same day discharge. Logistic regression analysis was performed to ascertain further clinical predictors of overnight stay. RESULTS: 249 patients underwent minimally invasive myomectomies. 120 (48%) were admitted for at least one overnight stay while 129 (52%) were discharged the same day. Overnight stay compared to same day discharge was associated significantly with older age (38 vs. 35 years), lower pre-op hematocrit (36% vs. 38%), prior cesarean section (12% vs. 2%) or myomectomy (12% vs. 5%), single site procedures (30% vs. 10.1%), prolonged operative time (185 vs. 139 min), and intraoperative or post-operative complication including blood loss > 1000ml (7.5% vs. 0%). Logistic regression analysis found that 5% decrease in hematocrit, single site operation, 30 min increase in operative time are significantly predictive of any overnight stay. CONCLUSIONS: Perioperative factors such as lower hematocrit as well as intraoperative factors such as single site operations and prolonged operative time are predictive of overnight hospital stay.
REPRODUCTIVE SURGERY P-261 Tuesday, October 31, 2017 REDUCED PORT ROBOTIC MYOMECTOMY: FEASIP. Tyan,a BILITY AND SAFETY. H. Young,a a b a E. Abi Khalil, M. V. Vargas, C. Q. Marfori, G. Moawad.c a Obstetrics and Gynecology, The George Washington University, Washington, DC; bDepartment of Obstetrics and Gynecology, Division, George Washington University Medical Center, Washington, DC; cThe George Washington University, Washington, DC. OBJECTIVE: To assess optimal candidates for a three-port robotic-assisted myomectomy. DESIGN: A retrospective cohort of patients undergoing robotic-assisted myomectomy by fellowship trained minimally invasive gynecologists. MATERIALS AND METHODS: A total of 213 consecutive patients undergoing robotic- assisted myoemtomy between 2012 and 2016 were selected. Procedure requiring R 4 ports were labeled as‘‘multi-port’’; surgeries done only through 3 ports were labeled as ‘‘reduced port’’. RESULTS: The two populations were homogeneous for baseline demographics, surgical history and concomitant procedures at the time of myomectomy. The multiport group had larger tumor burden evidenced by mean number of fibroid removed (Multiport 6.1 vs. Reduced 3.7, p <0.01) mean weight of fibroid removed (Multiport 401.7g vs. Reduced 268.2g, p¼0.01).To assess the feasibility of the reduced port myomectomy, appropriate regression models were used for the following 5 outcomes: intraoperative and postoperative complications, estimated blood loss, operative time and length of hospital stay. Based on the regression analysis, the total surgery time of reduced port myomectomy is on average 38.86 (95% CI: 18.7458.98) minutes shorter than the multi-port approach and the estimated blood loss in reduced myomectomy is in average 135.85 (95% CI: 10.22-261.47) mL less than the traditional approach. No significant difference for intraoperative or postoperative complication between traditional versus reduced robotic myomectomy. However, length of hospital stay for reduced port myomectomy was on average only 39% as long as those who underwent a multiport myomectomy (p¼0.04), reinforcing the safety of this procedure. CONCLUSIONS: In properly selected patients based on tumor burden, the three-port robotic myomectomy is an effective substitute for the multi-port approach with comparable safety profiles and better cosmetic results. P-262 Tuesday, October 31, 2017 EFFECTS OF MYOMAS AND MYOMECTOMY ON ASSISTED REPRODUCTIVE TECHNOLOGY OUTCOMES. C. N. Fortin, C. Hur, M. Radeva, T. Falcone. Obstetrics, Gynecology, and Women’s Health Institute, Cleveland Clinic, Cleveland, OH. OBJECTIVE: The current evidence regarding the impact of fibroid removal on assisted reproductive technology (ART) outcomes is inconclusive. The primary aim of this study is to determine the effects of fibroids, and their removal, on ART outcomes. DESIGN: Single institution retrospective cohort study of infertility patients who underwent a myomectomy prior to initiation of either in vitro fertilization (IVF) or intrauterine insemination (IUI) between August 2006 and October 2015.
Vol. 108, No. 3, Supplement, September 2017
P-260 Tuesday, October 31, 2017 PREDICTORS OF POST-OPERATIVE ADMISSION FOR MINIMALLY INVASIVE MYOMECTOMIES. H. Young,a E. D. Abi Khalil,a P. Tyan,a D. E. Park,b M. V. Vargas,c C. Q. Marfori,a G. Moawad.a aObstetrics and Gynecology, The George Washington University, Washington, DC; bEpidemiology and Biostatistics, The George Washington University, Washington, DC; cDepartment of Obstetrics and Gynecology, Division, George Washington University Medical Center, Washington, DC. OBJECTIVE: To identify predictors of post-operative admission after minimally invasive myomectomies. DESIGN: Single-center, retrospective cohort study including patients receiving a minimally invasive myomectomy at an urban, academic university. MATERIALS AND METHODS: Pre-operative and operative characteristics, as well as intraoperative and post-operative complications were collected. T-test was used to compare characteristics of cases with overnight
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ASRM Abstracts
stay versus cases with same day discharge. Logistic regression analysis was performed to ascertain further clinical predictors of overnight stay. RESULTS: 249 patients underwent minimally invasive myomectomies. 120 (48%) were admitted for at least one overnight stay while 129 (52%) were discharged the same day. Overnight stay compared to same day discharge was associated significantly with older age (38 vs. 35 years), lower pre-op hematocrit (36% vs. 38%), prior cesarean section (12% vs. 2%) or myomectomy (12% vs. 5%), single site procedures (30% vs. 10.1%), prolonged operative time (185 vs. 139 min), and intraoperative or post-operative complication including blood loss > 1000ml (7.5% vs. 0%). Logistic regression analysis found that 5% decrease in hematocrit, single site operation, 30 min increase in operative time are significantly predictive of any overnight stay. CONCLUSIONS: Perioperative factors such as lower hematocrit as well as intraoperative factors such as single site operations and prolonged operative time are predictive of overnight hospital stay.
REPRODUCTIVE SURGERY P-261 Tuesday, October 31, 2017 REDUCED PORT ROBOTIC MYOMECTOMY: FEASIP. Tyan,a BILITY AND SAFETY. H. Young,a a b a E. Abi Khalil, M. V. Vargas, C. Q. Marfori, G. Moawad.c a Obstetrics and Gynecology, The George Washington University, Washington, DC; bDepartment of Obstetrics and Gynecology, Division, George Washington University Medical Center, Washington, DC; cThe George Washington University, Washington, DC. OBJECTIVE: To assess optimal candidates for a three-port robotic-assisted myomectomy. DESIGN: A retrospective cohort of patients undergoing robotic-assisted myomectomy by fellowship trained minimally invasive gynecologists. MATERIALS AND METHODS: A total of 213 consecutive patients undergoing robotic- assisted myoemtomy between 2012 and 2016 were selected. Procedure requiring R 4 ports were labeled as‘‘multi-port’’; surgeries done only through 3 ports were labeled as ‘‘reduced port’’. RESULTS: The two populations were homogeneous for baseline demographics, surgical history and concomitant procedures at the time of myomectomy. The multiport group had larger tumor burden evidenced by mean number of fibroid removed (Multiport 6.1 vs. Reduced 3.7, p <0.01) mean weight of fibroid removed (Multiport 401.7g vs. Reduced 268.2g, p¼0.01).To assess the feasibility of the reduced port myomectomy, appropriate regression models were used for the following 5 outcomes: intraoperative and postoperative complications, estimated blood loss, operative time and length of hospital stay. Based on the regression analysis, the total surgery time of reduced port myomectomy is on average 38.86 (95% CI: 18.7458.98) minutes shorter than the multi-port approach and the estimated blood loss in reduced myomectomy is in average 135.85 (95% CI: 10.22-261.47) mL less than the traditional approach. No significant difference for intraoperative or postoperative complication between traditional versus reduced robotic myomectomy. However, length of hospital stay for reduced port myomectomy was on average only 39% as long as those who underwent a multiport myomectomy (p¼0.04), reinforcing the safety of this procedure. CONCLUSIONS: In properly selected patients based on tumor burden, the three-port robotic myomectomy is an effective substitute for the multi-port approach with comparable safety profiles and better cosmetic results. P-262 Tuesday, October 31, 2017 EFFECTS OF MYOMAS AND MYOMECTOMY ON ASSISTED REPRODUCTIVE TECHNOLOGY OUTCOMES. C. N. Fortin, C. Hur, M. Radeva, T. Falcone. Obstetrics, Gynecology, and Women’s Health Institute, Cleveland Clinic, Cleveland, OH. OBJECTIVE: The current evidence regarding the impact of fibroid removal on assisted reproductive technology (ART) outcomes is inconclusive. The primary aim of this study is to determine the effects of fibroids, and their removal, on ART outcomes. DESIGN: Single institution retrospective cohort study of infertility patients who underwent a myomectomy prior to initiation of either in vitro fertilization (IVF) or intrauterine insemination (IUI) between August 2006 and October 2015.
Vol. 108, No. 3, Supplement, September 2017