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Robot Assisted Laparoscopic Hysterectomy with Fetus in-situ for Placenta Percreta in Second Trimester
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Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97
Conclusion: Minimally invasive abdominal cerclage is a safe alternative to laparotomy, when performed by a surgeon with appropriate training and technical skills, providing patients with improved surgical outcomes without impairing the obstetric outcomes.
Son MA,1,* Alagkiozidis I,2 Paiva C,1 Elfeky A1. 1Minimally Invasive Gynecology Surgery Department, Maimonides Medical Center, Brooklyn, NY; 2Gynecologic Oncology, Maimonides Medical Center, Brooklyn, NY *Corresponding author.
Open Communications 15: Reproductive (11:00 AM − 12:00 PM)
Video Objective: To describe a technique of robotic-assisted laparoscopic hysterectomy of a second trimester gravid uterus with placenta percreta Setting: A step-by-step explanation of the surgery using video (instructive video). Interventions: In this video, we describe the surgical approach opted for this patient desiring pregnancy termination and no desire for future fertility. Minimally invasive surgery was recommended considering decreased blood loss, postoperative pain and hospital stay. Also considering her prior surgical history, the laparoscopic approach would offer better visualization for lysis of adhesions. Intraoperatively, the uterus was found to have adhesions anteriorly to the abdominal wall as well as bladder adhesions to the lower uterine segment. Generalized increased vascularity was observed. The blood supply from the utero-ovarian and the uterine vessels were tackled prior to releasing the adhesion of the anterior wall of the uterus to the anterior abdominal wall. The lower uterine segment was adherent to the bladder, thereby the lateral approach was used to enter the paravesicular space to create a bladder flap to mobilize the bladder inferiorly. An End to End (EEA) sizer was used to identify the colpotomy site. The cardinal ligament were coagulated and transected to lateralize the paracervical tissue. The colpotomy was then performed and the specimen was then exteriorized intact vaginally. The vaginal cuff was then closed in a continuous fashion using 0-VLoc. Estimate blood loss was 300mL. Postoperatively, patient was hemodynamically stable, and post-operative labs were found to be within normal limits. Patient was discharged in stable condition on post-operative day one. Conclusion: Robot assisted hysterectomy is feasible and superior to open approach in a patient with a second trimester pregnancy complicated by placenta percreta with completion of child bearing.
11:49 AM Outcomes After Uterine Artery Embolization and Other Treatment Modalities for Uterine Arteriovenous Malformation: A Multicenter Review from the Society of Gynecologic Surgeons Fellows Pelvic Research Network Arvizo C,1,* Chichura A,2 Plewniak KM,3 McCaffrey C,4 Miazga E,5 Ladanyi C,6 Yunker AC7. 1Vanderbilt University Medical Center, Nashville, TN; 2Cleveland Clinic, Cleveland, OH; 3OB/GYN (Minimally Invasive Gynecologic Surgery), Montefiore Hospital/Albert Einstein College of Medicine, Bronx, NY; 4Division of Urogynecology, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; 5University of Toronto, Toronto, ON, Canada; 6Minimally Invasive Gynecologic Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN; 7Division of Gynecologic Minimally Invasive Surgery, Vanderbilt University Medical Center, Nashville, TN *Corresponding author. Study Objective: To compare treatment outcomes between women managed with uterine artery embolization (UAE) and women treated with other modalities for uterine arteriovenous malformations (AVM) Design: Retrospective cohort Setting: Five academic centers participating in the Fellows’ Pelvic Research Network (FPRN) Patients or Participants: Women 18 years or older with pelvic ultrasound or other imaging diagnosis of uterine AVM between January 2006 and December 2013 Interventions: Patients received either UAE or other conservative treatment options, which varied based on provider preference. Other treatment options included expectant management, hormones, methylergonovine, dilation and curettage (D&C), tranexamic acid. Women who underwent hysterectomy as first-line treatment were excluded. Measurements and Main Results: Chart review was performed to gather data. Preliminary data analysis of 23 patients who met inclusion criteria at 3 different sites was performed. Twenty-one women (91.3%) underwent ultrasound and 6 (26.1%) ultimately had angiography while one patient had magnetic resonance angiography (MRA) performed. Of the 7 patients who had angiography or MRA, 5 confirmed a true uterine AVM. The majority of women presented with abnormal bleeding (82.6%). For first-line treatment, 5 patients underwent UAE, 14 had expectant management, 3 were given methylergonovine (1 patient was administered IV conjugated estrogen concurrently), 3 were given oral contraceptive pills, 2 underwent D&C, 1 patient underwent hysteroscopic resection, 1 received tranexamic acid and 1 patient received medroxyprogesterone acetate. Five patients were managed with a second-line treatment, 13 did not require additional treatment and 5 patients were lost to follow up. Fourteen patients had documented resolution. Conclusion: Uterine AVM occur very infrequently but should be considered in the differential diagnosis of abnormal uterine bleeding. Although initial imaging showed concern for a uterine AVM, at least 2 of 7 patients who underwent subsequent angiography did not confirm the diagnosis. In women with concern for AVM, confirmatory imaging should be performed prior to any treatment that may affect future fertility. Open Communications 16: Robotics (11:00 AM − 12:45 PM) 11:00 AM Robot Assisted Laparoscopic Hysterectomy with Fetus in-situ for Placenta Percreta in Second Trimester
Open Communications 16: Robotics (11:00 AM − 12:45 PM) 11:07 AM The Impact of Robotic Assisted Total Laparoscopic Hysterectomy on Pelvic Floor Function and Sexual Function. Forsgren C*. Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden *Corresponding author. Study Objective: To investigate the long-term effects of hysterectomy on benign indication on pelvic floor function and sexual function. Design: Prospective clinical cohort study Setting: Academic affiliated district general hospital. Patients or Participants: Patients undergoing hysterectomy for benign disease between 2016 and 2018 Interventions: A comparison of robotic assisted total laparoscopic hysterectomy with traditional techniques of surgery regarding pelvic floor function and sexual function. Measurements and Main Results: The study includes 259 women going through hysterectomy. Participants fills in validated questionnaires (PFIQ, PFDI-20, FSFI) on pelvic floor function and sexual function before surgery, six months, 1, 3 and 5 years after surgery. General health and obstetric history are registered in a separate protocol. Multivariate regression and nonparametric statistics are used. The one-year results are not complete but will be presented in November 2019. The results for the six-months follow up of the first 150 women show that the mean age at surgery was 50.2 (SD 9,7), the mean parity was 1,8 (SD 1,2) and mean BMI was 26.4 (SD 4.9). Robotic assisted laparoscopic hysterectomy was performed in 37,3% of the women, laparoscopic hysterectomy in 22%, laparoscopically assisted hysterectomy in 1,1%, vaginal hysterectomy in 3,3% and abdominal hysterectomy in 36,7%. There was a significant higher amount of bleeding at surgery 453 ml (range 50-1300) in the abdominal cohort. Urinary, bladder and pelvic symptoms
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97
Conclusion: Minimally invasive abdominal cerclage is a safe alternative to laparotomy, when performed by a surgeon with appropriate training and technical skills, providing patients with improved surgical outcomes without impairing the obstetric outcomes.
Son MA,1,* Alagkiozidis I,2 Paiva C,1 Elfeky A1. 1Minimally Invasive Gynecology Surgery Department, Maimonides Medical Center, Brooklyn, NY; 2Gynecologic Oncology, Maimonides Medical Center, Brooklyn, NY *Corresponding author.
Open Communications 15: Reproductive (11:00 AM − 12:00 PM)
Video Objective: To describe a technique of robotic-assisted laparoscopic hysterectomy of a second trimester gravid uterus with placenta percreta Setting: A step-by-step explanation of the surgery using video (instructive video). Interventions: In this video, we describe the surgical approach opted for this patient desiring pregnancy termination and no desire for future fertility. Minimally invasive surgery was recommended considering decreased blood loss, postoperative pain and hospital stay. Also considering her prior surgical history, the laparoscopic approach would offer better visualization for lysis of adhesions. Intraoperatively, the uterus was found to have adhesions anteriorly to the abdominal wall as well as bladder adhesions to the lower uterine segment. Generalized increased vascularity was observed. The blood supply from the utero-ovarian and the uterine vessels were tackled prior to releasing the adhesion of the anterior wall of the uterus to the anterior abdominal wall. The lower uterine segment was adherent to the bladder, thereby the lateral approach was used to enter the paravesicular space to create a bladder flap to mobilize the bladder inferiorly. An End to End (EEA) sizer was used to identify the colpotomy site. The cardinal ligament were coagulated and transected to lateralize the paracervical tissue. The colpotomy was then performed and the specimen was then exteriorized intact vaginally. The vaginal cuff was then closed in a continuous fashion using 0-VLoc. Estimate blood loss was 300mL. Postoperatively, patient was hemodynamically stable, and post-operative labs were found to be within normal limits. Patient was discharged in stable condition on post-operative day one. Conclusion: Robot assisted hysterectomy is feasible and superior to open approach in a patient with a second trimester pregnancy complicated by placenta percreta with completion of child bearing.
11:49 AM Outcomes After Uterine Artery Embolization and Other Treatment Modalities for Uterine Arteriovenous Malformation: A Multicenter Review from the Society of Gynecologic Surgeons Fellows Pelvic Research Network Arvizo C,1,* Chichura A,2 Plewniak KM,3 McCaffrey C,4 Miazga E,5 Ladanyi C,6 Yunker AC7. 1Vanderbilt University Medical Center, Nashville, TN; 2Cleveland Clinic, Cleveland, OH; 3OB/GYN (Minimally Invasive Gynecologic Surgery), Montefiore Hospital/Albert Einstein College of Medicine, Bronx, NY; 4Division of Urogynecology, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada; 5University of Toronto, Toronto, ON, Canada; 6Minimally Invasive Gynecologic Surgery, University of Tennessee College of Medicine Chattanooga, Chattanooga, TN; 7Division of Gynecologic Minimally Invasive Surgery, Vanderbilt University Medical Center, Nashville, TN *Corresponding author. Study Objective: To compare treatment outcomes between women managed with uterine artery embolization (UAE) and women treated with other modalities for uterine arteriovenous malformations (AVM) Design: Retrospective cohort Setting: Five academic centers participating in the Fellows’ Pelvic Research Network (FPRN) Patients or Participants: Women 18 years or older with pelvic ultrasound or other imaging diagnosis of uterine AVM between January 2006 and December 2013 Interventions: Patients received either UAE or other conservative treatment options, which varied based on provider preference. Other treatment options included expectant management, hormones, methylergonovine, dilation and curettage (D&C), tranexamic acid. Women who underwent hysterectomy as first-line treatment were excluded. Measurements and Main Results: Chart review was performed to gather data. Preliminary data analysis of 23 patients who met inclusion criteria at 3 different sites was performed. Twenty-one women (91.3%) underwent ultrasound and 6 (26.1%) ultimately had angiography while one patient had magnetic resonance angiography (MRA) performed. Of the 7 patients who had angiography or MRA, 5 confirmed a true uterine AVM. The majority of women presented with abnormal bleeding (82.6%). For first-line treatment, 5 patients underwent UAE, 14 had expectant management, 3 were given methylergonovine (1 patient was administered IV conjugated estrogen concurrently), 3 were given oral contraceptive pills, 2 underwent D&C, 1 patient underwent hysteroscopic resection, 1 received tranexamic acid and 1 patient received medroxyprogesterone acetate. Five patients were managed with a second-line treatment, 13 did not require additional treatment and 5 patients were lost to follow up. Fourteen patients had documented resolution. Conclusion: Uterine AVM occur very infrequently but should be considered in the differential diagnosis of abnormal uterine bleeding. Although initial imaging showed concern for a uterine AVM, at least 2 of 7 patients who underwent subsequent angiography did not confirm the diagnosis. In women with concern for AVM, confirmatory imaging should be performed prior to any treatment that may affect future fertility. Open Communications 16: Robotics (11:00 AM − 12:45 PM) 11:00 AM Robot Assisted Laparoscopic Hysterectomy with Fetus in-situ for Placenta Percreta in Second Trimester
Open Communications 16: Robotics (11:00 AM − 12:45 PM) 11:07 AM The Impact of Robotic Assisted Total Laparoscopic Hysterectomy on Pelvic Floor Function and Sexual Function. Forsgren C*. Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden *Corresponding author. Study Objective: To investigate the long-term effects of hysterectomy on benign indication on pelvic floor function and sexual function. Design: Prospective clinical cohort study Setting: Academic affiliated district general hospital. Patients or Participants: Patients undergoing hysterectomy for benign disease between 2016 and 2018 Interventions: A comparison of robotic assisted total laparoscopic hysterectomy with traditional techniques of surgery regarding pelvic floor function and sexual function. Measurements and Main Results: The study includes 259 women going through hysterectomy. Participants fills in validated questionnaires (PFIQ, PFDI-20, FSFI) on pelvic floor function and sexual function before surgery, six months, 1, 3 and 5 years after surgery. General health and obstetric history are registered in a separate protocol. Multivariate regression and nonparametric statistics are used. The one-year results are not complete but will be presented in November 2019. The results for the six-months follow up of the first 150 women show that the mean age at surgery was 50.2 (SD 9,7), the mean parity was 1,8 (SD 1,2) and mean BMI was 26.4 (SD 4.9). Robotic assisted laparoscopic hysterectomy was performed in 37,3% of the women, laparoscopic hysterectomy in 22%, laparoscopically assisted hysterectomy in 1,1%, vaginal hysterectomy in 3,3% and abdominal hysterectomy in 36,7%. There was a significant higher amount of bleeding at surgery 453 ml (range 50-1300) in the abdominal cohort. Urinary, bladder and pelvic symptoms