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Robotic Assisted Laparoscopic Myomectomy of Extremely Large Uterine Fibroid
Abstracts / Journal of Minimally Invasive Gynecology 18 (2011) S1–S23 salpingectomy on the ovarian response in patients undergoing controlled ovarian hyperstimulation (COH) for IVF treatment. Design: A Retrospective matched case control study. Setting: A University-based tertiary medical center. Patients: 36 women who underwent controlled ovarian stimulation cycles for in-vitro fertilization (IVF) before and after salpingectomy. Intervention: Laparoscopic salpingectomy for unilateral or bilateral hydrosalpinx or ectopic pregnancy. Measurements and Main Results: We measured the number of dominant follicles and oocytes aspirated before and after salpingectomy. We also evaluated maximal estradiol levels, duration of stimulation and average daily dose of gonadotrophins. Results: The overall number of dominant follicles and the number of oocytes aspirated before and after salpingectomy were comparable (7.2 3.8 vs. 7.3 3.7 and 10.2 6.6 vs. 10.3 7.4 respectively). Maximal E2 levels and the daily dose of gonadotrophins before (1899 185 pg/ml and 217.8 10.0 IU) and after surgery (1997 231 pg/ml and 239 16.3IU) were also similar. There was no significant difference in the number of dominant follicles before and after surgery on the operated side (3.8 2.2 vs. 3.7 2.0). Regression analysis to assess the effect of unilateral versus bilateral salpingectomy showed no effect on the main outcome measured. Conclusion: This is a large retrospective study of 36 patients who acted as their own controls before and after surgery making the conclusions solid. Contrary to previous and recent publications, we found that unilateral or bilateral salpingectomy does not influence ovarian response in terms of number of follicles or hormonal activity in patients undergoing controlled ovarian hyperstimulation for IVF treatment. 20
Plenary 4dReproductive Issues (11:40 AM d 11:49 AM)
Two and Three-Dimensional Ultrasound Evaluation of Adenomyosis and Histological Correlation on Ultrasound Targeted Biopsies of the Myometrium at Hysterectomy Luciano DE,1 Albrecht L,1 LaMonica R,1 Luciano AA,1 Exacoustos C.2 1 Obstetrics and Gynecology, University of Connecticut, New Britain, Connecticut; 2Obstetrics and Gynecology, Universita degli Studi di Roma Tor Vergata, Rome, Italy Study Objective: The aim of this study was to evaluate the 2D and 3D TVS detectable morphological alterations of the myometrium and junctional zone induced by adenomyosis and correlate these findings to histopathological features of targeted hysterectomy biopsies. Design: Prospective study comparing results of 2D/3D TVS to histopathological findings of the entire uterus and of ultrasound based targeted myometrium biopsies. Setting: University based Community Hospital. Patients: Premenopausal patients referred for hysterectomy. Intervention: A 2D/3D TVS was performed prior to hysterectomy providing a volume acquisition of the uterus to evaluate: alterations of the endometrial-myometrial junctional zone (JZ), min JZ and max JZ thickness, presence of myometrial cystic areas and hyperechoic striations, asymmetry of myometrial wall. Localization and position of the lesions in the myometrial wall were accurately described. The presence of at least one of the signs was considered diagnostic for adenomyosis. Measurements and Main Results: Forty premenopausal patients underwent 2D/3D TVS and hysterectomy. The prevalence of adenomyosis at histology was 65% and the mean age 42.1. Seven patients had previous endometrial ablation and 7 were on medical therapy and were considered separate for the statistical analysis. Of the 26 patients with no previous treatment 20 had adenomyosis on the targeted biopsies of the myometrium. The accuracy in diagnosing adenomyosis improved from 77% (sensitivity 80%, specificity 67%) in 2D to 89% (sensitivity 90%, specificity 83%) in 3D. Alterations in the JZ and the hyperechoic areas were most common in patients with adenomyosis. JZ max thickness was significantly greater in patients with adenomyosis than without (8.0 3.5 vs 5.5 1.2mm). Diagnostic accuracy was decreased to 57% in patients with previous endometrial ablation or on medical therapy (sensitivity 86%, specificity 29%).
S7
Conclusion: Alterations in the JZ seen by 3D TVS have a high diagnostic accuracy for adenomyosis. Endometrial ablation alters the appearance of the JZ compromising the accuracy of diagnosing adenomyosis. 21
Video Session 1dRobotics (11:00 AM d 11:07 AM)
Robot Assisted Laparoscopic Resection of Retroperitonealized Adnexa Swan KA, Advincula AP. Celebration Health, Celebration, Florida This video demonstrates a robot assisted laparoscopic resection of a leftsided retroperitonealized adnexa. The patient is a 40 year female with known didephic uterus and history of endometriosis. She presents with worsening left side pain and dysmenorrhea. Surgical evaluation demonstrates a retroperitonealized left adnexa with endometrioma. Dense adhesions are present and require enterolysis. The left ureter is adherent to the posterior adnexa and requires extensive ureterolysis. 22
Video Session 1dRobotics (11:08 AM d 11:16 AM)
Robotic Assisted Laparoscopic Myomectomy of Extremely Large Uterine Fibroid McCoy TW. Florida Institute for Reproductive Medicine, Jacksonville, Florida This video presents the Robotic-assisted laparoscopic myomectomy of a large 17cm fibroid in a 24 week gestational age uterus. The goal of this video is to show a standardized approach to a myomectomy, which can allow for a minimally invasive laparoscopic route for a myomectomy of a very large uterus which may have otherwise been performed abdominally. 23
Video Session 1dRobotics (11:17 AM d 11:24 AM)
Efficient Steps for Robotic Supracervical Hysterectomy Gurshumov EL, Lewis C, Salamon C, Culligan P. Division of Urogynecology and Reconstructive Pelvic Surgery, Atlantic Health, Morristown, New Jersey To illustrate efficient techniques developed for performing robotic assisted laparoscopic supracervical hysterectomy. Description: As the technology becomes more widely available, an ever-growing number of hysterectomies are being performed with robotic assistance. There are a number of technical nuances unique to robotic- assisted surgery – some of these may even be considered poor technique if employed during ‘‘straight stick’’ laparoscopy. In this video we describe efficient approach to robotic-assisted supracervical hysterectomy- that makes full use of the technical advantages afforded by the 3D view and instrument range of motion. 25
Video Session 1dRobotics (11:31 AM d 11:39 AM)
Robotically Assisted Laparoscopic Myomectomy – An Introduction Mansour FW, Kives S, Lefebvre G. Department of Gynecology, St. Michaeal’s Hospital, University of Toronto, Toronto, Ontario, Canada The traditional open approach to myomectomy is associated with significant operative morbidity. This surgery is also currently performed via conventional laparoscopy and provides the advantages of shorter hospitalization, faster recovery, fewer adhesions, and less blood loss than open myomectomy when performed by skilled surgeons. Alternatively, the robotic approach offers surgeons a magnified three-dimensional visual field and enhanced dexterity with instruments capable of 360-degree movement at their surgical hands. In this video presentation, we present a 28 year-old nulligravida with a 9 cm fibroid and menorrhagia. This case illustrates the role of robotics in helping surgeons achieve precise dissection and enucleation of fibroids and a better approximation of the
Plenary 4dReproductive Issues (11:40 AM d 11:49 AM)
Two and Three-Dimensional Ultrasound Evaluation of Adenomyosis and Histological Correlation on Ultrasound Targeted Biopsies of the Myometrium at Hysterectomy Luciano DE,1 Albrecht L,1 LaMonica R,1 Luciano AA,1 Exacoustos C.2 1 Obstetrics and Gynecology, University of Connecticut, New Britain, Connecticut; 2Obstetrics and Gynecology, Universita degli Studi di Roma Tor Vergata, Rome, Italy Study Objective: The aim of this study was to evaluate the 2D and 3D TVS detectable morphological alterations of the myometrium and junctional zone induced by adenomyosis and correlate these findings to histopathological features of targeted hysterectomy biopsies. Design: Prospective study comparing results of 2D/3D TVS to histopathological findings of the entire uterus and of ultrasound based targeted myometrium biopsies. Setting: University based Community Hospital. Patients: Premenopausal patients referred for hysterectomy. Intervention: A 2D/3D TVS was performed prior to hysterectomy providing a volume acquisition of the uterus to evaluate: alterations of the endometrial-myometrial junctional zone (JZ), min JZ and max JZ thickness, presence of myometrial cystic areas and hyperechoic striations, asymmetry of myometrial wall. Localization and position of the lesions in the myometrial wall were accurately described. The presence of at least one of the signs was considered diagnostic for adenomyosis. Measurements and Main Results: Forty premenopausal patients underwent 2D/3D TVS and hysterectomy. The prevalence of adenomyosis at histology was 65% and the mean age 42.1. Seven patients had previous endometrial ablation and 7 were on medical therapy and were considered separate for the statistical analysis. Of the 26 patients with no previous treatment 20 had adenomyosis on the targeted biopsies of the myometrium. The accuracy in diagnosing adenomyosis improved from 77% (sensitivity 80%, specificity 67%) in 2D to 89% (sensitivity 90%, specificity 83%) in 3D. Alterations in the JZ and the hyperechoic areas were most common in patients with adenomyosis. JZ max thickness was significantly greater in patients with adenomyosis than without (8.0 3.5 vs 5.5 1.2mm). Diagnostic accuracy was decreased to 57% in patients with previous endometrial ablation or on medical therapy (sensitivity 86%, specificity 29%).
S7
Conclusion: Alterations in the JZ seen by 3D TVS have a high diagnostic accuracy for adenomyosis. Endometrial ablation alters the appearance of the JZ compromising the accuracy of diagnosing adenomyosis. 21
Video Session 1dRobotics (11:00 AM d 11:07 AM)
Robot Assisted Laparoscopic Resection of Retroperitonealized Adnexa Swan KA, Advincula AP. Celebration Health, Celebration, Florida This video demonstrates a robot assisted laparoscopic resection of a leftsided retroperitonealized adnexa. The patient is a 40 year female with known didephic uterus and history of endometriosis. She presents with worsening left side pain and dysmenorrhea. Surgical evaluation demonstrates a retroperitonealized left adnexa with endometrioma. Dense adhesions are present and require enterolysis. The left ureter is adherent to the posterior adnexa and requires extensive ureterolysis. 22
Video Session 1dRobotics (11:08 AM d 11:16 AM)
Robotic Assisted Laparoscopic Myomectomy of Extremely Large Uterine Fibroid McCoy TW. Florida Institute for Reproductive Medicine, Jacksonville, Florida This video presents the Robotic-assisted laparoscopic myomectomy of a large 17cm fibroid in a 24 week gestational age uterus. The goal of this video is to show a standardized approach to a myomectomy, which can allow for a minimally invasive laparoscopic route for a myomectomy of a very large uterus which may have otherwise been performed abdominally. 23
Video Session 1dRobotics (11:17 AM d 11:24 AM)
Efficient Steps for Robotic Supracervical Hysterectomy Gurshumov EL, Lewis C, Salamon C, Culligan P. Division of Urogynecology and Reconstructive Pelvic Surgery, Atlantic Health, Morristown, New Jersey To illustrate efficient techniques developed for performing robotic assisted laparoscopic supracervical hysterectomy. Description: As the technology becomes more widely available, an ever-growing number of hysterectomies are being performed with robotic assistance. There are a number of technical nuances unique to robotic- assisted surgery – some of these may even be considered poor technique if employed during ‘‘straight stick’’ laparoscopy. In this video we describe efficient approach to robotic-assisted supracervical hysterectomy- that makes full use of the technical advantages afforded by the 3D view and instrument range of motion. 25
Video Session 1dRobotics (11:31 AM d 11:39 AM)
Robotically Assisted Laparoscopic Myomectomy – An Introduction Mansour FW, Kives S, Lefebvre G. Department of Gynecology, St. Michaeal’s Hospital, University of Toronto, Toronto, Ontario, Canada The traditional open approach to myomectomy is associated with significant operative morbidity. This surgery is also currently performed via conventional laparoscopy and provides the advantages of shorter hospitalization, faster recovery, fewer adhesions, and less blood loss than open myomectomy when performed by skilled surgeons. Alternatively, the robotic approach offers surgeons a magnified three-dimensional visual field and enhanced dexterity with instruments capable of 360-degree movement at their surgical hands. In this video presentation, we present a 28 year-old nulligravida with a 9 cm fibroid and menorrhagia. This case illustrates the role of robotics in helping surgeons achieve precise dissection and enucleation of fibroids and a better approximation of the