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Short-Term Influence of Melatonin on Rats Following Whole Ovarian Cryopreservation and Transplantation
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201 Design: Basic research. Setting: Clinical center and School of medicine. Patients: SCID mice. Intervention: Laparoscopically-induced PM xenografted mouse model was conducted by xenografting human uterine myoma fragments into the abdominal cavity of SCID mice and hormonal manipulation was performed using this mouse model to demonstrate the role of oestrogen in the development of implanted PMs. Immunohistochemistry of oestrogen receptor α (ERα), progesterone receptor (PR), vimentin, vascular endothelial growth factor (VEGF), microvessel density (MVD) and Ki-67 index was performed and compared. Measurements and Main Results: In the patient with PMs, ERα, PR, angiogenesis and proliferative property expression were upregulated in PM lesions compared to uterine myomas. In the laparoscopically-induced PM mouse model, implanted myomas had more steroid receptor expressions, angiogenesis and proliferative property compared with pre-xenografted or non- implanted myoma. Depletion of oestrogen in the ovariectomized (OVX) mice decreased laparoscopically-induced PM implantations. In comparison, the implantations of PMs were increased with additional E2 supplement. Hormonal manipulation in the PM mouse model, including AI, GnRHa and SERM groups, were compared and AI significantly decreased the implantations, steroid receptor, angiogenesis, cell density, and proliferative index of PMs compared with control group. Furthermore, GnRHa significantly decreased VEGF and MVD expressions compared with control group. Conclusion: These data highlight the crucial role of oestrogen in the development of laparoscopically-induced PMs and suggest that hormone manipulation may be a potential therapeutic agent.
187
Open Communications 16 – Research & Science (2:15 PM - 3:15 PM) 2:54 PM – GROUP B
Abdominopelvic Dissemination of Leiomyomas Following Minimally Invasive Surgery and Tissue Morcellation – a Case Series Stockwell EL,1 Khuu T,2 Kowalski LD2. 1Women’s Specialty Care, Las Vegas Minimally Invasive Surgery, Las Vegas, Nevada; 2Nevada Surgery & Cancer Care, Las Vegas, Nevada Study Objective: This report is a case series that describes differing presentations of abdominopelvic leiomyomatosis following minimally invasive surgery with morcellation. Leiomyomatosis peritonealis disseminata (LPD) is a rare disease in which multiple smooth muscle tumor nodules spontaneously stud the pelvic and peritoneal surfaces, often giving the appearance of metastatic ovarian or peritoneal carcinoma. A disease similar to LPD has been described due to iatrogenic seeding of the peritoneal cavity during morcellation of leiomyomas at the time of minimally invasive surgical procedures. Another variant, benign metastasizing leiomyomas (BML), can imbed in distant organs. Design: Case series. Setting: Private gynecologic oncologic practice. Patients: Three women in their 40’s were diagnosed with abdominopelvic leiomyomatosis following laparoscopic myomectomy in two cases and laparoscopic hysterectomy of a large fibroid uterus in the other. All patients presented with pelvic pain. Imaging studies of the first patient revealed multiple pelvic and intraabdominal solid masses. At surgery, leiomyomatosis was found in fifteen different locations, including omentum and pelvic peritoneum. Preoperative CT of the second patient showed a conglomerate of small intraabdominal nodules involving the liver. At laparotomy, disseminated leiomyomatosis was identified and all nodules were resected, including a resection of the right lobe of the liver. In the final case, leiomyomatosis involved the right pararenal tissues and the left kidney, requiring partial nephrectomy. Intervention: Each woman underwent diagnostic laparoscopy converted to laparotomy and tumor debulking surgery. The two women with a uterus also underwent hysterectomy. Measurements and Main Results: Final pathology demonstrated benign disseminated leiomyomas in all cases.
S77
Conclusion: We conclude that great care should be taken to place all fibroid tissue in a containment system prior to tissue extraction at the time of minimally invasive surgery. Extensive exploration at the end of extraction should also be performed to identify and remove any residual tissue fragments.
188
Open Communications 16 – Research & Science (2:15 PM - 3:15 PM) 3:01 PM – GROUP B
Measures to Reduce Peri- and Intra-Operative Blood Loss at Myomectomy: a Survey of Obstetrician-Gynecologists Yeung GW,1 Frecker H,2 Kives SL,1 Robertson D1. 1Department of Obstetrics and Gynecology, Division of Gynecologic Surgery and Pelvic Medicine, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada; 2Department of Obstetrics and Gynecology, Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada Study Objective: To determine current measures used by Canadian obstetrician-gynecologists (Ob/Gyns) to optimize patients undergoing myomectomy during the peri- and intra-operative periods, and to identify gaps in knowledge or barriers to access of blood conservation methods. Design: Survey. Setting: Full- or community- academic affiliated hospital. Patients: Patients undergoing myomectomies for benign disease performed by Canadian obstetrician gynecologists. Intervention: A self-administered electronic questionnaire was distributed to Canadian Ob/Gyns from September through December 2016. Measurements and Main Results: 68/120 (57%) completed responses were analyzed. Most respondents were general Ob/Gyn [72.1% (49) Ob/Gyn, 20.6% (14) Ob/Gyn-MIS, 4.4 % (3) MIS, 2.9% (2) GYN], who worked in the community [70.6% (48)] and practiced >10 years [67.7% (46)]. 79.4% (54) delay surgery to correct anemia. Most common preoperative medical agents used were: Tranexamic acid (94.1%), Ulipristal acetate (92.6%), GnRH agonist (79.4%), and Combined hormonal contraception (58.8%). Majority had access to hematology [83.8% (57)] and to IV iron [98.5% (67)], and have previously ordered IV iron before [82.4% (56)]. However, respondents had variable knowledge of oral and IV iron dosing and administration. Most common intra-operative agents used were: 94.1% (64) Vasopressin [subserosal (SS) 59.4% vs. intra-myometrial (IMM) 40.6%], 26.6% (17) Vasopressin with Epinephrine (SS 58.8% vs. IMM 41.2%), 73.5% (50) IV Tranexamic acid, 66.2% (45) Mechanical tourniquet, 33.8% (23) Misoprostol, 22.1% (15) Uterine artery ligation, 17.6% (12) Topical sealant, and 11.8% (8) Intra-op blood salvage. 52.9% (36) estimated 250–499 mL blood loss, <10% personal transfusion rate [73.5% (50)], but 69.1% (47) were uncertain of institutional transfusion rate. Conclusion: Most gynecologists delay surgery to correct anemia, but are uncertain of institutional transfusion rate, iron dosing and administration, and optimal peri-/intra-operative multi-modal approach for blood loss conservation. Education and creation of a clinical pathway to address uncertainty in measures to reduce bleeding can lead to decreased perioperative morbidity for myomectomy patients.
189
Open Communications 16 – Research & Science (2:15 PM - 3:15 PM) 3:08 PM – GROUP B
Short-Term Influence of Melatonin on Rats Following Whole Ovarian Cryopreservation and Transplantation Ding Y,1 Shao J,2 Li J,1 Zhang Y,1 Hua K,1 Wang X2. 1Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China; 2Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
S78
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201
Study Objective: To explore the short-term impacts of melatonin on rats after whole ovarian cryopreservation and transplantation (WOCP&TP) and its mechanisms. Design: Rats after WOCP&TP were randomly divided into three groups with 10 rats respectively: no melatonin group, low-dose group (25 mg/kg), Highdose group (50 mg/kg). Melatonin was injected i.p. for 2 or 4 days respectively. The control group underwent sham operation and was given saline solution. Setting: Animal Experiment Efficacy Evaluation Center, School of Pharmacy, Fudan University, Shanghai, China. Patients: Lewis rats aged 8–10 weeks weighing 180-200g. Intervention: Ovarian function was assessed by hormone levels and the ovarian morphology with follicle count. The anti-inflammatory ability of melatonin was assessed by MPO in ovarian tissue and the serum levels of IL-6, TNF-α and NF-κB. The antioxidant capacity of melatonin was assessed by SOD and MDA in ovarian tissue. The anti-apoptotic ability of melatonin was assessed by immunohistochemistry and TUNEL assay. Measurements and Main Results: After both 2 days and 4 days of WOCP&TP, there was significant difference in the ovarian function, the antioxidant index, the anti-inflammatory index and the apoptotic rates compared three transplantation groups to control group (p < .05). After both 2 days and 4 days of WOCP&TP, there was significant difference in every detective index compared high-dose group to no melatonin group (p < .05). While compared low-dose group to no melatonin group, significant difference only could be seen after 4 days of WOCP&TP (p < .05). There was significant difference compared high-dose group to low-dose group (p < .05). Significant difference also could be seen in high-dose group and low-dose group compared the index after 2 days with the index after 4 days (p < .05). Conclusion: Melatonin could protect the ovarian function after WOCP&TP with dose and time dependent, which may be achieved by its antioxidation, anti-inflammation and anti-apoptosis.
index (BMI), parity, prior cesarean section, ovarian cyst, and specimen morcellation. Subcriteria were scaled, then added, generating a complexity score (CS).
Data were adjusted for site. Linear regression analysis was used to determine which complexity factors affected operative times. Measurements and Main Results: Mean operative time for all hysterectomy approaches was 119.7 min. Increasing CS significantly correlated with longer operative times for TLH and RATLH (p < .001). When compared to TLH, RATLH required less operative time for equally complex cases.
WEDNESDAY, NOVEMBER 15, 2017
190
Open Communications 17 – Laparoscopy (3:25 PM - 5:05 PM) 3:25 PM – GROUP A
Quantifying Critical Components Predictive of Surgical Complexity and Operative Times for Total Laparoscopic Hysterectomy – a Multicenter Study Pacis MM,1 Lenihan JP,2 Abi Khalil E,3 Huynh TQ,4 Rieger MM,5 Breen MT,5 Makai G,4 Moawad G,3 Stetter C,6 Kunselman AR,6 Harkins G1. 1Department of Obstetrics and Gynecology, Penn State Health Milton S. Hershey Medical Center, Hummelstown, Pennsylvania; 2 Department of Obstetrics and Gynecology, Multicare Health Systems, Tacoma, Washington; 3Department of Obsetrics and Gynecology, The George Washington University, Washington, District of Columbia; 4 Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware; 5Department of Women’s Health, University of Texas Dell School of Medicine, Austin, Texas; 6Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania Study Objective: To develop a method quantifying predictors of surgical complexity as correlated with operative times. To determine if surgical approach, conventional (TLH) versus robotic (RATLH), affects operative time given similar complexity factors. Design: Retrospective multicenter cohort study. Setting: Two academic tertiary care centers and two community health systems specializing in minimally invasive gynecologic surgery. Patients: Women ages 20 to 68 undergoing either TLH or RATLH for benign indications between December 2011 and January 2017. Intervention: Data were collected for 350 patients, and grouped according to hysterectomy approach – 200 underwent TLH and 150 had RATLH. Parameters considered to influence surgical difficulty for total laparoscopic hysterectomy included uterine size and shape, adhesions, body mass
Specific factors including larger uterine size (p < .001), prior cesarean sections (p = .003), ovarian cystectomy (p = .003), and morcellation (p < .001) contributed to increasing operative times for both approaches. Aberations in uterine shape and higher BMI significantly increased operative time for TLH (p = .003, p = .03), but not RATLH (p = .22, p = .63). Extensive adhesiolysis significantly increased operative times for RATLH (p = .004), but not TLH (p = .52). Surgical trainee participation increased operative times in both groups (p < .001). Conclusion: Implementing a scoring method can predict surgical complexity as a function of operative time for TLH and RATLH. Factors that significantly impact operative times include greater uterine weights, prior cesarean delivery, ovarian cystectomy, and morcellation. A robotic approach may decrease operative times for similarly complex cases compared with TLH.
187
Open Communications 16 – Research & Science (2:15 PM - 3:15 PM) 2:54 PM – GROUP B
Abdominopelvic Dissemination of Leiomyomas Following Minimally Invasive Surgery and Tissue Morcellation – a Case Series Stockwell EL,1 Khuu T,2 Kowalski LD2. 1Women’s Specialty Care, Las Vegas Minimally Invasive Surgery, Las Vegas, Nevada; 2Nevada Surgery & Cancer Care, Las Vegas, Nevada Study Objective: This report is a case series that describes differing presentations of abdominopelvic leiomyomatosis following minimally invasive surgery with morcellation. Leiomyomatosis peritonealis disseminata (LPD) is a rare disease in which multiple smooth muscle tumor nodules spontaneously stud the pelvic and peritoneal surfaces, often giving the appearance of metastatic ovarian or peritoneal carcinoma. A disease similar to LPD has been described due to iatrogenic seeding of the peritoneal cavity during morcellation of leiomyomas at the time of minimally invasive surgical procedures. Another variant, benign metastasizing leiomyomas (BML), can imbed in distant organs. Design: Case series. Setting: Private gynecologic oncologic practice. Patients: Three women in their 40’s were diagnosed with abdominopelvic leiomyomatosis following laparoscopic myomectomy in two cases and laparoscopic hysterectomy of a large fibroid uterus in the other. All patients presented with pelvic pain. Imaging studies of the first patient revealed multiple pelvic and intraabdominal solid masses. At surgery, leiomyomatosis was found in fifteen different locations, including omentum and pelvic peritoneum. Preoperative CT of the second patient showed a conglomerate of small intraabdominal nodules involving the liver. At laparotomy, disseminated leiomyomatosis was identified and all nodules were resected, including a resection of the right lobe of the liver. In the final case, leiomyomatosis involved the right pararenal tissues and the left kidney, requiring partial nephrectomy. Intervention: Each woman underwent diagnostic laparoscopy converted to laparotomy and tumor debulking surgery. The two women with a uterus also underwent hysterectomy. Measurements and Main Results: Final pathology demonstrated benign disseminated leiomyomas in all cases.
S77
Conclusion: We conclude that great care should be taken to place all fibroid tissue in a containment system prior to tissue extraction at the time of minimally invasive surgery. Extensive exploration at the end of extraction should also be performed to identify and remove any residual tissue fragments.
188
Open Communications 16 – Research & Science (2:15 PM - 3:15 PM) 3:01 PM – GROUP B
Measures to Reduce Peri- and Intra-Operative Blood Loss at Myomectomy: a Survey of Obstetrician-Gynecologists Yeung GW,1 Frecker H,2 Kives SL,1 Robertson D1. 1Department of Obstetrics and Gynecology, Division of Gynecologic Surgery and Pelvic Medicine, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada; 2Department of Obstetrics and Gynecology, Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada Study Objective: To determine current measures used by Canadian obstetrician-gynecologists (Ob/Gyns) to optimize patients undergoing myomectomy during the peri- and intra-operative periods, and to identify gaps in knowledge or barriers to access of blood conservation methods. Design: Survey. Setting: Full- or community- academic affiliated hospital. Patients: Patients undergoing myomectomies for benign disease performed by Canadian obstetrician gynecologists. Intervention: A self-administered electronic questionnaire was distributed to Canadian Ob/Gyns from September through December 2016. Measurements and Main Results: 68/120 (57%) completed responses were analyzed. Most respondents were general Ob/Gyn [72.1% (49) Ob/Gyn, 20.6% (14) Ob/Gyn-MIS, 4.4 % (3) MIS, 2.9% (2) GYN], who worked in the community [70.6% (48)] and practiced >10 years [67.7% (46)]. 79.4% (54) delay surgery to correct anemia. Most common preoperative medical agents used were: Tranexamic acid (94.1%), Ulipristal acetate (92.6%), GnRH agonist (79.4%), and Combined hormonal contraception (58.8%). Majority had access to hematology [83.8% (57)] and to IV iron [98.5% (67)], and have previously ordered IV iron before [82.4% (56)]. However, respondents had variable knowledge of oral and IV iron dosing and administration. Most common intra-operative agents used were: 94.1% (64) Vasopressin [subserosal (SS) 59.4% vs. intra-myometrial (IMM) 40.6%], 26.6% (17) Vasopressin with Epinephrine (SS 58.8% vs. IMM 41.2%), 73.5% (50) IV Tranexamic acid, 66.2% (45) Mechanical tourniquet, 33.8% (23) Misoprostol, 22.1% (15) Uterine artery ligation, 17.6% (12) Topical sealant, and 11.8% (8) Intra-op blood salvage. 52.9% (36) estimated 250–499 mL blood loss, <10% personal transfusion rate [73.5% (50)], but 69.1% (47) were uncertain of institutional transfusion rate. Conclusion: Most gynecologists delay surgery to correct anemia, but are uncertain of institutional transfusion rate, iron dosing and administration, and optimal peri-/intra-operative multi-modal approach for blood loss conservation. Education and creation of a clinical pathway to address uncertainty in measures to reduce bleeding can lead to decreased perioperative morbidity for myomectomy patients.
189
Open Communications 16 – Research & Science (2:15 PM - 3:15 PM) 3:08 PM – GROUP B
Short-Term Influence of Melatonin on Rats Following Whole Ovarian Cryopreservation and Transplantation Ding Y,1 Shao J,2 Li J,1 Zhang Y,1 Hua K,1 Wang X2. 1Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China; 2Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
S78
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201
Study Objective: To explore the short-term impacts of melatonin on rats after whole ovarian cryopreservation and transplantation (WOCP&TP) and its mechanisms. Design: Rats after WOCP&TP were randomly divided into three groups with 10 rats respectively: no melatonin group, low-dose group (25 mg/kg), Highdose group (50 mg/kg). Melatonin was injected i.p. for 2 or 4 days respectively. The control group underwent sham operation and was given saline solution. Setting: Animal Experiment Efficacy Evaluation Center, School of Pharmacy, Fudan University, Shanghai, China. Patients: Lewis rats aged 8–10 weeks weighing 180-200g. Intervention: Ovarian function was assessed by hormone levels and the ovarian morphology with follicle count. The anti-inflammatory ability of melatonin was assessed by MPO in ovarian tissue and the serum levels of IL-6, TNF-α and NF-κB. The antioxidant capacity of melatonin was assessed by SOD and MDA in ovarian tissue. The anti-apoptotic ability of melatonin was assessed by immunohistochemistry and TUNEL assay. Measurements and Main Results: After both 2 days and 4 days of WOCP&TP, there was significant difference in the ovarian function, the antioxidant index, the anti-inflammatory index and the apoptotic rates compared three transplantation groups to control group (p < .05). After both 2 days and 4 days of WOCP&TP, there was significant difference in every detective index compared high-dose group to no melatonin group (p < .05). While compared low-dose group to no melatonin group, significant difference only could be seen after 4 days of WOCP&TP (p < .05). There was significant difference compared high-dose group to low-dose group (p < .05). Significant difference also could be seen in high-dose group and low-dose group compared the index after 2 days with the index after 4 days (p < .05). Conclusion: Melatonin could protect the ovarian function after WOCP&TP with dose and time dependent, which may be achieved by its antioxidation, anti-inflammation and anti-apoptosis.
index (BMI), parity, prior cesarean section, ovarian cyst, and specimen morcellation. Subcriteria were scaled, then added, generating a complexity score (CS).
Data were adjusted for site. Linear regression analysis was used to determine which complexity factors affected operative times. Measurements and Main Results: Mean operative time for all hysterectomy approaches was 119.7 min. Increasing CS significantly correlated with longer operative times for TLH and RATLH (p < .001). When compared to TLH, RATLH required less operative time for equally complex cases.
WEDNESDAY, NOVEMBER 15, 2017
190
Open Communications 17 – Laparoscopy (3:25 PM - 5:05 PM) 3:25 PM – GROUP A
Quantifying Critical Components Predictive of Surgical Complexity and Operative Times for Total Laparoscopic Hysterectomy – a Multicenter Study Pacis MM,1 Lenihan JP,2 Abi Khalil E,3 Huynh TQ,4 Rieger MM,5 Breen MT,5 Makai G,4 Moawad G,3 Stetter C,6 Kunselman AR,6 Harkins G1. 1Department of Obstetrics and Gynecology, Penn State Health Milton S. Hershey Medical Center, Hummelstown, Pennsylvania; 2 Department of Obstetrics and Gynecology, Multicare Health Systems, Tacoma, Washington; 3Department of Obsetrics and Gynecology, The George Washington University, Washington, District of Columbia; 4 Department of Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware; 5Department of Women’s Health, University of Texas Dell School of Medicine, Austin, Texas; 6Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania Study Objective: To develop a method quantifying predictors of surgical complexity as correlated with operative times. To determine if surgical approach, conventional (TLH) versus robotic (RATLH), affects operative time given similar complexity factors. Design: Retrospective multicenter cohort study. Setting: Two academic tertiary care centers and two community health systems specializing in minimally invasive gynecologic surgery. Patients: Women ages 20 to 68 undergoing either TLH or RATLH for benign indications between December 2011 and January 2017. Intervention: Data were collected for 350 patients, and grouped according to hysterectomy approach – 200 underwent TLH and 150 had RATLH. Parameters considered to influence surgical difficulty for total laparoscopic hysterectomy included uterine size and shape, adhesions, body mass
Specific factors including larger uterine size (p < .001), prior cesarean sections (p = .003), ovarian cystectomy (p = .003), and morcellation (p < .001) contributed to increasing operative times for both approaches. Aberations in uterine shape and higher BMI significantly increased operative time for TLH (p = .003, p = .03), but not RATLH (p = .22, p = .63). Extensive adhesiolysis significantly increased operative times for RATLH (p = .004), but not TLH (p = .52). Surgical trainee participation increased operative times in both groups (p < .001). Conclusion: Implementing a scoring method can predict surgical complexity as a function of operative time for TLH and RATLH. Factors that significantly impact operative times include greater uterine weights, prior cesarean delivery, ovarian cystectomy, and morcellation. A robotic approach may decrease operative times for similarly complex cases compared with TLH.