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Single-Site Laparoscopic Comprehensive Staging Of Early Ovarian Cancer
S24 Measurements and Main Results: We identified 570 patients with a preoperative diagnosis of abnormal uterine bleeding or fibroids who underwent hysterectomy from 2012-2016. When stratified by age, there were no differences in BMI, parity or history of cesarean sections between the groups. Younger women (≤35) were more likely to have a preoperative diagnosis of pelvic pain, dysmenorrhea and a history of endometriosis (p<.001). Overall 55.8% of women attempted medical management prior to surgery with higher rates seen in women ≤35 and lowest rates in women ≥50 (73.6% vs 40%, p=0.001). Half of women ≤35 had no uterine pathology at the time of hysterectomy, and the rate of uterine pathology increased with increasing age (p<0.001). Compared to fibroids (12.5% ≤35 vs 44.5% ≥50, p<.001), adenomyosis was more common at younger ages (22.2% ≤35 vs 6.2% ≥50, p <.001). On multivariate logistic regression, younger age (≤35) remained an independent risk factor for absence of uterine pathology at time of hysterectomy. Prior uterine surgery including dilation and curettage, hysteroscopy and cesarean section were not associated with an increased rate of pathology at the time of hysterectomy. Conclusion: Women under the age of 35 are more likely to have benign pathology at the time of hysterectomy for abnormal bleeding despite higher rates of pelvic pain, dysmenorrhea and preoperative medical management. Gynecologic surgery does not increase the risk of adenomyosis or fibroids at the time of hysterectomy. Open Communications 2: Laparoscopy (11:30 AM — 12:45 PM) 12:26 PM A Resident Guide to Laparoscopic Myomectomy with Endometrial Cavity Preservation Ruhotina M,*,1,2 Loring M,3 Movilla PR3. 1Gyn Surgery, Newton Wellesley Hospital, Minimally Invasive Gynecologic Surgery, Newton, MA; 2 Obstetrics and Gynecology, Women & Infants Hospital of Rhode Island/ Brown University Residency in Obstetrics and Gynecology, Providence, RI; 3Minimally Invasive Gynecologic Surgery, Newton Wellesley Hospital, Newton, MA *Corresponding author. Video Objective: The objective of this video is to provide a surgical guide for gynecology residents prior to entering a laparoscopic myomectomy. Setting: The patient in this video is a 42 year old female with a history of abnormal uterine bleeding secondary to her known intramural 6 cm fibroid. Her bleeding was refractory to medical management, and she desired definitive surgical management with a laparoscopic myomectomy. Interventions: The patient underwent a laparoscopic myomectomy with endometrial cavity preservation and scalpel morcellation of the myoma. Conclusion: This video highlights five basic steps of laparoscopic myomectomy including major surgical considerations for each step. Additionally, the video highlights an example of endometrial cavity preservation. Residents with limited exposure to laparoscopic myomectomy can utilize this video as a reference prior to entering a laparoscopic myomectomy. Open Communications 2: Laparoscopy (11:30 AM — 12:45 PM) 12:33 PM Optimization of Pre-Operative Oral Analgesics in Patients Undergoing Ambulatory Minimally Invasive Hysterectomy Smith KA,* Frazzini Padilla PM, Cooper JA, Mehandru N, Zimberg SE, Sprague ML. Gynecology, Cleveland Clinic Florida, Weston, FL *Corresponding author.
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 Study Objective: To determine the optimal time to administer pre-operative non-opioid oral analgesics to achieve superior post-operative pain modulation in patients undergoing outpatient minimally invasive hysterectomy for benign disease. Design: Randomized controlled trial. Setting: Minimally invasive gynecologic surgery practice. Patients or Participants: Women undergoing benign minimally invasive hysterectomy. Interventions: From January 2018 to October 2018, 60 women aged 3467 years were randomized to treatment (n=30) and control (n=30). Patients in the treatment arm self-administered oral celecoxib, gabapentin, and acetaminophen 3-4 hours prior to surgery, while those in the control arm received these medications in the pre-anesthesia care unit. All patients were administered intravenous nausea and vomiting prophylaxis. Time of oral medication ingestion and orogastric tube placement were collected. Post-operatively, patients were administered intravenous ketorolac and pain scores were assessed on an eleven-point numeric rating scale. Pain medications and anti-emetics were administered as needed prior to discharge. Opioid consumption was collected and converted to oral morphine equivalents (OME). Patients were sent an electronic survey assessing patient satisfaction and surgical recovery score on post-operative day 10. Measurements and Main Results: 53 subjects (29 in treatment and 24 in control) were included in the study. Baseline characteristics were balanced between treatment and control arms, with the exception of pre-existing gastro-esophageal reflux which was higher in the treatment group (20.7% vs. 0.0%, p=.026). 24.1% of the treatment arm required OME >50 compared to 41.7% of the control group (p=.174). There were no significant differences in pain score at discharge (p=.234), patient satisfaction (p=.90), or surgical recovery score (p=.189). Conclusion: Advanced administration of pre-operative oral analgesia trended towards a decrease in immediate post-operative opioid use when compared to immediate pre-operative administration. Timing of administration had no impact on pain scores, patient satisfaction, or surgical recovery scores. Either technique of administration of pre-operative oral analgesia is acceptable. Open Communications 2: Oncology (11:00 AM — 11:30 AM) 11:00 AM Single-Site Laparoscopic Comprehensive Staging Of Early Ovarian Cancer Liang Z*. Obstetric & Gynecology, Southwest Hospital, Chongqing, China *Corresponding author. Study Objective: To review the single-site laparoscopic staging procedure in a series of patients with early ovarian cancer and compare results with the literature. Design: A prospective single-center study. Setting: A hospital in China. Patients or Participants: A total of 21 patients with apparent early stage ovarian cancer from January 2017 through March 2019. The histologic tumor types were epithelial tumors (18 patients) and dysgerminoma (2 patients). All the epithelial tumors were invasive (13 serous and 8 mucinous). Interventions: Single-site laparoscopic comprehensive staging was performed in all patients according to the International Federation of Gynecology and Obstetrics guidelines. Measurements and Main Results: Fifteen patients had previous adnexal surgery and diagnosis and surgical staging were performed in only 6 patients during the same surgery. The patients’ median age was 32.8 years (range 26−57). Four (19%) patients desired to maintain fertility and a conservative approach was performed for this group. Single-site laparoscopic staging was completed in 20 (95%) patients. In 1 case, a conversion to
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 laparoscopic was necessary as the para-aortic lymphadenectomy was completed because of a vessel injury that was repaired without difficulty. The median operative timewas 265 minutes (range 210−320) for radical surgery and 218 minutes (range 120−240) for the conservative approach. The mean hospital stay was 3 days. Of the 21 total patients, 6 (28.6%) were upstaged. The median follow-up was 24.7 months (range 1−27), with a disease-free survival of 100% and an overall survival of 100%. No recurrence was observed. Conclusion: A comprehensive surgical staging procedure is clearly indicated in cases of early ovarian cancer and oncologic guidelines should be respected. The Single-site laparoscopic approach could be a valid alternative to laparoscopic or laparotomy. Open Communications 2: Oncology (11:00 AM — 11:30 AM) 11:07 AM Case Report: Ureteral Obstruction at the Time of Hysterectomy after Uterine Artery Embolization Touchan F,*,1 van der Does L,1 Haworth L,1 Wahbe C2. 1Research, The Center for Innovative GYN Care, Rockville, MD; 2Research, Clara Maass Medical Center, Belleville, NJ *Corresponding author. Study Objective: To report ureteral obstruction at the time of hysterectomy following uterine artery embolization (UAE). Design: Case report. Setting: Clara Maass Medical Center. Patients or Participants: 42 year-old African-American woman. Interventions: Hysterectomy following UAE. Measurements and Main Results: Patient presented for total laparoscopic hysterectomy (TLH) for abnormal uterine bleeding and dysmenorrhea. Patient had a history of UAE two years prior, which resolved her symptoms. MRI during UAE showed no kidney abnormalities. Preoperative TLH evaluation included bimanual exam and transvaginal ultrasound, which showed a globular uterus. TLH with bilateral salpingectomy, adhesiolysis, and minor endometriosis excision were performed uneventfully. A routine post-procedural cystoscopy showed no jet from the right ureter. A stent was attempted, but obstruction was noted at the mid-ureter, 6 cm from the vesicoureteral junction. Retroperitoneal dissection showed a dilated distal ureter but no injury noted. Urology was consulted and intraoperative retrograde pyelogram showed dilated distal ureter with complete obstruction. Ureteroscopy showed a complete obstruction at the level of pelvic brim. Postoperative CT with IV contrast showed severe right renal atrophy. Labs showed normal BUN and creatinine levels, but a renal scan showed a non-functioning right kidney. Nephrology concluded that no surgery was needed to resect the atrophic kidney, and the patient was discharged on postoperative day one. Conclusion: Our experience is similar to a 2005 Canadian case report, in which a patient had complete ureteral obstruction following UAE, requiring nephrectomy. Although ureteral obstruction that results in unilateral non-functioning kidney following UAE is rare, it is likely an under-reported complication. As the uterine arteries supply the lower ureters, embolization could lead to segmental infarction of the ureter. Similarly, as leiomyoma necrose following UAE, peri-ureteral inflammation and infarction could occur. Physicians should be aware of these potential complications, and renal imaging may be indicated before hysterectomy in patients with prior UAE. Open Communications 2: Oncology (11:00 AM — 11:30 AM) 11:14 AM Occult Uterine Malignancy at the Time of Surgery for Benign Gynecologic Indications: An Updated Systematic Review
S25 Davenport ER,*,1 James L,2 Howard DL3. 1Obstetrics & Gynecology, Las Vegas Minimally Invasive Surgery, Las Vegas, NV; 2School of Medicine, University of Nevada, Las Vegas, Las Vegas, NV; 3Obstetrics and Gynecology, LVMIS-UNLV, Las Vegas, NV *Corresponding author. Study Objective: To conduct an updated systematic review to estimate the prevalence of occult uterine malignancy, of any subtype, among women undergoing surgery for benign gynecologic conditions. Design: Systematic review. Setting: N/A Patients or Participants: Women undergoing surgery for presumed benign gynecologic conditions. Interventions: Hysterectomy or Myomectomy. Measurements and Main Results: The PRISMA guidelines were followed in this systematic review. The search terms used were “occult malignancy” or “occult uterine pathology” paired with “morcellation” or “hysterectomy.” March 25, 2019 was the last date that articles were searched. We did not restrict articles based on language or publication date. Inclusion criteria included any peer-reviewed journal articles reporting occult uterine malignancy rates at the time of surgery for benign conditions, regardless of whether morcellation was used or not. We excluded articles that were reported exclusively on women with pre-operatively diagnosed or suspected uterine malignancies. Our search yielded a total of 233 journal articles, of which 53 met the criteria for a full-text review and 27 were included in the final systematic review. There were 339,420 patients across 9 countries that were included in these 27 studies. As a comparison, the previous systematic review done by the Agency for Healthcare Research and Quality (AHRQ) only included a total of 136,195 patients. There were a total 2,479 occult uterine malignancies (all subtypes combined) among these 339,420 patients. The crude unadjusted occult uterine malignancy rate was 0.73% (95% CI 0.70 − 0.76%). When we examined a subset of the included studies that reported specific data on women undergoing morcellation, there were 82 occult malignancies among a total of 25,422 patients (Crude proportion = 0.32% [95% CI 0.25 − 0.39%]). Conclusion: Based on this systematic review, incorporating over 300,000 patients, the overall prevalence of occult uterine malignancy at the time of surgery for benign gynecologic indications is approximately 0.73%. Open Communications 2: Oncology (11:00 AM — 11:30 AM) 11:21 AM Retroperitoneal Lymph Nodes: Cytoreduction in a Patient with Ovarian Cancer Suhner J,*,1 Tomita S,2 Kolev V2. 1Obstetrics and Gynecology, Mount Sinai St. Luke’s-West, New York, NY; 2Obstetrics and GynecologyGynecologic Oncology, Mount Sinai Hospital, New York, NY *Corresponding author. Video Objective: This video will exemplify the techniques necessary to safely complete a difficult dissection and debulking procedure in the obturator fossa in a patient with high-grade serous fallopian tube carcinoma. Setting: This patient is a 67-year-old who presented with a right sided complex adnexal mass and elevated CA-125 of 1300 with concern for malignancy. She was taken to the operating room for laparoscopic right salpingo-oophorectomy with possible hysterectomy and staging. The frozen section was consistent with high-grade serous fallopian tube carcinoma. A bulky retroperitoneal mass was found in the right obturator fossa and the patient underwent debulking procedure.
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 Study Objective: To determine the optimal time to administer pre-operative non-opioid oral analgesics to achieve superior post-operative pain modulation in patients undergoing outpatient minimally invasive hysterectomy for benign disease. Design: Randomized controlled trial. Setting: Minimally invasive gynecologic surgery practice. Patients or Participants: Women undergoing benign minimally invasive hysterectomy. Interventions: From January 2018 to October 2018, 60 women aged 3467 years were randomized to treatment (n=30) and control (n=30). Patients in the treatment arm self-administered oral celecoxib, gabapentin, and acetaminophen 3-4 hours prior to surgery, while those in the control arm received these medications in the pre-anesthesia care unit. All patients were administered intravenous nausea and vomiting prophylaxis. Time of oral medication ingestion and orogastric tube placement were collected. Post-operatively, patients were administered intravenous ketorolac and pain scores were assessed on an eleven-point numeric rating scale. Pain medications and anti-emetics were administered as needed prior to discharge. Opioid consumption was collected and converted to oral morphine equivalents (OME). Patients were sent an electronic survey assessing patient satisfaction and surgical recovery score on post-operative day 10. Measurements and Main Results: 53 subjects (29 in treatment and 24 in control) were included in the study. Baseline characteristics were balanced between treatment and control arms, with the exception of pre-existing gastro-esophageal reflux which was higher in the treatment group (20.7% vs. 0.0%, p=.026). 24.1% of the treatment arm required OME >50 compared to 41.7% of the control group (p=.174). There were no significant differences in pain score at discharge (p=.234), patient satisfaction (p=.90), or surgical recovery score (p=.189). Conclusion: Advanced administration of pre-operative oral analgesia trended towards a decrease in immediate post-operative opioid use when compared to immediate pre-operative administration. Timing of administration had no impact on pain scores, patient satisfaction, or surgical recovery scores. Either technique of administration of pre-operative oral analgesia is acceptable. Open Communications 2: Oncology (11:00 AM — 11:30 AM) 11:00 AM Single-Site Laparoscopic Comprehensive Staging Of Early Ovarian Cancer Liang Z*. Obstetric & Gynecology, Southwest Hospital, Chongqing, China *Corresponding author. Study Objective: To review the single-site laparoscopic staging procedure in a series of patients with early ovarian cancer and compare results with the literature. Design: A prospective single-center study. Setting: A hospital in China. Patients or Participants: A total of 21 patients with apparent early stage ovarian cancer from January 2017 through March 2019. The histologic tumor types were epithelial tumors (18 patients) and dysgerminoma (2 patients). All the epithelial tumors were invasive (13 serous and 8 mucinous). Interventions: Single-site laparoscopic comprehensive staging was performed in all patients according to the International Federation of Gynecology and Obstetrics guidelines. Measurements and Main Results: Fifteen patients had previous adnexal surgery and diagnosis and surgical staging were performed in only 6 patients during the same surgery. The patients’ median age was 32.8 years (range 26−57). Four (19%) patients desired to maintain fertility and a conservative approach was performed for this group. Single-site laparoscopic staging was completed in 20 (95%) patients. In 1 case, a conversion to
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 laparoscopic was necessary as the para-aortic lymphadenectomy was completed because of a vessel injury that was repaired without difficulty. The median operative timewas 265 minutes (range 210−320) for radical surgery and 218 minutes (range 120−240) for the conservative approach. The mean hospital stay was 3 days. Of the 21 total patients, 6 (28.6%) were upstaged. The median follow-up was 24.7 months (range 1−27), with a disease-free survival of 100% and an overall survival of 100%. No recurrence was observed. Conclusion: A comprehensive surgical staging procedure is clearly indicated in cases of early ovarian cancer and oncologic guidelines should be respected. The Single-site laparoscopic approach could be a valid alternative to laparoscopic or laparotomy. Open Communications 2: Oncology (11:00 AM — 11:30 AM) 11:07 AM Case Report: Ureteral Obstruction at the Time of Hysterectomy after Uterine Artery Embolization Touchan F,*,1 van der Does L,1 Haworth L,1 Wahbe C2. 1Research, The Center for Innovative GYN Care, Rockville, MD; 2Research, Clara Maass Medical Center, Belleville, NJ *Corresponding author. Study Objective: To report ureteral obstruction at the time of hysterectomy following uterine artery embolization (UAE). Design: Case report. Setting: Clara Maass Medical Center. Patients or Participants: 42 year-old African-American woman. Interventions: Hysterectomy following UAE. Measurements and Main Results: Patient presented for total laparoscopic hysterectomy (TLH) for abnormal uterine bleeding and dysmenorrhea. Patient had a history of UAE two years prior, which resolved her symptoms. MRI during UAE showed no kidney abnormalities. Preoperative TLH evaluation included bimanual exam and transvaginal ultrasound, which showed a globular uterus. TLH with bilateral salpingectomy, adhesiolysis, and minor endometriosis excision were performed uneventfully. A routine post-procedural cystoscopy showed no jet from the right ureter. A stent was attempted, but obstruction was noted at the mid-ureter, 6 cm from the vesicoureteral junction. Retroperitoneal dissection showed a dilated distal ureter but no injury noted. Urology was consulted and intraoperative retrograde pyelogram showed dilated distal ureter with complete obstruction. Ureteroscopy showed a complete obstruction at the level of pelvic brim. Postoperative CT with IV contrast showed severe right renal atrophy. Labs showed normal BUN and creatinine levels, but a renal scan showed a non-functioning right kidney. Nephrology concluded that no surgery was needed to resect the atrophic kidney, and the patient was discharged on postoperative day one. Conclusion: Our experience is similar to a 2005 Canadian case report, in which a patient had complete ureteral obstruction following UAE, requiring nephrectomy. Although ureteral obstruction that results in unilateral non-functioning kidney following UAE is rare, it is likely an under-reported complication. As the uterine arteries supply the lower ureters, embolization could lead to segmental infarction of the ureter. Similarly, as leiomyoma necrose following UAE, peri-ureteral inflammation and infarction could occur. Physicians should be aware of these potential complications, and renal imaging may be indicated before hysterectomy in patients with prior UAE. Open Communications 2: Oncology (11:00 AM — 11:30 AM) 11:14 AM Occult Uterine Malignancy at the Time of Surgery for Benign Gynecologic Indications: An Updated Systematic Review
S25 Davenport ER,*,1 James L,2 Howard DL3. 1Obstetrics & Gynecology, Las Vegas Minimally Invasive Surgery, Las Vegas, NV; 2School of Medicine, University of Nevada, Las Vegas, Las Vegas, NV; 3Obstetrics and Gynecology, LVMIS-UNLV, Las Vegas, NV *Corresponding author. Study Objective: To conduct an updated systematic review to estimate the prevalence of occult uterine malignancy, of any subtype, among women undergoing surgery for benign gynecologic conditions. Design: Systematic review. Setting: N/A Patients or Participants: Women undergoing surgery for presumed benign gynecologic conditions. Interventions: Hysterectomy or Myomectomy. Measurements and Main Results: The PRISMA guidelines were followed in this systematic review. The search terms used were “occult malignancy” or “occult uterine pathology” paired with “morcellation” or “hysterectomy.” March 25, 2019 was the last date that articles were searched. We did not restrict articles based on language or publication date. Inclusion criteria included any peer-reviewed journal articles reporting occult uterine malignancy rates at the time of surgery for benign conditions, regardless of whether morcellation was used or not. We excluded articles that were reported exclusively on women with pre-operatively diagnosed or suspected uterine malignancies. Our search yielded a total of 233 journal articles, of which 53 met the criteria for a full-text review and 27 were included in the final systematic review. There were 339,420 patients across 9 countries that were included in these 27 studies. As a comparison, the previous systematic review done by the Agency for Healthcare Research and Quality (AHRQ) only included a total of 136,195 patients. There were a total 2,479 occult uterine malignancies (all subtypes combined) among these 339,420 patients. The crude unadjusted occult uterine malignancy rate was 0.73% (95% CI 0.70 − 0.76%). When we examined a subset of the included studies that reported specific data on women undergoing morcellation, there were 82 occult malignancies among a total of 25,422 patients (Crude proportion = 0.32% [95% CI 0.25 − 0.39%]). Conclusion: Based on this systematic review, incorporating over 300,000 patients, the overall prevalence of occult uterine malignancy at the time of surgery for benign gynecologic indications is approximately 0.73%. Open Communications 2: Oncology (11:00 AM — 11:30 AM) 11:21 AM Retroperitoneal Lymph Nodes: Cytoreduction in a Patient with Ovarian Cancer Suhner J,*,1 Tomita S,2 Kolev V2. 1Obstetrics and Gynecology, Mount Sinai St. Luke’s-West, New York, NY; 2Obstetrics and GynecologyGynecologic Oncology, Mount Sinai Hospital, New York, NY *Corresponding author. Video Objective: This video will exemplify the techniques necessary to safely complete a difficult dissection and debulking procedure in the obturator fossa in a patient with high-grade serous fallopian tube carcinoma. Setting: This patient is a 67-year-old who presented with a right sided complex adnexal mass and elevated CA-125 of 1300 with concern for malignancy. She was taken to the operating room for laparoscopic right salpingo-oophorectomy with possible hysterectomy and staging. The frozen section was consistent with high-grade serous fallopian tube carcinoma. A bulky retroperitoneal mass was found in the right obturator fossa and the patient underwent debulking procedure.