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Surgical Treatment Patterns for Women with Newly Diagnosed Uterine Fibroids: Trends from 2010-2014
Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252 Setting: Computer software. Measurements and Main Results: The surgeon with the MAP at the time of surgery, has a special tool that concentrates all the details of the case. This MAP can be checked at any time in surgery and may guide the surgical team, even in the absence of medical records. Postoperatively, the MAP allows an evaluation of our propaedeutics in cases of endometriosis, comparing all the sites identified in the diagram preoperatively with the surgical findings. Conclusion: The MAP becomes an important tool for the physician selfevaluation, both on physical examination, as in the imaging. It’s possible to save patient data (demographic and patient complains) and image results as endometriosis findings, allowing it to be used for multicenter research protocols. 611 Cost-Benefit Analysis for the Utilisation of Detailed Preoperative Ultrasound in Women with Complex Endometriosis Disease Shakeri B. Obstetrics & Gynaecology, Nepean, Sydney, NSW, Australia Study Objective: About 15% of women who present to a gynaecology clinic have chronic pelvic pain (CPP). Up to 26% of this group will have underlying pouch of Douglas obliteration yet 82% of gynaecologists admit to not being able to perform advanced laparoscopic surgery. We aim to estimate the costs of a general gynaecologist’s conventional surgical approach (model 1) vs an ultrasound-based approach (model 2) to women with CPP and complex disease. Design: Model 1: general gynaecologist seeing women with suspected endometriosis proceeds directly to diagnostic laparoscopy without an advanced ultrasound examination, finds underlying POD obliteration/ complex endometriosis disease and then refers the woman to an advanced laparoscopic surgeon; model 2: general gynaecologist orders a detailed ultrasound examination by sonologist with expertise in endometriosis and refer cases with probable POD obliteration/complex endometriosis disease to a skilled advanced laparoscopic surgeon avoiding diagnostic laparoscopy. The costs to the public health system for consultation, ultrasound and various surgical interventions for endometriosis were retrieved from New South Wales Ministry of Health: consultation $A225, detailed ultrasound $A500, diagnostic laparoscopy $A2,541, colonoscopy $A4,880 and laparoscopic bowel surgery $A14,923. Calculations of the cost of treating complex disease were performed and compared for both clinical pathways. Measurements and Main Results: For an outpatient gynaecology unit that reviews 1000 new consultations annually, 15% (150/1000) women would present with CPP. Of these 26% (39/150) women would have underlying POD obliteration with complex endometriosis. With model 1 the cost of treating each complex case is $A23,970, whereas for model (2) $A21,203. This means that there is a cost saving of $A2767 per case or $A107,913 annually. Conclusion: If a general gynaecologist has access to expert ultrasound in the diagnosis of complex endometriosis, this results in significant cost savings to the public healthcare system. 612 Unexpected Severe Endometriosis at Laparoscopy Rajesh S, Guyer C. Gynaecology, Queen Alexandra Hopsital, Portsmouth, Hampshire, United Kingdom Study Objective: Were there clinical or radiological signs suggestive of suspected severe endometriosis pre-operatively? Design: Retrospective study. Setting: Endometriosis centre in the United Kingdom. Patients: 16 patients with severe endometriosis that were not suspected preoperatively. Intervention: There were 37 patients who had surgical treatment for stage 4 endometriosis in our unit from January 2015 to March 2016. Out of this 19 were suspected severe endmoetriosis who had appropriate work-up preoperatively. Rest of the 16 cases were looked at to see if we could have diagnosed them pre-operatively. Measurements and Main Results: 16 patients had an unexpected diagnosis of severe endometriosis at surgery.
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4 were totally unexpected having surgery for other reasons like menorrhagia etc. 4 were recurrent endometriosis with h/o previous surgery for mild/moderate endometriosis. 5 had endometriomas(unilateral/bilateral) on Trans vaginal ultrasound scan. 4 had a normal ultrasound scan but all had positive examination signs (tenderness) on bimanual exam. 2 patients declined VE. Conclusion: The suspicion for severe endometriosis should be high in cases with endometriomas esp bilateral lesions and those with h/o previous endometriosis. They should receive appropriate pre-operative imaging including MRI so that patients can be adequately counselled by the multidisciplinary team and surgery planned including allocation of adequate operating time. Virtual Posters – Hysteroscopy, Endometrial Ablation and Sterilization 613 Long-Term Clinical Outcomes of Thermal Balloon Endometrial Ablation (Thermablate EAS) with and without Concomitant Use of Levonorgestrel IntraUterine System in Women with Heavy Menstrual Bleeding: A Pilot Study Vilos GA,1 Rao S,1 Vilos AG,1 Abu Rafea B,1 Oraif A,2 Abduljabar H.2 1 Obstetrics and Gynecology, Western University, London, Ontario, Canada; 2Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia Study Objective: The LNG-IUS is an effective treatment of heavy menstrual bleeding (HMB) in up to 70% of women. The Thermablate balloon endometrial ablation (TBEA) system is comparable to all other non-hysteroscopic devices in treating HMB in up to 70% of women. In the present study, we hypothesized that combining the TBEA and LNGIUS will increase clinical outcomes in over 70% of women. Design: Prospective comparison of two cohorts of women with HMB. Inclusion of LNG-IUS to TBEA was patient driven. Setting: University-affiliated hospital. Patients: After REB approval and informed consent, 87 women with HMB, normal office endometrial biopsy and sonographically normal uterine cavity participated in the study; (TBEA, n=44 and TBEA+LNG-IUS, n=43). Intervention: TBEA and LNG-IUS placement took place in an operating room under general anesthesia. Hysteroscopy was performed pre- and post-TBEA and the LNG-IUS was placed immediately thereafter. Patients were assessed at 3, 6, 12 months and annually thereafter up to 5 years. Clinical outcomes included menstrual reduction (amenorrhea/ hypomenorhea), patient satisfaction and re-intervention. Measurements and Main Results: The age, BMI, parity and uterine sounding were equal in both groups. At a median follow up of 36 months (12-60), amenorrhea and re-intervention rates were 29.5% (13/44) v 60.5% (26/43, p\ 0.001), and 29.5% (13/44) v 7.0% (3/43, p\ 0.001) in the TBEA vs TBEA+LNG-IUS groups, respectively, with corresponding patient satisfaction of 61.5% (27/44) v 86.1% 37/43). There were 2 hysterectomies in the TBEA group for pain and bleeding. Adenomyosis was found in both and fibroids in one. One patient in the TBEA group required OCP while repeat resectoscopic endometrial resection was performed in all other failures and adenomyosis was found in 40% of specimens. Conclusion: The concomitant use of LNG-IUS immediately after TBEA significantly increases amenorrhea and patient satisfaction rates and decreases requirement for re-intervention compared with TBEA alone. 614 Surgical Treatment Patterns for Women with Newly Diagnosed Uterine Fibroids: Trends from 2010-2014 Bonafede M,1 Pohlman S,2 Riehle E,1 Adolph N,1 Troeger K.2 1Truven Health Analytics, Inc., Cambridge, Massachusetts; 2Hologic, Inc., Marlborough, Massachusetts
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Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252
Study Objective: To describe surgical treatment patterns among women with newly diagnosed uterine fibroids from 2010-2014. Design: A retrospective analysis using US administrative claims from 20102014. Patients: Women age 30 and older with a new diagnosis of uterine fibroid (ICD-9 code:218.x) between 2010 and 2014 and at least 12 months of continuous medical and pharmacy enrollment in the Truven Health MarketScan Commercial and Medicare Supplemental Databases. Measurements and Main Results: The use of specific diagnostic and treatment procedures and pharmacotherapy were evaluated in the 12month period following diagnosis. Women with a diagnosis of gynecologic cancer or a procedure code for a uterus >250g were excluded. Of 973,107 women with a uterine fibroid diagnosis, 292,318 represent eligible incident cases. Overall, 33.1% of women meeting the inclusion criteria underwent a surgical procedure within one year of a new fibroid diagnosis, decreasing steadily from 36.4% in 2010 to 29.5% in 2014. The largest decrease occurred for hysterectomy where 21.9% of women underwent hysterectomy in the year following diagnosis, with higher rates in 2010 (24.0%) than 2014 (19.3%). Hysterectomy represented a similar proportion of all surgical interventions throughout the study period (mean 66.0%). Yearly rates of hysteroscopic myomectomy in women newly diagnosed with fibroids were relatively stable (range 4.8%-5.4%), yet hysteroscopic myomectomy accounted for a larger proportion of surgical procedures in 2014 (11.2%) than 2010 (7.1%). The prevalence of curettage mirrored the observed surgical trend, decreasing slightly from 4.1% in 2010 to 3.0% in 2014. Uterine artery embolization was uncommon throughout the study period (\1% each year). Pharmacotherapy interventions, including intrauterine devices (IUD), increased slightly from 11.0% in 2010 to 12.9% in 2014. Conclusion: From 2010 to 2014, rates of surgical intervention within 12 months of a new diagnosis of uterine fibroids decreased. During the same time, minimally invasive procedures, like hysteroscopic myomectomy, became more prevalent.
615 Diagnostic Hysteroscopy in Asymptomatic Postmenopausal Women with Sonographically Abnormal Endometrial Findings Choi J-K,1 Park S-I,1 Kim T-H,2 Ryu S-Y,2 Lee E-D.1 1Departments of Obstetrics and Gynecology, Korea Cancer Center Hospital, Dongnam Institute of Radiological and Medical Sciences (DIRAMS), Busan, Jangan-eup, Gijang-gun, Korea; 2Departments of Obstetrics and Gynecology, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences (KIRAMS), Seoul, Korea Study Objective: Endometrial cancer is one of the most common gynecological malignancies, and patients usually present with vaginal bleeding, But 10-20% of patients have no symptoms. We evaluated asymptomatic postmenopausal women with sonographically abnormal endometrial findings by diagnostic hysteroscopic exam, and we compares hysteroscopic and pathologic diagnosis. Design: A Retrospective analysis. Setting: Korea Cancer center in Seoul and Busan, Korea. Patients: During the period between January 2015 and March 2016, a retrospective analysis was performed including 167 cases of women who were preoperatively diagnosed with a sonographically thickened endometrium, while asymptomatic. Intervention: The patients underwent hysteroscopic exam (4.5mm Storz hysteroscope) and dilatation and curettage of uterus (D&C) under local or general anesthesia, in addition to transvaginal sonography. Demographic, clinical and pathological outcomes were reported. Measurements and Main Results: Total of 167 patients were enrolled. The median age of the woman was 59 (range 47-79) years. Average endometrial thickness measured by ultrasound was 9.2 mm +/- 5.2 mm. On hysteroscopy review, 85 (50.9%) patients were reported as polyp, 21 (12.6%) as myoma and 14 (8.4%) as hyperplasia.
Table 2. Comparison between endometrial thickness and hysteroscopic findings
%4mm 5-10mm 11-15mm 16-20mm >20mm Total (%)
Hysteroscopic findings Normal EM Polyp
Myoma
Atrophy
Hyperplasia
Others
Total
10 14 3 0 0 27 (16.2)
3 9 4 4 1 21 (12.6)
4 10 1 0 0 15 (9.0)
3 4 5 2 0 14 (8.4)
2 3 0 0 0 5 (3.0)
38 95 23 8 3 167
16 55 10 2 2 85 (50.9)
Endometrial biopsies were performed on 140 patients (83.8%). Histopathological analysis showed that 67 (47.9%) patients presented polyp, 36 (25.7%) as normal endometrium, 25 (17.9%) as myoma, and 8 (5.7%) as atrophic endometrium. Simple hyperplasia was found in one patient with thickened endometrium but neither endometrial carcinoma nor complex hyperplasia was found.
Table 3. Results from diagnostic hysteroscopic findings compared with the histopathological findings
Normal EM Polyp Myoma Hyperplasia Other Total (%)
Histopathologic diagnosis Normal EM Polyp
Myoma
Atrophy
Hyperplasia
others
Total
11 12 0 6 3 36 (25.7)
0 5 19 0 1 25 (17.9)
2 3 0 0 1 8 (5.7)
0 0 0 1 0 1 (0.7)
0 1 0 0 2 3 (2.1)
13 84 23 7 7 140
0 63 4 0 0 67 (47.9)
In our data, the sensitivity, specificity and positive and negative predictive values for polyp, myoma and hyperplasia were relatively high, except of PPV for hyperplasia.
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4 were totally unexpected having surgery for other reasons like menorrhagia etc. 4 were recurrent endometriosis with h/o previous surgery for mild/moderate endometriosis. 5 had endometriomas(unilateral/bilateral) on Trans vaginal ultrasound scan. 4 had a normal ultrasound scan but all had positive examination signs (tenderness) on bimanual exam. 2 patients declined VE. Conclusion: The suspicion for severe endometriosis should be high in cases with endometriomas esp bilateral lesions and those with h/o previous endometriosis. They should receive appropriate pre-operative imaging including MRI so that patients can be adequately counselled by the multidisciplinary team and surgery planned including allocation of adequate operating time. Virtual Posters – Hysteroscopy, Endometrial Ablation and Sterilization 613 Long-Term Clinical Outcomes of Thermal Balloon Endometrial Ablation (Thermablate EAS) with and without Concomitant Use of Levonorgestrel IntraUterine System in Women with Heavy Menstrual Bleeding: A Pilot Study Vilos GA,1 Rao S,1 Vilos AG,1 Abu Rafea B,1 Oraif A,2 Abduljabar H.2 1 Obstetrics and Gynecology, Western University, London, Ontario, Canada; 2Obstetrics and Gynecology, King Abdulaziz University, Jeddah, Saudi Arabia Study Objective: The LNG-IUS is an effective treatment of heavy menstrual bleeding (HMB) in up to 70% of women. The Thermablate balloon endometrial ablation (TBEA) system is comparable to all other non-hysteroscopic devices in treating HMB in up to 70% of women. In the present study, we hypothesized that combining the TBEA and LNGIUS will increase clinical outcomes in over 70% of women. Design: Prospective comparison of two cohorts of women with HMB. Inclusion of LNG-IUS to TBEA was patient driven. Setting: University-affiliated hospital. Patients: After REB approval and informed consent, 87 women with HMB, normal office endometrial biopsy and sonographically normal uterine cavity participated in the study; (TBEA, n=44 and TBEA+LNG-IUS, n=43). Intervention: TBEA and LNG-IUS placement took place in an operating room under general anesthesia. Hysteroscopy was performed pre- and post-TBEA and the LNG-IUS was placed immediately thereafter. Patients were assessed at 3, 6, 12 months and annually thereafter up to 5 years. Clinical outcomes included menstrual reduction (amenorrhea/ hypomenorhea), patient satisfaction and re-intervention. Measurements and Main Results: The age, BMI, parity and uterine sounding were equal in both groups. At a median follow up of 36 months (12-60), amenorrhea and re-intervention rates were 29.5% (13/44) v 60.5% (26/43, p\ 0.001), and 29.5% (13/44) v 7.0% (3/43, p\ 0.001) in the TBEA vs TBEA+LNG-IUS groups, respectively, with corresponding patient satisfaction of 61.5% (27/44) v 86.1% 37/43). There were 2 hysterectomies in the TBEA group for pain and bleeding. Adenomyosis was found in both and fibroids in one. One patient in the TBEA group required OCP while repeat resectoscopic endometrial resection was performed in all other failures and adenomyosis was found in 40% of specimens. Conclusion: The concomitant use of LNG-IUS immediately after TBEA significantly increases amenorrhea and patient satisfaction rates and decreases requirement for re-intervention compared with TBEA alone. 614 Surgical Treatment Patterns for Women with Newly Diagnosed Uterine Fibroids: Trends from 2010-2014 Bonafede M,1 Pohlman S,2 Riehle E,1 Adolph N,1 Troeger K.2 1Truven Health Analytics, Inc., Cambridge, Massachusetts; 2Hologic, Inc., Marlborough, Massachusetts
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Abstracts / Journal of Minimally Invasive Gynecology 23 (2016) S1–S252
Study Objective: To describe surgical treatment patterns among women with newly diagnosed uterine fibroids from 2010-2014. Design: A retrospective analysis using US administrative claims from 20102014. Patients: Women age 30 and older with a new diagnosis of uterine fibroid (ICD-9 code:218.x) between 2010 and 2014 and at least 12 months of continuous medical and pharmacy enrollment in the Truven Health MarketScan Commercial and Medicare Supplemental Databases. Measurements and Main Results: The use of specific diagnostic and treatment procedures and pharmacotherapy were evaluated in the 12month period following diagnosis. Women with a diagnosis of gynecologic cancer or a procedure code for a uterus >250g were excluded. Of 973,107 women with a uterine fibroid diagnosis, 292,318 represent eligible incident cases. Overall, 33.1% of women meeting the inclusion criteria underwent a surgical procedure within one year of a new fibroid diagnosis, decreasing steadily from 36.4% in 2010 to 29.5% in 2014. The largest decrease occurred for hysterectomy where 21.9% of women underwent hysterectomy in the year following diagnosis, with higher rates in 2010 (24.0%) than 2014 (19.3%). Hysterectomy represented a similar proportion of all surgical interventions throughout the study period (mean 66.0%). Yearly rates of hysteroscopic myomectomy in women newly diagnosed with fibroids were relatively stable (range 4.8%-5.4%), yet hysteroscopic myomectomy accounted for a larger proportion of surgical procedures in 2014 (11.2%) than 2010 (7.1%). The prevalence of curettage mirrored the observed surgical trend, decreasing slightly from 4.1% in 2010 to 3.0% in 2014. Uterine artery embolization was uncommon throughout the study period (\1% each year). Pharmacotherapy interventions, including intrauterine devices (IUD), increased slightly from 11.0% in 2010 to 12.9% in 2014. Conclusion: From 2010 to 2014, rates of surgical intervention within 12 months of a new diagnosis of uterine fibroids decreased. During the same time, minimally invasive procedures, like hysteroscopic myomectomy, became more prevalent.
615 Diagnostic Hysteroscopy in Asymptomatic Postmenopausal Women with Sonographically Abnormal Endometrial Findings Choi J-K,1 Park S-I,1 Kim T-H,2 Ryu S-Y,2 Lee E-D.1 1Departments of Obstetrics and Gynecology, Korea Cancer Center Hospital, Dongnam Institute of Radiological and Medical Sciences (DIRAMS), Busan, Jangan-eup, Gijang-gun, Korea; 2Departments of Obstetrics and Gynecology, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences (KIRAMS), Seoul, Korea Study Objective: Endometrial cancer is one of the most common gynecological malignancies, and patients usually present with vaginal bleeding, But 10-20% of patients have no symptoms. We evaluated asymptomatic postmenopausal women with sonographically abnormal endometrial findings by diagnostic hysteroscopic exam, and we compares hysteroscopic and pathologic diagnosis. Design: A Retrospective analysis. Setting: Korea Cancer center in Seoul and Busan, Korea. Patients: During the period between January 2015 and March 2016, a retrospective analysis was performed including 167 cases of women who were preoperatively diagnosed with a sonographically thickened endometrium, while asymptomatic. Intervention: The patients underwent hysteroscopic exam (4.5mm Storz hysteroscope) and dilatation and curettage of uterus (D&C) under local or general anesthesia, in addition to transvaginal sonography. Demographic, clinical and pathological outcomes were reported. Measurements and Main Results: Total of 167 patients were enrolled. The median age of the woman was 59 (range 47-79) years. Average endometrial thickness measured by ultrasound was 9.2 mm +/- 5.2 mm. On hysteroscopy review, 85 (50.9%) patients were reported as polyp, 21 (12.6%) as myoma and 14 (8.4%) as hyperplasia.
Table 2. Comparison between endometrial thickness and hysteroscopic findings
%4mm 5-10mm 11-15mm 16-20mm >20mm Total (%)
Hysteroscopic findings Normal EM Polyp
Myoma
Atrophy
Hyperplasia
Others
Total
10 14 3 0 0 27 (16.2)
3 9 4 4 1 21 (12.6)
4 10 1 0 0 15 (9.0)
3 4 5 2 0 14 (8.4)
2 3 0 0 0 5 (3.0)
38 95 23 8 3 167
16 55 10 2 2 85 (50.9)
Endometrial biopsies were performed on 140 patients (83.8%). Histopathological analysis showed that 67 (47.9%) patients presented polyp, 36 (25.7%) as normal endometrium, 25 (17.9%) as myoma, and 8 (5.7%) as atrophic endometrium. Simple hyperplasia was found in one patient with thickened endometrium but neither endometrial carcinoma nor complex hyperplasia was found.
Table 3. Results from diagnostic hysteroscopic findings compared with the histopathological findings
Normal EM Polyp Myoma Hyperplasia Other Total (%)
Histopathologic diagnosis Normal EM Polyp
Myoma
Atrophy
Hyperplasia
others
Total
11 12 0 6 3 36 (25.7)
0 5 19 0 1 25 (17.9)
2 3 0 0 1 8 (5.7)
0 0 0 1 0 1 (0.7)
0 1 0 0 2 3 (2.1)
13 84 23 7 7 140
0 63 4 0 0 67 (47.9)
In our data, the sensitivity, specificity and positive and negative predictive values for polyp, myoma and hyperplasia were relatively high, except of PPV for hyperplasia.