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Total Laparoscopic Ureteroneocystostomy for Ureteral Endometriosis: A Single Center Experience on 160 Consecutive Cases
S22
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201
Goals of pathology excision must be for complete removal with minimal damaging effect or loss of surrounding healthy tissue. Damage to surrounding tissues can often be apparent, but sometimes are quite subtle to those without a trained eye. This damage can affect fertility and other components of women’s health. This video seeks to present visual cues to assist surgeons in identifying proper planes of dissection for pathology removal, using myomectomy and ovarian endometrioma cystectomy footage as examples. By identifying adherent tissue on pathology, avascular planes, using “overcut” on leiomyoma, and being aware of endometrium and ovarian follicle appearance, the surgeon can avoid unintentional healthy tissue trauma. Maneuvers to successfully complete the dissection are also demonstrated on film including serial rolling, sweeping and gentle wiping, curved motions, selective use of energy, careful millimeter-by-millimeter progression, pushing with spreading, and traction with counter-traction.
56
Plenary 8 – Education, Research & Science (3:25 PM – 5:05 PM) 4:55 PM – GROUP C
Surgical Management of Adenomyoma with Uterine Wall Dissection Post-Myomectomy: A Case Report Ely LK,1 Truong M,1 Advincula A.2 1Obstetrics and Gynecology, Virginia Commonwealth University Health System, Richmond, Virginia; 2 Obstetrics and Gynecology, Columbia University Medical Center, New York, New York The purpose of this video is to review the diagnosis and treatment of uterine adenomyosis and adenomyoma, and to describe the surgical management of an atypical adenomyoma case. The video presents the case of a 37yo G1P1011 who underwent a robotic myomectomy for symptomatic uterine fibroids but subsequently re-presented with worsening symptoms and was found to have an adenomyoma with complete uterine wall dissection. The video reviews pre-operative imagining and demonstrates the surgical management of this case.
TUESDAY, NOVEMBER 14, 2017
57
Open Communications 1 – Endometriosis & Adenomyosis (11:00 AM–12:00 PM) 11:00 AM – GROUP A
Total Laparoscopic Ureteroneocystostomy for Ureteral Endometriosis: A Single Center Experience on 160 Consecutive Cases Clarizia R,1 Caleffi G,2 Ceccarello M,1 Scarperi S,1 Bruni F,1 Ceccaroni M1. 1Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy; 2 Department of Urology, Sacred Heart Hospital, International School of Surgical Anatomy, Negrar, Verona, Italy Study Objective: To investigate the efficacy of laparoscopic ureteroneocystostomy in patients with deep infiltrating endometriosis (DIE) with ureteral and parametrial involvement. Design: Prospective observational study. Setting: Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona – Italy. Patients: 160 patients with DIE treated by laparoscopic radical excision and ureteroneocystostomy between January 2009 and December 2016 in a tertiary care referral center for endometriosis.
Intervention: In 58.7% of cases ureteroneocystostomy was performed with psoas hitch technique, with an average execution time of 92.3 min. Bowel resection was performed in 121 patients (75.6%) and 115 of them had a concomitant ileostomy (71.9%). Unilateral parametrectomy was performed in 61.9% of cases on the left side and 20.6% on the right side respectively, while bilateral parametrectomy was done in 33 patients (20.6%). Measurements and Main Results: Post-operative complications were infrequent: 7 cases of re-intervention (4.4%), 8 case of fever (5%), 4 patients required blood transfusion (2.5%), 3 cases of intestinal fistulas (1.9%) and 24 patients experienced impaired bladder voiding (15%). The mean followup time was 20.5 months (1–60). The study reported good clinical and surgical results in the medium and long term, with a 1.2% of recurrent parametrial endometriosis needing opposite side ureteroneocystostomy and a statistically significant regression of symptoms. Conclusion: The collected data show that in case of ureteral endometriosis, this technique is feasible, effective and safe, and provides good results in terms of relapses and control of symptoms. In endometriosis surgery, ureteral stricture itself cannot be considered the only factor conditioning the surgical decision for ureteroneocystostomy, which has to be tailored, taking into account the residual ureteral vascularization and its trophic aspects after ureterolysis and external endometriosis removal. 58
Open Communications 1 – Endometriosis & Adenomyosis (11:00 AM–12:00 PM) 11:07 AM – GROUP A
DNA Testing to Predict Endometriosis: Implications for Referral for Minimally Invasive Surgery Fogelson NS,1 Chettier R,2 Ward K2. 1Pearl Women’s Center, Portland, Oregon; 2Juneau Biosciences, Salt Lake City, Utah Study Objective: A proprietary DNA marker test has been developed for non-invasive prediction of endometriosis in pre-laparoscopy patients. The purpose of this study was to test the performance of this DNA marker panel in a set of known diagnosis samples. Design: DNA samples from 200 women with confirmed endometriosis and 200 women with no evidence of endometriosis were genotyped in a blinded fashion for 1067 low-frequency DNA variants associated with endometriosis. For this pilot study, risk of endometriosis was determined using an algorithm weighting each genotype results by the logarithm of the odds ratio as determined from a large training data set (1000 genotyped endometriosis patients and 33 000 published controls). Setting: Samples collected from around the country as part of ongoing research of Juneau Biosciences, a Utah-based genetics company. Patients: All patients voluntarily submitted DNA samples to Juneau Biosciences for research in the genetics of endometriosis. Patients provided access to medical records to confirm diagnoses and pathology. Intervention: N/A. Measurements and Main Results: 189 affected women (95%) with weighted score greater than 0.47 were correctly classified as having endometriosis while 176 of the unaffected women (88%) were classified as having low risk of endometriosis (weighted scores less than 0.47). The area under the receiver operator curve was 0.95. Conclusion: The panel of DNA markers tested provides actionable predictions. Improvements in the test algorithm are likely as interaction terms or biologic pathway data are considered. Prospective clinical trials are planned. Many women with pelvic pain wait years before getting a correct diagnosis. Non-invasive DNA testing may help to direct symptomatic patients to specialists who can effectively treat the disease state. DNA markers might have better correlation to the subtypes and extent of disease than histology alone. A subset of infertility patients who may benefit from surgical treatment of previously unknown disease prior to infertility treatment may be identifiable.
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201
Goals of pathology excision must be for complete removal with minimal damaging effect or loss of surrounding healthy tissue. Damage to surrounding tissues can often be apparent, but sometimes are quite subtle to those without a trained eye. This damage can affect fertility and other components of women’s health. This video seeks to present visual cues to assist surgeons in identifying proper planes of dissection for pathology removal, using myomectomy and ovarian endometrioma cystectomy footage as examples. By identifying adherent tissue on pathology, avascular planes, using “overcut” on leiomyoma, and being aware of endometrium and ovarian follicle appearance, the surgeon can avoid unintentional healthy tissue trauma. Maneuvers to successfully complete the dissection are also demonstrated on film including serial rolling, sweeping and gentle wiping, curved motions, selective use of energy, careful millimeter-by-millimeter progression, pushing with spreading, and traction with counter-traction.
56
Plenary 8 – Education, Research & Science (3:25 PM – 5:05 PM) 4:55 PM – GROUP C
Surgical Management of Adenomyoma with Uterine Wall Dissection Post-Myomectomy: A Case Report Ely LK,1 Truong M,1 Advincula A.2 1Obstetrics and Gynecology, Virginia Commonwealth University Health System, Richmond, Virginia; 2 Obstetrics and Gynecology, Columbia University Medical Center, New York, New York The purpose of this video is to review the diagnosis and treatment of uterine adenomyosis and adenomyoma, and to describe the surgical management of an atypical adenomyoma case. The video presents the case of a 37yo G1P1011 who underwent a robotic myomectomy for symptomatic uterine fibroids but subsequently re-presented with worsening symptoms and was found to have an adenomyoma with complete uterine wall dissection. The video reviews pre-operative imagining and demonstrates the surgical management of this case.
TUESDAY, NOVEMBER 14, 2017
57
Open Communications 1 – Endometriosis & Adenomyosis (11:00 AM–12:00 PM) 11:00 AM – GROUP A
Total Laparoscopic Ureteroneocystostomy for Ureteral Endometriosis: A Single Center Experience on 160 Consecutive Cases Clarizia R,1 Caleffi G,2 Ceccarello M,1 Scarperi S,1 Bruni F,1 Ceccaroni M1. 1Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona, Italy; 2 Department of Urology, Sacred Heart Hospital, International School of Surgical Anatomy, Negrar, Verona, Italy Study Objective: To investigate the efficacy of laparoscopic ureteroneocystostomy in patients with deep infiltrating endometriosis (DIE) with ureteral and parametrial involvement. Design: Prospective observational study. Setting: Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, Verona – Italy. Patients: 160 patients with DIE treated by laparoscopic radical excision and ureteroneocystostomy between January 2009 and December 2016 in a tertiary care referral center for endometriosis.
Intervention: In 58.7% of cases ureteroneocystostomy was performed with psoas hitch technique, with an average execution time of 92.3 min. Bowel resection was performed in 121 patients (75.6%) and 115 of them had a concomitant ileostomy (71.9%). Unilateral parametrectomy was performed in 61.9% of cases on the left side and 20.6% on the right side respectively, while bilateral parametrectomy was done in 33 patients (20.6%). Measurements and Main Results: Post-operative complications were infrequent: 7 cases of re-intervention (4.4%), 8 case of fever (5%), 4 patients required blood transfusion (2.5%), 3 cases of intestinal fistulas (1.9%) and 24 patients experienced impaired bladder voiding (15%). The mean followup time was 20.5 months (1–60). The study reported good clinical and surgical results in the medium and long term, with a 1.2% of recurrent parametrial endometriosis needing opposite side ureteroneocystostomy and a statistically significant regression of symptoms. Conclusion: The collected data show that in case of ureteral endometriosis, this technique is feasible, effective and safe, and provides good results in terms of relapses and control of symptoms. In endometriosis surgery, ureteral stricture itself cannot be considered the only factor conditioning the surgical decision for ureteroneocystostomy, which has to be tailored, taking into account the residual ureteral vascularization and its trophic aspects after ureterolysis and external endometriosis removal. 58
Open Communications 1 – Endometriosis & Adenomyosis (11:00 AM–12:00 PM) 11:07 AM – GROUP A
DNA Testing to Predict Endometriosis: Implications for Referral for Minimally Invasive Surgery Fogelson NS,1 Chettier R,2 Ward K2. 1Pearl Women’s Center, Portland, Oregon; 2Juneau Biosciences, Salt Lake City, Utah Study Objective: A proprietary DNA marker test has been developed for non-invasive prediction of endometriosis in pre-laparoscopy patients. The purpose of this study was to test the performance of this DNA marker panel in a set of known diagnosis samples. Design: DNA samples from 200 women with confirmed endometriosis and 200 women with no evidence of endometriosis were genotyped in a blinded fashion for 1067 low-frequency DNA variants associated with endometriosis. For this pilot study, risk of endometriosis was determined using an algorithm weighting each genotype results by the logarithm of the odds ratio as determined from a large training data set (1000 genotyped endometriosis patients and 33 000 published controls). Setting: Samples collected from around the country as part of ongoing research of Juneau Biosciences, a Utah-based genetics company. Patients: All patients voluntarily submitted DNA samples to Juneau Biosciences for research in the genetics of endometriosis. Patients provided access to medical records to confirm diagnoses and pathology. Intervention: N/A. Measurements and Main Results: 189 affected women (95%) with weighted score greater than 0.47 were correctly classified as having endometriosis while 176 of the unaffected women (88%) were classified as having low risk of endometriosis (weighted scores less than 0.47). The area under the receiver operator curve was 0.95. Conclusion: The panel of DNA markers tested provides actionable predictions. Improvements in the test algorithm are likely as interaction terms or biologic pathway data are considered. Prospective clinical trials are planned. Many women with pelvic pain wait years before getting a correct diagnosis. Non-invasive DNA testing may help to direct symptomatic patients to specialists who can effectively treat the disease state. DNA markers might have better correlation to the subtypes and extent of disease than histology alone. A subset of infertility patients who may benefit from surgical treatment of previously unknown disease prior to infertility treatment may be identifiable.