Oral Presentations

Oral Presentations

Journal of Minimally Invasive Gynecology (2006) 13, September/October Supplement THE JOURNAL OF MINIMALLY INVASIVE GYNECOLOGY Oral Presentations TUE...

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Journal of Minimally Invasive Gynecology (2006) 13, September/October Supplement THE JOURNAL OF

MINIMALLY INVASIVE GYNECOLOGY

Oral Presentations TUESDAY, NOVEMBER 7, 2006 Plenary 1—Adhesions (10:30

AM

– 10:41

AM)

1 TNF-alpha and IL6 Expression in Human Normal Peritoneal and Adhesion Fibroblasts: Regulation by Hypoxia 1 Amber DR, 2Rizk NN, 2Jiang J, 2Lu C, 2Saed GM, 1 Diamond MP. 1Wayne State University/Detroit Medical Center; 2Wayne State University School of Medicine, C.S. Mott Center, Detroit, Michigan Study Objective: We have previously identified phenotypic molecular differences between fibroblasts isolated from normal peritoneum and adhesions. Therefore, we sought to analyze TNF-alpha and IL6 mRNA levels in fibroblasts isolated from human normal peritoneum and adhesion tissues under normoxic and hypoxic conditions. Design: Prospective experimental study. Setting: Wayne State University, Detroit, Michigan. Patients: Primary fibroblast cultures established from normal peritoneum and adhesion tissues of three patients. Intervention: Normal and adhesion fibroblasts were cultured under normal (20% O2) and hypoxic (2% O2) conditions for 24 hours, after which total RNA was isolated from each cell type and treatment group. Measurements and Main Results: Relative mRNA levels of TNF-alpha and IL6 were quantified using real-time RTPCR, with results normalized to control levels of `-actin. TNF-alpha and IL6 mRNA were present in both normal peritoneal and adhesion fibroblasts. Normoxic adhesion fibroblasts exhibited significantly higher levels of TNFalpha and IL6 mRNA as compared to normoxic, normal peritoneal fibroblasts (100% increase, p < 0.05). Hypoxia treatment significantly increased both cytokine levels in normal peritoneal and adhesion fibroblasts. Although, the increase in TNF-alpha and IL6 mRNA levels of hypoxic normal fibroblasts reached those of normoxic adhesion fibroblasts (1000% increase, p < 0.05), the effect of hypoxia on adhesion fibroblasts was minimal compared to normoxic adhesion fibroblasts. Conclusion: TNF-alpha and IL6 mRNA are present in normal and adhesion fibroblasts and are significantly higher in adhesion fibroblasts. The differential expression of TNFalpha and IL6 between normal peritoneal and adhesion © 2006 AAGL. All rights reserved.

fibroblasts and their regulation by hypoxia indicate potential molecular pathways in the development of adhesions. Thus, further investigation specifically directed at the inhibition of TNF-alpha and IL6 may potentially reduce intra-abdominal adhesion development.

TUESDAY, NOVEMBER 7, 2006 Plenary 1—Adhesions (10:41

AM

– 10:52

AM)

2 Differential Expression of Estrogen, Progesterone, Androgen, and Prolactin Receptors in In Vitro Human Fibroblasts Isolated from Normal Peritoneum and Adhesions Detti L, Saed GM, Jiang ZL, Kruger M, Diamond MP. Wayne State University, Detroit, Michigan Study Objective: To characterize fibroblasts isolated from normal peritoneum and adhesion tissues (activated/inflammatory) in their ability to express various hormone receptors when cultured with exogenous estradiol to mimic an ovarian hyperstimulation cycle for infertility treatment. Design: This was a prospective experimental study. We utilized real time RT-PCR to determine mRNA levels for estrogen (ER-_, ER-`), progesterone (P), androgen (A), and prolactin (PRL) receptors in primary cultures of fibroblasts isolated from normal peritoneum and adhesion tissue. Both cell lines were treated ex-vivo with increasing concentrations of estradiol. Setting: University Laboratory. Patients: Primary cultures of fibroblasts isolated from normal peritoneum and adhesion tissue from 3 different patients. Intervention: Fibroblasts were treated with zero (control), 10-10, 10-8, and 10-6 Molar concentrations of 17`-estradiol and incubated for 24 hours at 37°C before performing RTPCR. The increasing molar concentrations represented the estradiol concentrations during the early follicular phase (serum), and during ovarian stimulation (serum and follicular). Measurements and Main Results: ER-_ receptors mRNA level was unchanged in normal fibroblasts at the different estradiol concentrations, but showed a marked increase in adhesion tissue cells at the 10-8 concentration. ER-` receptors showed a similar expression in normal and adhesion fibroblasts at the increasing estradiol concentrations, but

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Journal of Minimally Invasive Gynecology, Vol 13, No 5, September/October Supplement 2006

expression in adhesion fibroblasts was statistically lower at the 10-10 M and higher at the 10-6 M estradiol concentration. P-R expression, higher in normal versus adhesion fibroblast controls, was low at 10-10 M and 10-8 M estradiol concentrations in both cell lines, but increased exponentially at the 10-6 M in the normal peritoneum fibroblasts, to remain low in adhesion tissue fibroblasts. A-R showed a statistically higher expression in normal fibroblasts at rest. At 10-10 and 10-8 estradiol concentrations, expression was higher in adhesion fibroblasts. PRL-R expression was not different in normal peritoneum and in adhesion tissue fibroblasts, except for the 10-10 M estradiol concentration, where it showed an exponentially increased expression in the adhesion peritoneum fibroblasts. Conclusion: The ‘activation’ of adhesion fibroblasts seems to impact their response to estradiol in the expression of various hormone receptors. In particular, the increased expression of ER-_ and A receptors in adhesion fibroblasts may increase the potential for these cells to manifest enhanced responses to inflammation, infection, and/or endometriosis.

TUESDAY, NOVEMBER 7, 2006 Plenary 1—Adhesions (10:52

AM

– 11:03

AM)

3 Deficiency of L-Arginine in Human Adhesion Fibroblasts Leads to the Generation of Superoxide by Inducible Nitric Oxide Synthase Diamond MP, Saed GM, Abu-Soud HM. Wayne State University, Detroit, Michigan Study Objective: Since in chemical reactions iNOS in the absence of L-arginine creates superoxide, we tested the hypothesis that a deficiency in L-arginine in adhesion fibroblasts causes iNOS to produce superoxide, which consumes nitric oxide (NO), thereby resulting in the low NO levels observed in adhesion fibroblasts. Design: Cell culture Study. Setting: University Research Laboratory. Patients: Normal and adhesion fibroblasts isolated from gynecological surgical patients. Intervention: Addition of NADPH, iNOS and iNOS SiRNA. Measurements and Main Results: We have utilized an NOselective electrode to demonstrate the autoxidation (consumption) of nitric oxide in the absence of L-arginine following the addition to a stirred 0.2 M sodium phosphate buffer (pH 7.0) at 25°C under air of NADPH followed by iNOS. The same technique was utilized to determine nitric oxide consumption following the addition of homogenates isolated from normal fibroblasts, adhesion fibroblasts, and adhesion fibroblasts treated with small-interference RNA specific to iNOS, to silence its expression in adhesion fibroblasts. The final concentrations of additions were as follows: NADPH, 10°M; iNOS 150 nM. Compared to the rate of NO consumption by addition of NADPH or iNOS alone, the addition of NADPH followed by iNOS resulted in

a dramatic acceleration in the rate of NO consumption. The addition of iNOS followed by NADPH resulted in a similar dramatic acceleration in NO consumption. Homogenates from adhesion fibroblasts resulted in more NO consumption than normal peritoneal fibroblasts. However, when iNOS gene expression was silenced in adhesion fibroblasts by iNOS-SiRNA, NO consumption was significantly less than the untreated control. Conclusion: Our findings clearly show that L-arginine suppression in adhesion fibroblasts is sufficient to cause superoxide production by iNOS in adhesion fibroblasts. Determining the cause of L-arginine deficiency in adhesion fibroblasts may lead to future therapeutic interventions for postoperative adhesion development.

TUESDAY, NOVEMBER 7, 2006 Plenary 1—Adhesions (11:03

AM

– 11:14

AM)

4 Deoxyhexaenoic Acid Prevents and Mitigates the Adhesion Phenotype in Normal Human Peritoneal and Adhesion Fibroblasts 1 Victory R, 2Saed GM, 2Diamond MP. 1Wayne State University, Windsor, Ontario, Canada; 2Wayne State University Detroit, Michigan Study Objective: To determine if Deoxyhexaenoic acid (DHA) treatment protects normal peritoneal fibroblasts from hypoxia-induced adhesion phenotype development, and mitigates upregulation of the adhesion markers type I collagen, vascular endothelial growth factor (VEGF), and transforming growth factor-beta 1 (TGF-`1) in adhesion fibroblasts. Design: Prospective experimental study. Setting: University Medical Center. Patients: Primary cell cultures derived from three patients undergoing laparotomy with excision of adhesions and normal peritoneum. Intervention: Simultaneous treatment with and without hypoxia, and with or without 24 hours of DHA (100 μM). Measurements and Main Results: Real-time RT/PCR was used to quantify relative mRNA level changes of type I collagen, VEGF and TGF-`1. Results of repeated measures tests were significant when p < 0.05. DHA treatment completely prevented hypoxia induced adhesion phenotype development in normal human peritoneal fibroblasts, reducing adhesion marker mRNA levels to those of untreated, normoxic fibroblasts. Compared to hypoxic peritoneal fibroblasts, DHA reduced Type I collagen mRNA by 32% (13121 ± 89 vs. 19251 ± 176, p < 0.001), VEGF mRNA by 31% (12816 ± 316 vs. 18606 ± 320, p < 0.005), and TGF-‚1 mRNA by 44% (26607 ± 763 vs. 47768 ± 931, p < 0.01). DHA also dramatically reduced hypoxia effects on adhesion fibroblasts, decreasing type I collagen mRNA by 23% (22546 ± 494 vs. 29169 ± p < 0.01), VEGF mRNA by 54% (13184 ± 291 vs. 28607 ± 739, p < 0.005, equivalent to DHA-treated, hypoxic normal fibroblasts), and TGF-`1

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mRNA by 26% (57641 ± 224 vs. 77819 ± 1107, p < 0.01). Conclusion: DHA completely prevented hypoxia induced adhesion phenotype development and substantially mitigated hypoxia effects on adhesion fibroblasts, reducing type I collagen, VEGF and TGF-`1 mRNA levels in all treatment groups. Thus, DHA treatment may substantially reduce de novo adhesions and adhesion reformation, indicating a molecular basis for clinical trials of this potentially highly efficacious anti-adhesive adjuvant.

TUESDAY, NOVEMBER 7, 2006 Plenary 1—Adhesions (11:14

AM

– 11:25

AM)

5 Peroxide Mediated Degradation of Intergel (Ferric Hyaluronate, FeHA) In Vitro: Biochemical Mechanism and Treatment for Possible Intergel Reaction Syndrome (pIRS). Wiseman DM. Synechion, Inc., and International Adhesions Society, Dallas, Texas Study Objective: To elucidate a mechanism for pIRS. Design: The effect of hydrogen peroxide, a compound released during inflammation, on FeHA was observed in vitro. Setting: In vitro study. Intervention: Catechin and zinc chloride. Measurements and Main Results: Within hours of peroxide exposure there was a visible drop in FeHA viscosity, indicating a loss of complexation between iron and hyaluronic acid. Within 24 hours a rust-colored precipitate formed whose amorphous appearance became more granular within days. The supernatant progressively lost its viscosity and yellow color. Eventually the rust colored granular precipitate solubilised to a colorless, clear, thin, solution. The extent and speed of these effects were dose-dependent and inhibitable dose-dependently by zinc and catechin. Conclusion: This experiment suggests that leukocytederived peroxide (and other oxygen species) is capable of causing the degradation of FeHA, by scission of its hyaluronic acid chains. After the initial viscosity drop, iron hydroxide-HA oligomer complexes form an amorphous precipitate. HA oligomers are progressively destroyed leaving granular iron hydroxide. These are eventually resolubilised possibly as gluconate or ferryl species. These effects occur at peroxide concentrations calculated from the known peroxide output of leukocytes and their migration into inflammatory lesions. This sequence is consistent with the lateonset nature of pIRS. Once free of the FeHA, iron can participate in generating reactive oxygen species, resulting in pain and tissue damage. In addition to peroxide exposure in vivo, low level exposure during the peroxide sterilization of the FeHA container may begin its degradation, although not visibly. The participation of free and particulate iron in reaction types including granuloma, mesothelioma and carcinogenesis has been extensively described. The inhibitory effect of zinc and catechin provide further evidence of an oxidative

mechanism of pIRS, as well a clue as to the short and long term treatment of patients exposed to FeHA.

TUESDAY, NOVEMBER 7, 2006 Plenary 2—Urogynecology/Pelvic Floor Disorder (10:30 AM – 10:41 AM)

6 Sexual Function Before and After Vaginal Prolapse Surgery with Allograft Reinforcement Aschkenazi SO, Miller JJ, Botros S, Sand PK, Goldberg RP. Evanston Northwestern Hospital, Northwestern University, Evanston, Illinois Study Objective: To evaluate sexual function and graft tolerability in women before and one year after surgery for Pelvic Organ Prolapse (POP) incorporating transvaginal anterior allograft. Design: This is an ongoing, prospective, longitudinal, cohort study of women after POP repair surgery with anterior transvaginal placement of allograft. Setting: Outpatient clinic and University Hospital OR Patients: All consecutive women with grade 3-4 cystocele, and/or rectocele enrolled for pelvic reconstructive surgery with anterior allograft reinforcement from 09/03 to 02/06. Intervention: Women reported on dyspareunia by using a visual analog pain scale and completed a PISQ-12 questionnaire before and one year after surgery. Measurements and Main Results: McNemar’s test was used to compare responses to individual PISQ items preand postoperatively. Change in PISQ-12 total scores and individual scores was assessed using paired t-test. Outcomes were compared between groups with t-tests, chi2 tests, or Fisher’s exact tests, as appropriate. Of 75 women who underwent surgery for POP with graft reinforcement, 36 women completed over one year follow up (6-110 weeks), of which, 34 (94.4%) were sexually active. A midurethral sling was placed in 43 (59%) for concomitant SUI. Median age and parity was 58 years (33-86), and 2 years (1-7), respectively. There were no graft erosions. Self reported dyspareunia was present in 30/75 (40%) preoperatively compared with 4/34 (5.33%) at one-year postoperatively (p < 0.001). Significant improvement in selfreported dyspareunia was found postoperatively compared with preoperatively (p < 0.001). Analysis of total mean PISQ-12 scores and individual questions revealed significant improvement in sexual function across all domains (p < 0.001). Total mean sexual functioning scores on the PISQ-12 improved by 17 points postoperatively at one year (p < 0.001). For each individual PISQ question, resolution rates postoperatively ranged from 70.6% to 100%, no change in sexual function ranged form 0 to 29%, and worsening sexual function ranged from 0 to 12.5% (p < 0.008). Size effect of the change pre- compared to oneyear postoperatively for all questions but one, showed a large change (p > 0.8). Midurethral sling placement did not

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significantly affect postoperative total PISQ-12 scores (p = 0.503). Conclusion: After one year, incorporation of human cadaveric allograft for advanced cystocele appears to be safe and durable, with high rates of improved subjective self-assessment of dyspareunia and all aspects of sexual function addressed on the PISQ-12.

TUESDAY, NOVEMBER 7, 2006 Plenary 2—Urogynecology/Pelvic Floor Disorder (10:41 AM – 10:52 AM)

7 A Randomized Comparison of Gynecare and Boston Scientific Mid Urethral Tension Free Slings Agarwala N. University of Nebraska Medical Center, Omaha, Nebraska Study Objective: A randomized prospective comparison of TVT and Lynx mid urethral tension free slings was undertaken to evaluate efficacy, complication rates and training of residents. Design: Randomized prospective study. Setting: University Hospital. Patients: Ninety six women with stress urinary incontinence were consecutively assigned to TVT or Lynx between January 2004 and September 2005 at the University of Nebraska Medical Center. Intervention: Intra operative complications, ease of trocar placement, post operative voiding difficulties, subjective and objective cure rates and postoperative interventions were assessed. Statistical analysis with p < 0.05 was used as cut-off for significance. Measurements and Main Results: Both groups were similar in mean age, parity, weight, preoperative PVR, cystometric capacity, flow rate and urethral closure pressures. Postmenopausal status and previous incontinence surgery rate was also comparable. Half of the patients in both groups underwent multiple procedures. There were 2 trocar injuries for TVT and 3 for Lynx. Early postoperative voiding dysfunction was 21% vs 15% (p < 0.001) whereas prolonged catheterization for 2 weeks was similar at 4% for both. UTI rate was (10% vs. 13% respectively, p = 0.02). Subjective cure rates were 94 and 92% respectively. Urethral closure pressure < 14cm H2O was the identifiable risk for failure. Objective cure rates were 96% and 94% respectively suggesting that some subjective failure was likely due to de novo bladder over activity. One sling in Lynx group was removed for skin cellulites and one sling slit in TVT group for voiding dysfunction due to duplicated ureter on the left side. Conclusion: Despite similar efficacy, complication rates and failure rates, the incidence of postoperative voiding difficulties was better with Lynx likely due to mid urethral seal but it was difficult to place the Lynx trocar in patients with prior surgeries probably due to the blunt needle and notch. Residents favored the Lynx trocar due to its light weight and greater stability.

TUESDAY, NOVEMBER 7, 2006 Plenary 2—Urogynecology/Pelvic Floor Disorder (10:52 AM – 11:03 AM)

8 Long-Term Durability of a Nonsurgical Transurethral Radiofrequency Treatment for Female Stress Urinary Incontinence: A Retrospective Analysis 1 Appell RA, 2Wells WG, 3Lenihan JP, Jr., 4Kanellos A. 1 Baylor College of Medicine, Houston, Texas; 2Alabama Research Center, Birmingham, Alabama; 3Tacoma Women’s Specialists, Tacoma, Washington; 4Nevada Urology Associates, Reno, Nevada Study Objective: This retrospective study aimed to determine long-term durability of a nonsurgical, transurethral radiofrequency (RF) collagen remodeling treatment for women with stress urinary incontinence (SUI). Design: In a prospective, randomized, controlled clinical trial, 110 women with SUI were blindly randomized to receive RF collagen remodeling applied to the bladder neck and proximal urethra; 63 comparable women underwent identical sham treatment. Ninety-one active treatment group patients were evaluated at 1-year posttreatment. Further follow-up was conducted 36-42 months posttreatment, results of which are noted here. Setting: All women had been treated as outpatients. Patients: Twenty-two women who received active treatment participated in this follow-up. Intervention: Patients completed an Incontinence Quality of Life Questionnaire (IQOL), a 3-day voiding diary, and questionnaire about satisfaction with RF collagen remodeling and other SUI treatments. Measurements and Main Results: Outcome measurements were > 10-point IQOL improvement from baseline; any improvement from baseline at 1 year, with ongoing improvement at > 3 years; and decreased number of incontinence episodes at 1 year, with an ongoing decrease from baseline at > 3 years. Women who had not achieved success at 1 year and sought alternative treatments were evaluated for the impact of RF collagen remodeling on subsequent treatments. No long-term safety issues were identified. Sixteen women (73%) had improved IQOL scores (mean improvement, 17.6) similar results at 12 months. Twelve women (55%) had > 10-point IQOL improvement at > 36 months. A minority of women were dissatisfied with results after 3 years. Four women with recurrent SUI symptoms underwent additional incontinence procedures without negative impact. Conclusion: Nonsurgical, transurethral RF collagen remodeling is a safe and effective SUI treatment and has demonstrated durable improvement in quality of life, incontinence frequency, and patient satisfaction up to 43 months posttreatment. This treatment does not negatively impact subsequent incontinence procedures.

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TUESDAY, NOVEMBER 7, 2006

TUESDAY, NOVEMBER 7, 2006

Plenary 2—Urogynecology/Pelvic Floor Disorder (11:03 AM – 11:14 AM)

Plenary 2—Urogynecology/Pelvic Floor Disorder (11:14 AM – 11:25 AM)

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Safety of Inside-Out Transobturator Approach for Urinary Stress Incontinence Treatment: Prospective Multicentric Study of 984 Patients – French TVT-O Registry 1 Collinet P, 2Ciofu C, 3Costa P, 1Cosson M, 4Deval B, 5 Grise P, 6Jacquetin B, 2Haab F. 1Jeanne de Flandre Hospital, Lille University Hospital, Lille, France; 2Tenon Hospital, University Hospital of Paris, Paris, France; 3 University Hospital Nimes, Nimes, France; 4University Hospital of Nancy, Nancy, France; 5University Hospital of Rouen, Rouen, France; 6University Hospital of Clermont Ferrand, Clermont Ferrand, France

Randomized Trial of Laparoscopic Burch Colposuspension versus Tension-Free Vaginal Tape: Long-Term Follow-Up 1 Jelovsek JE, 1Barber MD, 2Karram MM, 1Walters, MD, 1 Paraiso MFR. 1Cleveland Clinic, Cleveland, Ohio; 2 Good Samaritan Hospital, Cincinnati, Ohio

Study Objective: Evaluate the safety of inside out transobturator approach for surgical treatment of urinary stress incontinence (USI). Design: Nine hundred eighty-four patients were included in a prospective mulcentric study. Surgical procedure was an isolated cure of USI. Each patient was followed up 4 weeks to 12 weeks after surgery to assess urinary functional results and quality of life. Setting: Urologic and gynaecologic surgery departments of university hospitals (89 investigators) Patients: Nine hundred and eighty-four women with symptomatic USI. Intervention: Isolated cure of USI using a sub urethral sling (TVT0® - Gynecare) by inside out transobturator approach Measurements and Main Results: Surgical procedure was performed under general anaesthesia for 54%, spinal anaesthesia for 40% and local anaesthesia for 6%. Mean operation time was 17.0 minutes. No bladder injury was noted. We observed 13 cases (1.3%) of vaginal wall perforation and one case of urethral injury (0.1%). Rate of re-intervention was 0.9%: one case of paravesical hematoma required a drainage and 8 cases of urinary retentions required a release mesh procedure. Concerning follow-up, no perineal neurological complication was encountered. Twenty-seven patients complained of residual pain (2.7%). No one required opioid or non-opioid analgesic medical treatment. Concerning functional results, patients were completely cured in 886 of cases (90.0%). USI was significantly reduced for 75 cases (7.6%); reduced for 11 cases (1.1%) and not modified for 12 cases (1.2%). Concerning urinary urgencies, we observed 36 de novo cases (5.3%). Dysuria was noticed in 17.3% (170/94). Six patients have been re operated: 2 partial resections of tape for vaginal erosion; 2 sections of sling for retention and 2 cures of persistent USI using retropubic sub urethral sling. Conclusion: The absence of major peri and postoperative complication stressed the safety of this technique compare to retro pubic procedure. Concerning functional evaluation and USI, the results are promising and seem equivalent to retro pubic tape.

Study Objective: To compare the long-term efficacy of laparoscopic Burch colposuspension (LBC) to tension free vaginal tape (TVT) for the treatment of urodynamic stress urinary incontinence (SUI). Design: Prospective randomized trial. Setting: Academic tertiary referral centers. Patients: Seventy-two women with urodynamic SUI from two institutions. Intervention: Subjects were randomized to either LBC or TVT from August 1999 through August 2002. Follow-up evaluations occurred 1, 2, and 4-7 years after surgery. Subjects completed the Incontinence Severity Index, Urogenital Distress Inventory (UDI) – 6, Incontinence Impact Questionnaire (IIQ) – 7, and global impression scale. Outcomes also included reoperation rates, use of medications, and complications. Measurements and Main Results: Median follow-up was 60.2 months (range 12-88) with 94% completing at least one follow-up visit. Seventy-two percent of subjects had longterm (4-7 year) follow-up. Subjects who received a LBC developed recurrent incontinence earlier than the TVT group (median time to recurrence 34 months versus >73 months, p = .04). At long-term follow-up, 55% of all subjects were dry, while 18% had slight incontinence and 26% had moderate or severe incontinence with no difference between groups. However, the significant improvement in the UDI-6 and IIQ-7 scores in both groups at 1-2 years were maintained throughout follow-up. Sixty-two percent in the LBC group and 68% in the TVT group reported they were, “much better” or “very much better” while 9% and 4% reported they were “much worse,” respectively. The reoperation rate for SUI was 9% in the LBC group and 4% in the TVT group. Anticholinergic medication use was reported in 12% of subjects at follow-up. Conclusion: TVT has superior long-term efficacy compared with LBC for the treatment of SUI. Quality of life significantly improves after both procedures and reoperations are uncommon. However, a substantial proportion of subjects overall have some degree of urinary incontinence 4-7 years after surgery.

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Journal of Minimally Invasive Gynecology, Vol 13, No 5, September/October Supplement 2006

TUESDAY, NOVEMBER 7, 2006 Plenary 3—Hysterectomy (10:30

AM

– 10:41

TUESDAY, NOVEMBER 7, 2006 AM)

Plenary 3—Hysterectomy (10:41

AM

– 10:52

AM)

11

12

Incidence of Lower Urinary Tract Injury and the Value of Routine Intraoperative Cystoscopy at the Time of Total Laparoscopic Hysterectomy Jelovsek JE, Chen CCG, Roberts SL, Paraiso MFR, Falcone T. Cleveland Clinic, Cleveland, Ohio

Radical Treatment of Benign and Malignant Uterine Conditions with Laparoscopic Intrafascial Hysterectomy Kulakov VI, Adamyan LV. Scientific Center for Obstetrics, Gynecology and Perinatology of Russian Academy of Medical Sciences, Moscow, Russian Federation

Study Objective: To determine the incidence of injury to the lower urinary tract during total laparoscopic hysterectomy and the accuracy and efficacy of intraoperative cystoscopy to prevent postoperative lower urinary tract complications. Design: Retrospective review. Setting: Academic, tertiary referral medical center. Patients: All patients who underwent total laparoscopic hysterectomy (AAGL Classification IVe) for benign disease from January 1, 2002 to December 31, 2005 are included. Subjects undergoing laparoscopic-assisted vaginal hysterectomy, supracervical hysterectomy, or hysterectomy for malignancy were excluded. Intervention: Intraoperative cystoscopy with intravenous indigo carmine was routinely performed on all patients. Relevant data were abstracted from a hospital-wide electronic record to determine the incidence and accuracy of intraoperative cystoscopy in the detection of lower urinary tract injury, potential predictors of injury, and the resulting postoperative complications. Measurements and Main Results: One hundred and twenty six consecutive subjects underwent total laparoscopic hysterectomy during the study period. Two (1.6%) cystotomies were noted and repaired prior to performing cystoscopy. Two additional cystotomies (1.6%) were detected during cystoscopy. Absent spill of dye was detected in two subjects; one (0.8%) with preexisting renal disease and one (0.8%) with ureteral obstruction that was relieved with subsequent suture removal. The overall incidence of injury to the lower urinary tract was 4.0%. No subjects required postoperative intervention to the lower urinary tract within the six-week perioperative period. Performing a ureterolysis was associated with an increased rate (OR 8.7 95%CI 1.2 to 170, p=0.024) of lower urinary tract injury. Conclusion: The rate of lower urinary tract injury during total laparoscopic hysterectomy is 4% in our population. Seventy-five percent of injuries would not have been detected intraoperatively without the use of routine cystoscopy. Intraoperative cystoscopy allows for recognition of unsuspected lower urinary tract injury and prevention of longterm complications and should be performed routinely at the time of total laparoscopic hysterectomy.

Study Objective: To evaluate the results of total laparoscopic hysterectomy (TLH) for treatment of benighn and malignant diseases. Design: Retrospective analysis of 2010 cases where total laparoscopic intrafascial TLH was performed for benign and malignant uterine conditions. Setting: Dept. Operative Gynecology of the Research Centre for Obst., Gyn., & Perinatology. Patients: The patients were aged 44.7±5.1 yrs. Average uterine size was 13.4 weeks, uterine weight - 710 g. Benign diseases were uterine myoma, adenomyosis, recurrent endometrial hyperplasia and their associations, malignant squamous cell cervical cancer (10 cases), and endometrial adenocarcinoma (17 cases) diagnosed prior to surgery. Intervention: All bening conditions and 11 cases of cervical cancer and were managed with TLH, while 6 women with cervical cancer were submitted for Schauta-Amreich hysterectomy after laparoscopic lymphadenectomy for staging of the disease. Measurements and Main Results: All procedures were done laparoscopically with no convertions to laparotomy. Morcellation of large myomatous uteri and lymphadenectomy were the steps consuming as much as a half of total operating time in more than a half of cases (av. 90,9±6,3 min.). No intra- or postoperative complications occurred, blood loss did not exceed 200 ml. Conclusion: Laparoscopic intrafascial technique is applicable in all cases of benign uterine disease and in carefully selected patients with cervical and endometrial cancer. The staging of the malignant condition by lymphadenectomy is essential for choice of operative volume can be successfully accomplished by laparoscopic approach.

TUESDAY, NOVEMBER 7, 2006 Plenary 3—Hysterectomy (10:52

AM

– 11:03

AM)

13 A Surgical Device and Technique for Safe Total Atraumatic Intrafascial (“TAIL”) Hysterectomy Hohl MK. University of Basel, Basel, Switzerland, Kantonsspital Baden, Baden, Switzerland Study Objective: This study was undertaken to test safety and feasibility of a device and surgical technique for total atraumatic intrafascial laparoscopic (“TAIL”) hysterectomy. Design: All patients admitted for hysterectomy due to benign pathology between 1996 and 2005 were included in

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Oral Presentations

a prospective cohort study. Patients’ pre-, intra-, and postoperative data were prospectively recorded and complications as they occurred using standardized data sheets. Setting: Advanced pelvic surgery teaching hospital. Patients: One thousand twenty-three patients underwent total laparoscopic (LH), 1012 abdominal (AH) and 534 vaginal hysterectomy (VH). Intervention: The totally reusable device (Hohl Manipulator, Storz AG, Tuttlingen/Germany) with anatomical design was used in LH. All crucial steps of the operation are performed in direct contact with the fringe of the cup. In difficult anatomic situations (large uteri, frozen pelvis) access to the ligaments and posterior fornix is often blocked. Therefore the uterine arteries are approached anteriorly by rotating the device to the opposite side and desiccated in safe distance from ureter and bladder. All ligaments are detached at the level of the paracervix leaving the “fascial ring” intact. Instruments and details of surgical technique are shown in the presentation. Measurements and Main Results: The incidence of severe complications (blood transfusions, reoperations, ureter, bladder and bowel lesions, wound dehiscence, infections and thromboembolic complications) was lower with LH (2.1%),VH (4.3%) or AH (14 %) (p < 0,01). Within the LH group there was no difference between experienced staff members and residents in training. A complete statistic analysis of results will be presented. Conclusion: Total LH using a standardised device and atraumatic surgical technique, had a very low incidence of severe complications compared to classical hysterectomy. Within 10 years LH increased from 16% to 71% whereas AH decreased from 57% to 8%.

TUESDAY, NOVEMBER 7, 2006 Plenary 3—Hysterectomy (11:03

AM

– 11:14

AM)

14 Total Laparoscopic Hysterectomy: Experience with 1703 Patients. Park YS, Lee CN, Chung C, Kim I, Kim Y. CHA General Hospital, Kangnam-ku, Seoul, Korea Study Objective: To evaluate feasibility and morbidity of total laparoscopic hysterectomy. Design: Retrospective chart review. Setting: University & 3 affiliated hospitals in South Korea. Patients: From March, 2000 to December, 2005, 1,703 women mostly with benign pathology underwent total laparoscopic hysterectomy. Intervention: Total laparoscopic hysterectomy. Measurements and Main Results: Of 1703 women, 1665 were completed the entire operations laparoscopically by 30 gynecologists. Patient characteristics were mean ages 44.9 ± 6.0 years old, mean parity 2.0 ± 0.9, mean estimated blood loss 299.2 ± 192.7 ml, mean total operating time 136.3 ± 48.1 minutes, mean uterine weight 259.3 ± 128.4 gm and mean hospital stay 6.7 ± 1.7 days. Overall complications

were 193 cases (11.3%) including 51 major complications (3.0%). Of 51, 17 urinary tract injuries (1.0%), 6 bowel injuries (0.4%), 1 vascular injury (0.1%), 11 vaginal vault eviscerations (0.6%), 4 active vaginal vault bleedings (0.2%), 7 excessive bleedings (0.4%), 3 abdominal wall hematomas (0.2%), 1 sepsis (0.1%), and 1 thromboembolic disease (0.1%). There were 37 laparoconversions (2.2%), and 45 reoperations (2.6%), but no fatality, neuropraxia, and port site hernia occurred. Among 30 surgeons, 20 performed more than 25 cases and their rate of major complications was 4.3%, others’ was 2.9%. However, big 4 surgeons’ major complication rates were 3.9, 5.8, 4.6, and 2.8% for each, and some occurred even at their more than 100th operation. Conclusion: TLH for the treatment of benign gynecologic diseases is safe and effective alternative to TAH. However, major complications may occur at highly experienced surgeons. TLH requires not only ample experience under supervision, but also thorough knowledge of surgical anatomy and good selection of patients even after achieving substantial learning curve. But randomized controlled trials are needed to reach agreements.

TUESDAY, NOVEMBER 7, 2006 Plenary 3—Hysterectomy (11:14

AM

– 11:25

AM)

15 Incidence of Dyspareunia and Vaginal Spotting After Laparoscopic Intracervical Subtotal Hysterectomy (LISH) 1,2 Chung MK, 2Glance J, 2Marsteller J, 2Medina R, 2 Shriver J. 1University of Toledo School of Medicine, Toledo Ohio, Ohio, Ohio Northern Univesity, Ada, Ohio; 2 Alliance for Women Health, Midwest Regional Center for Chronic Pelvic Pain and Bladder Control, Lima Memorial Hospital, Lima Ohio. Study Objective: To determine the incidence of postoperative dyspareunia, pelvic pain and vaginal spotting in patients with LISH. Design: Prospective cohort study. Patients: Eighty-nine patients diagnosed with menorrhagia. Measurements and Main Results: Prospective cohort study of 89 patients. From 2002 to March 2006, 89 women ages 21-56 diagnosed with menorrhagia with or without pelvic pain or dyspareunia, underwent outpatient LISH procedure and the outcomes were measured. Seventy-four patients had symptoms of abnormal uterine bleeding only, 15 patients had abnormal uterine bleeding with pelvic pain or dyspareunia. In the 74 patients, there was no immediate postoperative dyspareunia or pelvic pain during the follow up period of 6 months. One patient was diagnosed with dyspareunia secondary to vaginal dryness at 7 months post-op. Two patients had a diagnosis of interstitial cystitis after one year. Low back pain developed in one patient. There were 15 patients with pelvic pain and dyspareunia in addition to abnormal uterine bleeding. Twelve out of the 15

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Journal of Minimally Invasive Gynecology, Vol 13, No 5, September/October Supplement 2006

tested positive for painful bladder syndrome/IC pre-op. They were properly treated prior to LISH. Only 6 patients developed minimal vaginal spotting, one of which was on coumadin for thromboembolic disease. Conclusion: Our study shows the low incidence of postoperative pelvic pain/dyspareunia and vaginal spotting in LISH. It also clearly demonstrates that pelvic pain/dyspareunia should be evaluated and treated prior to offering the LISH. IC/painful bladder syndrome remains one of the bigger factors for women with dyspareunia and pelvic pain. The LISH procedure may be offered to those patients with dyspareunia or pelvic pain after being properly evaluated and treated for IC/painful bladder syndrome.

TUESDAY, NOVEMBER 7, 2006 Plenary 4—Endometriosis (11:35

AM

– 11:46

AM)

16 Deep Infiltrating Endometriosis: Endometriomas Are a Marker for a More Severe Disease Chapron C, Pietin-Vialle C, Chopin N, Borghese B, Foulot H. University of Paris V, Paris, France Study Objective: To investigate if ovarian endometriomas correlate with the severity of deeply infiltrative endometriosis (DIE). Design: Observational study between June 1992 and December 2005 (retrospective study between 1992 and 2000; prospective study between 2001 and 2005). Setting: University hospital. Patients: Continuous series of 500 patients suffering from pelvic pain who underwent complete surgical exeresis for DIE. Intervention: Complete surgical exeresis of deep infiltrating endometriosis. Measurements and Main Results: Comparison according to the presence or not of an ovarian endometrioma. The following criteria were analysed: age, weight, height, body mass index, preoperative pelvic pain scores, rAFS scores, number and location (uetrosacral (USL), vagina, bladder, intestine, ureter) of DIE lesions. These 500 patients presented 924 histologically proved DIE lesions: bladder (56 lesions; 6.0%); USL (463 lesions, 50.1%); vagina (167 lesions, 18.1%); ureter (19 lesions, 2.1%); intestine (219, 23.7%). The mean number of DIE lesions is 1.8 ± 1.3 (range 1 – 7) per patients. Age, weight, height, body mass index, and preoperative pelvic pain scores are not significantly different accoring to the presence or not of an ovarian endometrioma. R-AFS adhesions score (36.2 ± 28.7 versus 16.5 ± 23.7; p < 0.0001) and the mean number of DIE lesions per patient (2.51 ± 1.72 versus 1.64 ± 1.0; p < 0.0001) are significantly more important for patients with associated ovarian endometrioma. Patients with associated ovarian endometrioma present more severe posterior DIE lesions: vagina (RR = 5.98; OR 1.70; 95%CI: 1.1 – 2.6), intestine (RR = 34.5; OR 3.59; 95%CI: 2.3 – 5.6), ureter (RR = 8.6; OR 3.91; 95%CI: 1.4 – 10.4). DIE lesions infiltrating the USL are not correlated with the presence or not

of an ovarian endometrioma. Conclusion: Ovarian endometrioma appears to be marker for more severe DIE. In suspected cases of DIE gynecologists must perform a satisfactory preoperative work-up when ovarian endometriomas are diagnosed at transvaginal ultrasonography.

TUESDAY, NOVEMBER 7, 2006 Plenary 4—Endometriosis (11:46

AM

– 11:57

AM)

17 Laparoscopy for Intestinal Endometriosis, A Comparative Study of Two Surgical Concepts: Colorectal Resection versus Discoid/Superficial Excision 1,2,4 Ohana E, 3,4Bailey C, 3,4Leroy J, 1,2,4Wattiez A. 1 Hautepierre University Hospital, Strasbourg, France; 2 Department of Obstetrics and Gynaecology CMCO-SIHCUS Hospital, Schiltingheim, France 3Department of General Surgery A, University Louis Pasteur, Hôpitaux Universitaires, Strasbourg , France; 4I.R.C.A.D/E.I.T.S, Strasbourg, France. Study Objective: To compare the characteristics and surgical outcomes of two randomized groups of patients with intestinal endometriosis, one undergoing laparoscopic colorectal resection in our colorectal surgery unit and the second undergoing discal /mucosal excision by our gynaecologic surgical team. Design: Evaluation of patients who underwent laparoscopic surgery for bowel endometriosis between January 2002 to January 2006. Data included: age, body mass index, fertility, dysmenorrhoea, dyspareunia, rectorrhagia, operative data, hospital stay, complications. M.R.I studies verified the diagnosis and evaluated the degree of intestinal invasiveness. Follow up was done at 6 weeks, 6 months and one year and included detailed interview and physical exam. Setting: University hospitals, Strasbourg , France. Patients: In total there were 68 patients divided into two groups. group one comprising 49 patients were operated on by gynaecologic surgery team and second group comprising 19 patients operated on by the colo-rectal surgical team. Intervention: All patients underwent laparoscopic surgery under general anaesthesia. Group I had adhesiolysis and complete excision of all visible lesions either by superficial or discal excision. The colo-rectal surgery team performed laparoscopic segmental resection of the affected recto-sigmoid colon. We had no laparoconversions. Measurements and Main Results: The mean follow up time for group I was 14 months and 20 months for group II. No statistically significant differences were found between the two groups regarding their demographic characteristics, symptomatology profile or surgical history. In the gynaecologic group there were 5 cases of bowel complication and one ureteral injury (12%) compared with 4 cases of bowel complications and one ureteral injury in the colorectal group (26%), ( N.S, P=0.02). The hospital stay was longer in the colorectal group (7.4±2.6 days) vs. 4.8±3.2 days in the

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gynaecologic group. During follow-up there were no differences between the groups in quality of life improvement one year after the operation (~80% in both). In woman desiring pregnancy there were more pregnancies in the colorectal group compared to the gynaecologic one, (55% vs. 25% respectively, pv < 0.05). The recurrence rate in both groups were 8 and 10% (N.S). Conclusion: This unique study comparing two surgical philosophies for intestinal endometriosis shows that for a comparable groups of patients the results from superficial/ discal local excision and colorectal segmental resection are equivalent except for a longer hospital stay in the colorectal resection group and higher pregnancy rate in the same group. A tendency for less complications without a higher recurrence rate is noted in the gynaecologic surgery group.

TUESDAY, NOVEMBER 7, 2006 Plenary 4—Endometriosis (11:57

AM

– 12:08

PM)

18 Ureteral Endometriosis: An Underestimated Severe Multifocal Pelvic Disease Chapron C, Lopresti JP, Nguyen T, Chopin N, Borghese B, Foulot H, Amsallem D, Dousset B. University of Paris V, Paris, France Study Objective: To evaluate patient’s characteristics and to assess the results of surgical exeresis of deeply infiltrating endometriosis (DIE) for patients presenting painful functional symptoms and ureteral endometriosis. Design: Clinical study. Setting: University tertiary referral center for gynecologic surgery. Patients: Continuous series of 17 painful patients presented histologically proved deeply infiltrating endometriosis and ureteral endometriosis. Intervention: Complete surgical exeresis of deep endometriosis for patients with ureteral endometriosis. Measurements and Main Results: Retrospective study of medical, operative and pathological reports and analysis of questionnaires mailed to patients. Efficiency of surgical exeresis were assessed according to two methods: objective evaluation (verbal scale) and subjective evaluation (patients were asked to classify the improvement after surgery as one of the following: excellent, satisfactory, slight or no improvement). Prevalence of ureteral endometriosis in the DIE patients is 3.3% (17/515). In all the cases preopertaive imaging (intravenous pyelography and/or magnetic resonance uro-imaging) revealed ureteral stenosis. Ureteral DIE was unilateral in 15 cases (left in 11 cases and right in 4 cases) and bilateral in 2 cases. A silent loss of the renal function was diagnosed preoperatively for 4 patients (23.5%) by performing kidney scintigraphy. For these patients we performed an associated nephrectomy to the exeresis of all the DIE lesions. Ovarian endometriomas was observed in 9 cases (3 left, 1 right and 5 bilateral). Ureteral DIE was never isolated. In all the cases, patients present associated DIE

lesions: uterosacral ligaments (10 patients; 58.8%), posterior wall of the vagina (11 patients; 64.7%); bladder (3 patients; 17.6%) intestine (16 patients; 94.1%). The mean number of DIE lesions per patient was 4.0 ± 1.5 (range 2- 7). Surgical exeresis of all the DIE lesions was performed. Subjective evaluation showed that improvement was considered as excellent and/or satisfactory in 87.5% of the patients. For each symptoms, dysmenorrhea, deep dyspareunia non cyclic chronic pelvic pain, urinary tract symptoms and gastrointestinal symptoms the mean scores according to the numerical rating scale were significantly lower postoperatively. Conclusion: Ureteral DIE is a severe multifocal pelvic disease. Diagnosis must be evocated in cases of large and/or lateral DIE lesions during the clinical examination in order to avoid the non reversible loss of the renal function. Careful peroperative work-up is essential to know the exact distribution of the other associated DIE lesions. Satsifactory functional results are observed after surgical exeresis of all DIE lesions.

TUESDAY, NOVEMBER 7, 2006 Plenary 4—Endometriosis (12:08

PM

– 12:19

PM)

19 Incidence and Risk Factors of Perioperative Complications During Operative Laparoscopy for Endometriosis Jelovsek JE, Chen CCG, Roberts SL, Goldberg JM, Paraiso MFR, Falcone, T. Cleveland Clinic, Cleveland, Ohio Study Objective: To determine the incidence and risk factors of perioperative complications in women undergoing operative laparoscopy for endometriosis. Design: Retrospective review. Setting: Academic, tertiary referral medical center. Patients: All patients who underwent operative laparoscopy for suspected endometriosis from January 1, 2002 to December 31, 2005 are included. Patients with a primary diagnosis of malignancy, pregnancy, simple ovarian cysts, tuboovarian abscess, urinary incontinence, or pelvic organ prolapse were excluded. Intervention: Perioperative data were abstracted from a hospital-wide electronic record to determine the incidence and risk factors for developing *1 complication within the six-week perioperative period. Stage of endometriosis was classified using the ASRM Revised Classification. Forward stepwise regression was used to identify independent risk factors for perioperative complications. Measurements and Main Results: Seven hundred and five consecutive subjects underwent operative laparoscopy for suspected endometriosis. Endometriosis was confirmed in 77% of subjects including Stage I (40%), Stage II (26%), Stage III (12%), and Stage IV (22%). The overall incidence of developing *1 perioperative complication was 10.4% (95%CI 8.3 to 12.9). The most common complications were

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Journal of Minimally Invasive Gynecology, Vol 13, No 5, September/October Supplement 2006

anemia requiring transfusion (1.4%), abdominal wall hematoma (1.3%), and wound infection (1.3%). Bowel injury occurred in (0.9%), cystotomy (0.6%), ureteral obstruction (0.3%), ureteral fistula (0.1%), and major vessel injury (0.1%). Conversion to laparotomy occurred in 0.7%. Prior laparoscopy (adj.OR 3.0, 95%CI 1.2 to 8.8, p<0.03) and Stage 4 endometriosis (adj.OR 3.7, 95%CI 1.6 to 8.8, p<0.002) were independently associated with developing a perioperative complication while normal Functional Capacity (>7 METS) was associated with a reduced risk (adj.OR 0.26, 95% CI 0.11 to 0.62, p<0.002) of developing a complication. Conclusion: Procedure-specific complications continue to be a significant cause of morbidity in patients undergoing operative laparoscopy for endometriosis. Patients with a history of prior laparoscopy and Stage 4 endometriosis are at increased risk of developing perioperative complications.

TUESDAY, NOVEMBER 7, 2006 Plenary 4—Endometriosis (12:19

PM

– 12:30

PM)

sis. Of the 47 who underwent conservative surgery for endometriosis, 9 had no endometriosis noted in the pathology specimens submitted (19%). Two patients withdrew from the trial after surgery, two patients were lost to follow-up after relocating to a different city. Nineteen women completed the three month follow-up in the control group, 15 in the group receiving Trental. The mean age, gravidity, parity, body mass index, previous surgery for endometriosis, menstrual cycle and preoperative analgesic use did not differ significantly between the control and treatment. The VAS scores did not differ at the time of surgery, in both the control and the Trental group there was a significant improvement at each monthly interval (p < 0.05). The patients receiving Trental had significantly better VAS scores at two and three months following the surgery (p < 0.03) Conclusion: The use of Trental following conservative surgery for endometriosis resulted in improved VAS scores at 2 and 3 months following the procedure when compared to patients having only conservative surgery. The longer term use of Trental after conservative surgery may improve long term outcomes following surgical treatment for endometriosis.

20 Pentoxifylline (Trental) after Conservative Surgery for Endometriosis – A Randomized Control Trial 1 Thiel JA, 2Kamencic H. 1Regina Qu’Appele Health Region, Regina, Saskatchewan, Canada; 2University of Saskatchewan, Saskatoon, Canada Study Objective: To compare outcomes after conservative surgery for endometriosis with and without Trental. Design: Parallel group randomized control trial (Canadian Task Force classification Type 1). Setting: Tertiary care hospital Patients: Women with a diagnosis of endometriosis undergoing conservative surgery. Intervention: After obtaining informed consent, conservative surgery for endometriosis was completed by a single surgeon (JAT) and all suspected endometriotic lesions were widely excised using monopolar cautery and scissors. Randomization to the treatment or control groups was completed pre-operatively in the Day Surgery Unit by drawing coloured marbles. A preoperative Visual Pain Scale was completed. Following the surgery, patients were discharged home with prescriptions for Naprosyn, Dilaudid and Trental if in the treatment group. Measurements and Main Results: VAS scoring was completed monthly for three months. Each patient was seen for monthly review and pelvic examination. Daily analgesic use was recorded with an individual medication log. Ongoing treatment choice following completion of the three month follow-up was recorded. The relationship between the groups receiving Trental and the control group as well as analysis of the VAS scores at time of surgery and one, two and three months post-surgery was determined using a covariate mixed model ANOVA. Forty-nine patients were enrolled in the trial. One patient became pregnant prior to the surgery, one patient’s chart was not available for analy-

TUESDAY, NOVEMBER 7, 2006 Plenary 5—Oncology (11:35

AM

– 11:46

AM)

21 Laparoscopic Staging of Early Stage Ovarian and Fallopian Tube Neoplasms 1 Prasad Hayes M, 2Shamshirsaz A, 1Rahaman J, 1Nezhat FR. 1The Mount Sinai School of Medicine, New York, New York; 2SUNY Buffalo School of Medicine, Buffalo, New York Study Objective: This study evaluated the role of laparoscopy for surgical staging of early stage ovarian and fallopian tube cancers and compared outcomes of those presenting with an adnexal mass to those diagnosed with an occult cancer by prior salpingo-oophorectomy or cystectomy. Design: A review was conducted of all laparoscopic ovarian and fallopian tube cancer staging procedures performed by a single institution gynecologic oncology service from 1995 to 2006. Setting: Gynecologic Oncology Division of a university hospital with a fellowship training program. Patients: Twenty-seven patients with fallopian tube or ovarian cancer presumed to be stage I at the time of diagnosis. Intervention: Laparoscopic staging of ovarian and fallopian tube cancers for an adnexal mass or a known cancer diagnosed at the time of prior surgery. Measurements and Main Results: Seventeen patients presented with an adnexal mass (Group 1) and 10 patients presented for staging after diagnosis of an occult cancer (Group 2). Mean operative times for Groups 1 and 2 were 226 and 240 minutes, with a mean EBL 232 mL and 178 mL, respectively. One patient in Group 1 required an intra-operative blood transfusion and one patient developed a small bowel obstruction that

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Oral Presentations

resolved with conservative management. The mean number of para-aortic LN obtained was 11.9 with a median of 7 and a mean of 13 pelvic LN. There were three recurrences: in Group 1, two patients with LMP recurrences 9 and 36 months after surgery and in Group 2, one patient with stage IC clear cell ovarian cancer recurring after 11 months. Conclusion: There were minimal differences in the outcomes of patients who presented with adnexal masses versus those who had a prior surgical procedure with an occult cancer. Laparoscopic staging of these cancers appears to be comprehensive when performed by gynecologic oncologists experienced with advanced laparoscopy.

TUESDAY, NOVEMBER 7, 2006 Plenary 5—Oncology (11:46

AM

– 11:57

AM)

22 Management of Morcellated Gynecologic Malignancies Incidentally Found on Final Pathology Einstein H, Barakat RR, Abu-Rustum N. Memorial SloanKettering Cancer Center, New York, New York Study Objective: Our goal is to analyze the largest series of patients to date who have undergone morcellation or subtotal hysterectomy and are found to have malignancy on final pathology and to make observations regarding staging, treatment, and outcomes. Setting: Tertiary cancer center in the United States. Patients: A review of 18 patients referred to our institution with malignancy who had undergone morcellation or subtotal hysterectomy during their original surgery. Design and Intervention: Retrospective chart review of prospectively maintained database. The intervention was management of incompletely staged gynecologic malignancies morcellated at initial surgery. Measurements and Main Results: Between 1/00 and 4/06, 18 patients were identified. Seventeen had uterine cancer, and 1 had ovarian granulosa cell tumor. The mean follow-up interval was 1.6 years. Initially, 16 (89%) had stage I disease and 2 (11%) had stage III disease. Four (27%) of 15 patients who underwent complete staging were upstaged. Three of the upstaged patients are alive with disease, and 1 has no evidence of disease. All 11 patients who were not upstaged with secondary surgery remain disease free. Two of the 3 patients who were incompletely staged received radiotherapy, 1 of whom subsequently developed cervicovaginal carcinosarcoma. Conclusion: Reoperation for completion surgery and staging is important when gynecologic malignancy is found incidentally after morcellation. At least 25% of patients will be upstaged by reexploration. Patients who undergo completion surgery with staging and are not upstaged appear to have a good prognosis. Surgical staging is valuable for prognosis and may prevent unnecessary treatments.

TUESDAY, NOVEMBER 7, 2006 Plenary 5—Oncology (11:57

AM

– 12:08

PM)

23 Our Experience of Laparoscopic Radical Hysterectomy Gurjar A, Sathe R, Kashyap M, Puntambekar S. Galaxy Laparoscopic Institute, Maharashtra, India Study Objective: We have performed 200 lap.radical hysterectomies with a mean follow up of 18 months.This study is a preliminary report of our results. Design: All the patients of stage I to Stage IIA of cervical cancers are included. Setting: Since 2002 we have performed laparoscopic radical hysterectomies .All these patients have been followed up . Patients: 200 patients of early stage Ca Cervix were treated by laparoscopy. All of them were evaluated by experienced surgeons. Intervention: None of the patients required conversions to open surgery. Delayed complications like ureteric fistula were also treated laparoscopically. Measurements and Main Results: All the patients were evaluated from oncological safety and later followed up for recurrence. The average time taken was 120 minutes. Average blood loss was 50 cc. Average hospitalization was 3 days. 4 patients had ureteric fistulas and 2 had vesico vaginal fistulas. Our median follow up is 18 months. We had 3 vault recurrences and 2 paraaortic nodal recurrences which were treated by radiation. Conclusion: Our preliminary results show that laparoscopic radical hysterectomy is feasible and oncologically safe.

TUESDAY, NOVEMBER 7, 2006 Plenary 5—Oncology (12:08

PM

– 12:19

PM)

24 Laparoscopic Sentinel Lymph Node Mapping In EarlyStage Cervix Cancer—A Detailed Evaluation and Time Analysis Kushner DM, Connor JP, Wilson MA, Hafez GR, Chappell RJ, Stewart SL, Hartenbach EM. Carbone Comprehensive Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Study Objective To provide the first published data from a US center detailing methods and results of the laparoscopic (LSC) approach to sentinel lymph node (SLN) detection in cervix cancer. Design: IRB-approved, prospective, cohort study. Setting: Gynecologic Oncology program of a Comprehensive Cancer Center. Patients: Patients with stage IA2-IIA cervix cancer undergoing any form of radical primary surgical management Intervention: A total of 1 mL of Tc-99 sulfur colloid was injected in 4 quadrants of the cervix the morning of surgery, followed by hybrid SPECT/CT lymphoscintigraphy. After induction of anesthesia, 4 ml of blue dye (isosulfan

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Journal of Minimally Invasive Gynecology, Vol 13, No 5, September/October Supplement 2006

blue: saline, 1:1) was injected in a similar manner. Utilizing systematic LSC technique, mapping was performed with magnified visualization of the lymphatic system and a LSC gamma probe. All patients received a complete LSC pelvic lymphadenectomy. A specific institutional SLN protocol was followed for frozen section, hematoxylin and eosin, and cytokeratin staining. Measurements and Main Results: Between 12/03 and 2/06, twenty enrolled patients received 9 LSC-assisted radical vaginal hysterectomies, 7 radical abdominal hysterectomies, 2 LSC- assisted radical vaginal trachelectomies, and 2 LSC lymphadenectomies alone (secondary to positive lymph nodes). The mean tumor size was 2.5 cm—55% squamous cell and 40% adenocarcinoma. Nineteen percent the 64 SLNs were found in non-standard sites, including common iliac (11%), presacral (5%) and para-aortic (3%). Both the negative predictive value for the procedure and the accuracy of frozen section at determining a positive SLN on final analysis were 100%. The combined technique (dye and radiocolloid) detected SLNs bilaterally in 100% of the patients. If blue dye alone would have been used, this detection rate would have dropped to only 67.5%. The detection rate with blue dye was related to time. On the second side dissected in any one patient (right or left), there was a negative correlation between the number of blue SLNs found and elapsed surgical time (-0.7; p=0.001). In contrast, the projected detection rate if radiocolloid alone had been used was 100%. Conclusion: With close attention to detail, LSC SLN mapping can be introduced into gynecologic oncology centers with high detection rates, negative predictive values, and diagnostic accuracy. The visualization of blue dye in SLNs is transient, and this negative time correlation may explain the previously reported inferior detection rates with this technique.

Intervention: Total laparoscopic radical hysterectomy and abdominal radical hysterectomy (Type III). Measurements and Main Results: Table 1. Patient’s Characteristics Age (yrs) mean (range): Histology Squamous (SCC) Adenoca Adeno (SCC) Other FIGO stage ( n ) IA1 IA2 IB1 IB2 IIA LVSI Positive Lymph Nodes

TLRH (n=32) 48.1 (29-78)

RAH (n=32) 46.3 (31-78)

21 8 2 1

23

1 8 19 2 2 15 3

1 6 17 2 2 15 3

8 1

Table 2. Clinical Variables. TLRH (n=32) Mean duration of operation (min): mean (range)

RAH (n=32)

P value

332.8 241.5 p<0.0001 (213-464) (75-353)

Pelvic lymph nodes( n ): mean (range) 30 (10-61) 22 (8-42) p=0.0016 Transfusion (n. of pts ) 1 4 NS Intraoperative complication 1 1 NS Blood loss (cc): mean (range) 206.6 552 p<0.0001 (100-600) (100-1600)

TUESDAY, NOVEMBER 7, 2006 Plenary 5—Oncology (12:19

PM

– 12:30

PM)

25 A Case Controlled Study of Total Laparoscopic Radical Hysterectomy with Pelvic Lymphadenectomy (TLRH) versus Radical Abdominal Hysterectomy (RAH) in a Fellowship Training Program Zakashansky K, Chuang L, Gretz H, Nagarsheth NP, Rahaman J, Nezhat FR. Mount Sinai Medical Center, The Mount Sinai School of Medicine, New York, New York Study Objective: To assess the feasibility and safety of TLRH in early cervical cancer in a fellowship program. Design: A case controlled analysis of all patients treated with TLRH and patients treated with ARH between May 2000 and May 2006. Setting: Gynecologic oncology teaching medical center. Patients: Thirty two patients with cervical carcinoma FIGO Stages IA1-IIA treated with TLRH and matched for stage, age, histology and nodal status patients treated with ARH.

Table 3. Postoperative morbidity and outcome LRH RAH p value (n=32) (n=32) Post-op complications 8 5 NS Adjuvant therapy 31% 37% NS Mean duration of hospital stay (days) mean (range) 3.8 (2-11) 5.8 (3-9) p<0.0001 Median Follow-up (months) 24 36

There have been no recurrences observed in the laparoscopy group. Conclusion: TLRH yields comparable safety profile to ARH with a reduction in blood loss and hospital stay, and an increase in operative time. It is feasible to incorporate TLRH training into the surgical curriculum of gynecologic oncology fellows. Standardization of TLRH technique and consistent mentorship by an experienced faculty member is an imperative.

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TUESDAY, NOVEMBER 7, 2006 Plenary 6—Endoscopic Complications (11:35

TUESDAY, NOVEMBER 7, 2006 AM

– 11:46

AM)

Plenary 6—Endoscopic Complications (11:46

AM

– 11:57

AM)

26

27

Reducing Unnecessary Surgical Interventions: Risk Factors for Laparoscopic Conversion to Laparotomy in the Management of Ectopic Pregnancies 1,2 Abdallah ME, 1,3Victory R, 1,2Ambler DR, 1,3Diamond MP, 1,3Puscheck EE, 1,2Berman JM. 1Wayne State University, Detroit Medical Center; 2Hutzel Hospital; 3 University Women’s Care, Detroit, Michigan

Incidence and Patient Characteristics of Vaginal Cuff Dehiscence after Different Modes of Hysterectomies 1 Hur HC, 2Guido R, 2Mansuria S, 2Sanfilippo J, 2Lee T. 1 Beth Israel Deaconess Medical Center, Boston, Massachusetts; 2Magee-Womens Hospital, Pittsburgh, Pennsylvania

Study Objective: Reducing unnecessary surgical interventions is critical to therapeutic efficacy in ectopic pregnancy. Thus, we sought to determine factors predictive of converting laparoscopy to laparotomy for ectopic pregnancy. Design: Retrospective ectopic pregnancy database from January 2000 – February 2005. Setting: Detroit Medical Center, Detroit, Michigan. Patients: Three hundred and sixty-eight patients with laparoscopically managed ectopic pregnancies, including 67 conversions. Intervention: Laparoscopy, laparotomy or conversion. Measurements and Main Results: Abstracted data included surgical management, physician and fellow type (MFM, REI, gynecologist), preoperative hemoglobin, hematocrit and `hCG, ultrasonographically measured ectopic size and pelvic fluid volume (fluid), American Society of Anaesthesiologists (ASA) score, intraoperative bleeding, adhesions, tubal rupture, estimated blood loss (EBL), and procedure time. Covariates included demographics and previous abdominal surgery. Chi Squares revealed significant relationships between surgical conversion and previous abdominal surgery (p = 0.04), insurance type (p = 0.015), decreasing hemoglobin (p = 0.05) and hematocrit (p = 0.046), increasing fluid (p = 0.028), ASA score (p = 0.018), intraoperative bleeding (p < 0.001), abdomino-pelvic adhesions (p< 0.001), and EBL (p < 0.001), but not with physician or fellow type, average ectopic size, age, weight, marital status or race. Rupture and procedures occurring at night indicated trends towards significance (all p < 0.07). By logistic regression, conversion risks were markedly increased with low hematocrit (OR > 50, p = 0.017), increasing ASA (OR = 43, p = 0.017), intraoperative bleeding (OR >50, p < 0.001), adhesions (OR > 50, p < 0.001), and massive blood loss (OR >50, p = 0.007). Conclusion: Indeed, the success of laparoscopic treatment of ectopic pregnancy depends largely on surgical skill and experience. This study identified low preoperative hematocrit, massive blood loss, ASA and prior abdominal surgery to be associated with failed laparoscopic intervention. These factors can be estimated before surgery and help in selecting appropriate candidates for laparoscopy, hence decreasing morbidity and expense in managing ectopic pregnancy.

Study Objective: he purpose of this study was 1) to determine and compare the incidence of vaginal cuff dehiscence after different modes of hysterectomies (abdominal, vaginal, laparoscopically-assisted vaginal, total laparoscopic, or laparoscopic supracervical), and 2) to review the patient characteristics of hysterectomies complicated by vaginal dehiscences. Design: Observational case series. Setting: Large university teaching hospital. Patients: All patients undergoing a hysterectomy or vaginal cuff dehiscence repair at Magee-Women’s Hospital from January 2000 to March 2006 were analyzed in this study. Intervention: None Measurements and Main Results: A total of 7286 hysterectomies were performed at Magee-Women’s Hospital (MWH) via an abdominal, vaginal, laparoscopically-assisted vaginal, or laparoscopic approach. Twelve vaginal cuff dehiscences were repaired at MWH during this time period: ten were dehiscences following hysterectomies performed at MWH, while two were complications from hysterectomies performed elsewhere. The overall rate of dehiscence after hysterectomy at MWH was 0.16%. When analyzing the rate of dehiscence by year, the incidence increased markedly in 2005 to 0.68%. The yearly incidence of vaginal dehiscences status post hysterectomies at MWH was 0%, 0%, 0%, 0%, 0.09%, 0.68%, 0.30% from 2000 to March of 2006 respectively. Between January 2005 to March 2006, the rate of dehiscence by mode of hysterectomy was 4.93%, 0.29%, 0.12%, 0%, 0% among total laparoscopic, vaginal, abdominal, laparoscopically-assisted vaginal, and laparoscopic supracervical hysterectomies respectively. Eight of the twelve (67%) dehiscences occurred after total laparoscopic hysterectomies, two (16.67%) after total abdominal hysterectomies, and two (16.67%) after total vaginal hysterectomies. The age among the dehiscence patients ranged from 26 to 59 years (median age of 43 years). The time interval between the initial hysterectomies to the dehiscences ranged from 4 weeks to 11 years (median of eleven weeks). Seven patients reported intercourse as their trigger event. Seven patients presented with both cuff dehiscence and bowel evisceration. All dehiscence patients who had their initial hysterectomy at MWH received antibiotic prophylaxis at the time of hysterectomy. There are no recurrent dehiscences to date. Conclusion: Total laparoscopic hysterectomies may pose an increased risk of vaginal cuff dehiscence compared to other

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Journal of Minimally Invasive Gynecology, Vol 13, No 5, September/October Supplement 2006

modes of hysterectomy. Although the cause is not proven, the use of thermal energy in addition to other factors unique to laparoscopic surgery may be responsible. When performing laparoscopic hysterectomies, a supracervical approach should be considered unless a clear indication for a total laparoscopic hysterectomy is present.

laparoscopically. A increasing number of these complications are now being managed laparoscopically by the gynaecologist.

TUESDAY, NOVEMBER 7, 2006 Plenary 6—Endoscopic Complications (12:08

PM

– 12:19

TUESDAY, NOVEMBER 7, 2006

29

Plenary 6—Endoscopic Complications (11:57 AM – 12:08 PM)

Intestinal Endometriosis Laparoscopic Surgery and the Problem of Recto–Vaginal Fistula 1,2,4 Ohana E, 1,2,4Waters N, 3,4Bailey C, 3,4Leroy J, 1,2,4 Wattiez A. 1Hautepierre University Hospital, Strasbourg, France; 2CMCO-SIHCUS Hospital, Schiltingheim, France; 3University Louis Pasteur, Hôpitaux Universitaires, Strasbourg, France; 4 I.R.C.A.D/E.I.T.S, Strasbourg, France

28 Major Complications Associated with 1265 Major and Advanced Laparoscopic Procedures: A Prospective Review Johnston KM, Shukla A, Carlton M, Rosen D, Chou D, Cooper M, Reid G, Cario G. Sydney Women’s Endosurgery Centre, St. George Private Hospital, Sydney, New South Wales, Australia Study Objective: To identify the volume and type of surgery being performed. To review the incidence, nature of associated complications and reasons for conversion to laparotomy. Design: A multi-centre prospective case load analysis and chart review, identifying operations performed by 6 advanced laparoscopic surgeons over a 12-month period (1/1/05 to 31/12/05). Setting: Surgical cases were performed in 5 hospitals in Sydney, New South Wales. Patients: One thousand two hundred and sixty five women had a variety of major and advanced operative procedures performed. Measurements and Main Results: A total of 1265 major and advanced laparoscopic procedures were performed. Laparoscopic hysterectomy accounted for 364 cases (28.8%), pelvic floor repair and Burch colposuspension 280 cases (22.2%), excisional endometriosis surgery 354 cases (28%), adnexal surgery 177 cases (13.9%), adhesiolysis 75 cases (5.9%) and miscellaneous cases 15 (1.2%). Overall major complications in terms of bowel urological or major vessel injuries accounted for 8 cases (0.6%). There were 4 injuries of the bowel, 2 injuries to the bladder and 2 injuries to ureters. There were no major vessel injuries. There were no injuries associated with primary trochar or Verres insertion. The most common peri-operative morbidity reported was the requirement for blood transfusion, 11 cases (0.8%) and the second commonest was venous thromboembolism, 4 patients (0.4%). Six (0.5%) cases were converted to laparotomy, 2 as a result of a complication and 4 for technical reasons. Six of the eight complications were managed laparoscopically and a multidisciplinary input only sought in 4 of the eight complications. Conclusion: Despite the advanced nature of laparoscopic procedures performed by our group, the complication rate and conversion to laparotomy remains low. There is an increasing feasibility to perform traditional open operations,

PM)

Study Objective: To report and discuss the occurrence of Recto-Vaginal fistula as an important complication of intestinal endometriosis laparoscopic surgery. Design: A retrospective analysis of our prospective data base was performed to evaluate the patients who underwent laparoscopic surgery for bowel endometriosis between January 2002 to January 2006. Setting: University hospitals in Strasbourg, France. Patients: From January 2002 to January 2006, 69 patients with intestinal endometriosis underwent laparoscopic surgery for the excision of implants. We had 9 cases of bowel complications (~13%), six of them (~9%) developed RectoVaginal fistulas. Intervention: All patients underwent laparoscopic surgery under general anaesthesia, 50 patients were Operated by the gynaecologic surgery team, all passed a radical surgery with adhesiolysis and complete excision of all visible lesions, either by superficial excision or by discal excision, only in one case in this group a segmental resection was done. The colo- rectal surgery team performed in 19 patients a laparoscopic segmental resection of the recto-sigmoid colon. no laparoconversions were needed. Measurements and Main Results: 2 patients of the group passing superficial and discal excision(n=50) and 4 patients from the recto-sigmoid resection group (n=19) developed a Recto-Vaginal fistula (4% and 21% respectively).The age, B.M.I, fertility and surgical history were not statistically different between patient developing fistula and the rest of the group. The investigation of the cases developing fistula indicated that overture of both the vagina and rectum with the creation of two parallel suture lines is a risk factor for fistula formation (5 out of 6 patients), in the last patient only the vagina was opened but no leak test was done. Conclusion: One of the major complications we facing performing surgery for severe intestinal endometriosis is the development of Recto-Vaginal fistula. Recognizing the risk factors and the mechanism for its development will help avoiding its development. Bowel preparation, prophylactic antibiotics, optimal exposure and meticulous haemostasis

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are necessary. Additionally, we perform the leak test routinely and in high risk cases we take extra precaution and omental interposition to avoid direct contact between suture lines is done.

TUESDAY, NOVEMBER 7, 2006 Plenary 6—Endoscopic Complications (12:19

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– 12:30

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30 Three Simple Steps Minimize Laparoscopic Entry Injuries Vilos AG, Vilos GA, Abu-Rafea B, Hollett-Caines J, Ahyaneh ZN, Edris F. The University of Western Ontario, London, Ontario, Canada Study Objective: To determine whether 1) Low Initial Veres Intra-Peritoneal Pressure (LIVIP-Pressure), 2) High Pressure Pneumoperitoneum (HIP-Pneumo-Entry), and 3) Visual Entry with the ENDOTIPTM cannula, minimize laparoscopic entry related injuries. Design: Prospective cohort study (Canadian Task Force Classification II-3). Setting: University affiliated teaching hospital. Patients: All consecutive women undergoing laparoscopic surgery for various indications over an 18 months period. Intervention: Laparoscopy was performed on a total of 365 women. The insufflation pressure was recorded from a Storz insufflator as the needle traversed slowly through various layers of the abdominal wall. The initial Veres intra-peritoneal pressure was recorded and correlated against the body habitus and parity of women. In 100 consecutive women, the C02 volume, heart rate, blood pressure, oxygen saturation and pulmonary compliance were prospectively recorded at preset pressures on the insufflator of 10-, 15-, 20-, 25- and 30 mmHg. Visual entry with the ENDOTIP‘ cannula was used in 350 women. Following skin incision and establishment of HIP-Pneumoperitoneum, the cannula, housing a 00 laparoscope, was rotated clockwise applying minimal downward force. Various tissues were successively visualized as the blunt tip of the cannula traversed the abdominal wall and entered the abdomen. Measurements and Main Results: The number of Veres needle attempts was recorded in 324 women. Pneumoperitoneum was established after one, two or three attempts at the umbilicus in 82.4%, 10.9% and 4.0% of the patients, respectively. In 7 women (2.2%) pneumoperitoneum was established at the LUQ during a 4th attempt and in 2 women laparoscopy was abandoned for failure to establish pneumo after a 2nd attempt at LUQ. The abdomen was insufflated to 30 mmHg prior to the primary trocar/cannula insertion. The median VIP-pressure was 4 mmHg (range 210 mmHg). The IVIP-pressure, < 10 mmHg, correlated positively with women’s weight and BMI and negatively with parity. There was no statistically significant change in the heart rate or pulse pressure between intra-peritoneal pressure (IPP) of 15 and 30 mmHg. A decrease of 21% in pulmonary compliance from IPP 15 to 30 mmHg was of no

clinical significance. The LIVIP-Pressure and HIP-PnemuoEntry has been practiced by the principal author (GAV) since 1997 and the Visual entry since 2000. Since 1997, patients sustained two Veres punctures to colon (no treatment was required) and one transverse colon injury (colon was adhered to the entry site) with the primary trocar in 3000 consecutive laparoscopies. No injury has been experienced with the ENDOTIPTM cannula. Prior to 1997, the senior author had encountered 3 Veres needle punctures to bowel, 3 small-bowel injuries with the primary trocar, 2 large-bowel injuries with the primary trocar, and 2 primary trocar injuries to large bowel and major vessels in 3472 consecutive laparoscopies. Conclusion: 1) LIVIP-Pressure (< 10 mmHg) indicates intraperitoneal placement of the Veres needle. 2) The use of HIP-Pneumo-Entry is easier for the surgeon and safer for the patient. 3) Visual entry with the ENDOTIP‘ cannula offers an additional step towards a safer laparoscopic entry.

TUESDAY, NOVEMBER 7, 2006 Plenary 7—Myomas (2:45

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– 2:56

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31 A Randomized Controlled Trial Comparing the Laparoscopic and Minilaparotomic Approach for Uterine Leiomyomas: Surgical and Fertility Outcomes 1 Palomba S, 2Marconi D, 1Falbo A, 1Russo T, 3Mattei A, 2 Zupi E, 1Zullo F. 1University “Magna Graecia” of Catanzaro, Cantanzaro, Italy; 2University “Tor Vergata” of Rome, Rome, Italy; 3University of Florence, Florence, Italy Study Objective: To compare the minilaparotomic and laparoscopic approaches for the treatment of symptomatic uterine leiomyomas in terms of efficacy and fertility outcomes. Design: Randomized controlled trial. Setting: Departments of Obstetrics and Gynaecology of the Universities “Magna Graecia” of Catanzaro, “Tor Vergata” of Rome, and of Florence, Italy. Patients: One-hundred twenty two women with symptomatic uterine leiomyomas and unexplained infertility who wish to conceive. Intervention: Sixty-one patients underwent laparoscopic myomectomy (laparoscopic group), and other 61 patients underwent minilaparotomic myomectomy (minilaparotomic group). Measurements and Main Results: Surgical and reproductive outcomes were assessed. Enucleation time of leiomyomas and suturing time of the hysterotomy(-ies) were significantly (p<0.05) shorter after minilaparotomic myomectomy, whereas the degree of surgical difficulty resulted significantly (p<0.05) higher for the laparoscopic myomectomy. Intra-operative blood loss and number of pain drug used postoperatively were significantly (p<0.05) higher in minilaparotomic than in laparoscopic group. All other surgical outcomes evaluated were similar in both groups. Surgical data were significantly (p<0.05) influenced by leiomyoma

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Journal of Minimally Invasive Gynecology, Vol 13, No 5, September/October Supplement 2006

dimensions (>7 cm) and/or localization (posterior or intraligamentary). At the end of the 12-month follow-up period, the cumulative pregnancy, abortion and live-birth rates resulted similar between groups, whereas the cumulative probability of first pregnancy was significantly (P<0.05) higher in laparoscopic than in minilaparotomic group. Conclusion: Minilaparotomic and laparoscopic approach to myomectomy are two safe surgical procedures, even if further data on specific dimensions and localizations of fibroids are needed. To date, the laparoscopic approach seems to give better reproductive outcomes than the minilaparotomic one.

pregnancy and delivery rates were reported for most (82%) studies. Pregnancies and delivery rates were highly variable and because of study heterogeneity cannot be combined to increase study precision. Conclusion: The evaluation of myomectomy to improve fertility is limited by poor study design. We will present a model for study design that will allow more reliable evaluation of fertility and improved decision making.

TUESDAY, NOVEMBER 7, 2006 Plenary 7—Myomas (3:07

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– 3:18

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TUESDAY, NOVEMBER 7, 2006

33

Plenary 7—Myomas (2:56

Transvaginal Doppler-Guided Temporary Uterine Artery Occlusion for the Treatment of Symptomatic Fibroids Vilos GA, Vilos EC, Hollett-Caines J, Abu-Rafea B, Romano W. University of Western Ontario, Ontario, Canada

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32 Myomectomy and Reproductive Outcomes – A Systematic Overview 1 Pron G, 2Mocarski E, 3Parker WH, 4Tulandi T, 5Vilos GA. 1 University of Toronto, Toronto, Canada; 2St. Michael’s Hospital, Toronto, Ontario, Canada; 3University of California, Los Angeles, California; 4McGill Univesity, Montreal, Quebec, Canada; 5St. Joseph’s Health Center, London, Ontario, Canada Study Objective: Myomectomy has been the mainstay of conservative surgery for women desiring to maintain or enhance their fertility. The aim of this study was to evaluate the published literature on myomectomy and its impact on reproduction. Design: A systematic review of original peer reviewed reports published between 1975 and 2005. Setting: Several databases including Medline, CINAHL, EMBASE, Health STAR and EMB REVIEW were used to perform iterative searches. Patients: Reports involving small case series (< 10 cases), reviews articles, meta-analyses, letters and editorials were excluded. Intervention: An initial broad range of MeSH search terms for fibroids, myomectomy and reproductive outcomes were employed. Measurements and Main Results: Over a 31 year period, 77 original reports involving reproductive outcomes and myomectomy (15 hysteroscopic, 36 laparotomy and 26 laparoscopic) were identified. Comparisons between surgery study groups were confounded by study inclusion criteria and infertility work-ups. Infertility was the main treatment indication for 61% (47/77). Six reports involved effectiveness of prior myomectomy in assisted reproduction. The studies consisted mainly of clinical series (88%; 68/77). Other designs involved parallel cohorts (n=3), pre-post treatment (n=3) or pre-post treatment in parallel cohorts (n=1) and randomized trials (n=2). The majority of the studies involved small numbers of pregnancies; 87% (67/77) involved <50 pregnancies. The largest number of deliveries was as follows: hysteroscopy (66 deliveries); laparotomy (66 deliveries) and laparoscopy (100 deliveries). Crude

Study Objective: To assess the feasibility, safety and efficacy of transvaginal, Doppler-guided, temporary uterine artery occlusion using the flostatTM system in women with symptomatic fibroids. Design: Two ethics committee approved pilot studies. Setting: University-affiliated teaching hospitals. Patients: Thirty premenopausal women with an average age of 43 years (range 32-51). Intervention: Under general or conscious sedation, with paracervical block (n=17) or epidural analgesia (n=13), hysteroscopy and D&C were carried out and the uterine arteries were occluded. Occlusion was achieved by folding the vaginal tissues against the uterus by the vascular clamp. Following device placement, the patients were transferred to recovery area and the occlusion was maintained for a period of 6 to 9 hours. Measurements and Main Results: Patients were prescreened prior to treatment using the Ruta Menorrhagia Severity Scale, and ultrasound and/or MRI at baseline and 3 and 6 months to measure fibroid and uterine volumes. The uterine arteries were successfully occluded in all 30 patients. In one patient, the clamp was dislodged and removed after an adverse anesthesia event. There was significant reduction in menorrhagia with 81% of women reporting 15% or greater Ruta score at six months (average reduction 51%, range 7-81%). There were no cases of amenorrhea. For this group, the corresponding average reduction in uterine and dominant fibroid volume was 12% and 24%, respectively. In the second pilot study (n=13), the average reduction in uterine and dominant fibroid volume was 24% and 45%, respectively. Two patients developed symptomatic hydronephrosis, requiring placement of a temporary ureteral stent. Review of these two cases lead to procedural improvement which included preoperative patient hydration, insertion of Foley catheter after placement of the clamp, and monitoring urine output during occlusion. Conclusion: Temporary uterine artery occlusion provides the gynecologist with an alternative to uterine artery

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embolization (UAE). The system is simple and easy to apply. The efficacy is equivalent to UAE and complications are minimal.

TUESDAY, NOVEMBER 7, 2006

TUESDAY, NOVEMBER 7, 2006

The Evolution of Fibroid Cryotherapy: Early Intervention Model for Women’s Health Cowan BD, Sewell PE, Carroll CS, Pansky M, Zimberg S. University of Mississippi Medical Center, Jackson, Mississippi

Plenary 7—Myomas (3:18

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– 3:29

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34 Initial Experience at the Lahey Clinic Utilizing Magnetic Resonance Guided Focused Ultrasound to Treat Uterine Fibroids Bruno R, Dick AB, Briggs MH, McLellan R, Holland G. Lahey Clinic, Burlington, Massachusetts Study Objective: Initial one-year follow-up at the Lahey Clinic utilizing magnetic resonance guided focused ultrasound surgery (MRgFUS) to treat women suffering from uterine leiomyomata. Design: Over 25 pre or peri menopausal women with symptomatic uterine leiomyomata prospectively underwent MRgFUS. Patients completed a uterine fibroid symptom and quality of lift questionnaire (UFS-QOL) before and after treatment. Enrollment required symptomatic uterine fibroids scoring a minimum of 18 on the symptom severity questionnaire. Gynecologic examination and prior MRI confirmed a definitive diagnosis of uterine fibroids. Patients were evaluated at 3, 6 and 12 months after treatment. Setting: Tertiary care teaching hospital. Patients: 25 women aged 32 to 52 with significant fibroid related symptoms on the UFS-QOL who desired a uterine sparing procedure gave informed consent to be treated with MRgFUS. Intervention: Magnetic resonance imaging was used to target and control the noninvasive focused ultrasound thermal ablation of uterine fibroids. Patients were under conscious sedation during the procedure. Measurements and Main Results: To date 19 patients have returned for their one-year follow up. Starting at the 3month evaluation approximately 60% of patients demonstrated a significant decrease of at least 10 points on the symptom severity score of the UFS-QOL. This decrease continues to be demonstrated in those patients evaluated at 12 months. The average decrease at 3 and 12 months was 11 and 10 points, respectively. MRI follow-up confirmed a reduction in size or volume of the fibroids treated. There were no serious adverse events in patients that were treated Conclusion: In the short term MRgFUS appears to be a safe and effective nonsurgical alternative to treat those women significantly symptomatic from uterine fibroids that want to preserve their uterus or avoid major surgery. More long term follow-up is necessary to evaluate the persistency of these results.

Plenary 7—Myomas (3:29

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35

Study Objective: This report describes cryoablation of fibroids using MRI-directed and laparoscopically-assisted approaches. Design: The two different studies included twelve women treated with MRI-guided 2 and 3 mm cryoprobes and 20 patients treated with laparoscopically-assisted 17 gauge cryocryoneedles (Galil Medical) Setting: The MRI study was performed at the University of Mississippi Medical Center, and the laparoscopically-assisted cryomyolysis was performed at Cleveland Clinic Florida, Assaf Horafeh Medical Center Israel, and the University of Mississippi Medical Center. Patients: Thirty-two patients with uterine fibroids were recruited for these two studies. Twelve patients were treated with MRI and 20 patients were recruited for laparoscopic assisted therapy. Intervention: In all patients, the treatment strategy was to devitalize the fibroid by freezing the tumor. Primary goals were safety, reduce fibroid volume, and improve quality of life (QOL). Secondary goals included minimal intervention, rapid recovery and reduced costs. Measurements and Main Results: At six months, MRItreated patients showed 66% fibroid volume reduction. Ten patients showed improvement or resolution of symptoms; some experienced mild pain post-treatment, which was spontaneously resolved. Patients were discharged from the hospital within 24 hours. One patient returned for hysterectomy one year after cryoablation, and one patient underwent emergency surgery for a lacerated fibroid-associated vessel. In the laparoscopic-assisted cryotherapy, no intra- or postoperative adverse events occurred. Patients reported no significant post-treatment pain. The SSS-UFS-QOL (Spies, 2002) instrument detected significant (p < 0.05) aggregate improvement in questions related to bleeding and bulk syndrome. Fibroid volume reduction at 3-months was 57.1% (30 fibroids) and at 6-month was 81.6% (14 fibroids). Conclusion: MRI guided or laparoscopically-assisted US guided cryoablation are selective approaches directly targeting the fibroids. While MRI provides high resolution imaging, it is costly and less available. Conversely, sonography and laparoscopy are available tools frequently used by gynecologists, providing visualization and direct control of the procedure, thus saving time and costs. Advances in cryoneedle technology, combined with sonographic visualization provide highly targeted treatment for fibroids. In the future, office-based cryoablation holds potential for earlier intervention to devitalize fibroids before they produce symptoms.

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TUESDAY, NOVEMBER 7, 2006 Plenary 8—Hysteroscopy (2:45

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– 2:56

TUESDAY, NOVEMBER 7, 2006 PM)

Plenary 8—Hysteroscopy (2:56

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A Randomized Study Comparing an Operative Hysteroscopy System to Conventional Loop Resectoscopy for the Removal of Endometrial Polyps and Submucous Myomas 1 Bradley LD, 2Gimpelson RJ, 3Lukes A, 3Walmer D, 4Olive DL, 5Moore MD, 6Miller CE, 7Marc K, 7McGory DL, 8 Herbst S, 9Appleby D. 1Cleveland Clinic, Cleveland, Ohio; 2 St. Luke’s Hospital, Chesterfield, Missouri; 3Duke University Medical Center, Chapel Hill, North Carolina; 4 University of Wisconsin, Madison, Wisconsin; 5Advanced Women’s Health Insitute, Denver, Colorado; 6Lutheran General Hospital, Arlington Heights, Illinois; 7Newton Wellsley Hospital, Newton, Massachusetts; 8Institute for Women’s Health and Body, Wellington, Florida; 9 Biostatistics, Smith & Nephew Endoscopy, Andover, Massachusetts

Oral Desogestrel Plus Vaginal Raloxifene as Preoperative Treatment for Hysteroscopic Surgery: A Prospective, Randomized Evaluation 1 Cicinelli E, 1Pinto V, 1Nicoletti R, 1Tinelli R, 2Saliani N, 3 De Leo V, Cianci A, 1University Medical School of Bari, Bari, Italy; 2University Medical School of Siena, Siena, Italy; 3University Medical School of Catania, Catania, Italy

Study Objective: The purpose of this randomized study is to compare the performance of the Smith & Nephew Operative Hysteroscopy System to conventional loop resectoscopy. Design: The study design is a randomized controlled study. Setting: All procedures were performed on an out-patient basis in the hospital setting. Patients: The patients included in this study are adult females with endometrial polyps and/or type 0 or type 1 myomas, less than 4 cm in size. Intervention: Subjects were randomized to receive treatment using either the Smith & Nephew Operative Hysteroscopy System or conventional loop resectoscopy. Measurements and Main Results: A total of 167 lesions were treated in 97 patients in this study. 94 lesions in 48 patients, which included 73 polyps and 21 myomas, were treated with operative hysteroscopy system. 73 lesions in 49 patients, which included 51 polyps and 22 myomas, were treated with conventional loop resectoscopy. Two cases in the operative hysteroscopy group were terminated and 4 cases were converted to another procedure. Two cases in the loop resectoscopy group were terminated. Results: The operative duration for the operative hysteroscopy procedures was 10.2 minutes, and the mean fluid deficit for these procedures was 313 mL. The operative duration for the loop resectoscopy procedures was 12.7 minutes, and the mean fluid deficit for these procedures was 232 mL. Eighteen adverse events were reported among the operative hysteroscopy group, and 13 adverse events were reported among the loop resectoscopy group. Conclusion: The operative duration and fluid deficit were similar between patients in the operative hysteroscopy group and the loop resectoscopy group. This technique for the removal of endometrial polyps and submucous myomas may offer an effective alternative to conventional resectoscopy.

Study Objective: preoperative pharmacological thinning of the endometrium is recommended to facilitate hysteroscopic surgery. For this purpose danazol, GnRH analogues (GnRH-A), progestins and gestrinone have been indicated. However, all these drugs require 1 to 2 months for determining endometrial suppression. Shortening of the time to perform surgery may improve patient acceptability and working organization. In order to speed the endometrial suppression up we evaluated the rapid effects (< 2 weeks) of an original treatment combining oral progestins with vaginal raloxifene, a compound with selective antiestrogenic action, as preoperative endometrial preparation for operative hysteroscopy. Design: Prospective, randomized clinical study. Setting: University department of gynecology and obstetrics. Patients: Ninety patients with endouterine pathologies (endometrial polyps and septate uterus) on hysteroscopy performed on day 8-12 of cycle. Intervention: On day 1 of the subsequent menstrual cycle patients were randomized to start with oral danazol 200 mg/tid (n = 30) (danazol group, DAG), desogestrel 75 mg/d (n = 30) (DEG) and with oral desogestrel (n = 30) combined with raloxifene (75 mg) per vaginam for at least 7 days preceeding surgery (DVRG). Measurements and Main Results: Measurement of endometrial thickness on the same cycle day of pre-treatment and treatment cycles, side effects, surgeon satisfaction (0 to 10, VAS scale). At second evaluation mean percentage reduction in endometrial thickness in DVRG was significanlty greater than in other groups (DAG -15.4%, DEG -29.7%, DVRG -56.2%; p<0.001 and p<0.02, respectively). The rate of endometrial response was higher for the DVRG and DEG compared to DAG (93.0%, 87.6%, 71.1%). Surgeon satisfaction in terms of endometrial thinning was also greater in DVRG than in other groups. The DAG showed a higher incidence of moderate bleeding. Conclusion: Oral desogestrel plus vaginal raloxifene provided fast, low-cost and satisfactory preparation of the endometrium for operative hysteroscopy.

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TUESDAY, NOVEMBER 7, 2006 Plenary 8—Hysteroscopy (3:07

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– 3:18

TUESDAY, NOVEMBER 7, 2006 PM)

Plenary 8—Hysteroscopy (3:18

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39

Clinical Presentations May Alter the Accuracy of Sonohysterography- The Results of a Cohort Study 1 Sakhel K, 2Fanelli L, 3Fourment C, 1El-Mokadem H, 2 Wagner A. 1Synergy Medical Education Alliance, Michigan State University, Saginaw, Michigan; 2Women’s OBGYN PC, Saginaw, Michigan; 3St Mathew’s University, Grand Cayman Island, British West Indies

Investigation of Often Reported Ten Percent Hysteroscopy Fluid Overfill: Is This Accurate? Nezhat, CH, Fisher D. Atlanta Center for Special Pelvic Surgery, Atlanta, Georgia

Study Objective: The purpose of this study was to evaluate the accuracy of SHG for different clinical scenarios. Design: All women who underwent SHG subsequent hysteroscopy and dilatation and curettage were included in this historical cohort study between January 2003-August 2005. The hysteroscopy findings were confirmed by a review of the pathology findings. Sensitivity, Specificity, Positive Predicitve Value (PPV) and Negative Predictive Value (NPV) were calculated. Setting: The SHG was performed by a registered sonographer (RDMS) in a large 7 doctor suburban OBGYN office. Surgery was performed in 2 hospitals affiliated with a University OBGYN residency program. Patients: Women who presented with different clinical complaints and/or an abnormal ultrasound underwent SHG and hysteroscopy and dilatation and curettage. Intervention: The endometrial cavities were evaluated by SHG and then by hysteroscopy and dilatation and curettage. Measurements and Main Results: A total of 100 women were included in the study. The mean age was 47 ± 10 years with a range of 18-73. A statistical analysis generated the sensitivity, specificity, ppv and npv for the preoperative complaints of postmenopausal bleeding, menometrorrhagia, polyps and leiomyomas. For all patients the overall results were sensitivity 97.5%, specificity 84.2%, PPV 93%, and NPV 88.9%. As for the patients with postmenopausal bleeding, menometrorrhagia, polyps and leiomyomas the sensitivity, specificity, PPV and NPV were 100%, 100%, 100%, 100%; 95.5%, 80.0%, 93.3%, 85.5%; 82.0%, 82.1%, 87.7%, 74.4%; 91.0%, 70.0%, 86.0%, 79.3% respectively. There were 4 cases of endometrial carcinoma which were all noted as irregular endometrial lining on SHG. Conclusion: Sonohysterography is an accurate, useful and noninvasive tool in the preoperative evaluation. This may help in planning operative instrumentation and time. The accuracy of SHG is influenced by the clinical presentation. SHG may also be useful in the evaluation of postmenopausal bleeding.

Study Objective: The purpose of this study was to measure the volume and mass of irrigation fluid bags to assess the overfill of three common types of hysteroscopy irrigation fluids, 0.9% Normal Saline, 3% Sorbitol, and 1.5% Glycine to challenge the often quoted standard of assumption that overfill may be as high as 10% of the bag’s volume. Design: Comparative descriptive design. Setting: Laboratory setting with no clinical care. Patients: No patients were involved in this study. Intervention: There was no treatment intervention. Measurements and Main Results: Ten cases of irrigation fluid were obtained from the company. The volume and weight of drained fluid from 18 bags of 2000 mL 0.9% Normal Saline, 12 bags 3000 mL 3% Sorbitol, 8 bags of 3000 mL 1.5% Glycine, and 4 bags of 5000 mL 0.9% Normal Saline were measured. Institutional Review Board exemption was obtained. By volume, depending on the type of the fluids tested, the maximum overfill was observed to be between 3.3-5.0%. For confirmation, each bag was also weighed and found to have a maximum overfill between 2.8-5.6%, dependent on the volume and type of fluid measured. These findings were then compared to the manufacturer-provided overfill range of 1.5-6.0%. Conclusion: A key component of hysteroscopic complications such as fluid overload and severe dilutional hyponatremia are due to the failure to anticipate and quickly recognize fluid deficits. Contrary to assertions over the last 25 years that overfill is 10% or higher as a rule, it appears more reasonable to assume that (1) the degree of overfill is contingent upon the type and volume of fluid used; and (2) is more likely closer to 2.8-5.6%.

TUESDAY, NOVEMBER 7, 2006 Plenary 8—Hysteroscopy (3:29

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40 Intrauterine Trailing Essure Coils as a Predictor of Successful 3 Month Follow-Up Ultrasound 1 Thiel JA, 2Pierson R. 1Regina Qu’Appelle Health Region, Regina, Saskatchewan, Canada; 2University of Saskatchewan, Saskatoon, Canada Study Objective: To determine the number of trailing Essure coils visualized in the endometrial cavity on completion predicting successful follow-up by ultrasonography 3 months post-procedure. Design: Retrospective case control study (Canadian Task Force classification Type II-2).

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Setting: Ambulatory care clinic in a tertiary hospital. Patients: Ninety-eight women undergoing Essure tubal sterilization for permanent contraception. Intervention: The Essure procedure was completed using a 4 mm single channel operative hysteroscope with the aid of conscious sedation using fentanyl and midazolam. The number of coils trailing into the endometrial cavity on completion was noted. Following successful placement of the coils, each patient was booked for follow-up ultrasound at three months to determine placement of the coils. If the coils could not be ultrasonographically localized, a hysterosalpingogram was performed. Measurements and Main Results: Patients age, gravidity, parity and body mass index were recorded. The number of coils that remained in the endometrial cavity on completion of the Essure procedure was noted. Successful ultrasonographic follow-up at 3 months or results of the hysterosalpingogram in those where the ultrasound could not determine adequate cornual position of the coils were compared. The data were analyzed using a Mann-Whitney U-test. The mean patient age was 37 + 5 in the ultrasound only group and 37 + 4 in the ultrasound and HSG group. There was not significant difference in the gravidity or parity. Essure coils were successfully visualized bilaterally in the uterine cornua 3 months following the procedure in 81 of the 98 women (82%). The number of trailing coils in the ultrasound only group was 4.6 + 1.8 (mean + SD) on the right and 4.3 + 1.6 on the left. Seventeen women required hysterosalpingography to ascertain tubal occlusion because of an unsatisfactory ultrasound. The number of trailing coils in this group was 3.7 + 1.4 on the right and 4.3 + 1.3 on the left. There was no significant difference between the number of coils trailing in the ultrasound and ultrasound/hysterosalpingogram groups (right p<0.08, left p<0.67). The mean BMI in the ultrasound group (27.9 + 6.3) did not differ significantly from the ultrasound/hysterosalpingogram group (25.9 + 2.6, p<0.48) . Conclusion: Examination 3 months following Essure placement was successful in demonstrating adequate cornual positioning of the Essure coils in 82 percent of the women in the study. The number of trailing coils in the endometrial cavity on completion of the Essure procedure was not predictive of the success of the 3 month follow-up ultrasound . Patient BMI was not related to the success of the follow-up ultrasound examination.

TUESDAY, NOVEMBER 7, 2006 Open Communications 1—Complications & Surgical Techniques (2:45 PM – 2:51 PM)

41 Preoperative Vaginal Preparation with “Baby Shampoo” Compared to Povidone-Iodine Prior to Gynecologic Procedures Lewis L, Lathi R, Nezhat CR. Stanford University Hospital, Palo Alto, California Study Objective: A preoperative external and internal preparation is used to decrease the bacteria load in an effort to prevent postoperative infection after gynecologic surgery. Povidone-iodine (PI) is typically used as a skin as well as a vaginal preparation despite being responsible for significant vaginal irritation and allergic reactions. Recent studies suggest that it is the dilution of bacteria and not the antibacterial properties of a vaginal preparation that prevent infection. Given that the vagina has a unique microbial environment and the optimal vaginal preparation solution is unknown, we sought to compare two commonly used vaginal preparations at our institution. The objective of this study was to compare the postoperative infection rates between patients receiving either PI or baby shampoo vaginal preparations prior to gynecologic surgery. Design: This was a retrospective case series Setting: at a tertiary referral center. Patients: Patients were randomly selected who underwent minimally invasive gynecologic surgery including; hysteroscopy (diagnostic or operative), laparoscopic myomectomy, or laparoscopic hysterectomy (total or supracervical). A total of 112 cases were collected; 52 subjects having undergone surgery prior to the change to baby shampoo and 60 subjects after the change Measurements and Main Results: This was a retrospective case series at a tertiary referral center. All patients underwent minimally invasive gynecologic surgery including; hysteroscopy (diagnostic or operative), laparoscopic myomectomy, or laparoscopic hysterectomy (total or supracervical). Patients having surgery before July 2003 received a standard PI preparation and patients having surgery after that date received a vaginal prep with baby shampoo. For both preparation agents; the mechanical preparation, number and type of sponges used, and method of preparation were identical throughout the study. The agents used for vaginal preparation were either baby shampoo in a 1:1 dilution with sterile normal saline or a povidone-iodine 7.5% scrub solution. A total of 112 cases were collected; 52 subjects having undergone surgery prior to the change to baby shampoo and 60 subjects after the change. Charts were reviewed for evidence of infection within 30 days of surgery (symptoms of UTI, abdominal or vaginal wound infections, temperature > 100.4o F, and fungal or bacterial vaginitis). Statistical analysis was done using the Chi-square test. No significant differences were found in the types of cases performed, age of patients, or diagnosis of patients who under-

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went surgery with PI compared to baby shampoo. The infection rate while using the PI preparation was 7/52 or 13% (UTI = 4; abdominal wound = 3). The rate with baby shampoo was 5/60 or 8.3% (UTI = 3; abdominal wound = 1; fever = 1). The infection rate between the two groups of patients was not significantly different (p > 0.05). Conclusion: Baby shampoo was chosen as an alternative to PI because it is a non-irritating, alcohol-free, inexpensive ($0.38/oz for PI versus $0.26/oz for baby shampoo) mild detergent. This preliminary study suggests that baby shampoo is as effective as povidone-iodine in preventing postoperative infection.

TUESDAY, NOVEMBER 7, 2006 Open Communications 1—Complications & Surgical Techniques (2:51 PM – 2:57 PM)

42 Patient Selection and Surgical Technique May Reduce Major Complications of Laparoscopic-Assisted Vaginal Hysterectomy Roman J. Braemar Hospital, Hamilton, New Zealand Study Objective: To study the clinical outcome of patients who underwent laparoscopic-assisted vaginal hysterectomy especially with regards to early postoperative complications. Design: Retrospective study (Canadian Task Force classification II-3). Setting: Private hospital in Hamilton, New Zealand. Patients: Four-hundred and eighteen women. Intervention: Laparoscopic-assisted vaginal hysterectomy. Measurements and Main Results: Primary indication for surgery, operating time, hospital stay and major complications were analysed. Major complications were defined as life-threatening injuries, unintended major surgical procedures and conversions to laparotomy that occurred under duress (e.g., intraoperative haemorrhage). Complications were reported up to 6 weeks of postoperative time. The total early postoperative complication rate was 11.24%. There were no patients with damage to the bowel, ureters or bladder. There were no deaths. Major complications were 3 cases of partial vault dehiscence and 1 case of partial small bowel obstruction. The operation was performed successfully in 412 cases. Six patients needed a laparotomy. Conclusion: The present retrospective study shows laparoscopic-assisted vaginal hysterectomy is a safe surgical procedure. The possible reasons for the low complication rate reported are the surgical technique of ureteral dissection, the use of suitable instruments to expose the vaginal fornices, a consistent team approach and the selection of patients.

TUESDAY, NOVEMBER 7, 2006 Open Communications 1—Complications & Surgical Techniques (2:57 PM – 3:03 PM)

43 Laparoscopic Hysterectomy in Patients with Previous Caesarean Section. A Review of Complications Soo SC, Merkur H, Hardas G. Sydney West Area Health Service, Sydney, New South Wales, Australia Study Objective: This study was undertaken to investigate the complication rates associated with laparoscopic hysterectomy in patients who have had Caesarean section(s). To identify if there are specific complications that are higher in this group of patients and to compare these rates with patients who have not had Caesarean section(s). Design: Five hundred and eighty three patients had laparoscopic hysterectomy of which ninety four patients have had one or more previous Caesarean section. The data was prospectively collected between 1999 and 2006 and retrospectively analyzed. All peri-operative complications were documented and follow up was performed at 4 to 8 weeks in all cases. Analysis is by intention to treat. Major complications include inadvertent cystotomy, hemorrhage greater than 500mls and ureteric injury. Setting: Advanced gynecological endoscopy teaching hospitals. Patients: Ninety four patients with one or more previous Caesarean Section undergoing laparoscopic hysterectomy. Intervention: Laparoscopic hysterectomy completed with either laparoscopic assisted vaginal hysterectomy or total laparoscopic hysterectomy. Measurements and Main Results: Of the ninety four patients who had laparoscopic hysterectomy with previous Caesarean(s), the major complication rate was 14.9% (14/94) with a conversion to laparotomy rate of 7.4% (7/94). The complication rate for all laparoscopic hysterectomy in this study is 8.1% (45/583) which is comparable to most available published series. The complication rate for Laparoscopic hysterectomy in patients without previous Caesarean is lower at 6.3% (31/489). In particular the rate of inadvertent cystotomy was higher in the previous Caesarean section group at 5.3% (5/94) when compared to no previous Caesarean section at 0.8% (4/489). A higher major complication rate of 14.9% and a significant higher rate of inadvertent cystotomy of 5.3% was observed in the group of patients undergoing Laparoscopic Hysterectomy with one or more previous Caesarean. Conclusion: This study suggest that there is a higher major complication rate when performing Laparoscopic Hysterectomy in patients with previous Caesarean sections. This has important implications towards counseling and consenting in these patients for laparoscopic hysterectomy. There is currently inadequate data to suggest whether a laparoscopic, laparotomy or vaginal approach is safest in these patients and a randomized controlled trial comparing the above named approaches is needed.

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TUESDAY, NOVEMBER 7, 2006 Open Communications 1—Complications & Surgical Techniques (3:03 PM – 3:09 PM)

44 Safety of Total Laparoscopic Hysterectomy: A Comparison of Urinary Tract Complication Rates at a Gynecologic Fellowship Program to Historical Controls Farnam RW, Pollard RR, Ahluwalia PK. St. Elizabeth Medical Center, Utica, New York Study Objective: The primary goal of this study was to determine the safety of a Total Laparoscopic Hysterectomy procedure with regard to urinary tract complications. Specifically, all total laparoscopic hysterectomies performed at a GYN Laparoscopy Fellowship Program were considered. This Cohort was compared to historical controls for abdominal hysterectomy and laparoscopic hysterectomy. Comparisons of other major complications including bowel injury, blood transfusion, venous thromboembolism, fistula formation, and major vessel injury were included. Design: Two Hundred and Four women who underwent a Total Laparoscopic Hysterectomy procedure were included in a Retrospective Cohort study. All women who underwent a Total Laparascopic Hysterectomy procedure at either of two participating hospitals from the inception of the Fellowship Program in July 2003 until May 2006 were included. Urinary tract injuries and other major complications were determined by operating room record review and outpatient record review conducted at least one month after the procedure was performed. Setting: Two hospitals participating in an Advanced GYN Laparoscopy Fellowship Program. Patients: Two Hundred and Four women who underwent a Total Laparoscopic Hysterectomy procedure were included. Intervention: Total Laparoscopic Hysterectomy. Measurements and Main Results: A preliminary evaluation of the data indicates that when compared to historical controls for abdominal hysterectomy, there was no increased risk of bladder injury for total laparoscopic hysterectomy in the fellowship program cohort. There was an increased risk of ureteral injury as well as urinary tract injury for the fellowship program cohort, however the risk was significantly lower than historical controls for laparoscopic hysterectomies. Additionally there was no increased risk of other major complications except fistula formation, when compared to historical abdominal hysterectomy controls. Conclusion: The findings suggest that at a GYN Laparoscopy Fellowship Training Program a total laparoscopic hysterectomy procedure can be preformed safely, and without an increased risk of bladder injury when compared to an abdominal hysterectomy procedure. Additionally the relative risks of ureteral injury and urinary tract injuries, while increased, were significantly less than historical controls for laparoscopic hysterectomy. Also there was no increased risk of bowel injury, blood transfusion, venous

thromboembolism, and major vessel injury when compared to abdominal hysterectomy.

TUESDAY, NOVEMBER 7, 2006 Open Communications 1—Complications & Surgical Techniques (3:09 PM – 3:15 PM)

45 Complications of Advanced Laparoscopic Surgery for Endometriosis. A 5-Year Retrospective Observational Study Griffiths AN, Koutsouridou R, Penketh RJ. University Hospital of Wales, Cardiff, South Glamorgan, United Kingdom Study Objective: The aim of this study is to quantify and describe in the incidence of types of laparoscopic complications that occur when dealing with advanced laparoscopic surgery for endometriosis Design: A 5-year retrospective observation study Setting: The University Hospital of Wales Heath Park Cardiff UK. Patients: One hundred fourteen cases of advanced laparoscopic surgery for severe or extensive endometriosis. Measurements and Main Results: The overall intraoperative complication was 6/114 (5.26 %), numbers need to harm (NNH) was 19 cases. The overall postoperative complication rate was 14/114 (12.3 %) numbers needed to harm (NNH) 8 cases. The overall complication rate was 20/144 (17.5 %), NNH was 6. Although this initially seems high compared to the incidence of complications quoted by the RCOG information guideline it must be emphasised that these are only theupeutic laparoscopies for extensive or severe endometriosis. There complication rate is comparable with other studies looking at extensive or severe endometriosis laparoscopic surgery. Conversion to laparotomy occurred in 2/144 patients (NNH 57), Significant bleed occurred in 1/114 (NNH 115), Bowel trauma occurred in 1/114 (NNH 115). Superficial wound infection occurred in 3/114 (NNH 38), pelvic abscess formation occurred in 1/114 (NNH 115). Conclusion: Specific and personalized complication rates are of extreme value in the process of achieving a truly informed consent.

TUESDAY, NOVEMBER 7, 2006 Open Communications 1—Complications & Surgical Techniques (3:15 PM – 3:21 PM)

46 Neuro-Urological Complications of Surgical Treatment of Deep Endometriosis Volpi E, Castelli E, Sismondi P. University of Turin, Turin, Italy Study Objective: Analysis of the reported complications of surgical treatment of deep infiltrating endometriosis

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such as ureteral damage and urinary retention in comparison to our experience. Design: We reviewed the literature about the surgery of deep infiltrating endometriosis and urinary complications and compared it to our experience. Setting: University, tertiary care Measurements and Main Results: the incidence of major complications and more specifically of urinary and bowel injuries during surgery is very low. In our experience transient urinary retention was observed in about 30% of the patients even in patients with monolateral dissection, while no ureteral lesion was observed. However one patient had persistent urinary retention at one year from the surgical procedure. No persistent urinary retention is reported in the literature. Conclusion: In our experience the incidence of urinary lesions due to endometriosis’ surgery is higher than that found in literature. It can depend on the under-estimation in the literature or on our radical technique operating endometriosis. The radicality of this surgery is more evident for the ureteral and nerve dissection . We believe that little attention is paid in the literature to the urinary side effects of radical surgery for endometriosis.

TUESDAY, NOVEMBER 7, 2006 Open Communications 1— Complications & Surgical Techniques (3:21

PM

– 3:27

PM)

47 Conservative Management of Delayed Thermal Injuries to the Genito-Urinary Tract during Operative Laparoscopy Connell JM, Advincula AP, University of Michigan, Ann Arbor, Michigan Study Objective: To demonstrate that a delayed thermal injury to the ureter sustained during operative laparoscopy as a result of electrosurgical instrumentation can be managed conservatively with prolonged ureteral stent placement. Design: Retrospective case analysis. Setting: University teaching hospital. Patients: Three patients with a delayed thermal injury to the ureter that were identified post-operatively after an operative laparoscopy. Intervention: Intravenous pyelogram. Either retrograde ureteral stent placement and/or percutaneous nephrostomy with nephroureteral stent placement followed by serial balloon dilations. Measurements and Main Results: All patients underwent a total laparoscopic hysterectomy and sustained a unilateral ureteral injury. Two patients presented with flank pain and one with urinary incontinence. All patients underwent an intravenous pyelogram that confirmed ureteral injury, with evidence of a ureterovaginal fistula in the case of urinary incontinence. Urology was consulted in all cases. A retrograde ureteral stent placement was attempted in the two patients with flank pain. This was unsuccessful in 1 case

therefore a percutaneous nephrostomy with nephroureteral stent was placed. In the ureterovaginal fistula patient, a percutaneous nephrostomy with nephroureteral stent was attempted initially with success. Duration of management with serial balloon dilation and prolonged ureteral stenting were 3 and 7 months for the two patients who had complete resolution of injury on follow-up with a resultant patent ureter. The third case is still undergoing follow-up despite ureteral stent removal after 6 months. Conclusion: There is currently no description of conservative management of a delayed thermal ureteral injury in the gynecologic literature and a paucity of support in the urologic literature. Delayed thermal injuries to the ureter appear to be manageable with prolonged ureteral stenting as evidenced by the management of these three cases.

TUESDAY, NOVEMBER 7, 2006 Open Communications 1—Complications & Surgical Techniques (3:27 PM – 3:33 PM)

48 Equipment Malfunction: Causes and Consequences in Endoscopic Gynecological Surgery 1 Courdier S, 2Garbin O, 2Hummel M, 2Thoma V, 1Wattiez A. 1Hautepierre Hospital, University Hospital of Strasbourg, Strasbourg, France; 2SIHCUS-CMCO Hospital, University of Strasbourg, Schiltigheim, France Study Objective: To study equipment-related malfunction in gynecological endoscopy, their causes and consequences Design: One hundred twenty-six women were included in a monocentric prospective study. All women underwent endoscopic surgery between January and April 2006. Emergency surgical procedures and procedures where test equipment was used were excluded. Setting: Department of Gynecology Surgery, University Hospital. Patients: One hundred twenty-six women underwent endoscopic operations. Intervention: Endoscopic operations including 73 laparoscopies, 50 surgical hysteroscopies and 3 culdoscopies. Measurements and Main Results: Five types of malfunctions were identified: imaging circuit, fluid and light circuit, electrical circuit, and surgical instrument issues. We examined whether they were related to faulty connections between elements. Human factors, time spent rectifying the problem, as well as consequences for the patient were analyzed. Malfunction occurred in 58 surgical procedures (34.1%). Laparoscopies were equally affected as hysteroscopies (35.6% vs 38.0%). 41.3% of malfunctions originated from assembling fluid and light systems, 20.7% from the electric circuits, 6.9% from imaging devices, 31% from surgical instruments. 46.6% of malfunctions originated from plugs, pipes or cables. In laparoscopy, bipolar forceps and its cable was the most common cause of malfunction (28.9%), whereas small equipment (connection devices and joints) are mostly involved in hysteroscopy. Half of the mal-

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functions (50%) involved staff (nurses 75.8%, surgeons 24.3%). Time wasted due to malfunction resolutions accounted for 6.6% of the duration of laparoscopic interventions, and 17.1% of hysteroscopic interventions. 19% of equipment malfunction could have had serious consequences to the patient. No morbidity and mortality were noted. Conclusion: Equipment-related malfunction were frequent during endoscopic surgery. Laparoscopies and hysteroscopies were equally affected. The consequences of such malfunction were potentially serious. Identifying the causes and ensuring the staff is adequately trained enables the optimization of endoscopic surgery equipment during everyday use, with improved safety to the patient.

that need Laparotomy for repair the damage. Conclusion: No differences in both groups were found. Even that the use of the optiview trocar has been described since 1997, its general use is not well accepted in all the laparoscopic centers. The routine use that we have started in our Residency Programs with safety for the patient and good acceptance in the Medical Staff its only one aspect for the development of safety laparoscopic surgery even in heavy weight patients.

TUESDAY, NOVEMBER 7, 2006 Open Communications 1—Complications & Surgical Techniques (3:39 PM – 3:45 PM)

50

TUESDAY, NOVEMBER 7, 2006 Open Communications 1—Complications & Surgical Techniques (3:33 PM – 3:39 PM)

49 Successful Insertion of the Direct Visualization Trocar “Optiview” in Normal and Heavy Weight Patients during Laparoscopy 1 Godoy HS, 2Castillo A, 2Rivas R, 3Muraira R. 1Hospital Angeles del Pedregal, Obstetrics and Gynecology, Reproduccion y Genetica; 2General and Endoscopic Surgery; 3Reproducitive Medicine, Mexico, D.F., Mexico Study Objective: Evaluate the difficulty for the direct insertion of the main trocar in Laparoscopic procedure in Gynecological and no Gynecological surgery in normal and obese patients. Design: Prospective, observational study during a 12 months period. Setting: Universitary, Tertiary Care Hospital in México City, México. Patients: One hundred twenty female patientsdivided in two groups: I: gynecological surgery (normal weight) and II: No gynecological surgery (heavy weight) Intervention: Direct insertion of the “Optiview”Johnson & Johnson trocar, without pneumoperineum was evaluated by gynecologic and gastrointestinal laparoscopists in myomectomy, ectopic pregnancy, hysterectomy, ovarian cyst, infertility and gastric band application. Measurements and Main Results: Group I includes 60 gynecologic patients with mean age of 33.9 years and mean weight of 56.11 Kg. Group II includes 60 gastric band application patients with mean age of 35.95 years and mean weight of 116.37 Kg. We evaluate the difficulty to introduce the trocar throught the abdominal wall with direct visualization, the time for introduction, success or failure to reach the abdominal cavity and complications. We experienced difficultyin trocar introduction in Group I = 3 patients and Group II = 4 patients. The mean time for introduction was 21 seconds in Group I and 34 seconds in Group II. There were not wall, visceral or vascular damage in Group I. Only one patient in group II experienced vascular and visceral damage

Randomized Comparison of Reusable Trocarless Cannulae (ENDOTIP) and Standard Trocar/Cannula Systems During Laparoscopic Surgery 1,2 Abu-Rafea B, 2Vilos GA, 2Abyaneh ZN, 2Hollett-Caines J, 2 Vilos AG. 1King Fahad Medical City, Riyadh, Saudi Arabia; 2The University of Western Ontario, St. Joseph’s Health Care, London, Ontario, Canada Study Objective: The compare the insertion & intra-operative performance of reusable trocarless cannulae to standard trocar/cannula systems during routine laparoscopic surgery. Design: Prospective randomized trial. Setting: University-affiliated teaching hospital. Patients: From January 2005 through September 2005, 202 women underwent laparoscopic surgery by the senior author (GAV) for various indications. The median and (range) of age, parity and BMI of all patients were 34 years (15-58), 0 (0-8), and 24.8 kg/m2 (15-47.4), respectively. Intervention: Laparoscopy was performed under endotracheal anesthesia and muscle relaxants. With patients in suitable stirrups and the table in horizontal position, a reusable Veres needle was inserted at the umbilical site. An initial intra-peritoneal pressure < 10 mmHg was considered as an indicator of correct Veres needle placement. After establishment of pneumoperitoneum at 25-30 mmHg, access into the abdomen was established by the EndoTip cannula (n=102) or a 10 mm trocar/cannula system (n=100) in accordance with randomization sheet. Entry with the EndoTip is visual. All secondary 5 & 10 mm ports were established under visual control and were either EndoTip cannulae or trocars in accordance with the initial randomization. Measurements and Main Results: The two groups were comparable for age (p=0.27), BMI (p=0.46), indications for surgery, number of prior laparoscopies (p=0.46) and abdominal incisions (p=0.91), and number of Veres needle attempts (p=0.96). There was one large bowel injury in the standard trocar group. The extrusion rates of the secondary (5 mm cannulae) were 50% for the strait and 5% for the EndoTip, respectively (p=0.0001). Conclusion: 1- The study was not powered to determine entry-related complications. 2- Surgeon satisfaction.

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TUESDAY, NOVEMBER 7, 2006 Open Communications 2—Urogynecology/Pelvic Floor Disorder (3:50 PM – 3:56 PM)

51 Creating an Algorithm for the Treatment of Frequency/Urgency without Detrusor Instability and Application of Urethral Instability as a Prognostic Tool to Predict the Success of InterStim Sacral Nerve Stimulation Hashemi EA, McKinney TB, Greenleaf BA. Athena Women’s Medical Center and UMDNJ, Turnersville, New Jersey Study Objective: Creating an algorithm for the treatment of frequency/urgency without detrusor instability and application of urethral instability as a prognostic tool to predict the success of interstim sacral nerve stimulation. Design: Chart reviews and retrospective analysis of patient’s urodynamics were applied, using Medtronics multi P urodynamic machine and dual sensor T-DOC “air charged” urodynamic catheters. Sacral nerve stimulation using the InterStim system (Medtronic, Inc., Minneapolis, Minnesota) has been a promising therapy for patients with urge incontinence, urgency-frequency, and retention who failed medical and non-surgical therapy. The efficacy and success of Interstim has never been linked to any tangible neurological finding. We have looked at in this paper the correlation between urethral instability (Change in urethral pressure during filling phase of urodynamics of > 15 cm H2O pressure off of the baseline using TDOC dual sensor catheters) and the success of Interstim placement. This correlation has not been studied in the review of the literature. We have also looked at the crossover between interstitial cystitis (I.C.) patients that have failed medical management and have urethral instability and have successful treatment with Interstim. We are looking to create an algorithm for the treatment of patients with frequency/urgency and no detrusor instability (D.I.). Setting: Community base private office. Patients: Thirty-three patients with urethral instability, 28 patients with Interstitial cystitis Intervention: In the first group, a total of 33 patients in our office underwent baseline assessment, urodynamic evaluation, and sacral nerve stimulation at S3 using InterStim system (Medtronics, Inc., Minneapolis, Minnesota). All patients had undergone prior conventional treatments such as pharmacotherapy and/or surgical intervention for voiding dysfunction. In the second group, 28 patients with signs and symptoms of I.C. underwent baseline assessment, urodynamic evaluation, and cystoscopy using 70-degree cystoscope with biopsy and hydrodistension. We evaluated the outcomes of medical and InterStim therapy. Measurements and Main Results: In the first group, 28 patients had urethral instability documented on their urodynamics. Two patients had poor studies and could not use their data and two patients had retention of urine, however,

they had successful Interstims. All 33 patients had InterStim placed with an overall success rate of 79 % (26 out of 33). In looking at the success of InterStim with cross-reference to urethral instability as predictor, 24 of successes had urethral instability (86 %). Four had failure with urethral instability; however, one had retention with an atonic bladder as reason for InterStim placement. One patient with negative urethral instability had negative response to InterStim. In a group of 33 patients with InterStim therapy 12 patients had I.C. in addition to urethral instability. In this group, 11 out of 12 patients with I.C. and urethral instability showed improvement (more than 50% improvement in urinary symptoms) with InterStim. In another group of 28 patients with I.C. 18 patients had urethral instability on their urodynamic studies. All of the patients except one with urethral instability responded to hydrodistension, Elmiron, Hydroxyzine, Prelief, and DMSO or Heparin instillation. The one patient with urethral instability who failed medical therapy subsequently underwent successful InterStim placement with improvement of symptoms. Conclusion: Our algorithm for frequency and urgency without detrusor instability is as follow: If urodynamics + urethral instability and normal baldder capacity, go to medical therapy with dietary changes, alpha-adrenergic blocking agents (Hytrin/Flomax) and biofeedback with bladder drills; if fails go to InterStim. If urodynamics – urethral instability, go to cystoscopy with biopsy and hydrodistension and treatment for I.C. If urodynamics + urethral instability with decreased bladder capacity, go to cystoscopy with biopsy and hydrodistension and medical therapy for I.C. If fails go to Interstim. We will soon add a K+ challenge test to further differentiate I.C. in the earlier patient’s workup, which may allow us to bypass the biopsy. The future needs to create a prospective trial with pre and post operative urodynamics to see if Interstim corrects the urethral instability or just down regulates the signals thus alleviating the symptoms of frequency/urgency.

TUESDAY, NOVEMBER 7, 2006 Open Communications 2—Urogynecology/Pelvic Floor Disorder (3:56 PM – 4:02 PM)

52 Is the Mechanism of Action of the TOT the Same as the TVT? Ross JW. Center for Reproductive Medicine and Female Continence, Salinas, California, University of California School of Medicine, Los Angeles, California Study Objective: The aim was to investigate bladder neck (BN) and tape mobility and correlate this with the efficacy of the transobturator tension free sling (TOT) in treating stress urinary incontinence. The mode of action of the TOT is compared to the TVT. Design: A prospective analysis of 137 consecutive TOT bladder slings. Setting: Private Urogynecology clinic.

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Patients: One hundred and thirty-seven women (mean age 51.3, range 29-86) (parity 3.1, range 1-6) treated with urodynamic positive genuine stress incontinence (GSI). Intervention: Following a TOT midurethral bladder sling, perineal ultrasound was performed at rest and during Valsalva. The movement of the BN, tape, and urethral positions were documented. Vector length of the BN and tape were calculated at rest and during Valsalva, as was the _-angle (urethral angulation by the tape during Valsalva) postoperatively. Objective cure for urinary stress incontinence was determined by a negative cough stress test (CST done sitting with 250 mL in the bladder). Measurements and Main Results: One hundred and twenty-three of 137 women had negative CST with mean followup of 12.9 months (range 3-21). The BN vector length at rest and Valsalva preoperatively and postoperatively of 10.4 and 8.3 mm were not significant. The vector length of the tape was 5.9 mm. The urethral angulation of 29.7° at Valsalva following the tape placement was significant (p < 0.01). All tapes were at midurethra, with no signs of migration toward the BN. All tapes moved dorso cranial to ventro caudal during Valsalva. Conclusion: There is no significant change in BN position with the TOT, similar to findings with the TVT. There was no tape migration and there was significant urethral angulation seen with the tape, suggesting the TOT acts in kinking the urethra without significant urethral compression against the symphysis as seen with the TVT. TOT cure rates in short-term follow-up are comparable to the TVT.

TUESDAY, NOVEMBER 7, 2006 Open Communications 2—Urogynecology/Pelvic Floor Disorder (4:02 PM – 4:08 PM)

53 Treatment for Urinary Incontinence in Obese Patients Piskunova EV, Nudelman SV. Cosmetology & Plastic Surgery Center, Ekaterinburg, Russia Study Objective: To improve treatment outcome in patients with obesity and urinary incontinence. Design: Nine patients with obesity followed up between 2000 and 2006. Setting: Gynecology Department, Cosmetology and Plastic Surgery Center. Patients: One hundred and nine patients with obesity, mean age 44 years, mean BMW = 31.4 were followed up for 2 yrs and found to have extragenital pathology (89% cases), connective tissue dysplasia (CTD) (31.2%), delivery trauma history (24.8%), urinary incontinence (55.8%). Stress or mixed incontinence, or hyperactive bladder were observed in 42.4%, 32.6% and 25% of incontinence patients, respectively. All patients were subdivided into 3 groups: Group 1 (n= 49) with the history of abdominoplasty; Group 2 (n=27) with urinary stress incontinence (USI) undergoing combined abdominoplasty and USI correction; Group 3 (n=33) with USI undergoing surgical correction for USI and prolapse.

Intervention: Group 2 patients underwent combined abdominoplasty (with liposuction in 20 cases) and TOT/TVT for USI (with prolapse correction in 19 cases). Group 3 patients underwent surgical correction for USI (TVT or O-TVT) with pelvic organ prolapse correction in 24 cases. Measurements and Main Results: In Group 1 USI aggravation was observed after abdominoplasty in 72.7% of patients with USI, and 6.9% patients developed USI signs de novo. Group 2 vs. Group 3 patients had higher rate (18% vs 13.7%) of delayed micturition in early postoperative period and higher incidence of bladder perforation (6% vs. 1.8%). The mean micturition recovery time was 14 hrs. Conclusion: 55.8% of obesity patients had micturition disorders. Abdominoplasty is a risk factor for genital prolapse and USI progression. Negative factors for progression included massive excised abdominal flap, age, history of vaginal delivery, diseases-CTD-markers. Simultaneous treatment for obesity and USI is feasible. O-TVT is a method of choice for USI in obese patients. Simultaneous prolapse and USI correction with abdominoplasty is indicated if URP-test is below 60.

TUESDAY, NOVEMBER 7, 2006 Open Communications 2—Urogynecology/Pelvic Floor Disorder (4:08 PM – 4:14 PM)

54 Dyspareunia Associated with Transobturator Sling Cholhan HJ, Lee JT, Julia JJ. Women’s Continence Center of Greater Rochester, Rochester, New York Study Objective: To describe the development of dyspareunia as a complication of the tension-free sling procedure performed via the transobturator approach. Design: A retrospective review of the case-series report represents of twenty seven women with urodynamically-comfirmed stress urinary incontinence (SUI) who were treated with the transobturator slings from October 2004 to July, 2005. The preoperative evaluation consists of a comprehensive multi-channel urodynamic examination, a complete pelvic examination including the pelvic organ prolapse quantification system (POP-Q), and the quality-of-life questionnaire. The mid-urethral transobturator sling procedure was performed under the supervision of the senior author using polypropylene mesh (Obtryx TR Boston Scientific Corporation) via the same technique. The postoperative follow-up evaluation involved a comprehensive site-specific pelvic examination, a cough stress test, a voiding functional analysis, and a validated female sexual function index (FSFI), which included assessment of pain and discomfort with sexual intercourse. Measurements and Main Results: A total of 27/30 patients with transobturator slings was included in the report. Three patients were not counted (one patient expired; one patient was lost to follow-up; one patient declined). Eight patients were not sexually active. The remaining nineteen patients

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were sexually active. Total 11/27 (41%) cases were found to have “banding” phenomenon. There were 3/11 (27.3%) “banding” cases associated with patient who were underwent only transobturator sling procedure. 8/11 (72.7%) “banding” cases were found in patients undergone transobturator slings and other concurrent procedures. 4/19 (25%) women who were sexually active complained of dyspareunia. There were 4/11 (36.4%) patients with “banding” complained of dyspareunia. The remaining 7/11 (63.6%) patients who had “banding” did not have dyspareunia. Only one patient who has dyspareunia with “banding” was treated with transobturator sling procedure alone. Other three patients with dyspareunia had the combined TOT and concurrent procedures. Conclusion: We have identified a unique ever-reported morbidity, dyspareunia, as a reflection of TOT insertion in clinical practice. Although this study consists of a small caseseries report, it provides a better understanding of the mechanism for this complication. It also serves as a tool to further improve the surgical outcome and to decrease patient morbidity.

patients (mean age, 64.0 years) in the Apogee group, preoperatively, 81.3% had * grade III and 18.8% had grade II prolapse. Postoperatively, 87.5% of patients achieved B-W grade 0 or I. Of the 13 patients (mean age, 62.4 years) undergoing repair with porcine dermis graft and both Perigee and Apogee, preoperatively, 66.7% had grade III and 16.7% had grade II prolapse. Final postoperative evaluation showed that 100% of efficacy evaluable patients had B-W grade 0 or I. No cases of graft exposure were reported within this group of patients. Pain was reported by very few patients (Perigee, 0/32 [0%]; Apogee, 1/18 [5.6%]; and Perigee and Apogee combination, 1/13 [7.7%]. Conclusion: Pelvic organ prolapse repair using porcine dermis grafts with Perigee and/or Apogee systems is effective in treating POP, as shown within the first year. There was no mesh exposure and very few postoperative complications.

TUESDAY, NOVEMBER 7, 2006 Open Communications 2—Urogynecology/Pelvic Floor Disorder (4:20 PM – 4:26 PM)

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TUESDAY, NOVEMBER 7, 2006 Open Communications 2—Urogynecology/Pelvic Floor Disorder (4:14 PM – 4:20 PM)

55 Efficacy and Safety of Porcine Dermal Grafts in Patients Undergoing Pelvic Organ Prolapse Repair 1 Davila GW, 2Lukban JC, 3Patel M, 4McCammon K. 1 Cleveland Clinic Foundation Florida, Weston, Florida; 2EVMS Department of Obstetrics and Gynecology, Norfolk, Virginia; 3Piedmont Urology Associates, Gastonia, North Carolina; 4Sentara Norfolk General, Virginia Beach, Virginia Study Objective: To assess outcomes following pelvic organ prolapse (POP) repair using porcine dermis grafts (InteXen) for anterior wall prolapse (Perigee; AMS, Minnetonka, MN) and/or vaginal vault and posterior wall prolapse (Apogee). Design: Retrospective chart reviews of each investigator’s first 7 patients in each category: Apogee, Perigee, or combined Apogee and Perigee for POP. Follow-up averaged 4.2 months (range 1-12 months). Setting: Urogynecology and urologic pelvic surgery teaching hospitals and community based physician practices. Patients: Reviews of 63 patient charts at 4 clinical sites. Intervention: Porcine dermis grafts were used for POP repair with a transobturator anterior prolapse repair system and/or vaginal vault and posterior repair system. Measurements and Main Results: Porcine dermis graft and the Perigee system were used in 32 patients (mean age, 63.8 years). In recorded preoperative assessment, 51.6% of patients had severe pelvic prolapse (Baden-Walker [B-W] grade * III) and 9.7% had B-W grade II. Postoperatively, 90.0% of patients achieved B-W grade 0 or I. Of the 18

Retrospective Analysis of Efficacy and Safety of Perigee and Apogee in Patients Undergoing Repair for Pelvic Organ Prolapse 1 Davila GW, 2Flaherty JF, 3Lukban JC, 4Beyer R, 5Patel M, 6 Moore RD. 1Cleveland Clinic Foundation Florida, Weston, Florida; 2InterMed, Portland, Maine; 3EVMS Department of Obstetrics and Gynecology, Norfolk, Virginia; 4Women’s Healthcare Specialists, Paw Paw, Michigan; 5Piedmont Urology Associates, Gastonia, North Carolina; 6Atlanta Urogynecology Associates, Alpharetta, Georgia Study Objective: To assess outcomes following pelvic organ prolapse (POP) repair with a transobturator anterior prolapse repair system (Perigee; AMS, Minnetonka, MN, USA) and/or vaginal vault and posterior repair system (Apogee) using polypropylene mesh or porcine dermis grafts. Design: Reviews of 299 patient charts were conducted. Investigators collected data on a maximum of their first 7 patients in each category: Apogee only, Perigee only, or combined Apogee and Perigee. Prolapse grade was recorded using the Baden-Walker Halfway System. Parameters included demographics, medical history, pre- and postoperative evaluation of POP and LUTS, and information regarding peri- and postoperative surgical complications. Setting: Retrospective review at 15 clinical centers. Patients: Women with genital prolapse who underwent pelvic reconstructive surgery. Intervention: Patients who underwent surgical procedures including Apogee only, Perigee only, or combined Apogee and Perigee, were reviewed. Measurements and Main Results: Follow-up ranged from 1-8.7 months. The Perigee system was used in 122 patients (mean age, 61.4 years). Preoperatively, 78.7% had grade III and 21.3% had grade II prolapse. Significant improvement

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(grade 0) was seen in 93.3%; the remaining 6.7% achieved grade I. Of the 82 Apogee patients (mean age, 64.0 years), preoperatively, 56.1% had grade III and 43.9% had grade II prolapse. 100% had prior enterocele, 97.7% had prior rectocele, and 88.0% had prior vault prolapse achieved grade 0, and 12.0% with prior vault achieved grade I prolapse. Of the 95 undergoing repair with both Perigee and Apogee, preoperatively, 63.9% had grade III prolapse and 36.1% had grade II prolapse. Final postoperative evaluation showed that 95.7% had prior cystocele, 100% had prior enterocele, 100% had prior rectocele, and 95.5% with prior vault were noted to have grade 0 prolapse. Device-related complications, including pain, were demonstrated in < 1% of patients. Mesh exposure rates were low (overall, 29/298 [9.7%]; Perigee, 5/121 [4.1%]; Apogee, 10/82 [12.2%]; and Perigee and Apogee combination, 14/95 [14.7%]). Of these 29 patients, 9 (31.0%) required in-office therapy; and 9 (31.0%) required surgical treatment. Conclusion: POP repair with Perigee and/or Apogee systems with polypropylene or porcine dermis grafts are effective in treating POP with few postoperative complications.

TUESDAY, NOVEMBER 7, 2006 Open Communications 2—Urogynecology/Pelvic Floor Disorder (4:26 PM – 4:32 PM)

57 Treatment of Genital Prolapse Performed by Laparoscopic Promontofixation with Mesh: A Series of 138 Patients Botchorishvilli R, Rivoire C, Canis M, Wattiez A, Gaia G, Jardon K, Mage G. Polyclinique Gynécologie Obstétrique, CHU Clermont Ferrand, Clermont Ferrand, France Study Objective: To evaluate the feasibility, the anatomical and functional long term results of laparoscopic promontofixation for genital prolapse. Design: Retrospective monocentric series of 138 consecutive patients who underwent laparoscopc promontofixation for genital prolapse with the installation of 2 meshes: between 01/01/1998 and 31/12/2003. A clinical and urogynaecological evaluation with a minimum follow up of 1 year has been performed. The mean follow up to the study is 31 months (12-79). Setting: Gynaecology and Obstetrics Department of a Universitary Hospital. Patients: One hundred thirty-eight patients with uro-genital prolapse have been operated, 7 were lots to follow up. Intervention: Laparoscopic promontofixation with 2 prosthesis: A first prevesical and a second prerectal prosthesis fixed to the levator ani muscle, treatment of stress urinary incontinence by Burch colposuspension. Measurements and Main Results: The main duration of the procedure is 190 minutes without any conversion to laparotomy or major perioperative complications. 98% of patients are satisfied with the operation. 16 patients (12%) presented a recurrence of clinical symptom due to prolapse with a

maximum delay of 40 months. Fifteen patients (14%) presented an anatomical recurrence grade 3 and 4, associated with clinical symptom in 8 cases. 7 patients (5%) have been reoperated to apply tension to the prosthesis fixed to the promontory. 57 patients (46%) presented a postoperative stress urinary incontinence; among these, 9 had no treatment of urinary incontinence. Seven patients (5%) presented vaginal erosion, 2 prosthesis (1%) have been removed. At 40 months, the probability of anatomical success is stable at 0.8018 with a confidence interval of 95 %. Conclusion: Laparoscopic promontofixation appears as a feasible and safe technique for the treatment of genital prolapse. The associated treatment of stress urinary incontinence must be improved.

TUESDAY, NOVEMBER 7, 2006 Open Communications 2—Urogynecology/Pelvic Floor Disorder (4:32 PM – 4:38 PM)

58 The Laparoscopic Lateral Suspension Using Mesh for Cure of POP Is a Safe Technique Dubuisson JB, Sandrine J, Wenger JM, Ghahremani M. Hôpitaux Universitaires de Genève, Geneve, Switzerland Study Objective: To demonstrate that the laparoscopic lateral suspension using mesh is a safe procedure with a low rate of complications. Design: Prospective analysis of 112 consecutive cases of genital prolapse, with or without SUI, treated laparoscopically by lateral suspension using mesh. The study was carried out to report the complications of the surgery. Setting: University Hospital of Geneva, Switzerland. Patients: One hundred twelve women, mean age: 55.67+/11.82 (34-81) years, BMI: 26.37+/-3.98 (18-37) with stage II, III and IV genital prolapse according to the POPQ classification: Stage II, III and IV cystocele was noted in 91%, stage II, III and IV hysterocele in 62.5%, stage II, III and IV rectocele in 54.5%. All the candidates for laparoscopy were included. Intervention: The laparoscopy consisted of a tension-free lateral suspension (above the iliac crest) using a polyester mesh (30 x 3 cm) (Mersilene) according to our previously published technique. A Burch was performed when SUI was present (58%), a STLH was associated in 33 patients among 85 (38.8%). Measurements and Main Results: Assesment of success rate, peri-operative complications, postoperative complications and recurrences. The procedure was successfully completed in all 112 patients without conversion to laparotomy. Only 1 operative complication (0.9%) occurred: 3mm bladder injury sutured immediately, without any complications. We observed 7 postoperative minimal complications (6.25%) related to the technique of suspension: ablation of a nonabsorbable suture in the posterior wall of the vagina without anesthesia (n=2), pelvic pain with spontaneous relief (n=3), pelvic hematoma resolved sponta-

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neously (n=2). Only 1 post operative complication (0.9%) needed a reoperation (incisional trocar hernia). No vaginal mesh erosion occurred. Conclusion: Lateral suspension is a safe procedure without any major complications.

TUESDAY, NOVEMBER 7, 2006 Open Communications 2—Urogynecology/Pelvic Floor Disorder (4:38 PM – 4:44 PM)

59 A Bufffering System to Prevent Erosion of Synthetic Mesh in Minimally Invasive Vaginal Repairs Ross JW. Center for Reproductive Medicine and Female Continence, Salinas, California, University of California School of Medicine, Los Angeles, California Study Objective: To test the efficacy of a porcine dermis buffer in preventing mucosal erosion and improving outcome of a minimally invasive polypropylene (PP) mesh system for vaginal repairs. Design: Prospective analysis of 57 consecutive cases of transobturator &/or ischio-rectal pelvic floor repair. Setting: Private urogynecology clinic. Patients: Fifty-seven women (age 43-89) with Stage 2 or greater POP-Q anterior &/or posterior vaginal vault prolapse. Intervention: Twenty-six transobturator anterior (BSA) and 31 ischio-rectal posterior (BSP) vaginal repairs. Measurements and Main Results: At 12.6 months (range 3-21) the cure rate (< stage 2) was 94 and 95% for the BSA and BSP. There was one mucosal erosion (1.7%) in a patient with a concomitant vaginal hysterectomy, which was repaired with local excision of the mesh and tension free closure of the mucosa. There was delayed incisional healing (defined as > 6 weeks) in 12 patients (range 10-14 weeks). There was significant improvement in the Pelvic Symptom Inventory (PSI) and Quality of Life Scale (QOLS) questionnaires (P < 0.01). Complications included dyspareunia (2), dyschezia (2) and post op bleeding (1). Conclusion: The BSA-BSP repairs have good short term outcomes with a very low mucosal erosion rate. The buffered transobturator/ischio-rectal support system appears to be an effective minimally invasive vaginal repair system. The use of bio-engineering in the development of support systems can significantly improve outcome. The delayed healing seen with the current buffering system could possibly be improved by utilizing a thinner layer of porcine dermis.

TUESDAY, NOVEMBER 7, 2006 Open Communications 2—Urogynecology/Pelvic Floor Disorder (4:44 PM – 4:50 PM)

60 Laparoscopic Sacral Colpopexy using Gynemesh as Graft Material - Experience and Results Agarwala N. University of Nebraska Medical Center, Omaha, Nebraska Study Objective: To evaluate the safety and efficacy of PROLENE graft for sacral colpopexy and ease of use laparoscopically. Design: Retrospective review. Setting: University hospital. Patients: Seventy-four patients with recurrent prolapse of the apex or severe uterine prolapse (Stage II - IV). Intervention: Laparoscopic sacral colpo or cervico pexy using Gynemesh as the graft material. Measurements and Main Results: Seventyfour patients from March 2003 to March 2006 underwent a sacro pexy. Fifty one patients had recurrent apical prolapse, twenty two patients had uterovaginal prolapse Stage III or IV and one patient had uterovaginal prolapse Stage II and insisted on retaining the uterus. Mean age was 61.3 years ( 48- 76 years) and mean BMI was 34 ( 24 - 41). Laparoscopic sacral colpo or cervico or utero pexy was performed successfully in seventy two patients. Average blood loss was less than 25 cc and the average hospital stay was 1.1 days ( range 1-2 days). One surgery was terminated due to dense rectosigmoid adhesions to the cuff requiring a laparotomy and partial sigmoid resection due to redundancy and post dissection trauma to the sigmoid. Another one was completed as a Prolift procedure due to finding of a prior mersilene mesh that was densely adherent to the pelvic contents. Fifty two patients also had a concurrent sling procedure performed for incontinence. Intraoperative and post operative complications included one middle sacral bleed managed by suturing in the middle sacral region and one postoperative cervical abscess requiring reoperation and removal of the graft at 10 days. All patients were evaluated at 2 weeks and 6 weeks post operatively and pelvic exam performed. Then they were followed annually. Seventy patients are extremely happy and satisfied with the surgery. Post operative recovery has been uneventful and subjective and objective cure is 100%. One patient with sacro-uteropexy still has Stage I prolapse of her cervix, but it feels well supported. There have been no cases of graft exposure or recurrence (up to 36 months follow up). The patient with cervical abscess and graft removal has also healed with no recurrence of her prolapse. Conclusion: Laparoscopic sacral colpo or cervico pexy is a safe and effective procedure with excellent results. Gynemesh, a wide pore polypropelene mesh seems to be an excellent graft material with low risk for graft infection or erosion (1.4%).

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TUESDAY, NOVEMBER 7, 2006

TUESDAY, NOVEMBER 7, 2006

Open Communications 2—Urogynecology/Pelvic Floor Disorder (4:50 PM – 4:56 PM)

Open Communications 2—Urogynecology/Pelvic Floor Disorder (4:56 PM – 5:02 PM)

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Laparoscopic Sacral Colpopexy: The Learning Curve, Hospital Stay, and Complications. A Retrospective Review of the First Two Years of Use 1 Ballonoff CM, 1McBride A, 1,2Keil K. 1Exempla St. Joseph’s Hospital; 2Rose Medical Center, Denver, Colorado

Laparoscopic Uterovaginal Suspension to the Uterosacral Ligaments: A Review of 39 Cases

Furr RS, 2Lin LL, 1Tan CY, 1Liu CY, 2Bhatia NN. Chattanooga Women’s Laser Center, Chattanooga, Tennessee; 2Harbor-UCLA Medical Center, Torrance, California

Study Objective: The objective of this study is to characterize the learning curve over the initial 2 years of performing the laparoscopic sacral colpopexy (LSC). Design: After Institutional Review Board approval, a retrospective review of all hospital and clinic charts from women undergoing LSC by the Co-Investigators (KK) or (AM) was conducted. Data collected included standard demographics, medical and surgical histories, surgical assistants, the length of surgery, concomitant procedures performed, intra- and perioperative complications, preoperative prolapse stage, and hospital length of stay. Setting: Urogynecology private practice at a community teaching hospital. Patients: Twenty-eight women who underwent a LSC. Intervention: All patients underwent a LSC for vaginal vault prolapse. Measurements and Main Results: The mean age was 59 years. All patients were diagnosed with stage 2 to 4 apical prolapse. Twenty three patients had a history of hysterectomy and thirteen had a history of prior prolapse surgery. The mean number of concomitant procedures performed with the LSC was 4, including cystoscopy. Mean total OR time of each surgery was 184 minutes (range 118-500 minutes). When subtracting out concomitant procedures, the mean OR time for the LSC alone was 127 minutes (range 81-188 minutes). The mean length of the first five surgeries (193 min) was statistically longer than the last five surgeries (106 min)[LSC portion data]. Intraoperative complications included three incidental cystotomies, all repaired without significant sequelae (one by mini-laparotomy and two by laparoscopy). There was no trend in the distribution of intraoperative complications. The mean estimated blood loss was 100 mL with one patient requiring a blood transfusion. The median length of stay in the hospital was 26 hours. Conclusion: There is a significant learning curve when changing to a laparoscopic approach for a complex surgery. Laparoscopic sacral colpopexy is safe with the benefit of a short hospital stay.

Study Objective: To describe the surgical technique of laparoscopic uterovaginal suspension using the uterosacral ligaments. To review the efficacy and the durability of this laparoscopic technique. Design: Retrospective analysis (Canadian Task Force classification II-2). Setting: Private practice. Patients: Thirty-nine, all with advanced symptomatic uterovaginal prolapse. Intervention: Laparoscopic uterovaginal suspension to the uterosacral ligaments. All patients also had other site specific defects that were repaired concomitantly. Measurements and Main Results: Efficacy and anatomical outcome were assessed by the Baden-Walker halfway system before and after the surgical procedures. Preoperatively, all 39 patients showed evidence of grade 2 prolapse or greater. Patients were evaluated at six weeks, six and twelve months postoperatively and yearly thereafter. The mean follow up was 24.7 months, with a range of 10 months to 9 years. Postoperatively, 36 patients (92.3%) had no recurrence of prolapse and 3 patients (7.7%) had recurrence of uterine prolapse, grade 2 or greater. Of the 3 patients with recurrent prolapse, one patient had an asymptomatic grade 2 prolapse, and did not want any further intervention. Two patients experienced symptomatic recurrence and had subsequent hysterectomy at 7 and 36 months respectively. Our major complication rate was one case (2.6%) in which the patient experienced unilateral buttock pain immediately after the suspension procedure and required release and replacement of the suspension suture on the affected side. There were no intraoperative complications. The only minor postoperative sequela was urinary tract infections. The average operating time for the uterovaginal-uterosacral ligament suspension was 16 minutes (+ 4 min). Conclusion: Laparoscopic uterovaginal suspension to the uterosacral ligaments is a safe and effective treatment for appropriately selected women with symptomatic uterovaginal prolapse who desire uterine preservation.

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TUESDAY, NOVEMBER 7, 2006

TUESDAY, NOVEMBER 7, 2006

Open Communications 2—Urogynecology/Pelvic Floor Disorder (5:02 PM – 5:08 PM)

Open Communications 2—Urogynecology/Pelvic Floor Disorder (5:08 pm – 5:14 pm)

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Thigh Abscess Mistaken For Sarcoma Following Trans-Obturator Tape 1 Yeung P, 2Sokol AI, 2Walton B, 2Iglesia CB. 1Georgetown University School of Medicine, Washington, DC; 2 Washington Hospital Center, Washington, DC

Laparoscopic Pelvic Floor Repair: An Ongoing Prospective Observational Trial Lam AM, Condous GS, Royal North Shore Hospital, University of Sydney Centre for Advance Reproductive Endosurgery, Sydney, New South Wales, Australia

Study Objective: To describe the first known case of transobturator sling abscess mistaken for inflammatory sarcoma. Design: Case report with literature review. Setting: Washington Hospital Center. Patient: A 44-year-old Caucasian female one year statuspost ObTape‚ trans-obturator mid-urethral sling (Mentor Corporation, Santa Barbara, CA) presented to orthopedic surgery for left medial thigh pain and mass. Intervention: Intravenous antibiotics, multiple surgical wound debridements with placement of a wound vacuumassisted closure device, and transvaginal/medial thigh sling excision. Measurements and Main Results: Orthopedic oncology evaluated the patient for pain and a thigh mass. Multiple muscle biopsies of the enlarging mass were inconclusive, raising concern for inflammatory sarcoma. Surgical intervention for persistent groin pain and drainage established the diagnosis of an abscess. After several debridements involving the subcutaneous tissues and adductor muscles, sling material was found along the medial thigh exiting the obturator foramen. The patient was referred to Urogynecology for evaluation and transvaginal sling excision was performed from the left obturator space and suburethrally to the right ischiopubic ramus. Seventy-five percent of the infected sling material was successfully removed and the thigh wound healed by secondary intention. Cultures grew out Bacteroides fragilis and peptostreptococcus with rare beta hemolytic Group C Streptococcus. The patient subsequently developed recurrent stress urinary incontinence. Review of the MAUDE database indicates 194 ObTape‚ complications reported to the FDA since 2003. Ischiorectal fossa and obturator abscesses were each reported twice. No reports of thigh abscess mistaken for inflammatory sarcoma have been previously reported in the medical literature. Conclusion: Despite its minimally invasive nature, transobturator slings can be associated with serious complications, which may present in atypical ways. Patients may unknowingly present to other specialties for management of these complications, leading to unnecessary interventions and delayed diagnosis.

Study Objective: To evaluate the role of laparoscopic pelvic floor repair (PFR) in women with vault or uterovaginal prolapse. Design: Prospective observational ongoing study. The prolapse was graded according to the POP-Q classification. All women underwent laparoscopic PFR with or without mesh. Suture PFR performed according to DeLancey’s classification: Level 1 PFR involved suture plication of uterosacral ligaments to apex of the vagina to re-establish apical supports of vault. Level 2 PFR involved posterior and/or anterior compartment approach. If present, central anterior and posterior vaginal fascial defects were repaired concomitantly with standard anterior/posterior colporrhaphy, respectively. Ages, operating time, length of stay, follow-up and complications were recorded. Setting: Centre for Advanced Reproductive Endosurgery. Patients: Thirty-three consecutive women with varying degrees of uterovaginal/vault prolapse. Intervention: Performing laparoscopic PFR with or without mesh. Measurements and Main Results: Thirty-three consecutive women to date enrolled. Mean age: 55.1 years (range 35 – 74 years). 97% (32/33) were multiparous. 84.8% (28/33) presented with prolapse and 60.5% (19/33) had undergone previous hysterectomy. preoperative POP-Q staging: Stage I: 3%; stage II: 30.3%; stage III: 54.5%; stage IV: 12.1%. 57.6% (19/33) underwent laparoscopic mesh sacrocolpopexy; 33.3% (11/33) laparoscopic suture PFR; 9.1% (3/33) laparoscopic mesh hysteropexy; 72.7% (24/33) underwent concomitant vaginal repair of central defects. Mean operating time: 110 minutes (50-60); mean length of stay: 2.9 days (2-5); mean length of follow-up: 2.9 months (1-7). Only one intra-operative complication: inferior epigastric artery injury. postoperative POP-Q staging: Stage 0: 97%; stage I: 3%; stage II: 30.3%; stage III: 54.5%; stage IV: 12.1%. This one stage I woman at follow-up believed that the operation had failed. Conclusion: Early results suggest laparoscopic PFR, with or without mesh, in women who present with utero-vaginal/vault prolapse is associated with high rates of success. This approach is safe and associated with few complications.

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TUESDAY, NOVEMBER 7, 2006 Open Communications 2—Urogynecology/Pelvic Floor Disorder (5:14 PM – 5:20 PM)

65 Pelvic Organ Prolapse Posterior Repair Laparoscopic Supralevator Repair (Lam Procedure) O’Shea RT, Seman E, Cook J, Behnia-Willison F. Flinders Endogynaecology, Flinders University, Flinders Medical Centre, Morphett Vale South Australia, Australia Study Objective: To analyze the long-term success of laparoscopic supralevator repair of the posterior vaginal compartment. Design: A prospective cohort study of 143 patients undergoing laparoscopic supralevator repair Setting: Public university hospital Patients: Overall 424 patients underwent laparoscopic pelvic floor repair. Of these 143 underwent laparoscopic supralevator repair. Intervention: Laparoscopic supralevator repair Measurements and Main Results: All patients were assessed objectively and subsequently postoperatively using the POPQ system. Assessment was subsequently performed on an annual basis with objective POPQ followup up to five years. Mean age 63 years (37-89) with a mean weight 71.9kg (48-124). Mean hospital stay was recorded at 4.3 days (2-6). Average follow-up was 75 weeks (4-292). Success rates were recorded at 96%. The most common recurrence occurred in the anterior compartment. Conclusion: Laparoscopic supralevator repair is technically a difficult procedure. However, we found it to be extremely successful for prolapse of the upper two thirds of the posterior vagina.

TUESDAY, NOVEMBER 7, 2006 Open Communications 3—Hysteroscopy (3:50

PM

– 3:56

PM)

66 Septate Uterus Before and After Hysteroscopic Metroplasty: Three Dimensional Sonographic Evaluation and Follow-up

Arduini D, Exacoustos C, Zanetti H, Vaquero E, Lanzi G, Lazzarin N, Valli E, Amoroso C, Zupi E. University of Rome “Tor Vergata,” Rome, Italy Study Objective: The septate uterus presents an important decrease of live birth rate that can be improved significantly by doing hysteroscopic metroplasty. The purpose of this study was to evaluate by 3D transvaginal sonography (TVS) the uterine cavity morphology of septate uteri before and after hysteroscopic metroplasty and to correlate these findings to pregnancy outcome. Design: After 3D TVS patients with a septate uterus and a history of infertility or recurrent miscarriage underwent, hysteroscopic metroplasty. After at least two months from the metroplasty all patients had a second 3D TVS. At the 3D scan volume of the uterus was obtained and diagnosis of the septum

was done on the coronal view of the uterus based on the outer shape and the angle of the fundal indentation. Length and width of the septum were measured before septoplasty and after, if some septal residual can be still observed. Setting: University hospital. Patients: Twenty-one premenopausal patients with a septate uterus. Intervention: 3D TVS before and after hysteroscopic metroplasty. Measurements and Main Results: Of the 21 patients with septate uterus 8 present, at the 3D TVS after hysteroscopic metroplasty, a septum residual tissue. In 4 of these patients this residual tissue had a length more than 10 mm and more than the 30% of the septum before treatment. Of the 8 patients with residual tissue 3 had a repeated pregnancy loss, 1 had a preterm delivery at 32 weeks, 1 had a term delivery with a placenta accrete, 1 had a normal pregnancy and 2 underwent a second metroplasty Conclusion: 3D TVS is a standardized tool to diagnose, differentiate and quantify uterine septa and has to be add also in the follow–up management after hysteroscopic metroplasty in order to evaluate the effect of surgery helping to counsel patients for the next pregnancy or for planing a second surgical approach.

TUESDAY, NOVEMBER 7, 2006 Open Communications 3—Hysteroscopy (3:56

PM

– 4:02

PM)

67 Clinical Evaluation of Caesarean Scar Pouch Detected by Hysteroscopy Bettocchi S, Ceci O, Scioscia M, Vicino M, Pinto L, Pontrelli G, Costantino A. University of Bari, Bari, Italy Study Objective: Postmenstrual brown bleeding can occur in fertile women with a history of caesarean section. This study was undertaken to evaluate whether this abnormal uterine bleeding can be due to a collection of blood in the Caesarean scar pouch. Design: All women referred to our Office Hysteroscopy Centre for postmenstrual uterine bleeding and a history of one or more low-segment Caesarean sections (LSCS) were recruited to this prospective cohort study. Setting: University hospital. Patients: Twenty-four women with postmenstrual spotting were enrolled. Intervention: Transvaginal sonography and office hysteroscopy were performed to evaluate the presence of a caesarean scar pouch. The area under the scar (bell-shaped pouch area) was sonographically calculated on a sagittal median view of the uterus. Measurements and Main Results: At ultrasound assessment, three patients presented suspected endometrial polyps (12.5%) whereas a Caesarean scar pouch was the only sonographic finding in 21 cases (87.5%). Hysteroscopy confirmed the presence of endometrial polyps in the three cases and they were removed. No other pathology was found at

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hysteroscopy in the remaining 21 cases but a brown blood collection beneath the scar pouch, drained thereafter. No correlation was found between the number of previous caesarean sections and either the pouch area or symptoms. Usually, the larger the pouch the longer the period of bleeding episodes. None of the patients had had a recent LSCS (< 2 years); the surgery-to-symptoms interval was 3.2 ± 1.8 years. Conclusion: The presence of anatomic defects in the isthmus area of the uterine cavity following LSCS can be detected by transvaginal sonography and confirmed by hysteroscopy. The Caesarean scar is known to be responsible for ectopic pregnancy, uterine rupture, an unusual localization of endometriosis, and abnormal uterine bleeding (bleeding disturbance). We report a high frequency of postmenstrual spotting due to blood collection in the scar pouch in reproductive-age women with a history of LSCS. On sonographic evidence of a Caesarean poach and absence of endocavitary pathology in fertile women with previous LSCS, referred for postmenstrual brownish spotting, the clinician can reassure the patient and book a hysteroscopy at leisure.

TUESDAY, NOVEMBER 7, 2006 Open Communications 3—Hysteroscopy (4:02

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68 Malformations of Uterus and Vagina: Endoscopy for Diagnosis and Treatment 1 Adamyan LV, 1Yarotskaya EL, 1Tkachenko ER, 2Makiyan ZN, 1Bobkova MV. 1Scientific Center for Obstetrics, Gynecology and Perinatology of Russian Academy of Medical Sciences; 2Moscow State University of Medicine and Dentistry, Moscow Russian Federation Study Objective: Estimation of value of endoscopy for diagnosis and surgery in patients with malformations of genitalia. Design: Analysis of 1310 cases of malformations managed by various approaches. Setting: Department of Operative Gynecology of the Scientific Center for Obst., Gyn. & Perinatology. Patients: Five hundred twenty nine cases of genital malformations were managed by endoscopic approach: 179 cases of uterine septum, 7 cases of bicornuate uterus, 101 case of non-communicating uterine horn, vaginal and uterine aplasia (211 cases), vaginal aplasia with functional uterus (31 case). Measurements and Main Results: Laparoscopy and hysteroscopy came effective in all cases to diagnosis the malformation correctly. Resectoscopy was used for management of uterine septum with subsequent complete restoration of endometrium and full-term pregnancy rate of 57.5%. In patients with aplasia of uterus and vagina laparoscopy was applied on all steps of colpopoiesis from pelvic peritoneum, resulting in adequate neovagina capacity and epithelium morphology; in 7 cases bicornuate uterus was managed by hysteroscopic-laparoscopic metroplasty resulting in fullterm pregnancy in 5 patients. Rudimentary horns were removed by laparoscopy with resolution of severe pelvic

pain due to hematometra; in 26 cases of functional uterus and vaginal aplasia laparoscopic hysterectomy was performed, while 5 analogous cases were successfully managed by creation of utero-perineal or utero-tubal-perineal tunnel. Conclusion: Endoscopy methods provide final correct diagnosis and adequate management of both symmetric and asymmetric malformations of uterus and vagina. Hysteroresectoscopy is the method of choice in case of uterine septum, and the important step of combined hysterolaparoscopic metroplasty. In asymmetric anomalies laparoscopy is a minimally invasive approach both for radical and reconstructive treatment, simultaneous management of concomitant diseases.

TUESDAY, NOVEMBER 7, 2006 Open Communications 3—Hysteroscopy (4:08

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69 The Role of Outpatient Diagnostic Hysterocopy in Assisted Reproduction: A Review of 1768 Cases Garbin O, Ziane A, Waters N. SIHCUS-CMCO, Schiltigheim, France Study Objective: To study the feasibility and utility of outpatient diagnostic hysteroscopy in infertile patient involved in Assisted Reproduction Technology (ART). Design: Monocentric retrospective study between May 1994 and January 2006. Setting: An outpatient hysteroscopic consultation of a teaching hospital. Patients: Out of a total of 4563 procedures, 1768 were performed before or during ART, 641 (36.2%) after implantation failure in in vitro fertilization (IVF), 537 (30.4%) before enrolment in IVF, 339 (19.2%) after failure of intrauterine insemination (IUI), 228 (12.9%) before IIU, and 23 (1.3%) after difficult or failed embryo transfer during IVF. Intervention: Diagnostic hysteroscopy with a rigid and panoramic hysteroscope. Measurements and Main Results: The feasibility of the hysteroscopy was graded (easy, difficult, impossible) along with the quality of the view (good, acceptable, poor, nil), and the condition of the cervical canal, the shape of the uterine cavity, its size, the condition of endometrium and myometrium along with any treatment performed were noted. The passage of the cervical canal was easy in 83.4%, difficult in 13.1 % and impossible in 3.5 %. The quality of the view was good in 87.8 %, acceptable in 7.1 %, poor in 1.2 % and nil in 3.8 %. Pathology of the cervical canal was found in only a few, except in the group of difficult or failed of embryo transfer, which had a 10 % incidence of cervical stenosis (versus 2.4 % for the general population). Uterine malformations were noted in 4.1 %. Pathology of the endometrium was found commonly, with hyperplasia in 6.7 %, polyps in 6.7%, chronic endometritis in 4.9 % , synechiae in 2.4 %. Pathology of the myometrium was rare with 2.8% sub-mucous myomas, 2.5 % intra-mural myomas, and

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1% adenomyosis. In more than 20 % of the cases, a treatment was prescribed at the end of the procedure : operative hysterocopy in 13.1%, medical treatment in 4.8%, hormonal treatment in 3.1% and myomectomies in 0.6%. Conclusion: Outpatient diagnostic hysteroscopy is feasible in the majority of patients included in ART and permitted the diagnosis and treatment of findings where pathology was found.

TUESDAY, NOVEMBER 7, 2006 Open Communications 3—Hysteroscopy (4:14 pm – 4:20 pm)

70 Analysis of Reproductive Outcome Before and After Laparoscopic or Hysteroscopic Myomectomy for 229 Infertility Patients Xia E. Beijing Fuxing Hospital Affiliate of Capital University of Medical University Hysteroscopic Center, Beijing, China Study Objective: To analyze the influence of myoma on fertility and to evaluate the conception rate, pregnancy loss rate and the pregnancy rate before and after laparoscopic or hysteroscopic myomectomy for the infertile women. Design: Retrospectives study. All patients had been submitted to preoperative sonography, diagnostic hysteroscopy and dialatation and curettage. Patients with disordered cavity were preformed TCRM and those with normal cavity preformed TLM. Laparoscopic combine hysteroscopic surgery should be taken if it is necesseary. Setting: Teaching Hospital. Patients: From January 1998 to January 2005 , infertility patients of myomas under 40 years old came into research, with at lest one year’s infertility history, male infertility, ovulation factors and tubal obstruction were excluded. Intervention: Patient went to clinic post-operation of 1 month, 3 months, 6 months to have physical examination and sonography, in order to find recurrence in time. Until February 2006, letter or telephone informed consent was obtained from all patients about their reproductive outcome. 229 cases were followed up .The follow-up interval is 1 to 6 years. The conception rate, pregnancy loss rate before and after myomectomy were recorded. Different groups were divided by the type, number, location and size of myoma, the factors which can improve the pregnancy rate were analyzed. SPSS 11.5, Student’s t-test and chi-square test were adopted for statistical analyses. Measurements and Main Results: In 131 cases of hysteroscopic surgery, 96 cases of laparoscopic surgery and two cases of laparoscopic combine hysteroscopic surgery, pregnancy rate (50.38%, 64.89%) were improved significantly by TCRM, p=0.000, pregnancy loss rate got decreased., (69.33%, 11.11%), p=0.000; the pregnancy rate was improved also after laparoscopic myomectomy (22.92%, 35.42%), p=0.057, the pregnancy loss rate got lower (24.00%, 18.92%), p= 0.630, but the difference was not significant. For TCRM group, the postoperative pregnancy rate

is irrelative with the type, location and size of myoma, p=0.119, p=0.148, p=0.358. The pregnancy prognosis was improved significantly for younger patient and single myoma, also for infertility caused by myoma p=0.000, p=0.000, p=0.016. For TLM group, the postoperative pregnancy rate is irrelative with the type, location and single or multiple of myoma, also for infertility caused by myoma. p=1.000, p=0.848, p=0.594, p=0.678. The pregnancy prognosis was improved significantly for younger patient and bigger myoma. Conclusion: Submucous myoma can decrease pregnancy rate and increase pregnancy loss rate. It should be removed for any size or location and type. Pregnancy rate can be improved after surgery. Subserous myoma and small intralmural myoma seemed to have no influence to pregnancy prognosis, it can be observed and expected for natural pregnancy. TLM can be taken for more than 2 years infertility history or recurrent abortion and premature delivery, other examination for infertility can also be done at the same time.

TUESDAY, NOVEMBER 7, 2006 Open Communications 3—Hysteroscopy (4:20

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71 Clinical Evaluation of 2379 One-Step Resectoscopic Myomectomies Lin BL. Kawasaki Municipal Hospital, Kawasaki, Japan Study Objective: To assess the outcome after one-step operative resectoscopy for the treatment of submucous myoma Design: Retrospective analysis of 2379 consecutive cases of one-step resectoscopic myomectomy performed by Dr. B.L. Lin from January 1985 to April 2006. Setting: Kawasaki Municipal Hospital. Patients: 2379 women. Intervention: One-step resectoscopic myomectomy Measurements and Main Results: The mean operating time was 29.4 minutes (2329 cases) and the mean specimen weight was 24.8 g (2335 cases). Two patients who developed hyponatremia recovered after treatment. Five patients had uterine perforation. Two patients were repaired successfully through laparoscopy and the other three patients were without any event. The results of longterm follow up were as follows: 43 patients underwent hysterectomy. 21 patients received abdominal myomectomy. 65 patients had repeated resectoscopic myomectomy. 150 patients had full term deliveries (109 vaginal deliveries and 41 Cesarean sections). Conclusion: Our one-step resectoscopic myomectomy is a safe and effective method for treatment of submucous myoma.

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TUESDAY, NOVEMBER 7, 2006 Open Communications 3—Hysteroscopy (4:26

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72 Hysteroscopic Resection of the Septate Uterus Using Bipolar Diathermy: Anatomical and Reproductive Outcomes Garbin O, Schindler L, Machu J, Waters, N. SIHCUSCMCO, Schiltigheim, France Study Objective: To evaluate the efficacy of hysteroscopic metroplasty using bipolar diathermy for a septate uterus. Design: Retrospective monocentric study. Setting: Teaching university hospital. Patients: Sixty patients with a septate uterus. Mean age was 30.9 ± 5.4 (19-42). Eight patients had a complete septate uterus (class Vb of AFS) and 52 subtotal (class Va of AFS). 32 patients were infertile. Sixty patients had 81 previous pregnancies with 59 spontaneous miscarriages (72,8%), 6 preterm deliveries (7.4%) and 12 live births (14.8%). Intervention: Section of the uterine septum using a 5 mm operative hysteroscope and bipolar diathermy (Versapoint®) with saline as a solution media. Measurements and Main Results: The main outcomes were anatomical result, assessed by hysterosalpingogram, complications of the procedure and pregnancy outcomes. Anatomical results were good in 80 % of the cases. Twelve women (20%) had a residual septum and required a second procedure. There were two cases of minor fluid overload and 1 case of late haemorrhage. The mean follow-up was 38.9 ± 22.9 months (6-88). Four patients were lost to followup and 3 no longer desired pregnancy. 39 women (69.6%) conceived with 56 pregnancies. 41 of them were spontaneous (73.2%). There were 37 live births (68.5%) and 2 ongoing pregnancies in the third trimester. The spontaneous miscarriage rate was 21.4%. 33 women had at least one live birth (58.9%). Conclusion: Hysteroscopic metroplasty using bipolar diathermy (Versapoint®) is both safe and effective in increasing live birth rate and reducing the abortion rate. Our data suggest that this surgery can improve pregnancy outcome.

TUESDAY, NOVEMBER 7, 2006 Open Communications 3—Hysteroscopy (4:32 pm – 4:38 pm)

73 Comparison of New Hysteroscopic Shaving Technique to Remove Intrauterine Polyps with Conventional Electroresection Schoot BCD, Jaspers J. Catharina Hospital, Eindhoven, The Netherlands Study Objective: comparison of a novel hysteroscopic shaving technique of endometrial polyps and controls using electroresection. Design: retrospective comparative study.

Setting: department OB / GYN. Patients: Thirty-five consecutive patients presenting with irregular uterine bleeding, and diagnosed to have intrauterine pathology (polyp > 1 cm; < 3 cm). Intervention: Treatment with conventional monopolar resection technique for removal of intrauterine polyps (Egroup) (Storz, Tuetlingen, Germany) or removal of polyps using intrauterine shaving blades (IUR) (S-group) (Smith & Nephew, Andover, USA). Measurements and Main Results: Patient characteristics were similar in both groups (age, anaesthesia, size of polyps). The time to prepare the shaving procedure in the OR was similar in both groups ((S-group) 12 [10-15]; (Egroup). 11 [9-15] minutes; median [range]). Procedure time was related to the size of the polyps (1 cm: (S-group) 2 [15] minutes; (E-group). 3 [2-6] minutes; > 2 cm ((S-group) 7 [3-12] minutes; (E-group). 11[5-17] minutes). Fluid loss in both groups was comparable ((S-group) 80 [20-120]; (Egroup) 70[30-110] cc). The surgeons indicated that the shaving-technique was less complex compared to the electroresection, due to improvement in visibility and simplicity (performance rating: 8 [Scale 1-10]). The main advantage the IUR is the continuous aspiration of tissue fragments (polyps, myoma’s) trough the instrument. Both techniques cost the same amount of time. Although by subjective scaling, the electroresection technique was judged to be more complex and may have a higher risk of complications. The group of patients in our study was small, but tend to indicate quicker removal of larger polyps. Conclusion: Preliminary data in this study demonstrated that although the time to remove small polyps is equal, removal of larger polyps tended to be quicker done with the hysteroscopic shaving technique. Judgement of the gynaecologists concerning safety and operators experience towards this novel shaving technique was rated “good.”

TUESDAY, NOVEMBER 7, 2006 Open Communications 3—Hysteroscopy (4:38 pm – 4:44 pm)

74 Hysterosocopic Removal of Intrauterine Disorders: A Comparison of the Intrauterine Morcellator to Conventional Resectoscopy Jansen FW, van Dongen H, Emanuel MH. Leiden University Medical Centre, RC Leiden, Netherlands Study Objective: To compare the learning curve of residents in training for the intra uterine morcellator and conventional resectoscopy. Design: Randomized controlled trial. Setting: University teaching hospital and university-affiliated teaching hospital. Patients: Patients with endometrial polyps or submucous myomas type 0 scheduled for hysteroscopic removal. Intervention: Patients were treated by residents in training with the new hysteroscopic morcellator or with conventional resectoscopy.

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Measurements and Main Results: Primary outcome measures were the assessment of the ease of use and performance measured by operating time, fluid deficit, number of instrumentation insertions and subjective surgeon satisfaction scores. Secondary outcome measures were complications in terms of perforations, bleeding and TUR-syndrome. Sixty patients were randomized to either the intra uterine morcellator or conventional resectoscopy. Time of surgery, number of insertions of the instrument and total amount of fluid used during surgery were significantly lower for the intra uterine morcellator than for conventional resectoscopy. Subjective surgeon satisfaction scores were significantly better as well for the new technique. Conclusion: The new technique of hysteroscopic morcellation for the removal of endometrial polyps and submucous myomas may offer a safe alternative to conventional resectoscopy with a shorter learning curve as it seems easier to perform. Additionally, the implementation of hysteroscopic surgery onto daily gynaecological practice, which is a matter of concern, may accelerate with this newly introduced technique.

TUESDAY, NOVEMBER 7, 2006 Open Communications 3—Hysteroscopy (4:44 pm – 4:50 pm)

75 The Tissue Effects of Versapoint Bipolar Electrodes: An In-Vitro Study 1 Farrugia M, 2Ghali L, 3Hussain S, 4Perrett D. 1East Kent Hospitals NHS Trust, Canterbury, United Kingdom; 2 Middlesex University, Enfield, London, United Kingdom; 3 Whipps Cross University Hospital, London, United Kingdom; 4William Harvey Research Institute, University of London, London, United Kingdom Study Objective: Versapoint hysteroscopic electrodes operate in saline and use a different current pathway than traditional monopolar electrosurgery in non-conductive media. A vapour pocket is created around the active electrode, and this high temperature envelope vaporises tissue it comes into contact with, making it an effecting cutting instrument. The first part of the study aimed at identifying tissue shrinkage at the endo-myometrial junction and the second part aimed at measuring the zone of thermal necrosis and the size of the vapour pocket of each of the 5 electrodes. Design: A comparative study. Setting: A University Hospital in London, United Kingdom Patients: Tissue was obtained from patients undergoing hysterectomy for benign indications. Intervention: Fresh full-thickness human uterine wall was placed in a specially constructed jig and submitted to electrosurgical insult. Vaporisation (cutting) was carried out for each electrode at least 5 times, and coagulation was carried out at 5, 10, 15 and 20 seconds. Measurements and Main Results: Tissue was snap-frozen in liquid nitrogen and sectioned in a cryostat. The tissue was incubated and stained for NADH-dehydrogenase and counterstained with nuclear fast red. Slide images were digitised

and following calibration, measurements of the zone of thermal necrosis were taken. Tissue shrinkage was found to be 15.52% (SD 5.32). The electrode with the deepest tissue effect was the Spring electrode, with an average 2.3mm (SD0.163). The Zero-degree electrode created a zone of vaporisation of approximately 4mm and below that a zone of thermal necrosis of 1.34mm (SD0.133). The coagulating effect ranged from 3.2 mm at 5 sec to 7.3mm at 20 seconds. Conclusion: Versapoint bipolar electrodes are effective at tissue vaporisation and coagulation. The effect of the vapour pocket created is repeatable and well defined during tissue vaporisation.

TUESDAY, NOVEMBER 7, 2006 Open Communications 3—Hysteroscopy (4:50

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76 Study on Safety of Transcervical Resection of Big Intracavitary Fibroids - Analysis of 70 Cases Xia E. Beijing Fuxing Hospital Affiliate of Capital University of Medical University Hysteroscopic Center, Beijing, China Study Objective: To evaluate the safety and feasibility of big (>3cm) intracavitary fibroids treated by transcervical resection of myoma (TCRM). Design: TCRM was performed by five steps: resection, grasp, twist, drawing and delivery. Surgery was monitored by B ultrasound and/or laparoscopy routinely. Serum Na+,K+CL+ blood sugar and osmolality of venous blood was inspected and calculated. Clinical symptom and signs were observed. Setting: Teaching Hospital. Patients: Since May 2002 to Dec. 2005 70 cases of big intracavitary fibroids were performed TCRM. Intervention: Thirty cases of big intracavitary fibroids were pretreated with GnRH agonists 1~4 agents. Cervical priming was done by cervical dilator at evening before surgery. TCRM was performed by five steps: resection, grasp, twist, drawing and delivery. Surgery was monitored by B ultrasound and/or laparoscopy routinely. Serum Na+,K+CL+ blood sugar and osmolality of venous blood was inspected and calculated. Clinical symptom and signs were observed. Measurements and Main Results: The successful rate of one-stage was 97.14%. The mean diameter of fibroids was 4.91±1.26cm (>3~7.5cm). The mean weight of fibroids was 31.23±18.12gm (11~182gm). The mean operating time was 30.62±12.1min (5~60 min). Intraoperative bleeding was 5 ~1500mL, Bleeding 1500mL was encountered in uterine perforation. Of 17 cases postoperative serum Na+, K+ concentration decreased and blood sugar level elevated, compared with preoperative level the differences were significantly. Complications were temporary fever 4 cases, uterine perforation 1 case and mild hyponatraemia 2 cases. Conclusion: TCRM is a mini-invasive, safe and availability therapy for big intracavitary fibroids. Pretreatment with GnRH-a and cervical priming, B ultrasonography and/or

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laparoscopy monitoring, serum biochemical inspection, Furosemide 20mg injected intravenously when surgery lasted 30min were the main measure to prevent hyponatraemia.

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TUESDAY, NOVEMBER 7, 2006

Risk Reduction in Hysteroscopic Treatment of Submucous Myomata 1 Gallinat A, 2Niesel A, 1Biel P. 1Day Clinic Altonaer Strasse, Hamburg, Germany; 2Klinik Preetz, Preetz, Germany

Open Communications 3—Hysteroscopy (4:56 pm – 5:02 pm)

77 Hysteroscopic Resection of Large Myomas: A New Technique 1

2

1

Thurkow AL, Kok T. St. Lucas Andreas Ziekenhuis, Amsterdam, Netherlands; 2Vrije Universiteit Medisch Centrum, Amsterdam, The Netherlands Study Objective: Assess the feasibility of a new resection technique for large myoma’s. Design: Retrospective observational study 1996-2006. Setting: Non-university teaching hospital. Patients: Menorrhagia and intracavitary myoma’s > 3 cm. Intervention: hysteroscopic hemisection and enucleation, followed by extraction under visual control. Measurements and Main Results: Complete resections, complications. 91% complete resection, 3 perforations during blind extraction, frequent fluid overload without sequelae. Conclusion: The technique of hemisection, enucleation and extraction is feasible and probably the best technique to use in case of large myomas in order to prevent incomplete resection or fluid complications. A new technique is shown by which myoma’s are fragmentated either by resection or by vaporisation (both are demonstrated) and removed from the capsula through blunt dissection with the same instrument. The fragments are removed with a polyp forceps or a Corson’s myoma grasper under endoscopic or ultrasound control. The technique is a fast and safe alternative for the classical resection techniques and results in a higher percentage of complete resections, especially in cases of large myoma’s and myomas with deep intramural protrusion. Since not all of the tissue is vaporised pathological examination remains possible even when using a vaporizing electrode. The use of bipolar energy prevents the problems of fluid overload and electrolyte shift known in non-conductive distension media used in monopolar resection techniques. Type II myomas up to a diameter of 6 cm have been completely resected in one session with this technique. Several video fragments and an animation is shown to discuss the procedure. Further randomised studies are to be performed to compare the technique with the conventional resection technique.

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78

Study Objective: Comparison of different methods in treatment of submucous myomata. Design: Advantages of new technologies in single cases. Setting: Day clinic. Patients: Women suffering from abnormal uterine bleeding, sterility cases. Intervention: Operative hysteroscopy. Measurements and Main Results: Various techniques are in use to treatment of submucous myomata. According to size and localisation of a myoma there are advantages of single methods. At general the resectoscope is seen worldwide as “gold standard.” By shortened resection time, fluid resorbtion is reduced .By the lack of chip harvesting in between, a continous overview is achieved. And all these advantages lead to a risk reduction. By the new developed Master Resectoscope chips are immediately removed out of the uterine cavity and a continous overview during the entire operation is achieved. By shortened resection time, fluid resorbtion is reduced. Even rare complications like air embolism are avoided, as the Master Resectoscope has to be introduced only once at the beginning and is removed at completion of operation. Surgical procedure of resection is the same like using the conventional resectoscope. Chip removal without affecting hydrometra is performed automatically. Conclusion: The main complications which are due to the distension medium as fluid overload and hyponatremia and to the resectoscope itself like perforation and bleeding (bad overview) are reduced significantly.

TUESDAY, NOVEMBER 7, 2006 Open Communications 3—Hysteroscopy (5:08 PM – 5:14 PM)

79 The Composition of Gaseous Products Released during Hysteroscopic Uterine Tissue Vaporization: An In Vitro Model 1 Farrugia M, 2Wang Y, 3Hussain S, 4Perrett D. 1East Kent Hospitals NHS Trust, Canterbury, United Kingdom; 2 London Metropolitan University, London, United Kingdom; 3Whipps Cross University Hospital, London, United Kingdom; 4William Harvey Research Institute, University of London, London, United Kingdom Study Objective: Vaporisation of tissue is the mechanism by which electrosurgery results in cutting. A sufficiently high power density in the vicinity of the active electrode

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causes cellular water to boil and high molecular weight compounds to break into smaller molecules. Steam will liquefy immediately as will compounds with boiling points below 37°C. This study aimed at comparing residual gases released by traditional monopolar electrosurgery and comparing this to 2 new hysteroscopic systems operating in saline, the Versapoint VRS System and the Olympus TCRis. Design: A comparative study. Setting: A University Hospital in London, United Kingdom Patients: Tissue was obtained from 20 patients undergoing hysterectomy for benign indications. Intervention: Fresh full-thickness human uterine wall was obtained and placed in a specially constructed jig and immersed in the appropriate distension medium (either 1.5% glycine or 0.9% saline solutions). Care was taken to avoid contamination from atmospheric air. Tissue was vaporised and the gases collected for analysis. Measurements and Main Results: Gases were analysed with a Carlo Erba GC6000 gas chromatograph and an Alltech CTR I steel column. This allowed simultaneous analysis of permanent gases and light hydrocarbons. The detector was a thermal conductivity detector (TCD) set at 120°C. Gases with boiling points above 37°C identified included hydrogen, carbon dioxide, carbon monoxide, oxygen, ethene, ethane, ethyne, nitrogen and methane. Conclusion: This study identified the constituent gases released during human uterine tissue vaporisation using 3 different hysteroscopic systems currently available for clinical use. The gas composition is similar, with carbon monoxide, hydrogen and carbon dioxide making up 80% of gases released.

TUESDAY, NOVEMBER 7, 2006 Open Communications 3—Hysteroscopy (5:14

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– 5:20

gery, the gases and cellular fragments enter the venous system and travel towards the heart. These fragments, like gas micro-bubbles are highly echogenic at ultrasound imaging frequencies. We compared images from 8 hysteroscopic procedures to ultrasound videos taken by using clear distension medium, a proprietary ultrasound contrast medium (Optison, Amersham Medical) and de-gassed tissue fragments obtained from human uterine tissue vaporisation. Design: A blinded randomised study Setting: A University Hospital in London, United Kingdom Patients: Eight patients undergoing hysteroscopic resection of fibroids, 4 using monopolar and 4 bipolar loop resectoscopes Intervention: Two consultant radiologists with an interest in gas embolism viewed 10-20 second video clips of the 8 patients, 4 controls, 4 clips using Optison and 4 clips using degassed fragments. Measurements and Main Results: The radiologists were blinded to the source of the video clip. Independently, they were asked to identify whether or not gas emboli could be seen in the video images. The order of the video clips was randomised. The operative hysteroscopy imaging, the degassed fragment and the Optison video clips could not be distinguished. The controls were correctly identified as showing no gas emboli. Conclusion: Echogenic foci in the right heart chambers during operative hysteroscopy are not pathognomonic for air or gas embolism. Tissue fragments generated during electrosurgical vaporisation mimic micro-emboli and cannot be distinguished by trained radiologists. The presence of echogenic fragments in the circulation may explain the presence of ‘asymptomatic gas emboli’ previously reported in the literature. An alternative method of investigating the entry of gas in the venous system during operative hysteroscopy needs to be developed.

PM)

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Are Echogenic Foci in the Right Heart Chambers Identified By Precordial Echography during Operative Hysteroscopy Pathognomonic for Air or Gas Embolism? 1 Farrugia M, 2Farrugia M, 3Gupta R, 4Hussain S, 5Perrett D. 1East Kent Hospitals NHS Trust, Canterbury, United Kingdom; 2Newham University Hospital, London, United Kingdom; Lewisham University Hospital, London, United Kingdom; 4Whipps Cross University Hospital, London, United Kingdom; 5William Harvey Research Institute, University of London, London, United Kingdom

Open Communications 4—Instruments & Surgical Techniques (3:50 PM – 3:56 PM)

Study Objective: Ultrasound is the method of choice in identifying gas emboli in decompression sickness, due to its high sensitivity and ease of use. This has been extended to identify gas emboli in hysteroscopy. During operative hysteroscopy, uterine tissue is broken into water vapour, volatile components and non-volatile cellular fragments. The latter range in size from microns to millimetre fragments in diameter. As blood vessels are opened during sur-

81 A Novel Method and Apparatus for Laparoscopic Tissue Grasping that Reduces Tissue Trauma Ott DE. Biomedical Engineering, Mercer University, Macon, Georgia Study Objective: This study design evaluated and compared traditional grasping devices by histology and pressure measurements at angulations between 0-135o with an inventive method and apparatus for tissue grasping, stabilization and manipulation using a gentle negative pressure suction cup method and apparatus. Design: Different size, shape and weight tissue samples (fallopian tube, ovary and small bowel) were used to evaluate and compare the ability of a newly developed negative pressure vacuum suction cup device and con-

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ventional levered graspers to hold and move tissue using pressure profiles and histologic comparisons of serosal loss and deep tissue hemorrhage. Setting: University and private biomedical research facilities. Intervention: Grasp for stabilization while suturing and moving 50, 100 and 150 gram tissue load movement was evaluated at various reflection angles. Measurements and Main Results: A thin film transducer was interposed between three different levered grasping jaws to obtain their grasping tissue contact imprint, spatial distribution and magnitude of pressure generated at angulations of the grasping device to tissue between 0-135o. Mean maximum pressure of all levered graspers was significantly increased over that of vacuum suction devices at all weights and angles. All of the traditional grasping devices caused histologic serosal loss and 60% caused hemorrhage. Based on the configuration of the vacuum cup there was serosal damage in only 12% and no hemorrhage. Conclusion: Traditional levered laparoscopic graspers are problematic and fail to protect tissue within its grasp from trauma because of excessive mechanical advantage and require a solution. There is a difference between currently used devices and the new negative pressure vacuum device that successfully resolves these problems. There is a clear technical advantage of the suction cup negative pressure method and apparatus over conventional devices to achieve a safer and less traumatic method of laparoscopic tissue grasping, stabilization and manipulation.

TUESDAY, NOVEMBER 7, 2006 Open Communications 4—Instruments & Surgical Techniques (3:56 PM – 4:02 PM)

82 Stokes-Polarimetry Imaging: A Novel Approach to Assessing Intrabdominal Tissue Injury 1 Milad M, 2Wu P, 2John R, 1Lindner D, 2Walsh JT. 1 Northwestern University, Department of Obstetrics and Gynecology; 2School of Engineering and Applied Science, Chicago, Illinois Study Objective: To assess the feasibility of using StokesPolarimetry to detect sub-clinical intra-abdominal collagen changes associated with various surgical injuries. Design: Stokes Polarimetry Imaging fully quantifies the polarization properties of remitted light from tissue and creates two-dimensional image-maps that allow structures to be differentiated according to polarization-based metrics. A system was established that allows variation of both incident and illumination polarization to maximize resolution of tissue structures. In previous studies, the collagen matrix of normal skin and cutaneous scars were readily differentiated. The current study quantifies intra-abdominal collagenous changes following a variety of surgical injuries. Setting: Northwestern Center for Advanced Surgical Education

Patients: Porcine surgical model. Intervention: Intraoperative Stokes Polarimetry imaging. Measurements and Main Results: Image sets were collected during comparing a scalpel to monopolar vaporization. Differing hemostatic techniques were also imaged including suture ligation and monopolar desiccation with direct coupling. Peritoneal injury from sharp dissection and blunt peritoneal separation was evaluated. Bladder defects were created and imaged after closure with either 3-0 polygalactin on a tapered needle, 3-0 chromic catgut on a tapered needle or 4-0 polygalactin using an Endostitch (US Surgical, Norwalk, CT) device. A variety of peritoneal injuries were also imaged including surgical gauze abrasion, argon beam coagulator and monopolar desiccation. Alterations in tissue effect undetectable by the naked eye were noted. Collagenous changes were identified lateral to the injury creating a zone of disruption readily visualized by polarimetry imaging. Conclusion: We were able to demonstrate disruption of peritoneal collagen fibers following abrasions, blunt dissection, and electrosurgically induced injuries. The extent of fine fiber damage differed depending on the operative technique applied. Stokes-polarimetry may provide an opportunity to identify subclinical collagenous disruption and improve surgical efficiency for a variety of gynecologic conditions from endometriosis to malignancy.

TUESDAY, NOVEMBER 7, 2006 Open Communications 4—Instruments & Surgical Techniques (4:02 PM – 4:08 PM)

83 The Biswas Uterine Elevator and Cup for Use in Laparoscopic Hysterectomy Soo SC, Merkur H. Sydney, New South Wales, Australia Study Objective: This study was undertaken to review the Biswas uterine elevator and cup for use in laparoscopic hysterectomy. To review the complications, safety and subsequent advancement of the technique in relation to the use of the Biswas elevator and cup. Design: An analysis of prospectively collected data identified fivehundred and eightythree patients who had undergone Laparoscopic hysterectomy of which three hundred and seventy one patients had laparoscopic hysterectomy using the Biswas uterine elevator and cup. The data was collected prospectively between 1999 and 2006 with the commencement of use of the elevator from 2002 onwards. All major intra operative complications and failures of the Biswas uterine elevator and cup were documented. Setting: Advance gynecological endoscopy teaching hospitals. Patients: Three hundred and seventy one patients had laparoscopic hysterectomy using the Biswas uterine elevator and cup. Intervention: Laparoscopic hysterectomy completed with either Laparoscopic Assisted Vaginal Hysterectomy or Total

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Laparoscopic Hysterectomy. Measurements and Main Results: Of the three hundred and seventy one patients identified, 1 major complication directly related to the use of the Biswas uterine elevator and cup was identified. This involved the left ureter which was damaged following the incorrect placement of the Biswas uterine elevator. The elevator was unable to be inserted into the uterine cavity in 1 case which was caused by the gross disruption of the uterine cavity by multiple fibroids. Major complications related to the Biswas elevator and cup rate of 0.29% (1/371) and failure rate of 0.29% (1/371). Conclusion: Invented by the late Dr. Nicholas Biswas in 2001, the Biswas uterine elevator and cup is a reusable device which combines the advantage of a uterine elevator in situ (allowing maneuvering of the uterus) and cup which elevates the vaginal vault for subsequent anterior and posterior colpotomy. The Biswas elevator and cup has undergone refinement and since the ureteric injury the technique has been modified so that the elevator is inserted under laparoscopic vision.

TUESDAY, NOVEMBER 7, 2006 Open Communications 4—Instruments & Surgical Techniques (4:08 PM – 4:14 PM)

84 The On-Q Pain Pump for Pain Relief after Laparoscopic Surgery

Dulemba JF, Medler-Pelzel C. North Texas Hospital, Denton, Texas Study Objective: To decrease pain, and pain medication usage, following laparoscopic surgery. Design: One hundred eighty women in a retrospective cohort study were included. All women had undergone laparoscopic surgery, and evaluated their pain after the pump was removed with a questionnaire. Setting: A community hospital, and private gynecologic practice. Patients: One hundred eighty women undergoing laparoscopic surgery. Intervention: Following Completion of all laparoscopic surgery, the On-Q pain pump was inserted above the symphysis, with the catheter placed in the culdesac under laparoscopic vision. One half percent marcaine, 100cc’s, was infused at a rate of 2cc/hour. The pump was removed, by the patient, after 2 days. Measurements and Main Results: Seventy-eight percent of the patients completed the survey. 86% of the patients felt an increase in pain after the pump was removed. 89% of the patients with previous surgeries felt they had significant less pain using the pump. 68% of the patients used no narcotics while the pump was in place. 91% of the patients said they would want the pump again if they had another surgery. The majority of patients used less pain medication, and felt less pain after laparoscopic surgery. No complications were noted.

Conclusion: The insertion of the On-Q pain pump decreases pain, and results in less pain medication usage following laparoscopic surgery.

TUESDAY, NOVEMBER 7, 2006 Open Communications 4—Instruments & Surgical Techniques (4:14 PM – 4:20 PM)

85 The Mangeshikar Uterine Manipulator: New Instrument for Total Laparoscopic Hysterectomy Mangeshikar PS. Center for Gynecological Endoscopic Surgery, Mumbai, India Study Objective: The Mangeshikar Uterine Manipulator (MUM) has been developed by the author as a reusable ultra-lightweight instrument for effective manipulation of the uterus and adnexae during Total Laparoscopic Hysterectomy (TLH). Design: Prospective study undertaken by the author over six years to develop the final instrument for safe clinical use. Setting: Private practice. Patients: One hundred and twenty-five consecutive patients enrolled for TLH underwent the procedure in a prospective study using the MUM from Feb 2004 to Feb 2006. Of these, Fibroids (55.2%) (n=69), Endometriosis (20.8%) (n-26) were the main indications for TLH. Bipolar Energy with scissors dissection or the ACE Harmonic Forceps were the energy sources used. Measurements and Main Results: The MUM consists of 1. Insert with a pair of claws to grasp the cervix and allows intrauterine rods of varying lengths for different uterine sizes 2. Outer tube 3. Handle with a safety lock 4. Vaginal delineating device of varying diameter for safe vaginal circumcision without injuring the surrounding organs and preventing gas leak during TLH. The MUM allows ante version and retroversion movements providing maximal exposure of the anterior and posterior aspects of the uterus especially the uterovesical fold and the uterosacral ligaments. It allows lateral movements providing optimal exposure of the Infundibulo-pelvic and Broad Ligaments. The MUM facilitated intrafascial TLH in all 125 patients without damaging the ureter, bladder or rectum and zero conversion to laparotomy. Conclusion: The key to a successful TLH is effective uterine manipulation and the MUM promises to be a safe effective, reusable and user-friendly instrument for the procedure.

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TUESDAY, NOVEMBER 7, 2006 Open Communications 4—Instruments & Surgical Techniques (4:20 pm – 4:26 pm)

86 Total Laparoscopic Hysterectomy - A New Technique with the Singh Uterine Cannula and Funnel (SUCF) Wong NSW. University of New South Wales, Sydney, Sydney NSW, Australia Study Objective: To describe and analyse the advantages of a new surgical technique of total laparoscopic hysterectomy (TLH) using a Singh Uterine Cannula and Funnel (SUCF). Design AND Setting: A description of the TLH technique using a SUCF will be presented. Patients: A series of 100 consecutive patients receiving total laparoscopic hysterectomy for benign uterine pathology using SUCF was recruited in the study. Measurements and Main Results: Variables analysed included patient demographics, operative time, intraoperative and postoperative complications. The data are used to demonstrate the safety, ease and speed of this new technique using a SUCF. A preliminary analysis of the mean operative time, intraoperative and postoperative complications analysed from this series was less than 5%. It compares favourably with reported data from the literature. Individual reports of urinary tract injury, bleeding or developed pelvic/vault haematoma, or required conversion, would be described and discussed together with the techniques adopted in the study. Conclusion: Harry Reich performed the world’s first laparoscopic hysterectomy in 1989. Since then, TLH has been feted as the 21st Century Approach to Hysterectomy (Cario AAGL). However, the uptake of the operative approach has taken longer than most laparoscopic procedures. The time taken to perform the operation and injuries to bladder, ureters and difficulty in securing the uterine vessels may be some of the reasons. Gynaecologists are often hesitant in performing the procedure, choosing instead to perform Laparoscopic Assisted Vaginal Hysterectomy (LAVH). We describe this new TLH technique that addresses the safety issues by the use of an innovative Instrument (SUCF) designed by one of the authors. Data of operative time, intraand postoperative complications supported the claim of safety, ease and speed of this technique.

TUESDAY, NOVEMBER 7, 2006 Open Communications 4—Instruments & Surgical Techniques (4:26 PM – 4:32 PM)

87 Using a “Cut-Loop System” to Reduce Operative Time for Supracervical Laparoscopic Hysterectomy Albuquerque LF, Albuquerque LA. Cinica Abuquerque, Rio Claro, Sao Paulo, Brazil Study Objective: The purpose of our study was to review the time of surgery using the Monopolar Cut-Loop System

for Supra Cervical Laparoscopy Hysterectomy. Design: Last 20 cases retrospective analysis. Setting: Centro Medico Especializado (Clinica Albuquerque), Rio Claro, Sao Paulo, Brazil. Patients: Last 40 cases, underwent a Supracervical Laparoscopic Hysterectomy. Intervention: The procedure was performed using two groups and the same team of surgeons and the same techinique. We used the (Tripolar)-Bipolar Cutting System to seal the vascular pedicles and the Monopolar Cut-Loop system to cut the uterus. And 20 cases was performed using (Tripolar)-Bipolar Cutting System to seal the vascular pedicles and 10 mL scissors to cut the uterus. In all cases the uterus was removed from the abdominal cavity mainly by electric morcellation. Measurements and Main Results: Mean patient age was 48.1 years of group (01) and 47.7 years of group (02). Clinically, the uterus was enlarged in 7 patients group (01) and 6 patients group (02), and preoperative ultrasound scanning suggested the presence of uterine myomas in 7 patients group (01) and 5 patients group (02). In addition to hysterectomy 6 patients had concomitant pelvic surgery group (01) and 4 on group (02). The mean total operating time was 43.5 minutes group (01) and 57.2 minutes group (02). There were no bowel or urinary tract injuries, unintended laparotomy, return to operating room, or anesthetic complications on both groups. At follow-up, all patients were satisfied with surgery. Conclusion: Laparoscopicaly subtotal hysterectomy using the (Tripolar)-Bipolar Cutting System and the Cut-Loop system and electric morcelation to treatment of therapyresistant menorrhagia is safe, and, can be performed as an outpatient procedure, and is associated with reduced operating time.

TUESDAY, NOVEMBER 7, 2006 Open Communications 4—Instruments & Surgical Techniques (4:32 PM – 4:38 PM)

88 Laparoscopic Supracervical Hysterectomy Using the Plasma Kinetic Needle and Morcellator System

Matute-Labrador A, Minoli VC, Ortiz E, Cano R. American British Cowdray Medical Center Study Objective: To evaluate the safety and medium-term outcomes of laparoscopic supracervical hysterectomy using the plasma kinetic needle and morcellator system. Design: Prospective observational study. Setting: Medical center. Patients: 80 patients who underwent LSH. Measurements and Main Results: Prospective observational study at ABC Medical Center, in Mexico City. Eighty patients, who underwent laparoscopic supracervical hysterectomy for benign condition from May 2004 through November 2005, were including. The procedure was performed using the plasma kinetic needle system to separate

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the cervix from the uterus at the internal os level; the uterus was removed from the abdominal cavity with the morcellator system. The endocervical canal was electro coagulated; an interceed mash was placed over the cervical stump. Mean patient age was 42.3 year. Median parity was 2, mean duration of symptoms was 1 year. Clinically, the uterus was enlarged in all patients; preoperative ultrasound suggested the presence of uterine fibroids in 60 patients. Mean total operating time was 45 minutes; mean estimated blood loss was 100 ml. overall major complication rate was less than 1%. There were no bowel injuries; we had one intentionally urinary bladder injury secondary to adhesions, laparoscopic primary closure was performed with no further complications. NO patient required blood transfusion. At follow up, all patients were satisfied with surgery results. Conclusion: Laparoscopic supracervical hysterectomy using the plasma kinetic needle demonstrates to be a safe procedure, time saving method as well as the morcellator system. Overall patient satisfaction was high. I state that laparoscopic supracervical hysterectomy using the plasma kinetic needle and the morcellator system is minimal invasive surgical technique, and can be recommended if vaginal hysterectomy is contraindicated and there are no indications for cervix excision.

TUESDAY, NOVEMBER 7, 2006 Open Communications 4—Instruments & Surgical Techniques (4:38 PM – 4:44 PM)

89 Laser Fluorescent Intraoperative Diagnosis of Gynecologic Diseases 1 Adamyan LV, 1Belyaeva LA, 2Stepanian AA, 1Kiselev SI. Moscow State University of Medicine and Dentistry Moscow, Russian Federation; Center for Women’s Care and Reproductive Surgery, Atlanta, Georgia Study Objective: To enhance effectiveness of early and differential diagnosis of gynecologic diseases using the method of laser fluorescent spectroscopy with Alasens (preparation based on aminolevuline acid, Russia). Design: Prospective analysis of the 1992 spectrums from 85 patients with 141 pathologic conditions. Patients: Eighty-five patients (aged 23 – 56 yrs) with associations of gynecologic diseases (ovarian benign and malignant tumors, endometrial hyperplasia and cancer, cervical cancer. Intervention: All patients underwent diagnostic or surgical laparoscopy and hysteroscopy, accompanied by intraoperative laser-spectroscopic examination using the device LESA01-Biospec (Russia) 3-8 hours after oral administration of Alasens and followed by pathology investigation. Measurements and Main Results: Benign tumors and cysts appeared to have low index of fluorescence, while in malignant tumors the fluorescence intensity was 1.7 times higher than in borderline tumors. The method was also effective to reveal metastasis in lymphoid nodes, omentum, peritoneum. Index of diagnostic contrasting in adenocarcinoma in situ

was 2 times higher than in endometrial polyp. Microinvasive, invasive and in situ cervical cancer provided 5.7 times more pronounced fluorescence intensity compared to intact tissues. Only in some endometriotic patients intensive cumulation of Alasens-induced protoporphirine IX was documented, possibly providing evidence of high proliferative activity in the endometriotic foci. Conclusion: Laser fluorescent spectroscopy with Alasens allows intraoperative differential diagnosis of benign and malignant conditions of genitalia, thus providing guidelines for choice of adequate operating volume.

TUESDAY, NOVEMBER 7, 2006 Open Communications 4—Instruments & Surgical Techniques (4:44 PM – 4:50 PM)

90 Autofluorescence Laparoscopy: A New Diagnostic Tool in the Diagnosis of Endometriosis 1 Buchweitz O, 2Staebler A, 1Tio J, 1Kiesel L. 1University of Munster, Department of Gynecology and Obstetrics; 2 Department of Pathology, Munster, Germany Study Objective: To evaluate the feasibility of autofluorescence laparoscopy in the diagnosis of endometriotic lesions. Design: Prospective analysis (Canadian Task Force classification II-2). Setting: University hospital. Patients: Ninety-eight consecutive patients undergoing laparoscopy for suspected endometriosis. Intervention: Laparoscopic surgery under white light illumination and autofluorescence diagnosis. Measurements and Main Results: Total number of endometriotic lesions diagnosed under white light illumination and with autofluorescence diagnosis. The biopsy-based sensitivity of white light diagnosis alone and white light illumination and autofluorescence for detecting non-pigmented peritoneal endometriotic lesions was 67 % compared to 94% (1.4-fold increase). The corresponding specificity was 70% as opposed to 84 %. Occult areas of endometriosis were discovered using autofluorescence diagnosis. Deepinfiltrating and ovarian endometriosis display no reduced autofluorescence. Conclusion: The combination of white light illumination and autofluorescence is significantly superior to white light ilumination alone in detecting non-pigmented endometriotic lesions. Autofluorescence diagnosis of non-pigmented endometriotic lesions may become an alternative to fluorescence diagnosis following application of 5-aminolevulinic acid, especially because of no side effects.

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TUESDAY, NOVEMBER 7, 2006

TUESDAY, NOVEMBER 7, 2006

Open Communications 4—Instruments & Surgical Techniques (4:50 PM – 4:56 PM)

Open Communications 4—Instruments & Surgical Techniques (4:56 PM – 5:02 PM)

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Robot-Assisted Laparoscopic Myomectomy versus Abdominal Myomectomy: A Comparison of Surgical Outcomes and Costs Advincula AP, Xu X, Goudeau S, Ransom S. University of Michigan, Ann Arbor, Michigan

Robot-Assisted Laparoscopic Myomectomy Represents an Improvement over Standard Laparotomy for Patients with a Limited Number of Fibroids Ascher-Walsh CJ, Capes T. Mt. Sinai School of Medicine, New York, New York

Study Objective: To compare the surgical outcomes of myomectomy managed by robot-assisted laparoscopy with those performed by traditional laparotomy and to analyze the financial impact of these two approaches. Design: Retrospective case-matched analysis. Setting: University teaching hospital. Patients: Fifty-eight patients with symptomatic leiomyomata. Intervention: Myomectomy via robot-assisted laparoscopy or traditional laparotomy. Measurements and Main Results: An equal number of case-matched patients based on age, BMI, and fibroid weight were analyzed in each group. Among these three variables, there were no statistically significant differences between the robotic and laparotomy groups. Mean age was 36.6 versus 35.9 years, mean BMI was 25.2 versus 28.3 kg/m2, and mean fibroid weight was 227.9 versus 223.8 grams respectively. Robot-assisted laparoscopic myomectomy patients had decreased estimated blood loss (mean 195.7 versus 364.7 ml) and length of stay (mean 1.48 versus 3.62 days) when compared to the laparotomy group. Both of these differences were statistically significant at p < 0.05. Operative times were significantly longer in the robotic group (mean 231.4 versus 154.4 minutes, p < 0.05). Complication rates were higher in the laparotomy group. Although professional fees were not different between the two groups (mean $3,312.51 versus $2,584.28), hospital fees were significantly higher for the robotic group (mean $30,345.90 versus $13,609.15, p < 0.05). Interestingly, the median reimbursement rates, both professional and hospital, were not significantly different between the robotic and laparotomy groups ($10, 605.86 versus $9,943.50). Conclusion: As a new technology, it is not unexpected that a robotic approach to myomectomy costs more than a traditional laparotomy. On the other hand, the decreased estimated blood loss, complication rates, and length of stay with the robotic approach in the end may prove to have a significant societal benefit.

Study Objective: To compare surgical and postoperative results of robot-assisted laparoscopic myomectomy versus standard myomectomy via laparotomy in patients with less than 5 fibroids. Design: Retrospective, case-control study (Canadian Task Force classification II-B). The first 15 patients having undergone a robotic-assisted laparoscopic myomectomy with the DiVinci system from Intuitive Surgical were compared to a historical cohort of patients having undergone a myomectomy via laparotomy. The groups were compared for surgical and postoperative variables. Setting: University hospital Patients: Fifteen women who underwent robot-assisted laparoscopic myomectomy. Women offered this option had to have 3 or less fibroids confirmed pre-operatively by MRI. Fifty women with three or less fibroids having undergone a myomectomy via laparotomy from a previously reported study on treating postoperative myomectomy via laparotomy patients with ketorolac. Intervention: Charts were reviewed to determine length of surgery, operative and postoperative complications as well as other surgical and postoperative variables including length of stay Measurements and Main Results: There was no statistically significant difference between the patients in terms of age, indication for surgery, fibroid weight, ethnicity, body mass index, or parity. There was a significant increase in the average time of surgery for the robotic-assisted procedure versus the procedure via laparotomy: 231min versus 138 min (p=0.003). There was a significant decrease in blood loss in the robotic-assisted cases: 245cc versus 459cc (p=0.009), as well as change in hematocrit on postoperative day 1: 5.17 versus 7.09 (p=0.05), length of hospital stay: 1.3 days versus 3.3 days (p=0.000), days to regular diet: 1.1 versus 2.3 (p=0.000), and febrile morbidity: 0% versus 38% (p=0.000). In addition, all patients having undergone a laparotomy received a postoperative patient controlled anesthesia device for pain control while all patients having undergone the robot-assisted laparoscopic procedure had pain controlled via a standing order for intravenous ketorolac and oral acetaminophen/oxycodone available on demand up to two tablets every 6 hours. There were no significant differences in operative or postoperative complications. Conclusion: While the robot-assisted cases took significantly longer, primarily due to the need for laparoscopic morsellation of the fibroids, the majority of other variables improved in comparison to similar procedures via laparotomy. The robot offers an improvement to the care of women with a small number of symptomatic myomas.

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TUESDAY, NOVEMBER 7, 2006 Open Communications 4—Instruments & Surgical Techniques (5:02 PM – 5:08 PM)

93 A Comparison of Traditional Laparoscopic Supracervical Hysterectomy versus Robot-Assisted Laparoscopic Supracervical Hysterectomy Ascher-Walsh CJ, Capes T. Mt. Sinai School of Medicine, New York, New York Study Objective: To compare the surgical time and results from the initial five supracervical hysterectomies performed with the daVinci robot-assisted laparoscopic system with the same procedures performed over the same time period with standard laparoscopic equipment. Design: Retrospective, case-control study (Canadian Task Force classification II-B). The data from the first 5 patients having undergone a robotic-assisted laparoscopic supracervical hysterectomy with the daVinci system from Intuitive Surgical were compared with that from patients having undergone the same procedure with standard laparoscopic equipment over the same time period. They were compared for surgical and postoperative variables. Setting: University Hospital. Patients: 10 women having undergone laparoscopic supracervical hysterectomy from 1/1/2006 through 4/30/2006, five of whom had the procedure performed via robot-assisted laparoscopy and five performed thru traditional laparoscopic methods. All procedures were performed under the guidance of the same senior surgeon. Intervention: Due to limited availability of the daVinci robot system at our institution, patients who were considered candidates for a laparoscopic supracervical hysterectomy were scheduled for surgery without information on it’s availability. The daVinci robotic system was used when available for this procedure. Use was determined only by availability of the equipment and not by the specifics of each case. Charts were reviewed to determine length of surgery, operative and postoperative complications as well as other surgical and postoperative variables, including length of stay. Measurements and Main Results: There was no statistically significant difference between the patients in terms of age, indication for surgery, uterine weight, ethnicity, body mass index, or parity. There was no significant decrease in the average time of the robotic-assisted procedure versus the standard laparoscopic procedure: 158 minutes versus 157 minutes. (p=0.983). There was no significant decrease in blood loss: 120cc versus 132cc (p=0.743), change in hematocrit on postoperative day 1: 2.21 versus 2.32 (p=0.842), or length of hospital stay: 1.0 days versus 1.0 days (p=0.999). There were no operative or postoperative complications in either group. The first patient in the robot-assisted group was the only patient with previous abdominal surgery and had extensive adhesions from two previous Cesarean sections. When she is excluded from the analysis, the only change in the comparison is a sig-

nificant decrease in operative time in the robot-assisted group, 117minutes versus 157 minutes (p=0.022). Conclusion: For a surgeon with extensive experience performing laparoscopic supracervical hysterectomies, using a robot-assisted system does not significantly change the surgical time or outcome during the initial experience with the device. It may result in decreased operative time as demonstrated when the more complicated case is excluded. With greater experience the benefit of decreased surgical time may become more apparent. This benefit will need to be weighed against the increased number of port sites used in the robot-assisted procedure as well as the decreased opportunity for resident surgical training when using the device.

TUESDAY, NOVEMBER 7, 2006 Open Communications 4—Instruments & Surgical Techniques (5:08 PM – 5:14 PM)

94 The Early Learning Curve Thought to Be Associated With Robot-Assisted Laparoscopic Myomectomy Does Not Apply to Surgeons with an Extensive History in Advanced Laparoscopic Surgery Capes T, Ascher-Walsh CJ. Mt. Sinai School of Medicine, New York, New York Study Objective: To compare the surgical time and results from the initial five procedures performed with the daVinci robot-assisted laparoscopic system with the last five performed to evaluate for the presence of a learning curve in surgeries performed by a surgeon with extensive advanced laparoscopic experience. Design: Retrospective, case-control study (Canadian Task Force classification II-B). The data from the first 15 patients having undergone a robotic-assisted laparoscopic myomectomy with the daVinci system from Intuitive Surgical were evaluated for surgical and postoperative variables. The initial five cases were compared to the final five cases to determine if there was any evidence of a learning curve. Setting: University hospital. Patients: Fifteen women having undergone robotic-assisted laparoscopic myomectomy. Women offered this option had to have 3 or less fibroids confirmed pre-operatively by MRI, a uterus no larger than 20 weeks size on office exam and no previous uterine surgery. Intervention: Charts were reviewed to determine length of surgery, operative and postoperative complications as well as other surgical and postoperative variables including length of stay. Measurements and Main Results: The was no statistically significant difference between the patients in terms of age, indication for surgery, fibroid weight, ethnicity, body mass index, or parity. There was no significant decrease in the average time of the robotic-assisted procedure from the first 5 procedures versus the last 5: 216 minutes versus 245 minutes. (p=0.561). There was no significant decrease in blood loss: 210cc versus 280cc (p=0.523), change in hematocrit on post-

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operative day 1: 6.03 versus 4.32 (p=0.667), or length of hospital stay: 1.2 days versus 1.4 days (p=0.667). There were no operative or postoperative complications in either group. Two surgical time outliers existed. The first case took 285 minutes, probably resulting from a lack of experience with trocar placement, robot attachment, and device controls. The 11th case had technical problems with the morsellator which unnecessarily added over an hour to the case. If these two cases were excluded, the average total length of time in both groups decreases as does the surgical time difference between the groups, 199 minutes versus 210 minutes (p=0.764). Conclusion: With a long history of performing advanced laparoscopic procedures, there is no significant learning curve in using the DiVinci robot except for the initial procedure in which additional time is spent learning to appropriately set-up the robot and use the various instruments in an actual patient. Surgeons with a long history of advanced laparoscopic procedures should feel comfortable using the robotic-assisted device for procedures once they have trained on the components specific to the device itself.

gery. Other concomitant surgeries were performed including hysterectomy (45%), slings (35%), anterior repair (85%), posterior repair (95%), lysis of adhesions (45%), and oophorectomy (20%). All underwent cystoscopy. Average surgical time was 5 hours and 13 minutes. Estimated blood loss was 17 cc. The length of stay was 1.3 days. One patient required laparotomy at the time of surgery due to hemorrhage from the middle sacral artery. One postoperative fever and incident of urinary retention lasting 3 days were seen. Two patients had slight infections of the trocar sites treated with oral antibiotics. All had their prolapse successfully treated at follow-up. Conclusion: The robotic sacrocolpopexy is a feasible alternative to the traditional open procedure. The procedure did not detract from the residents’ education because of concomitant procedures and the need to elevate their laparoscopic assisting skills. A randomized control trial comparing open versus robotic techniques is warranted.

TUESDAY, NOVEMBER 7, 2006

Open Communications 5—Pregnancy/Reproductive Surgery (3:50 PM – 3:56 PM)

Open Communications 4—Instruments & Surgical Techniques (5:14 PM – 5:20 PM)

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Experience with Robotic Sacrocolpopexies in a Community-Based Teaching Hospital Flora RF, Fanning J, Tan C, Babbitt T, Mendiola A. Summa Health System, Northeastern Ohio Universities College of Medicine, Akron, Ohio

Methotrexate Use in Patients with Relative and Absolute Contraindications: Time to Reconsider the Current Guidelines 1,3 Victory R, 1,2Abdallah ME, 1,2Ambler DR, 1,3Diamond MP, 1,3Puscheck EE, 1,2Berman JM. 1Wayne State University, Detroit Medical Center; 2Hutzel Hospital; 3 University Women’s Care

Study Objective: The purpose of this study was twofold. The first was to describe our experience in utilizing the DaVinci robot in performing sacrocolpopexies. The second is to evaluate the robot’s effect on resident education. Design: All patient charts that underwent robotic sacrocolpopexy for the repair of vaginal vault prolapse were reviewed. A single urogynecologic surgeon performed them with assistance from a gynecologic oncologist and Ob/Gyn residents. All underwent extensive preoperative evaluation. Postoperative visits were at 1 week; 1, 2, and 3 months; and 1 year. Concomitant incontinence and prolapse surgeries were performed as required. Setting: Urogynecology and reconstructive pelvic surgery practice in community based, university affiliated teaching hospital. Patients: Twenty patients underwent the procedure between April 2004 to June 2005. All had stage 3 to 4 prolapse. One patient had previously failed a previous abdominal sacrocolpopexy. Intervention: The procedure was performed in an identical manner to the open procedure. Using the DaVinci robot, two pieces of soft polypropylene were used to attach the vaginal apex to the sacrum. Measurements and Main Results: The average weight was 158 pounds. Ninety percent had previous abdominal sur-

Study Objective: Although ACOG has recommendations for methotrexate treatment of ectopic pregnancies, clinical decisions frequently result in exceptions to indication and contraindication criterion. Thus, we sought to determine the outcomes of methotrexate managed ectopic pregnancies, when one or more relative or absolute contraindications were present. Design: Retrospective ectopic pregnancy database from Jan 2000 – February 2005. Setting: Detroit Medical Center, Detroit, Michigan. Patients: One hundred ninety-eight patients with tubal ectopic pregnancies receiving the first dose of methotrexate. Intervention: Methotrexate administration, readministration or surgical therapy. Measurements and Main Results: Inclusion criteria, at first presentation, included, presence of pain, vaginal bleeding, adnexal mass > 3.5cm, ‚`hCG > 6000 IU, and/or cul de sac fluid volume, and need for subsequent therapy. Pain occurred in 139 patients (mild 32.3%, moderate 25.3%, severe 12.6%, unknown 4.5%), with 18.0% (n = 25/139) requiring additional therapy (methotrexate 20%; surgery 80%; tubal rupture 36%). Bleeding was present in 144 patients (mild 55.1%, moderate 16.7%, severe 1%, unknown 4.5%), with 15.3% (n = 22/144) requiring additional therapy (methotrexate 22.7%; surgery 77.3%; tubal rupture 45.5%). Ectopic size > 3.5cm was present in 16 patients

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with 18.8% (n = 3/16) requiring surgical therapy for tubal rupture. There were 23 patients with `hCG values > 6000 IU, of which 47.8% (n = 11/23) required further therapy (methotrexate 45.5%; surgery 54.5%; tubal rupture 36.3%). The volume of cul de sac fluid was available in 123 patients (minimal 54.5%, moderate 7.1%, severe 0.5%, unknown 7.6%), with 16.3% (n = 20/123) requiring either methotrexate (20.0%) or surgery (80.0%; tubal rupture 35%). Conclusion: While the majority of patients with methotrexate contra-indications required no further therapy, failure occurred in 15% - 47.8%, resulting in 50% - 100% of affected patients requiring urgent or emergent surgical intervention. Thus, amending the list of absolute contraindications to include ectopic size > 3.5cm and `hCG values > 6000 IU may be prudent.

TUESDAY, NOVEMBER 7, 2006 Open Communications 5—Pregnancy/Reproductive Surgery (3:56 PM – 4:02 PM)

97 Laparoscopic Management of Torsion Improves the Rate of Adnexal Conservation Takacs P, Bratter J, Chakhtoura N., Medica C. University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida Study Objective: To compare complications and rate of conversion between normal weight, pre-obese and obese women who underwent laparoscopic management of ectopic pregnancy. Design: Retrospective Chart Review (Canadian Task Force classification II-3). Setting: Tertiary teaching hospital. Patients: One hundred eighty three patients who had laparoscopic management of ectopic pregnancy were placed in three groups based on their body mass index (BMI) using the WHO’s classification: normal-weight (BMI 18.5-24.9 kg/m2), pre-obese (BMI 25-29.9 kg/m2), and obese (BMI>30 kg/m2). Intervention: Retrospective comparisons of complications between normal, pre-obese and obese women. Measurements and Main Results: Out of one hundred eighty three patients, who underwent laparoscopic management of ectopic pregnancy, 95 women were normal weight, 58 were pre-obese and 30 were obese. The groups were not significantly different with respect to age, gravity or parity, history of abdominal surgery, previous ectopic pregnancy, or previous history of pelvic inflammatory disease, adhesions or endometriosis. The rate of conversion to laparotomy was not significantly different in obese or pre-obese women to that of normal weight women. In addition, pre-obese and obese women did not have a significant increase in the length of surgical time or blood loss. The rate of complications was similar between the groups. The only significant finding between the groups was the length of hospital stay which was substantially increased in obese women com-

pared to normal weight women. Conclusion: Laparoscopic management of ectopic pregnancy in obese and pre-obese women does not increase the risk of conversion to laparotomy, higher blood loss, longer surgeries and other complications. However obese women are at increased risk of a longer hospital stay. Obese and preobese women should not be excluded from undergoing laparoscopic management of ectopic pregnancy.

TUESDAY, NOVEMBER 7, 2006 Open Communications 5—Pregnancy/Reproductive Surgery (4:02 PM – 4:08 PM)

98 Should Ruptured Tubal Ectopic Pregnancies Be Managed Laparoscopically? 1 Ambler DR, 1Victory R, 1,2Abdallah ME, 1Diamond MP, 3 Puscheck EE, 3Berman JM. Wayne State University, Detroit Medical Center, University Women’s Care; 2Hutzel Hospital, Detroit, Michigan; 3University Women’s CareSouthfield, Southfield, Michigan Study Objective: To determine factors associated with successful laparoscopic management of ruptured tubal pregnancies and to compare the outcomes to patients solely managed by laparotomy. Design: Retrospectively collected ectopic pregnancy database. Setting: Detroit Medical Center, Detroit, Michigan. Patients: One hundred eighty seven cases reporting surgically confirmed tubal rupture with 127 undergoing laparoscopy, 89 laparotomy, and 29 of which were conversions. Intervention: Abstracted data included laparoscopy, laparotomy, conversion, physician and fellow type (MFM, REI, gynecologist), preoperative hemoglobin, hematocrit, `HCG (IU), gestational age (days), ultrasound-determined ectopic size, cul de sac fluid, American Society of Anaesthesiologists score (ASA), intraoperative bleeding, adhesions, tubal rupture, estimated blood loss (EBL)(mL), operative time, operative duration (min) and hospital stay (days). Covariates included demographics and previous history of abdominal surgery. Results were significant when p<0.05. Measurements and Main Results: Chi Squares revealed that successful laparoscopy was associated with no previous abdominal surgery (p = 0.016), absence of adhesions (p < 0.001), reduced intra-abdominal bleeding (p<0.001), decreased EBL (p=0.002), decreasing gestational age (p=0.01), reduced blood transfusions, lower `Hcg levels (10425 +/- 2011 vs. 22761 +/- 4291, p < 0.001), increased operative duration (87 +/- 3 vs. 60 +/- 2, p < 0.001) and reduced hospital stay (0.75 +/- 0.09 vs. 2.9 +/- 0.22, p = 0.038). There were no significant differences between laparoscopy and laparotomy in regards to physician, fellow, hemoglobin, hematocrit, average ectopic size, cul de sac fluid volume, ASA, operative time, insurance type, age, weight, race or marital status. Conclusion: Ruptured ectopics are amenable to laparoscopic management, with resultant decreases in blood loss,

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reduced need for blood transfusions and substantially reduced hospital stay, with only a minimal clinical difference in operative duration. However, conversion to laparotomy is dependent on massive intra-abdominal blood loss, pelvic adhesions, and elevated `Hcg levels.

TUESDAY, NOVEMBER 7, 2006 Open Communications 5—Pregnancy/Reproductive Surgery (4:08 PM – 4:14 PM)

99 Diagnosis and Treatment of Cornual Pregnancies Our Experience with 27 Cases Soriano D, Mashiach R, Vicus D, Zolti M, Alkalay M, Bitman G, Schiff E, Seidman D, Goldenberg M. The Chaim Sheba Medical Center, Ramat Gan, Israel Study Objective: To summarize fifteen years of diagnosis and treatment of cornual pregnancies. Design: Retrospective cohort study (Canadian Task Force classification II-3). Setting: A tertiary referral hospital. Patients: Twentyseven women diagnosed with cornual pregnancies. Intervention: Four cases (16 %) were handled conservatively, 3 with systemic MTX and leukoverin, and one with ultrasound guided KCl injection to the amniotic sac. Laparoscopy was performed in 20 (74%) of the patients. Laparotomy was performed in 8 cases, 4 were converted from laparoscopy, and 3 started as laparotomy. Either resection of the cornua and/or Endoloop placement were performed. In four cases further treatment after surgery was required: ultrasonographic guided KCl, MTX, or KCl & MTX injection to the amniotic sac, and systemic MTX injection, one case each. Measurements and Main Results: Twelve patients (44%) had previous extra-uterine pregnancies. Nineteen pregnancies (70.3%) were conceived spontaneously and 8 (29.6%) through in-vitro fertilization. The mean gestational age (LMP) was 56 days gestation. The average and median serum hCG levels were 31,199 and 6,653, respectively. Six of the women (22%) were admitted in hypovolemic shock. Nine patients (33.3%) were asymptomatic upon admission, 14 (52%) had abdominal pain, and 8 (29.6%) were evaluated for vaginal bleeding. One woman developed hypovolemic shock after admission. Only 17 of the 27 pregnancies (63%) were diagnosed as a cornual pregnancy by ultrasound before the therapeutic procedure. Blood transfusion was given in seven cases (26%) during surgery. The mean number of days of hospitalization was 7.2 days. Conclusion: Cornual pregnancy is a rare and potentially life threatening complication. It is often misdiagnosed by ultrasonography. A high index of suspicion and early intervention are required. Proper surgical technique is essential.

TUESDAY, NOVEMBER 7, 2006 Open Communications 5—Pregnancy/Reproductive Surgery (4:14 PM – 4:20 PM)

100 Laparoscopic Management of Heterotopic Pregnancy: Obstetric Outcome and Long-Term Newborn Follow-up Soriano D, Mashiach R, Vicus D, Zolti M, Alkalay M, Bitman G, Schiff E, Seidman D, Goldenberg M. The Chaim Sheba Medical Center, Ramat Gan, Israel Study Objective: To summarize the diagnosis and treatment of heterotopic pregnancies (HP) in Sheba Medical Center. Design: Aetrospective cohort study extending over eleven years. (Canadian Task Force classification II-3). Setting: A tertiary referral hospital. Patients: Nineteen women with laparoscopically confirmed HPs. Intervention: Laparoscopic surgery. Measurements and Main Results: Seven of the women (37%) were admitted in hypovolemic shock. Eight of 17 patients (47%) were diagnosed ultrasonographically before the laparoscopic procedure. During the laparoscopic procedure a ruptured tube was found in 8 of the 17 (47%) ectopic pregnancies, blood transfusion was needed in 7 (41%) and conversion to laparotomy was required in two cases (10%). Salpingectomy was performed in 12 (92%) of the 13 tubal ectopic pregnancies (three corneal, one ovarian, one tubal stump). All, but one, of the patients conceived by ovulation induction or IVF. The pregnancy outcome consisted of 12 take home babies (term and preterm) and six miscarriages (two second trimester). Long term followup showed that all 12 babies developed normally. Conclusion: Women receiving ovulation induction or a history of pelvic surgery are at increased risk for HP. Patients with a HP are at a high risk for presenting at diagnosis with hypovolemic shock and therefore requiring blood transfusion. Laparoscopic intervention is a safe method of the management of HP in experienced hands. The outcome of the intrauterine pregnancy in cases of HP needing surgical intervention is good.

TUESDAY, NOVEMBER 7, 2006 Open Communications 5—Pregnancy/Reproductive Surgery (4:20 pm – 4:26 pm)

101 Surgical Outcomes for Laparoscopic Cerclage: The Toronto Laparoscopic Cervical Cerclage Group Experience 1,2 Singh SS, 1,3Whittle WL, 1,2Leyland NA, 1,3Allen LM, 1,3 Thomas J, 1,3Windrim R. 1Singh S. 1St. Joseph’s Health Centre; 2University of Toronto; 3Mount Sinai Hospital; Toronto, Ontario, Canada Study Objective: To determine surgical outcome(s) and successful pregnancy rate associated with the laparoscopic approach to the cervico-isthmic cerclage (LCC) in women fol-

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lowed by the Toronto Laparoscopic Cervical Cerclage Group. Design: Prospective cohort study from 2002 to present. Setting: Academic hospital with a tertiary level maternalfetal medicine program and a community-academic hospital; both with an advanced endoscopy program. Patients: Patient selection criteria included: history of one or more second trimester loss(es), failed vaginal cerclage in index pregnancy, history of cervical surgery/trauma and/or history of DES exposure. Intervention: The cerclage was placed at the cervico-isthmic junction using a 1-0 non-absorbable monofilament suture using the laparoscopic approach. Measurements and Main Results: Forty-five (45) patients were candidates for LCC. 21 cases were completed in the first trimester of the index pregnancy; 24 were completed non-pregnant. Six (6) cases of intrapartum cerclage were converted to laparotomy due to poor visualization (n=2) and/or uterine vessel bleeding (n=5). No laparoscopic entry complications or other surgical/long-term morbidities were recorded. 42 pregnancies have been reported; 10 patients are not yet pregnant and 8 pregnancies are currently ongoing. 9 pregnancies were lost prior to viability or resulted in a neonatal death; failure of cerclage integrity was not associated with pregnancy loss. To date, the “take-home baby rate” for the LCC is 74%. Conclusion: LCC appears to have a low surgical complication rate; conversion to laparotomy occurred only in pregnant patients due to the technical challenges associated with an enlarged uterus and/or patient size. The interval procedure is less difficult and also allows for management of concomitant disease such as endometriosis prior to conception. The LCC is associated with a reasonable rate of pregnancy success; LCC integrity does not contribute to pregnancy loss. The LCC may prove to be a reasonable alternative approach to the abdominal cervico-isthmic cerclage.

TUESDAY, NOVEMBER 7, 2006 Open Communications 5—Pregnancy/Reproductive Surgery (4:26 PM – 4:32 PM)

102 Laparoscopic Transabdominal Cervicoisthmic Cerclage During Pregnancy - 10 Years Experience Cho CH, Shin SJ, Kwon SH, Cha SD, Yoon SD. Keimyung University, School of Medicine, Daegu, South Korea Study Objective: To evaluate and describe our experience in the management of recurrent second trimester miscarriage and preterm delivery after the failure of transvaginal cervical cerclage by laparoscopic transabdominal cervicoisthmic cerclage (LTCC). Design: Forty women were included in retrospective review (Canadian Task Force Classification III) Setting: Tertiary care teaching hospital. Patients: Forty women in whom it was not technically possible perform transvaginal cerclage. Intervention: LTCC.

Measurements and Main Results: Mean gestational age at time of cerclage placement was 12.1 weeks (range 1114weeks). Mean operating time of cerclage placement was 56 minutes (range 30-100 min). Thirty-eight patients successfully delivered 42 live babies (4 set of twins; live birth rate 93%). Mean baby weight was 2718g.Two losses occurred after rupture of membrane at 19 and 20 weeks gestational age after cerclage. There was no operative or immediate postoperative complication. Conclusion: LTCC during pregnancy can be safe and effective treatment for well-selected patients with cervical incompetence, and eliminates the need for open laparotomy.

TUESDAY, NOVEMBER 7, 2006 Open Communications 5—Pregnancy/Reproductive Surgery (4:32 PM – 4:38 PM)

103 Novel Application of Polypropylene Sling: Transvaginal Cervico-Isthmic Cerclage in Women with High Risk of Preterm Delivery Fernandez H, Deffieux X, Senat MV, Gervaise A, Bonnet K, Frydman R. APHP, Antoine Beclere Hospital, Clamart, France Study Objective: To describe a novel technique of transvaginal cervico-isthmic cerclage with a polypropylene sling in prevention of preterm labour in high risk pregnant women. Design: Retrospective study (descriptive). Setting: University Hospital (Department of Obstetrics and Gynecology). Patients: 21 women presenting with high risk of preterm delivery: prior histories of pregnancy losses in the second trimester and prior failure of Mac Donald’s cerclage and/or absent portio vaginalis of the cervix. The median age of the patients was 32.8 years (range 22–39 years). Intervention: Cerclage was performed between 12 and 16 weeks of gestation. A polypropylene tape was placed at the cervico-isthmic junction by vaginal route. Caesarean delivery was systematically performed in all patients since the cerclage was considered to be definitive. Measurements and Main Results: No intra-operative complication occurred. The median operating time was 36 minutes (+/-6) (range 30–45 min). The median length of stay was 1.4 days (+/-0.5). Mean gestational age and birth weight at delivery were respectively 37.1 weeks (+/-1.8) and 2850 g (+/-745). Preterm birth rate was 19% (4/21). One neonatal death occurred following amniotic fluid infection at 34 weeks. Birth at less than 32 weeks occurred in only one patient (4%). Conclusion: Transvaginal cervico-isthmic cerclage using polypropylene sling may be considered as an effective and minimally invasive alternative to the trans-abdominal cervico-isthmic cerclage in women presenting with high risk of preterm delivery.

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TUESDAY, NOVEMBER 7, 2006

TUESDAY, NOVEMBER 7, 2006

Open Communications 5—Pregnancy/Reproductive Surgery (4:38 PM – 4:44 PM) 104

Open Communications 5—Pregnancy/Reproductive Surgery (4:44 PM – 4:50 PM)

Treatment of Patients of Reproductive Age Using Invasive Radiologic Techniques Murvatov KD, Obelchak IS, Myshenkova SA, Murvatova LA, Adamyan LV. Moscow State University of Medicine and Dentistry, Moscow, Russian Federation Study Objective: To evaluate the potentialities and results of invasive radiologic techniques in patients requiring preservation of reproductive function. Design: Retrospective analysis of 29 cases of selective embolization of uterine artery for uterine myoma and of 60 cases of transcervical recanalization of uterine tubes. Setting: Department of Reproductive Medicine and Surgery of the Moscow State Medical-Stomatologic University. Patients: Twenty-nine patients with uterine myoma aged 42.3±5.9 yrs., complaining of excessive bleeding and/or pelvic pain and refusing to undergo hysterectomy; 60 infertile patients aged 26.5±3.8 yrs with proximal tubes impatency. Intervention: Embolization with conic metallic spiral devices was carried out under local anesthesia by transfemoral approach in the radiographic operating room, after selective catheterization and arteriography of uterine artery. Recanalization of uterine tubes was performed with double-lumen catheter introduced under simultaneous selective salpingography with angiographic catheter and accompanied by laparoscopy in 19 cases. Measurements and Main Results: No complications were documented. On the 3-4th day after embolization severe pelvic pain developed in most patients requiring analgetic therapy for 5 consecutive days. 1-3 months after embolization all patients were symptoms-free and the spiral computer tomography was performed to evaluate fibroid size, perfusion, and angiodegenerative changes, showing regression of the fibroid size up to 35% and significant regression of the myoma perfusion. Recanalization appeared effective to restore tubal patency in 51 (85.0%) of cases with overall pregnancy rate of 58.3% within 9 months after the procedure. Conclusion: Embolization of uterine arteries and recanalization of uterine tubes are effective, safe and minimally traumatic alternatives to corresponding surgical modalities conventionally used for treatment of uterine myoma and tubal infertility in patients of reproductive age.

105 Effect of Ovarian Cystectomy for Ovarian Endometrioma on Ovarian Response to Superovulation during In Vitro Fertilization and Embryo Transfer Ma CH, Qiao J, Han JS, Wang HY, Peking University Third Hospital, Beijing, China Study Objective: This study was undertaken to evaluate the effect of laparoscopic ovarian cystectomy for endometrioma. Design: This retrospective study included three respects. The first was to evaluate the ovarian response to stimulation conducted for IVF treatment in women who had undergone laparoscopic cystectomy for endometriomas compared with that in women who had undergone peritoneal endometriosis lesion excision but no ovarian cystectomy. The second was to determine ovarian response to COH in operated and contralateral intact ovaries of the same patient in terms of number of follicles, number of oocytes retrieved and the rate of no oocyte retrieved. The third was to evaluate the relationship between laparoscopic cystectomy undertaken by one surgeon group and loss of follicles by examing stripped ovarian tissue. Setting: University teaching hospital. Patients: Two hundred five women under 38 years old who underwent in vitro fertilization (IVF) between Jan, 2001 and March 2006 were included. The study group consisted of 127 patients with ovarian endometriomas who had undergone laparoscopic cystectomy. The control group consisted of 78 patients with endometriosis that confirmed by laparoscopy and /or had peritoneal lesion coagulation, but no ovarian cystectomy. Eighty eight patients with unilateral cystectomy were also analyzed.Twenty cases of laparoscopic removal of ovarian endometrioma, histologically confirmed in the focal endometrial epithelial linning were retrospectively reviewed. Intervention: Laparoscopy surgery for endometrioma in vitro fertilization and embryo transfer. Measurements and Main Results: There was no statistically difference in the mean age between the two groups (study group: 32.9±3.2 years; control group: 33.0±3.00 years). Nor was the mean duration of infertility statistically different between these two groups (study group: 5.3±3.1 years; control group: 4.5±2.6 years).Basal FSH level in all patients was under 12IU/L. The days of stimulating , the number of gonadotropin ampules, the number of follicles, the number of oocytes were, respectively, 11.9±2.6 versus 10.9±2.3, 49.4±22.8 versus 42.3±20.3, 9.8±5.3 versus 13.5 ± 6.1, 9.8 ± 5.3 versus 13.5 ± 6.1 in the study group and control group. The differences were statistically significant (P<0.05). Fertilization rate and implantation rate were similar. The number of high quality embryos and embryo transferred were statistically lower in study group than that in control group (4.8±3.4 versus 6.9 ±4.6, 2.4 ±0.8 versus 2.7 ± 0.7,

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respectively).Pregnancy rate in study group was 37.7%, while 27.8% in control group. A reduced number of dominant follicles and oocytes was observed in the operated gonad. The number of follicles, the number of oocytes were, respectively, 3.8±3.1 versus 6.4 ±3.6, 3.2 ±2.8 versus 6.0 ±3.8 in the treated ovary and the contralateral ovary. The differences were statistically different. Normal ovarian stroma was found in 17/20 (85%) of all cysts microscopically. The primordial follicle was found within the capsule of 15/20(75%) cases. Conclusion: Laparoscopic excision of endometriomas is associated with a quantitative damage to ovarian reserve.

pregnancy and outcome of achieved pregnancy). Only one patient suffered from postoperative retention of urine (probably unrelated to the procedure), while the rest of the patients tolerated the procedure of ovarian suspension well without difficulty in removal of the suture tied to the abdominal skin. Table one summarizes patient’s characteristics and table two presents outline of achieved pregnancies. Conclusion: Temporary ovariopexy by temporary mobilization of the ovary away from its bed following lysis of extensive adhesions associated with endometriosis seems to be a safe procedure, associated with favorable reproductive outcome in infertile women with endometriosis.

TUESDAY, NOVEMBER 7, 2006

TUESDAY, NOVEMBER 7, 2006

Open Communications 5—Pregnancy/Reproductive Surgery (4:50 PM – 4:56 PM)

Open Communications 5—Pregnancy/Reproductive Surgery (4:56 PM – 5:02)

106

107

Ovarian Suspension during Laparoscopic Conservative Surgery for Endometriosis-Associated Infertility: A Cohort of 59 Consecutive Cases 1,3 Mitwally MF, 2Palmer KG, 3Elhammady E, 4Eddib A, 3 Diamond MP, 5Ashraf M, Abuzeid M. 1The University of New Mexico, Albuquerque, New Mexico; 2Michigan State University College of Human Medicine, East Lansing, Michigan; 3Wayne State University, Detroit, Michigan; 4 University at Buffalo (UB), State University of New York (SUNY), Buffalo, New York; 5Michigan State University, East Lansing, Michigan

The Clinical Outcomes of Laparoscopic Diagnosis and Management of Infertility with Distal Fimbrial Obstruction Wang HY, Qiao J, Ma CH. Peking University Third Hospital, Beijing, China

Study Objective: Present the outcome of 59 consecutive infertile women who underwent temporary ovarian suspension to prevent postoperative adhesion formation during laparoscopic conservative surgery for endometriosis-associated infertility. Design: Case series. Setting: Infertility treatment center. Patients: A series of 59 consecutive infertile women who underwent laparoscopic surgery for the management of infertility. Intervention: Laparoscopic surgery including staging & conservative management of endometriotic lesions. Temporary ovariopexy (ovarian suspension) was carried out by suturing the ovarian ligament into the abdominal wall (using non-absorbable suture, tied to the abdominal skin) to mobilize the ovary away from its bed following lysis of adhesions and excision of endometriosis. The suture tied to the abdominal skin was cut, freeing the ovary within one week following surgery. Patients were followed for about 24 months while trying to achieve pregnancy by trying natural intercourse, followed by infertility intervention when spontaneous pregnancy was not achieved (ovarian stimulation with intrauterine insemination or assisted reproduction). Achieved pregnancies were followed until delivery or pregnancy loss. Measurements and Main Results: Safety of the procedure (complications), and reproductive outcome (achievement of

Study Objective: To retrospectively review the coincident rate of the diagnosis for distal fimbrial obstruction of infertility between laparoscopy and hysterosalpingography(HSG), between laparoscopy and ultrasound examination. To observe the pregnancy outcomes of management of distal fimbrial obstruction of infertility by laparoscopy. Setting: Reproductive Medicine Center, Peking University Third Hospital. Design: From 2000 to 2005, 53 patients underwent HSG and ultrasound examination before laparoscopy. After laparoscopy the patients were divided into two groups: 1. Normal Group included 11 patients without tube adhesion and the fallopian tubes were patent, after operation patients were encouraged to try pregnancy. 2. Abnormal Group included 42 patients with tube adhesion or distal fimbrial obstruction. They underwent salpingolysis or salpingostomy by laparoscopy. The pregnancy outcomes were followed-up at least 6 months after surgery (ranged 6–48 months). 3 patients in Normal Group and 14 patients in Abnormal Group got lost in follow-up. Patients: Fifty-three patients with distal fimbrial obstruction diagnosed by HSG underwent laparoscopy combined hysteroscopy examination. All patients had normal ovaries and uterus findings and had normal hormonal level and menstrual cycle. The husbands? seminal analysis were normal. Measurements and Main Results: Comparing with laparoscopic findings, the coincident rate, false positive rate, false negative rate were 82.1% (86/106), 14.4% (15/106), 3.8% (4/106) of HSG; 81.1% (86/106), 1.9% (2/106), 17.0% (18/106) of ultrasound examination. The pregnancy rate was 37.5% (3/8) in Normal Group and all of them were intrauterine pregnancy, the pregnancy rate was 14.3% (4/28) in Abnormal Group and all of them were ectopic pregnancy.

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Conclusion: Comparing with laparoscopic findings, the false positive rate of HSG was higher than that of ultrasound examination (14.2% versus 1.9%, p<0.05), the false negative rate of ultrasound examination was higher than that of HSG (17.0% versus 3.8%, p<0.05). The pregnancy rate was lower and patients likely to be have ectopic pregnancy in Abnormal Group. Laparoscopy offers accurate diagnostic evidences in examinations of infertility, the patients with normal fallopian tube and no pelvic adhesion had a higher natural pregnancy rate.

TUESDAY, NOVEMBER 7, 2006 Open Communications 5—Pregnancy/Reproductive Surgery (5:02 pm – 5:08 pm)

108 Laparoscopic Tubal Re-anastomosis 1,2 Patel SS, 1,2Jhala YM, 1Patel RR, 1Vaghashiya HP. 1 Mayflower Womens Hospital, Gujarat, India; 2Sterling Hospital, Ahmedabad, India Study Objective: To report the outcome of laparoscopic tubal re-anastomosis procedure. Design: Retrospective study of 184 cases. Setting: Tertiary referral center for Gynaec endoscopic surgery in India. Patients: Total 184 cases (age group 25-35) between years 1996-2005. Intervention: Laparoscopic tubal re-anastomosis. Measurements and Main Results: Out of 184 cases, 126 were of TL reversal, 38 cases of tubal block due to PID, 7 cases of tubal block due to previous ectopic pregnancy and 13 cases of failed tubal cannulation. In the study of 184 cases of laparoscopic tubal re-anastomosis between year 19962005, procedure was performed bilaterally in 137 cases while unilateral procedure was done in 39 cases however in 8 cases we could not perform due to multiple blocks in tube. Out of these 184 cases, 145 (78.8%) had conceived and 6 patients had ectopic pregnancies. Out of 102 cases of isthmo-isthmic, 93 conceived. Out of 39 cases of isthmoampullary anastomosis, 34 had conceived. Out of 24 cases of ampullo-ampullary anastomosis, 12 conceived. Out of 9 juxtamural-isthmic anastomosis, 4 have conceived. In juxtauterine-isthmic anastomosis out of 3 cases, one had conceived. Out of 7 cases of intramural-isthmic anastomosis 3 had conceived. Conclusion: Tubal re-anastomosis can be done laparoscopically in selected cases with good pregnancy outcome. Laparoscopic tubal re-anastomosis has introduced a new dimension to reproductive surgery. It is important to realize that the learning curve is considerably long and the technique may be difficult for some, despite their best efforts.

TUESDAY, NOVEMBER 7, 2006 Open Communications 5—Pregnancy/Reproductive Surgery (5:08 PM – 5:14 PM)

109 The Value of Second Look Laparoscopy Following Short Term Pituitary Suppression for Infertility Caused By Endometriosis Byrne HP, Ball E, Davis C. The Centre for Reproductive Medicine and Surgery, Barts and the London NHS Trust, St. Bartholomew’s Hospital, London, United Kingdom Study Objective: To determine the outcome of 3-stage combined medical and surgical treatment for severe grade 4 endometriosis. Design: A prospective observational cohort study (n=11). Setting: St Bartholomew’s Hospital London, which is a tertiary referral centre for infertility and minimal access surgery. Patients: Eleven patients with severe Grade 4 endometriosis confirmed at the time of laparoscopy who wished to become pregnant. Intervention: Laparoscopic adhesiolysis and laser to endometriosis was performed followed by 3 months of pituitary down-regulation with Goserelin acetate (Zoladex) and then second look laparoscopy with adhesiolysis and laser to endometriosis as required. Measurements and Main Results: Preoperative visual analogue pain (VAP) scores and length of infertility were measured. Following the 3 stage treatment approach pain scores were repeated and the interval to achieving a pregnancy measured. The mean age of patients at the time of initial surgery was 34.1 years. The mean preoperative VAP score was 7.3 compared to the mean post treatment VAP score of 3.8. Seven of the patients (63.6%) had achieved a pregnancy within 12 months of completing treatment and the mean time to pregnancy was 7.8 months. No complications occurred during or after treatment. Conclusion: Combined laparoscopic and medical treatment is an important therapeutic option for women with pelvic pain and infertility due to severe (grade 4) endometriosis. Adopting a combined approach of laparoscopic excision of endometriosis and short term pituitary suppression followed by second look laparoscopy offers a good treatment option for women wishing to reduce pelvic pain and enhance fertility.

TUESDAY, NOVEMBER 7, 2006 Open Communications 5—Pregnancy/Reproductive Surgery (5:14 PM – 5:20 PM)

110 Transvaginal Endoscopy: Is it Really a New Window to the Pelvis? A Review of 2000 Procedures Verhoeven HC. Center for Reproductive Medicine and Endocrinology, Dusseldorf, Germany Study Objective: To evaluate the role of transvaginal endoscopy in the investigation of female infertility.

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Design: Retrospective analysis of 2000 consecutive cases of transvaginal endoscopy performed by the same surgeon between January 2000 and January 2005. Setting: A private center for reproductive medicine, endocrinology and endoscopy Patients: Two thousand infertile patients without obvious pathology. Intervention: A diagnostic hysteroscopy, transvaginal laparoscopy, salpingoscopy and methylene blue test were performed in all patients. Measurements and Main Results: In total, 1920 (96,00%) of the procedures were completed. No pathology or pathology of minor significance was found in 1520 (79,10%). Unexpected major pathology was diagnosed in 480 (25,00%). The diagnostic findings resulted in 74 operative laparoscopies and 406 medical therapies and assisted reproductive technologies. No major complications occurred in this series. Intraperitoneal bleeding was seen in 46 patients (2.3%). Bowel perforation occurred in 6 (0.3%) patients and was managed conservatively with antibiotics, 4 of these occurred during the first 50 cases, only 2 during the remaining 1950 cases. Conclusion: Female infertility should be investigated latest after 6 months of fertility-focused intercourse. Transvaginal endoscopy is a new window to the pelvis and can be proposed as a first-line technique.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 9—Fertility (10:30

AM

– 10:41

AM)

111 Global Endometrial Dysfunction Secondary to Scarring of the Cervix and Lower Uterine Segment Only — A New Form of Uterine Infertility? — Clinical and Non-human Primate Model Evidence Palter SF, Coad J, Slayden OD. Gold Coast IVF, Syosset, New York Study Objective: In Asherman’s Syndrome scarring of the majority of the endometrial cavity is believed to induce amenorrhea and infertility. In this study we identified a novel form of the disease where obstruction of menstrual outflow alone suppressed endometrial function in the absence of fundal uterine scaring. We also developed a macaque model that reproduced this novel pattern of endometrial dysfunction. Design: Human cohort study with prospective primate model. Setting: Referral based infertility/endoscopy practice and Primate Research Center. Patients: Eight women with adhesions confined to the cervical canal and lowermost uterine segment (LUS) with hypo-amenorrhea and infertility who had no adhesions involving the upper cavity. Six adult ovariectomized rhesus macaques. Intervention: Women underwent 3D SHG scar localization and assessment for hematometria and endometrial thickness (EMT) followed by hysteroscopic lysis of adhesions.

Ovariectomized macaques were treated with estradiol and progesterone to induce artificial menstrual cycles. The animals underwent focal surgical attachment of the inner myometrial surfaces just above the cervical os to partially close the uterine-cervical junction. Uteri were collected after 5 artificial cycles. Measurements and Main Results: In women, EMT was assessed via ultrasound and days of bleeding were recorded. Scar location and percentage of cavity involvement were recorded for the cervical canal, LUS, and fundus. In macaques, amount of menstruation was recorded and EMT measured histologically. Despite cervical obstruction, no women had cyclic pain or hematometria. EMT was thin (< 4 mm) in all patients. Endometrial biopsies showed atrophic linings without adhesion despite cycling in-phase. Apoptotic cells were inappropriately seen in the proliferative phase. Four women had wide dilations of the cornua and ostia. Hysteroscopic lysis of the obstructing lower adhesions restored normal menstrual flow and EMT. In macaques menstrual bleeding was reduced (77%) and EMT was significantly thinned (P < 0.05). No hematometria were observed. Conclusion: Scaring of the cervical canal and LUS caused atrophy of the upper noninvolved endometrium without the development of cyclic pain or hematometria. The dilated cornual angles/ostia suggest increased endometrial pressure from obstructed outflow as a potential mechanism. This observation documents a novel form of uterine dysfunction which could represent a new etiology of uterine infertility in patients with lesser degrees of cervical obstruction and which can be modeled in a nonhuman primate for further study.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 9—Fertility (10:41

AM

– 10:52

AM)

112 Contrast Tuned Imaging and Second Generation Contrast Agent ‘SonoVue’: A New Ultrasound Approach to Evaluate Tubal Patency Exacoustos C, Zupi E, Szabolcs B, Amoroso C, Amadio A. Aromanini ME, Arduini D. University of Rome “Tor Vergata,” Rome, Italy Study Objective: Transvaginal hystero-salpingo-contrastsonography (TVS HyCoSy) with saline mixed with air solution appears to be an inexpensive and accurate method of determining tubal patency, especially if tubes are patent. Less accuracy has been shown when tubal occlusion especially unilateral occurs. The aim of this study to test if a new dedicated contrast-enhanced ultrasound technology can contribute to a more accurate diagnosis of tubal occlusion. Design: Prospective study, patients underwent HyCoSy with saline mixed with air and subsequently with the “ contrast tuned imaging” technology (CnTI, ESAOTE) applied to endovaginal probe after intrauterine injection of the second-generation contrast agent SonoVue (sulphur hexafluo-

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ride microbubbles Bracco Imaging) The CnTi technology allows the detection of contrast in the tube by discriminating the harmonic answer of contrast microbubbles from ultrasound echoes coming from tissue and organs. Setting: University hospital. Patients: Two hundred twelve patients submitted to TVS and HyCoSy for primary or secondary infertility. Intervention: All the patients underwent TVS HyCoSy, if the tubes seems not to be patent by injection of saline mixed with air, a solution with SonoVue was injected in the uterine cavity and tubes and CnTI was applied. Measurements and Main Results: Of the 212 patient that underwent HyCoSy with saline and air, 52 showed a tubal occlusion, 21 bilateral and 31 unilateral for a total number of 73 suspected occluded tubes. At the HyCoSy test with SonoVue and CnTI only 45 tubes seems to be occluded and in the other 28 tube the passage of SonoVure was observed. HyCoSy with Sonovue demonstrated a high concordance with laparoscopic dye test (89.7%). Conclusion: The advantage of this low acoustic pressure technique is that the bubbles are not immediately destroyed but can be detected during several minutes This permits a easier evaluation of tubal patency and a better visualization of tubal course.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 9—Fertility (10:52

AM

– 11:03

AM)

113 Septate Uterus in Infertile Patients: Histological Evaluation of the Septum and Correlation to Pregnancy Outcome by 3D Power Doppler Ultrasound Scan Zanetti H, Zupi E, Sorrenti G, Valli E, Vaquero E, Lazzarin N, Lanzi G, Exacoustos C, Arduini D. University of Rome “Tor Vergara,” Rome, Italy Study Objective: Several mechanisms have been proposed to explain infertility and early pregnancy loss in case of septate uterus. As possible etiological factors some authors suggest a poor vascularization in connective or fibro-elastic septal tissue, unable to provide adequate blood supply to the developing embryo. In contrary other studies, observing in the septum a greater proportion of muscle tissue and more vessels suggest that pregnancy wastage is caused by higher contractility due to the increased muscle content. Furthermore hysteroscopic incision technique of the uterine septum was recently discussed based on the tissue content of the septum (muscle or fibrosis). The aim of our study was to evaluate the hystological structures of specimens of uterine septa obtained by hysteroscopic metroplasty and to correlate the findings to 3D transvaginal ultrasound (3D TVS) echostructure and vascularization of the septum in order to clarify the role of type of septal tissue content in the infertility pathogenesis. Design: Patients with recurrent miscarriage or infertility and septate uterus diagnosed by office hysteroscopy and 3D TVS underwent hysteroscopic metroplasty. On 3D TVS coronal

view of the uterus, septal length, width, echostructure and vascularization by means of Power Doppler, were evaluated. During hysteroscopic removal of the uterine septum at least two biopsies (samples) of the septum were obtained Setting: University hospital and university-affiliated hospital. Patients: Nineteen patients with history of recurrent abortion or infertility affected by partial or complete uterine septum. Intervention: Hysteroscopic resection of the uterine septum and hystological evaluation of the septal tissue. Measurements and Main Results: Hystological findings showed in 8 cases more connective tissue and few vessels and in 11 cases normal myometrium and vessels with thick muscle wall. In both groups the endometrium was often asynchronous. 3D TVS of the 11 septa with myometrium content showed in 10 cases moderate to marked vascularization in the septum whereas absent or poor vascularization was observed in all 8 cases with fibrotic septa. Increased uterine bleeding during hysteroscopic resection of the septum was observed in 6 patients, all with hystological findings of prevalent muscle content in the septum Conclusion: Uterine septa can contain prevalent or connective poor vascularized tissue or normal vascularized myometrium. These different types of septal content can be diagnosed (suspected) by 3D Power Doppler TVS and can guide the modality of septal removal. However the different hystological findings of uterine septum content suggest that probably pathogenesis of infertility in these patients is multifactorial and not caused only by the type of the septal tissue.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 9—Fertility (11:03

AM

– 11:14

AM)

114 May Laparoscopic Cystectomy Impair the Ovarian Reserve? Vignali M, Odorizzi MP, Zangheri G, Bertazzoli E, Stoppelli S, Busacca M. Clinical Osterico Ginecologica, Universita’ di Milano, Ospedale Macedonio Melloni, Milan, Italy Study Objective: To investigate potential damage to ovarian reserve after cystectomy of benign ovarian cysts. Design: Prospective study. Setting: Tertiary care university hospital. Patients: Fifty-four patients who underwent laparoscopic excision of monolateral (n. 36) or bilateral (n. 9) benign ovarian cysts. Intervention: Serial transvaginal ultrasound examinations preoperatively and during the first and third postsurgical menstrual cycles. Antral follicle count, ovarian volume, stromal blood flow, and side of ovulation were evaluated. A prospective statistical analysis comparing ecographic characteristics of the affected gonad preoperatively and at first and second postsurgical control was performed. Measurements and Main Results: Antral follicle count and stromal blood flow were not significantly affected by sur-

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gery. However, the number of antral follicles in the sick ovary was statistically lower than in the contralateral, while no significant difference between the two was noted after surgery. While ovarian volume was similar in the cystic and in the contralateral intact gonad before surgery, the volume of the operated ovary was significantly reduced at the first (p < .03) and second ultrasound evaluation (p < .004). An increased probability of ovulation in the intact gonad was observed at both assessments. Conclusion: The presence of an ovarian cyst could impair the ovarian function in terms of reduction of the number of antral follicles. Laparoscopic excision of ovarian cysts is associated with a significant injury to ovarian reserve, at least immediately after surgery. This damage does not seem to involve ovarian vascularization.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 9—Fertility (11:14

AM

– 11:25

AM)

115 Laparoscopic Management of Torsion Improves the Rate of Adnexal Conservation Takacs P, Bratter J, Chakhtoura N, Medina C. University of Miami School of Medicine, Miami, Florida Study Objective: To review the characteristics of women with adnexal torsion, to document the changing trends in the surgical management and to evaluate the effect of an ongoing laparoscopic training program for resident surgeons on the rate and success of laparoscopic management. Design: Retrospective chart review (Canadian Task Force classification II-3). Setting: University tertiary medical center. Patients: One hundred women with adnexal torsion treated surgically at the University of Miami, Jackson Memorial Hospital between 1/1/1995 and 12/31/2004. Intervention: A formal, ongoing laparoscopic training program has been established in 1999. Measurements and Main One hundred women were treated for adnexal torsion over a 10-year period. The mean age 66 (± SD) was 30.8 (± 13.0) years. Fifty percent of women with torsion were nulliparous, and sixty percent of torsions involved the right adnexa. Most patients presented with pelvic pain (100%), nausea/vomiting (41%), elevated WBC (> 12,000, 80%). Adnexal mass was noted on physical exam in 45% or by ultrasound in 88% of cases. The mean (± SD) size of the mass was 11.1 (± 5.3) cm. Laparoscopic management was accomplished in 20% of cases. Patients were 4.2 times more likely to undergo laparoscopic management of adnexal torsion after the establishment of the laparoscopy training laboratory (OR 4.27, 95%CI 1.40–13.21, p < 0.01). Women were 2.5 times more likely to undergo conservative surgery (detorsion with or without cystectomy) if the approach was laparoscopic (OR 2.55, 95%CI 1.13–5.73, p = 0.03). In addition, younger women (age < 30 years) were more likely to undergo ovarian conversation (OR 4.14, 95% CI 1.14–16.42, p = 0.02). The size of the mass, ultrasound

characteristics, time from initial symptoms to surgery was not statistically different between the radically or conservatively treated patients. The most common pathology was hemorrhagic cysts (24%), followed by dermoid cysts (19%), hydro-salpingx or para-tubal cysts 15%, and cystadenomas (15%). Conclusion: Laparoscopic approach for the management of torsion in younger women may improve the likelihood of adnexal preservation.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 10—Endometrial Ablation (10:30

AM

– 10:41

AM)

116 Benefits and Pitfalls of Food and Drug Administration Summary of Safety and Effectiveness Data and Manufacturer and User Facility Device Experience Database Related to Global Endometrial Ablation Devices Gimpelson RJ. St. Luke’s Hospital, Chesterfield, Missouri, St. Louis University School of Medicine, St. Louis, Missouri Study Objective: Assess the utility of Summary of Safety and Effectiveness Data (SSED) and the Manufacturer and User Facility Device Experience Database (MAUDE) in the evaluation of global endometrial ablation (GEA) devices. Design: GEA data from SSED and MAUDE were reviewed. MAUDE entries were categorized according to event type, and injuries were evaluated for contributing factors. Setting: SSED provides treatment protocols and objective data for evaluating performance measures and can be useful for validating marketing claims. MAUDE allows for review of adverse events reported during commercial use. Patients: Patients experiencing a MAUDE-reported event secondary to GEA. All MAUDE entries received by FDA prior to January 1, 2006 were included. (Updated data will be presented.) Intervention: Data were reviewed for ThermaChoice, Hydro ThermAblator, HerOption, NovaSure, and Microwave. Measurements and Main Results: Although a valuable tool, MAUDE is associated with significant limitations if used to compare various technologies (e.g., duplicate reporting, inability to assess the rate of adverse events, and often subjective description of events with incomplete information regarding patient selection, operative technique, injury and follow-up care). Analysis of factors contributing to patient injury allows for corrective action by both manufacturers and physicians. Results: Of MAUDE-reported bowel/internal extrauterine injuries secondary to GEA, 33% are likely due to off-label use or use in patients contraindicated for treatment, underscoring the importance of appropriate patient selection (ThermaChoice 24%, HTA 25%, HerOption 0, NovaSure 55%, MEA 17%). Conclusion: SSED and MAUDE data are valuable sources of information when evaluated in the proper context. Clinical results reported in SSED are credible but should

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only be expected with strict adherence to the protocol described. One should exercise caution in interpretation of information from MAUDE database. Use of these data for competitive purposes are inappropriate and detract from the goal of transparency in adverse event reporting and the timely correction of device-related problems.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 10—Endometrial Ablation (10:41

AM

– 10:52

AM)

117 Five Year Follow-Up of RCT Comparing NovaSure and ThermaChoice Endometrial Ablation Bongers M, Kleijn C, Mol BW. Maxima Medical Centre, Veldhoven, The Netherlands Study Objective: To evaluate the five year follow-up amenorrhea rates, reIntervention and quality of life associated with the NovaSure procedure in comparison with ThermaChoice balloon ablation. Design: Randomised, double-blind, study 2:1 randomisation NovaSure versus ThermaChoice. Setting: Teaching hospital. Patients: A total of 124 pre-menopausal women suffering from menorrhagia with the PBLAC > 150 or more. Intervention: A total of 124 pre-menopausal women suffering from menorrhagia with the PBLAC > 150 or more. Measurements and Main Results: PBAC and additional surgical Intervention were evaluated at 5 years. Quality of life evaluation was assessed 12 months and five years after the ablation treatment. At 12 months follow-up the amenorrhea rate in the NovaSure arm was 56% compared to 8% in the ThermaChoice arm. At five years follow-up 80% of the women respond to the follow-up 85% in the NovaSure arm and 72% in the ThermaChoice arm. Fifteen patients underwent a hysterectomy 8 in the NovaSure group (12%) and 7 in the ThermaChoice group (23%). Amenorrhea was reported in 40% in the NovaSure arm and in 29% in the balloon arm. Conclusion: Clinical results demonstrate that the NovaSure System is an effective and safe second-generation device, yielding significantly lower re-Intervention rates when compared to ThermaChoice.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 10—Endometrial Ablation (10:52

AM

– 11:03

AM)

118 Review of 500 Cases of Endometrial Ablation With the Use of the HTA System for the Treatment of Menorrhagia Donovan JJ. Louisville Physician’s for Women, Louisville, Kentucky. Study Objective: An ongoing project to assess the efficacy and safety of endometrial ablation with the use of the HTA System for the treatment of menorrhagia. Design: Retrospective arm. Setting: Private practice.

Patients: Patients with menorrhagia due to benign causes: 500 patients treated to date with the HTA system with postoperative follow-up of 6 to 48 months with continuing treatment. Intervention: Endometrial ablation was performed with the HTA System, which circulates free-flowing heated saline throughout the uterine cavity for 10 minutes under direct hysteroscopic visualization. Measurements and Main Results: At least six months after treatment, women were contacted, or questioned during follow-up visits, regarding their menstrual history. Amenorrhea was defined as no bleeding at all and Eumenorrhea as normal periods or less. Over seventy percent (70%) of the patients reported amenorrhea. Over seventy percent (70%) of the patients reported amenorrhea. There were no complications resulting from the procedure. Hysterectomy rates and pathology findings on failures will be discussed. Conclusion: The HTA System is a very safe and effective treatment for menorrhagia, with over a 70% amenorrhea rate (updated rate to be presented) in patients with follow-up from 6 to 60 months.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 10—Endometrial Ablation (11:03

AM

– 11:14

AM)

119 Clinical Evaluation of Gynecare ThermaChoice III Uterine Balloon Therapy System for Menorrhagia Garza Leal JG, Pena A, Donovan A, Cash C, Jr. Hospital Universitario, Monterrey, Mexico Study Objective: The primary objective of the study is to determine the rate of post-procedure amenorrhea at the 12month follow-up visit with the use of GYNECARE THERMACHOICE III (T3) Uterine Balloon Therapy (UBT). There are three secondary objectives: to confirm the postprocedure incidence of normal bleeding levels is comparable to the levels observed in the GYNECARE THERMACHOICE I (T1) clinical trial; to determine the effect of post procedure curettage on bleeding patterns, post operative discharge and post operative pain; to evaluate system utility as indicated by equipment events that require Intervention as compared to the events in the T1 clinical trial. Design: Two hundred fifty females with menorrhagia were entered in a randomized, prospective, multi-center, controlled study between 2003 and 2005. Each site was expected to enroll between 12 and 40 patients. These patients were assessed preoperatively for eligibility criteria, diary score via the Pictorial Bloodloss Assessment Chart (PBAC) and quality of life questionnaire. The randomization occurred in the OR prior to the procedure to either post ablation curettage or no post ablation curettage. Post procedure, the study patients were followed up at 2 weeks, 6 months and 12 months, additional contact at 24 and 36 months. They were required to complete monthly PBAC diaries up till and including month 12 as well as quality of life questionnaires at months 6 and 12.

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Journal of Minimally Invasive Gynecology, Vol 13, No 5, September/October Supplement 2006

Setting: Thirteen hospitals (12 US and 1 Mexico). Patients: Pre-menopausal women, thirty years of age or older with menorrhagia not responsive to prior medical therapy. Intervention: GYNECARE THERMACHOICE III Uterine Balloon endometrial ablation. Measurement And Main Results: The incidence of amenorrhea among those randomized to no post- procedure curettage was compared to the incidence of amenorrhea among those in the T1 clinical trial by the propensity score method. 250 patients were taken to the OR, 246 were treated, 35 have been withdrawn/lost and 225 are active. The mean pre-op diary score was 1123.5 (248 patients), mean 6-month diary score was 3.5 (220 patients) and mean 12-month diary score was 0 (160 patients). There are 31 cases out of 250 (12.4%) that experienced procedure related events. Conclusion: Final analysis on the 12-month amenorrhea data (primary endpoint) is currently under way and the results will be available at the time of the presentation. For equipment usability, one of the secondary endpoints, T3 had an observed rate of 12.4% of equipment related events as compared to 18.6% observed with T1 and 31.7% with GYNECARE THERMACHOICE II (T2).

42.1–45.3) vs. 43.3 (95%CI: 42.2–44.5); t-test p = 0.7] & [31 months (95% CI: 26–36) vs.32 (95% CI: 28–36); t-test p = 0.7] respectively. The use of NovaSure and ThermaChoice was homogenous within the groups [r2 test p = 0.6]. During the follow-up, 10 women (11%) in the coagulopathy group had hysterectomy or re-ablation compared to 8 (9 %) in the reference group, with no difference in the survival distribution of treatment failure events [LogRank test p = 0.8]. The warfarin subgroup had less treatment failures 3% (1/34) compared to 16% (9/57) in nonwarfarin. [Relative risks: 0.3 (95% CI: 0.04–2.6) vs. 1.8 (95%CI: 0.7–4.4); r2 test of interaction p = 0.1]. Conclusion: GEA is a long-term effective treatment for menorrhagia in women with coagulopathy. Women on Warfarin therapy are less prone to treatment failure compared to women with congenital or acquired coagulopathies.

WEDNESDAY, NOVEMBER 8, 2006

The Efficacy and Quality of Life with the TOT Bladder Sling Ross JW. Center for Reproductive Medicine and Female Continence, Salinas, California, University of California School of Medicine, Los Angeles, California

Plenary 10—Endometrial Ablation (11:14

AM

– 11:25

AM)

120 Global Endometrial Ablation (GEA) Is an Effective Treatment for Menorrhagia in Women With Coagulopathy El-Nashar SA, Hopkins MR, Pruthi RK, Barnes SA, Gebhart JB, Cliby WA, Famuyide AO. Mayo Clinic, Rochester, Minnesota Study Objective: To evaluate the long-term efficacy of Global Endometrial Ablation (GEA) in the treatment of menorrhagia in women with coagulopathy. In addition, the variability of efficacy in two coagulopathy subgroups (Warfarin and non-warfarin subgroups) was evaluated. Design: A retrospective “historical” cohort study (Canadian Task Force classification II-2). Setting: A Midwestern academic medical center. Patients: Using a record linkage system, 91 women with coagulopathy were identified, out of 943 (9.7%) who underwent GEA (January, 1995–December, 2005). Coagulopathy group included Warfarin and non-Warfarin subgroups. NonWarfarin subgroup included Von-Willebrand, acquired thrombocytopenias, and acquired coagulopathies associated with liver failure and other miscellaneous disorders. A reference group (91 women) was randomly selected from the same cohort. This sample size provided an 85% power to detect a 15% difference in treatment failure (hysterectomy or re-ablation) during the follow-up. Intervention: GEA procedures (NovaSure and Therma Choice). Measurements and Main Results: There was no difference in the mean age or duration of follow-up between the coagulopathy and the reference group [43.7 years (95% CI:

WEDNESDAY, NOVEMBER 8, 2006 Plenary 11—Urogynecology/Pelvic Floor Disorder (10:30 AM – 10:41 AM)

121

Study Objective: To test the efficacy and the impact on quality of life (QOL) for the TOT in treating stress urinary incontinence. Design: Prospective analysis of 157 consecutive TOT bladder slings. Setting: Private urogynecology clinic. Patients: Mean age 51.2 (range 29–86) with a urodynamic diagnosis of stress incontinence. Intervention: Transobturator tension-free midurethral bladder sling. Measurements and Main Results: Fifty-eight percent of patients were Hispanic, 39% Caucasians, and 3% other with a mean follow-up of 12.2 months (range 3–24). Patient subjective satisfaction was 122 (89%) cured, improved 6 (4%), and failed 9 (7%). One hundred and twenty-three (90%) were objectively cured as determined by a dry cough stress test done at 3, 6, 12, and 24 months. Ninety percent of the objective failures had VLPP < 80 cm H2O. Surgery time for the TOT was 12.4 ± 5 minutes, estimated blood loss 85 ± 35 mL, and 63% were outpatient procedures. Complications included one vaginal mesh erosion and two delayed healing of vaginal incisions (> 6 weeks). There were no bladder or urethral injuries. Twenty-one per cent had voiding dysfunction (positional changes to void = 93% of post operative complaints). There was significant improvement in UDI-6 and IIQ-7 urinary QOL questionnaires and VAS scores (p < 0.001), while there was no significant change in PISQ12 sexual function questionnaire.

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Conclusion: The short term subjective and objective outcome of the TOT appears to equal the TVT. The TOT is a simple, fast, and a well tolerated procedure that does not enter the pelvic cavity, which eliminates bowel and vascular injury possible with the TVT. The more oblique angle of the TOT mesh distributes pressure over a larger vaginal area than the TVT. This could decrease the risk of vaginal and urethral erosions. There is significant improvement in the quality of life as demonstrated QOL and VAS scores.

was 1 mesh exposure in each group. Conclusion: Vaginal vault repair from a vaginal approach provided a comparable clinical outcome to an abdominal approach. Abdominal sacrocolpopexy provided longer vaginal length and less dyspareunia.

WEDNESDAY, NOVEMBER 8, 2006

123

Plenary 11—Urogynecology/Pelvic Floor Disorder (10:41 AM – 10:52 AM)

Vaginal Mesh Erosion After Transvaginal Repair of Cystocele Using the Placement of a Prosthetic Mesh: Management and Functional Outcomes 1 Deffieux X, 1Huel C, 2de Tayrac R, 1Gervaise A, 1Bonnet K, 1Frydman R, 1Fernandez H. 1APHP, Antoine Beclere Hospital, Clamart, France; 2CHU Caremeau, Nimes, France

122 Comparative Analysis of Vaginal Versus Abdominal Vault Suspension Davila GW, Biller D, Jean-Michel M. Cleveland Clinic Florida, Weston, Florida Study Objective: To compare outcomes of vaginal vault suspension by vaginal approach to vaginal vault suspension by abdominal approach. Design: A retrospective review of 69 patients who underwent either transperineal vault suspension utilizing porcine dermis graft (Apogee™, American Medical Systems, Minnetonka, MN) (Group 1, N=35) or abdominal sacrocolpopexy utilizing polypropylene mesh (Group 2, N=34). Additional procedures were performed as needed. Demographics and preoperative and postoperative POP-Q values were collected. Primary outcomes were POP-Q values of total vaginal length and point C. Secondary outcome measures included perioperative complication and dyspareunia rates. Comparisons between surgical groups were performed using paired t-test. Setting: Section of urogynecology in a tertiary referral center. Patients: Women who underwent surgery for vaginal vault prolapse. Intervention: Patients underwent transperineal vault suspension utilizing porcine dermis graft (Apogee) or abdominal sacrocolpopexy utilizing polypropylene mesh. Measurements and Main Results: There was no statistically significant difference in age, gravity, and parity (p=0.48, 0.94, 0.74, respectively). Mean follow-up for group 1 was 4 months (range 1.5–12), and for group 2 was 8 months (range 1.5– 25). Mean postoperative TVL for group 1 was 7.99 cm, and 9.16 cm for group 2 (p < 0.001). Mean postoperative point C for group 1 was –6.49 cm, and –8.80 for group 2 (p < 0.001). Recurrent vault prolapse (stage < 2) occurred in 3 (7.1%) in group 1, and 0 in group 2. In group 1, TVL changed by –0.95 cm (p < 0.001); in group 2, TVL changed by +0.20 cm (p = 0.55). In group 1, point C changed by –2.88 cm (p = 0.002); in group 2, point C changed by –9.94 cm (p < 0.001). Dyspareunia rates for groups 1 and 2 were 15.8% and 5.3%, respectively. Complications in group 2 included 1 proctotomy, 1 enterotomy, and 1 cystotomy. There

WEDNESDAY, NOVEMBER 8, 2006 Plenary 11—Urogynecology/Pelvic Floor Disorder (10:52 AM – 11:03 AM)

Study Objective: The objective of this study was to describe the management of vaginal graft erosion after transvaginal repair of cystocele using polypropylene mesh. Design: We retrospectively analyzed 34 cases of vaginal mesh erosion. Surgical modalities and functional outcome after excision of exposed mesh are described. Setting: University Hospital (Department of Obstetrics and Gynecology). Patients: Thirty-four consecutive cases of vaginal mesh extrusion. Intervention: Patients were treated either with conservative therapy or surgery (partial removal of the extruded mesh). Functional outcome were compared to those of 111 women who have undergone the same procedure without vaginal graft erosion. Measurements and Main Results: Among the 34 patients, 23 (68%) were treated with administration of intravaginal estrogen local antiseptic. At 6 months follow-up, only 3 patients presented with complete re-epithelisation of the vagina. Eighteen patients (53%) necessitated a partial excision of the mesh, associated with a vaginal mucosal closure. In 10 cases the procedure was successful, with no recurrence at 3–20 months follow-up. In 2 cases, vaginal erosion recurred after 3–6 months, but the patients were asymptomatic. In 4 cases vaginal erosion recurred and necessitated iterative partial excision of the mesh. In one case, the vaginal erosion recurred twice, and it was decided to perform a complete excision of the mesh. The prevalence of dyspareunia, urinary urge symptoms, voiding dysfunction symptoms and global satisfaction rate in women with vaginal erosion in patient without erosion, was respectively 12% vs. 11% (p = 0.89); 8% vs. 9% (p = 0.95); 8% vs. 10% (p = 0.81); and 88% vs. 93% (p = 0.51). Conclusion: Management of vaginal erosion is simple and is associated with a low rate of morbidity. However, patients should be informed that vaginal graft erosion can occur.

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Journal of Minimally Invasive Gynecology, Vol 13, No 5, September/October Supplement 2006

WEDNESDAY, NOVEMBER 8, 2006 Plenary 11—Urogynecology/Pelvic Floor Disorder (11:03 AM – 11:14 AM)

124 Pelvic Organ Prolapse Repair Using Polypropylene Mesh McKinney TB, Greenleaf BAB. Athena Women’s Medical Center, Turnersville, New Jersey Study Objective: To assess the efficacy and safety of neovagina graft interpositioning in patients with pelvic organ prolapse. Design: Retrospective analysis of 250 patients with pelvic organ prolapse as measured by the Pelvic Organ Prolapse Quantitative Score. All patients underwent neovagina surgery with polypropylene mesh between September 2002 to May 2006. All patients underwent complete history and physical examinations, in office cystoscopy, urodynamcis, POPQ scoring, and post operative follow-up at 3-, 6- and 12month intervals. Setting: Urogynecology and advanced pelvic surgery in a private office and teaching hospital. Patients: Two hundred fifty patients with pelvic organ prolapse. Intervention: Each patient underwent corrective prolapse surgery with the interposition of a polypropylene graft (Gynemesh or Prolift, Ethicon, Johnson and Johnson). Anterior vaginal incisions were made with a transverse incision while posterior grafts were placed with a triangular vaginal incision. This graft served to replace and re-enforce the already damaged pelvic fascia such as the pubocervical and/or rectovaginal fascia. Graft was placed by simple interpositioning with minimal attachment to the surrounding tissue, or by the passing of graft arms tunneled through the obturator notch , levators near the ischial spine, and/or lateral to the perineal body with either an IVS tunneler, Mentor Hook, or the Prolift System. Grafts were occasionally stabilized with minimal additional suturing into surrounding tissue. Additional incontinence procedure were only performed on those patients with intrinsic sphincter deficiency. Measurements and Main Results: Patients underwent POPQ scoring before and after surgery. Post operative complications such as recurrence and mesh erosion were evaluated. Contributing factors were also evaluated such as history of smoking, BMI, previous surgeries, topical estrogen use, history of previous hernia repair, largest vaginal birth weight, and effects on incontinence were evaluated. The average patient age was 60 years old (range 32–90) with an average BMI of 27.61 (20.36–38.27). 68% had a smoking history. Ninety-nine percent had a history of vaginal deliveries with average baby weight in grams equaling 3694. Sixty five percent of patients had a history of previous prolapse surgery that had failed. Seventy seven percent of the patients complained of incontinence previous to surgery, while only 4% had continued incontinence after surgery. Of those that still experience incontinence, it was due to urge or mixed incontinence, not stress incontinence. There was a 19% graft exposure rate after surgery of which 5% required further

surgical Intervention while the others healed with the application of topical estrogen cream. POPQ scoring revealed the majority of the patients had a stage II or worse prolapse prior to surgery. There was only a 12% recurrence rate with 84% of these occurring in the anterior compartment. There were no recurrences of more than stage II by POPQ scoring. There were no bleeding events requiring transfusion or deaths associated with this study. Conclusion: Neovagina prolapse correction with polypropylene interposition is a safe technique with low recurrence rates, and minimal morbidity and mortality. Graft exposure is the greatest adverse effect of this procedure though most are easily managed with the application of estrogen topical creams and increased healing time. There is no need for additional incontinence procedures in patients with genuine urinary stress incontinence. With the newer techniques and grafts, this surgery had become easier to perform with less risks of recurrence. This is an ongoing study that will be evaluating continued durability evaluating patients at the 3-, 6-, 12-month and yearly thereafter intervals.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 11—Urogynecology/Pelvic Floor Disorder (11:14 AM – 11:25 AM)

125 Laparoscopic Paravaginal Repair for Anterior Vaginal Prolapse O’Shea RT, Seman E, Cook J, Behnia-Willison F. Flinders University, Flinders Medical Centre, Adelaide, South Australia Study Objective: To analyze the long-term success of laparoscopic paravaginal repair for anterior compartment prolapse. Design: A prospective cohort study of 274 women with anterior compartment prolapse undergoing laparoscopic paravaginal repair. Setting: Public university hospital and private practice. Patients: Overall 424 patients underwent laparoscopic pelvic floor repair. Of these 274 women underwent laparoscopic paravaginal repair. Intervention: Laparoscopic paravaginal repair. Measurements and Main Results: All patients were assessed objectively preoperatively and subsequently postoperatively using the POPQ system. They were also assessed on an annual basis again, using the POPQ system with follow-up up to five years. Eighty-four women were subsequently diagnosed with residual central defect (midline cystocoele). Of these 20 patients underwent a graft reinforced anterior colporrhaphy at a mean interval of 14 months. Laparoscopic paravaginal repair produced an objective cure rate of 74%. However, when patients who subsequently underwent a midline anterior repair were included the objective success rate was 82%. In addition, a significant number of women had subsequent midline defect on objective assessment but were completely asymptomatic and declined further surgery.

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Conclusion: Laparoscopic paravaginal repair followed by a graft reinforced anterior colporrhaphy where necessary produces an overall objective prolapse cure rate of 82%.

WEDNESDAY, NOVEMBER 8, 2006

WEDNESDAY, NOVEMBER 8, 2006

Laparoscopic Excision of Lesions Suggestive of Endometriosis or Otherwise Atypical in Appearance: Correlation Between Visual Findings and Final Histologic Diagnosis Albee RB, Sinervo K, Fisher DT. Center for Endometriosis Care, Atlanta, Georgia

Plenary 12—Endometriosis (11:35

AM

– 11:46

AM)

126 Diagnosis of Stage I Endometriosis: Comparing Visual Inspection to Histologic Biopsy 1 Kazanegra R, 2,3Zaritsky E, 2,4Lathi RB, 2Nezhat CR. 1 Abington Memorial Hospital, Abington, Pennsylvania; 2 Center for Special Minimally Invasive Surgery; 3Stanford Medical Center; 4Reproductive Endocrinology and Infertility; Palo Alto, California Study Objective: The objective of our study is to evaluate the positive predictive value (PPV) of surgical diagnosis compared to biopsy findings by severity of disease. Design: Retrospective case series. Setting: Academic referral center. Patients: Patients who had laparoscopic biopsies for suspected endometriosis were included. In ten consecutive months 156 patients were diagnosed with endometriosis. 104 of these patients had biopsies. Intervention: Surgical treatment included both resection and ablation of endometrial implants. Measurements and Main Results: The same surgeon performed all the surgeries. The location of the biopsies were recorded and sent to pathology for diagnosis. The pathologic diagnosis was then compared to the original stage of endometriosis at the time of surgery and the PPV was calculated. Chi-square analysis was done to evaluate biopsy accuracy by stage and location per biopsy and per patient. A total of 238 biopsies were taken from 104 patients. The ages of the patients ranged from 13–65 averaging 35.96 ± 7.58. The overall PPV was 87% for all patients. There were a total 73 suspected endometriomas removed and 165 peritoneal implants excised. The PPV per biopsy of stage I–IV endometriosis was 66%, 78%, 92% and 81% respectively. The PPV per patient of stage I–IV endometriosis was 75%, 89%, 100%, and 90 % respectively. Stages II–IV were significantly more likely to be confirmed by biopsy than stage I disease (p < .05). When endometriomas and peritoneal biopsies were analyzed separately there was no difference in PPV (79% vs. 77%). Conclusion: There was a high PPV for all patients in our study. However, when stage I endometriosis when compared to stages II–IV PPV was significantly lower. The PPV per patient was higher than the PPV per biopsy indicating that the ability to diagnose endometriosis may be improved by performing multiple biopsies. PPV of visual inspection is high, but not without errors. Therefore, in order to avoid misdiagnosis particularly in stage I disease, every attempt should be made to confirm diagnosis by biopsy.

Plenary 12—Endometriosis (11:46

AM

– 11:57

AM)

127

Study Objective: To correlate visual diagnosis of excised peritoneal abnormalities suspected as endometriosis with histologic diagnosis. Design: A prospective study of 512 patients undergoing laparoscopy for evaluation of pelvic pain. All areas of the viscera and peritoneum either atypical in appearance and/or suggestive of endometriosis were excised and examined histologically. All excised areas were documented in a diagram by the surgeon according to anatomic site and visual description and were labeled as either suggestive of endometriosis or atypical in appearance. The pathology department, blinded to the surgeon’s suspicion of endometriosis, evaluated specimens for the presence or absence of endometriosis. Setting: A private practice referral center for endoetriosis treatment. Patients: From February 1992 to December 1998, 512 patients underwent laparoscopic excision of endometriosis. The primary indication for surgery was pelvic pain with either a prior surgical diagnosis or clinical history consistent with endometriosis. Intervention: Laparoscopic excision of abdominal and pelvic viscera and peritoneum either suggestive of endometriosis or otherwise atypical in appearance. Measurements and Main Results: Diagrams detailing appearance, anatomic site, and surgeon’s suspicion as endometriosis verses atypical lesion lesions were compared with the final histologic diagnosis. Using visual criteria for the diagnosis of endometriosis, the positive predictive value was 85.4%; sensitivity, 69.2%; negative predictive value 48.5% and specificity 71.1%. The prevalence was noted to be 71.0%. Atypical appearing tissue not presumed to be endometriosis was confirmed to be endometriosis histologically in 51.5% of cases. Accurate diagnosis of endometriosis was lowest in ovarian lesions and highest in cul-de-sac and bowel lesions. Overall ability to predict endometriosis was 84% using visual criteria of typical as well as “atypical” appearance at laparoscopy. Conclusion: When the surgical objective is complete eradication of endometriosis, complete excision of all lesions suggestive of endometriosis as well as tissue atypical in appearance is imperative since 51% of those cases prove to be endometriosis.

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WEDNESDAY, NOVEMBER 8, 2006 Plenary 12—Endometriosis (11:57

AM

– 12:08

WEDNESDAY, NOVEMBER 8, 2006 PM)

Plenary 12—Endometriosis (12:08

PM

– 12:19

PM)

128

129

Visualization of Endometriosis Using a New Autoflourescence-Based Laparoscopy System Palter SF. Gold Coast IVF, Syosset, New York

Multislice Spiral Computerized Tomography After Water Enema in the Diagnosis of Bowel Endometriosis Remorgida V, Ferrero S, Biscaldi E, Fulcheri E, Ragni N, Rollandi GA. San Martino Hospital and University of Genoa, Genoa, Italy

Study Objective: Endometriosis is a common cause of pelvic pain and female infertility. The ability of the surgeon to diagnose it is related to individual experience especially for subtle lesions. Lesions have also been seen microscopically that were not visible to the naked eye. This study evaluated a new autoflourescence based laparoscopy system’s ability to improve the identification of endometriosis. Design: IRB approved prospective pilot cohort study. Setting: Referral based infertility and endoscopy practice. Patients: Women with infertility or chronic pelvic pain undergoing diagnostic laparoscopy for suspected endometriosis. Intervention: When certain compounds are excited by absorption of light energy the absorbed energy is emitted as light of a different wavelength and observed as fluorescence but is obscured by the illumination light, A novel laparoscopy system was designed that includes illumination and observation filters that allow the observation of this small amount of fluorescent light. Subjects underwent standard white light laparoscopy with documentation of all potential lesions followed by visualization with combinations of two illumination and two observation filters and as well as no filters (total 6 observation combinations). All potential lesions were sequentially scored intraoperatively by size character and location. Suspected lesions were excised and examined histologically. Measurements and Main Results: Observation of lesion size and number. All lesions recorded introperatively with standard scoring sheets. All lesions were digitally photographed with a standard sized marker to allow postop digital lesion size measurement and comparison. The majority of patients who had endometriosis visualized with white light had different additional pathology identified using the autoflourecsent system. Two distinct patterns of autoflourecsence were seen associated with endometriosis, 1) Reduced autoflourescence corresponding to bulk lesions on the peritoneum, and 2) a novel bright yellow-green glowing autoflourescent lesion primarily associated with early stage clear endometriosis or endosalpingiosis. The majority of lesions identified were documented to be endometriosis. In other cases the total lesion size was seen to be larger when the sytem was used compared with white light judged by lesion size measurements from digital intraoperative photos and computer based digital image measurements. Conclusion: This is the first prospective systematic study comparing the use of a new atuflourescence based laparoscopy system for the diagnosis of endometriosis directly compared to standard laparoscopy. Additional disease was identified. Further studies are justified to identify the physiologic basis of the observations and to determine if its use improves clinical outcomes.

Study Objective: To investigate the efficacy of multislice spiral computerized tomography after colon distension with a water enema (MSCTe) in the diagnosis of bowel endometriosis. Design: Prospective study. Setting: University hospital. Patients: Ninety-eight women with symptoms suggestive of colorectal endometriosis. Intervention: Before MSCTe, colonic distension was achieved by introducing 2000 mL of water. Patients were scanned on a 16-row MSCT scanner. The axial plane and multiplanar reconstructions were evaluated by two observers. Independently from the MSCTe findings, all women underwent laparoscopy. Measurements and Main Results: Locations, number of nodule/s, size of the nodule/s, and depth of bowel wall infiltration were determined. At surgery, after adequate adesiolysis, the bowel was systematically examined; all visible bowel endometriotic lesions were removed. MSCTe findings were compared with surgical and histological results. The endometriotic nature of all the bowel lesions removed at surgery was confirmed at histology. Laparoscopy confirmed the absence of bowel endometriosis in 22 out of 23 women with entirely normal colon at MSCTe. Abnormal findings suggestive of bowel endometriotic nodules were detected by MSCTe in 75 out of 76 patients with bowel endometriosis. MSCTe identified 110 (94.8%) out of the 116 bowel nodules removed at surgery; 6 nodules missed at MSCTe were located on the rectum. MSCTe correctly determined the degree of infiltration of the bowel wall in all the 34 serosal bowel nodules identified at MSCTe. In 6 nodules reaching the submucosa, the depth of infiltration was underestimated by MSCTe. MSCTe had a sensitivity of 98.7%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 95.7% in identifying women with bowel endometriosis. Conclusion: MSCTe is effective in determining the presence, size and depth of bowel endometriotic lesions.

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WEDNESDAY, NOVEMBER 8, 2006 Plenary 12—Endometriosis (12:19

PM

– 12:30

PM)

130 Delay in Diagnosis of Endometriosis in Israel: A Preliminary Report Soriano D, Mashiach R, Seidman D, Stockheim D, Zolti M, Schiff E; Goldenberg M. The Chaim Sheba Medical Center, Tel-Hashomer, Ramat Gan, Israel Study Objective: To determine the duration from the presentation of severe symptoms to definitive diagnosis of endometriosis. Design: Prospective study. Setting: Endometriosis clinic of a tertiary medical center. Patients: One hundred consecutive patients. Intervention: A structured questionnaire. Measurements and Main Results: The average age of the patients was 27 years. The mean age of severe dysmenorrhea was 20.5 years. 39.3% of the women suffered from these complaints as adolescents. 95.3% felt that they did not receive appropriate attention from their doctors. 73.1% did not get any treatment. 81% had severe pain during and perimenses. 25% reported continuous severe CPP. 88% had more than one symptom. The mean time for surgical diagnosis was 11 years. The indication for surgery in 75% of the patients was ovarian mass. 30.7% of women had urgent surgery due to acute abdominal pain. Surgery was performed by laparoscopy in 70.1% of the cases. Stage IV endometriosis was diagnosed in 53.5% of patients. Nearly one third of women had more than one operation. 8.5% of the women had extra reproductive organs involvement. Conclusion: In comparison with international reports our preliminary data suggest a longer delay in the definitive diagnosis of endometriosis. Education, improved awareness, and high level of suspension may shorten this crucial time interval and may help to alleviate the quality of life and prevent further organ damage.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 13—Oncology (11:35

AM

– 11:46

AM)

131 Loop Electrosurgical Excision Procedure Versus Cold Knife Conization for the Management of Cervical Intra-epithelial Neoplasia in Women with Unsatisfactory Colposcopic Examination: A Systematic Review and a Meta-analysis Famuyide AO, El-Nashar SA, Hopkins MR, Creedon DJ, Konecny GE, West CP, Montori VM. Mayo Clinic, Rochester, Minnesota Study Objective: The aim of this systematic review is to compare the safety and efficacy of loop electrosurgical excision procedure (LEEP) as an alternative to cold knife conization (CKC) in the treatment of women diagnosed with cervical intraepithelial neoplasia (CIN) who have unsatisfactory colposcopic examination.

Design: A systematic review and a meta-analysis. Patients: Women diagnosed with CIN who have unsatisfactory colposcopic examination. Methods: A MEDLINE and EMBASE databases literature search through February 2006 was performed to identify published clinical trials and cohort studies comparing CKC to LEEP. There was no restriction to language of publication. For each study, 2 reviewers independently assessed the methodological quality using validated scales and extracted outcome-data. Agreement was evaluated using k statistics. Funnel blot was used for the assessment of publication bias. Subgroups were specified a priori. Pooled Relative Risk (RR) and weighted mean difference (WMD) were used for binary and continuous outcomes respectively. Measurements and Main Results: There was no significant difference between LEEP and CKC on the rate of persistent and/or recurrent disease (primary outcome) [RR: 1.23, 95%CI (0.96, 1.57); (I2 = 21%, p = 0.21)]. The number needed to harm (NNH) is 1 in 100 women. LEEP was less time consuming, had less intra-operative bleeding and shorter hospital stay [WMD: –9.48 minutes, –42.38 cc, –1.48 days, respectively]. LEEP had less postoperative bleeding and fewer post-procedure infections [RR: 0.87, 0.31 respectively]. Less tissue was excised with LEEP vs. CKC [WMD: –0.35 cm (diameter), –0.48 cm (depths), –2.57 cm3 (volume), –2.55 grams (weight)]. The observed follow-up rates of cervical stenosis and unsatisfactory colposcopic examination were less in LEEP vs. CKC group [RR: 0.46, 0.73 respectively]. Conclusion: LEEP is an acceptable alternative to CKC in women with CIN and unsatisfactory colposcopy; especially in younger women with fertility concerns. This should be done with strict follow-up to enable prompt detection and treatment of persistent or recurrent disease.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 13—Oncology (11:46

AM

– 11:57

AM)

132 Non-Randomized Prospective Study of Laparoscopic versus Open Radical Hysterectomy Puntambekar S, Wagh G, Patil A. Galaxy Laparosopy Institute, Maharashtra, India Study Objective: The aim of the study is to evaluate whether the same oncological clearance is achieved by laparoscopic radical hysterectomy as by open radical hysterectomy. Design: Patients were randomized to undergo either open or laparoscopic radical hysterectomy. Setting: All the patients were operated by the same surgeon. Patients: All the patients of stage I A-IIA cervical cancers were included. Each group had ten patients and either open or laparoscopic radical hysterectomy was performed. Intervention: None of the laparoscopic procedures required conversion to open surgery. Measurements and Main Results: Each group was compared as to time taken, blood loss, post operative morbidity. The hystopathological comparison was done according to

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paracervical clearance, distal vaginal margin, and lymph node harvest. This study does not include disease free or overall survival. The average time taken was much less in open surgery but the average hospitalization and blood loss were more as compared to laparoscopic surgery. The paracervical clearance, distal vaginal margins and number of lymph nodes were the same. The open patients had ileus for a prolonged time. Conclusion: The results of laparoscopic radical hysterectomy are comparable to those of open radical hysterectomy in terms of oncological clearance. However laparoscopic surgery has an added benefit of decreased blood loss, decreased hospitalization, early recovery and early application of adjuvant therapy.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 13—Oncology (11:57

AM

– 12:08

PM)

133 Radical Vaginal Trachelectomy for Cervical Cancer: An Initial Experience Sonoda Y, Chi DS, Carter J, Barakat RR, Abu-Rustum NR. Memorial Sloan-Kettering Cancer Center, New York, New York Study Objective: To report on our initial experience with fertility-sparing radical vaginal trachelectomy (RVT) for patients with early-stage cervical cancer. Design: Data for patients undergoing RVT with laparoscopic pelvic lymphadenectomy from 11/01 to 5/06 were collected in a prospective database. Setting: Comprehensive cancer center. Patients: Thirty-eight patients with early-stage cervical cancer underwent surgery with the intent of fertility preservation. Intervention: RVT with laparoscopic pelvic lymphadenectomy. Measurements and Main Results: Median age was 31 yrs (22–40 yrs). FIGO stage was: IB1, 24; IA2, 7; IA1 with lymphovascular invasion, 7. Histology: squamous, 22; adenocarcinoma, 15; adenosquamous, 1. Parity was: zero, 31; one, 6; two, 1. Median BMI was 23 (19–42). One patient (3%) underwent immediate completion hysterectomy due to extensive endocervical disease. Median OR time was 330 min (220–480). Median pelvic lymph node count was 24 (9–50). Median blood loss was 100 ml (50–300 ml). Median hospital stay was 3 days (3–7). Four patients (11%) required a major Intervention for a perioperative complication: abscess drainage, 2; hysterectomy for bleeding, 1; ureteral stent placement for obstruction, 1. Two (5%) patients required a postoperative transfusion, and 1 (3%) developed chronic lymphedema. Four patients (11%) underwent adjuvant chemoradiation. Two patients (5%) subsequently underwent completion hysterectomy: 1 electively and the second for postoperative vaginal bleeding. Six (67%) of 9 patients attempting to get pregnant were able to conceive. Three patients (50%) required assisted reproductive tech-

niques. One patient spontaneously miscarried, 2 elected to terminate the pregnancy, 1 delivered by cesarean section at term, and 2 patients are currently pregnant. With a median follow-up of 12 months (1–52), all patients remain without evidence of disease. Conclusion: RVT is a very well-tolerated procedure with acceptable morbidity. This operation should be discussed as a possible option in highly selected patients.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 13—Oncology (12:08

PM

– 12:19

PM)

134 Laparoscopic Surgery of Endometrial Cancer—A Four-Year Follow-up Zhang Z, Guo S, Liu C, San C, Wand S, Li S, Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China Study Objective: To study the feasibility, safety and the survival of laparoscopic surgery on endometrium cancer. Design: Retrospective analysis. Setting: Hospital. Patients: From January 2002 to December 2004, 25 ladies with endometrial cancer were enrolled in. Laparoscopic surgery was performed according to the guidelines of laparotomy management of FIGO. The extensiveness and safety of the surgery, the survival of the patients was studied prospectively. Measurements and Main Results: Twenty-five patients suffered from endometrial adenocarcinoma, FIGO Ia 7, IIb 9, IIIc 8, IV 1, one of the patients was diagnosed suffered from salpingio-adenocarcinoma at the same times of the surgery. Age of the patients was 48 to 78 years old, mean 65.2 years old. One FIGO IIIc endometrial adenocacinoma patient was converted to laparotomy because of severe ureteral adhesion. The following surgeries were performed for the other 24 patients: laparoscopic classical extrafascial total hysterectomy/bilateral salpingo-oophorectomy, Wertheim hysterectomy/bilateral salpingo-oophorectomy, omentumectomy, appendectomy, systemic dissection/sampling of pelvic and presacral lymph nodes and sampling of para-aortic lymph nodes. The duration of sugery 3–6 hours, mean 3.5 hours. The volume of blood lose 100–400 mL, mean 150.8 mL, the range of parametrium was as extensive as laparotomy and the margin of uterus-sacral ligaments, cardinal ligaments and vaginal were clear of tumor according to pathological study. The number of pelvic lymph nodes resected systemically (18 patients) was 18–52, mean 30.5, by sampling (6 patients) it was 10–14, mean 12.5. For para-aortic lymph nodes sampling it was 2–11, mean 5.5. There were 18 metastasis lymph nodes detected. Adjuvant chemotherapy or radiotherapy was given according to the guidelines of gynecological oncology of CGOG. follow-up: 16–52 months, mean 42.6 months. Survive without evidence of disease 23, Died of the disease 1 (FIGO IV endometrial carcinoma, 12 months after surgery), no port site metastasis was detected.

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Conclusion: The benefits of laparoscopic surgery on endometrium cancer are: There is less blood lose during the operation, short hospital state, lower febrile, fewer antibiotics administration, better incision healing and less immune depression. The survival of the patients is as optimal as laparotomy. The disadvantages of laparoscopic surgery: the surgeon have no sensation, cannot control the very serious hemorrhage as quickly as optimally as laparotomy. Further study is warranted.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 13—Oncology (12:19

PM

– 12:30

PM)

135 Two Fertility-Sparing Approaches for Bilateral Borderline Ovarian Tumors 1 Zullo F, 1Palomba S, 2Marconi D, 1Russo T, 1Falbo A, 3 Mattei A, 2Zupi E. 1University “Magna Graecia” of Catanzaro, Catanzaro, Italy; 2University “Tor Vergata” of Rome, Rome, Italy; 3University of Florence, Florence, Italy Study Objective: The aim of the present study was to compare the effects of two laparoscopic fertility-sparing surgical procedures for the treatment of bilateral borderline ovarian tumors (BOT) on the safety and fertility in young women who desire to conceive as soon as possible. Design: Randomized controlled trial. Setting: Departments of Obstetrics & Gynecology, Universities of Catanzaro, of Rome, and of Florence; Italy. Patients: Thirty-two women affected by bilateral early stage BOT who desired to conceive. Intervention: Bilateral cystectomy (experimental group, (n = 15) or oophorectomy plus controlateral cystectomy (control group, n = 17). At the first recurrence after childbearing completion, each patient was treated with non-conservative standard treatment. Measurements and Main Results: Recurrences and reproductive events were recorded. After a follow-up period of 81 months [19 inter-quartile (IQR); 60–96 range], the cumulative pregnancy rate (14/15 vs. 9/17; p = 0.003) and the cumulative probability of first pregnancy (p = 0.011) resulted to be significantly higher in the experimental than in control group. No significant (p = 0.358) difference between groups was detected in cumulative probability of first recurrence. Conclusion: The laparoscopic bilateral cystectomy followed by non-conservative treatment is an effective surgical strategy for patients with bilateral early stage BOT who desire to conceive as soon as possible.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 14—Education (11:35

AM

– 11:46

AM)

136 Development of a Core Skills Curriculum for Teaching and Evaluating Laparoscopy Skill Robinson JK, Morris SN, Isaacson KB. MIGS Center, Newton-Wellesley Hospital, Newton, Massachusetts Study Objective: To develop and evaluate a curriculum for teaching and objectively evaluating laparoscopy skill. Design: Ten third-year Ob/Gyn residents participating in a 5-week minimally invasive surgery rotation completed the curriculum. The curriculum is based upon teaching and evaluating 7 “core” laparoscopic skills. Participants were pre- and post-tested on 8 separate timed exercises in a video-endoscopic trainer. Participants were instructed to practice the boxtrainer exercises, and complete a multi-level laparoscopy simulator curriculum in the lab. Core skills were further refined and evaluated in a half-day mid-rotation pig lab. A global assessment tool was developed to evaluate the participants’ core skills in the operating room (OR). Global OR assessments were performed at the mid-rotation pig lab and in the operating room at the end of the rotation. Three separate surgeons (2 staff and 1 fellow) performed the evaluations. Setting: Minimally invasive gynecologic surgery center at a university affiliated community hospital. Patients: Ten third-year OB/GYN residents. Intervention: Laparoscopy training and evaluation in both laboratory and live settings. Measurements and Main Results: Data on 9 of 10 participants is currently available. All participants demonstrated improvement in their core skills in both settings. Improvement from timed pre- to post-tests ranged from 50–70%. Reduction in errors of precision ranged from 47–100%. The 2 participants with the best post-test scores on the box trainers also scored highest on their overall OR global assessment scores. Simulator data suggests a correlation between number of overall simulator exercises attempted and final OR assessment scores. At no time was the difference between raters greater than 1 (scale of 1 to 5) for any single core skill for any of the participants. Conclusion: Core skills are useful for teaching and objectively evaluating laparoscopic skills. Inanimate laboratorybased training may help develop these core skills and subsequently transfer to operative performance. More rigorous evaluation of the curriculum model and OR assessment tool is warranted.

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WEDNESDAY, NOVEMBER 8, 2006

WEDNESDAY, NOVEMBER 8, 2006

Plenary 14—Education (11:46

Plenary 14—Education (11:57

AM

– 11:57

AM)

AM

– 12:08

PM)

137

138

Setting the Mark: Puff Ball Transfer Drill–Assessment of Laparoscopic Visual-Spatial Skills in Obstetrics and Gynecology Residents 1 Raff GJ, 1Bridwell Young S, 2Zollinger TW, 1Look KY. 1 Department of Obstetrics and Gynecology; 2Department of Family Medicine, Indiana University School of Medicine, Indianapolis, Indiana

How Valuable Are Advanced Laparoscopic Skill Courses? Lam AM, Condous G. Centre for Advanced Reproductive Endosurgery, Sydney, New South Wales, Australia

Study Objective: Structured and standardized means of educating and evaluating residents’ surgical skills are needed. Our aim was to develop a reliable laboratory-based laparoscopic skills drill and a valid objective structured assessment of technical skills (OSATS) scoring system to assess residents’ laparoscopic visual-spatial skills. Design: Indiana University School of Medicine ObstetricsGynecology residents were videotaped performing a puff ball transfer drill in two phases six months apart. Each blinded video was scored in random order by three faculty members utilizing an OSATS form developed specifically for the puff ball transfer drill by a multidisciplinary panel of expert laparoscopic surgeons. Categories included respect for tissue, knowledge of task, number of drops of the puff ball, correct use of instruments, dexterity/spatial orientation, respect for obstacles, and time. Setting: Laparoscopic laboratory at Indiana University School of Medicine. Patients: Thirty-three residents. Intervention: Participants were encouraged to participate in all possible laparoscopic surgeries and gynecology conferences between the two phases. Measurements and Main Results: The drill and OSATS scoring system demonstrated construct validity by comparing residency year with overall score, dexterity/spatial orientation, and respect for obstacles (p values ranging from 0.01 to < 0.005). Analysis of residents receiving failing scores in the dexterity/spatial orientation category by year of training revealed percentages ranging from 100% failure in the PGY1 class to no failures in the PGY-4 class during the first phase (p < 0.0005), and 60% failure in the PGY-1 class to no failures in the PGY-4 class during phase two (p = 0.037). The OSATS showed strong inter-rater reliability in phase one and two combined in overall score (p < 0.01), respect for tissue (p < 0.05), number of drops of the puff ball (p < 0.01), dexterity/spatial orientation (p < 0.01), and respect for obstacles (p < 0.01). Conclusion: The puff ball transfer drill and OSATS appear to be reliable and valid means of assessing laparoscopic visual-spatial skills.

Study Objective: To evaluate the effectiveness of advanced “hands on” laparoscopic skills courses. Design: Prospective observational ongoing study. Gynaecologists of varying experience who attended the CARE Level I course were assessed at the beginning of the one week intensive program. This involved both subjective (visual analogue scoring, VAS, for knowledge in anatomy, electrosurgery, harmonic scalpel, laparoscopy and its effect on general anaesthesia and entry techniques) and objective (Multiple choice questions, MCQs, and motor skill tasks) evaluation. This cohort was then re-assessed at the end of the course. The difference between the performances of each of the candidates was evaluated using the Wilcoxon signed rank test. P values < 0.05 represented statistical significance. Setting: Centre for Advanced Reproductive Endosurgery. Patients: Thirteen gynaecologists of varying experience. Intervention: Pre- and post-course evaluation of candidates’ knowledge and motor skills. Measurements and Main Results: Thirteen consecutive OB/GYN to date have been enrolled in the study - eight Specialists and five Trainees. Mean age – 44.4 years (range 35–58 years). Most advanced procedures performed by delegates included: LAVH (3/13), ovarian cystectomy (3/13), salpingectomy (5/13) and tubal ligation (2/13). Pre- and post-course subjective VAS improved significantly for all variables (p < 0.0081). Pre- and post-course mean MCQ results were 69.5% and 82.5%, respectively (p < 0.0002). Pre- and post-course mean number of “peas in a pod” alternating left and right hands were 2.9 and 4, respectively (p < 0.0068). Pre- and post-course mean times for using an endoloop to perform a salpingectomy in the “dry-lab” were 136 and 79 seconds, respectively (p < 0.0017). Conclusion: Advanced laparoscopic workshops do improve both knowledge base and motor skills according to the results in this study. The question of whether such skills are utilised when the delegates return to their own hospitals remains unanswered.

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WEDNESDAY, NOVEMBER 8, 2006 Plenary 14—Education (12:08

PM

– 12:19

PM)

139 Learning and Perception Differences in Two Dimensional versus Three Dimensional Camera Systems in Laparoscopic Surgery Lewis L, Zaritsky E, Santos M, Wang S, Heinrichs WL, Youngblood P, Nezhat CR. Stanford University Hospital, Palo Alto, California Study Objective: The two-dimensional (2D) video display is one of the many obstacles that a physician must overcome when performing laparoscopic surgery. Three-dimensional (3D) camera systems hope to overcome this challenge. Prior studies examining the ability to perform surgical tasks using 2D versus 3D camera systems have shown little difference between the two. However, these studies were conducted using early technology, and the subjects had prior surgical experience. In addition, we are unaware of a study that has compared the ability to learn laparoscopic tasks in 3D compared to 2D. The objective of our study was to evaluate if there is an improved ability to learn and perform laparoscopic tasks using the currently available 3D versus 2D camera systems. Design: Randomized prospective study. Setting: Stanford University Medical School. Patients: Surgically naïve medical students (n = 21) were given designated standardized tasks to perform using the 2D and the 3D camera systems. Measurements and Main Results: Surgically naïve medical students (n = 21) were given designated standardized tasks to perform using the 2D and the 3D camera systems. They were tested using the RealSim LTS2000, an established simulator affording several different tasks. Fifteen subjects performed three standardized tasks (peg manipulation, ring transfer, and bead manipulation) using both the 2D and 3D systems. They were randomized to start the exercises with either the 2D or 3D system. Six additional subjects were randomized to perform all three tasks four times with either the 2D or 3D system. The time required for completion and the accuracy of all subjects was recorded for analysis. The results were analyzed using the Wilcoxon and Chi-square tests. Overall there was no difference in age, computer literacy, game skill, surgical, or simulator experience. While there were slight differences in accuracy and time in some tasks performed, these were not statistically different. No difference in accuracy was observed, whether a subject started with 2D versus 3D. More subjects who first performed tasks in 2D perceived that it was easier to execute the tasks in 3D (65% vs. 0%) than those subjects who started in 3D (29% vs. 43%). For the six subjects that performed the task four sequential times with either 2D or 3D, their ‘learning curves’ showed no significant difference. Conclusion: In this small study, three dimensional camera systems did not significantly improve the novice surgeons’ operative accuracy or ability to learn more rapidly on a sur-

gical simulator. It is interesting to note that subjects who began with 2D tasks, 3D was later perceived to be easier, but not vise versa. These findings suggest that learning laparoscopic skills are not hindered by 2 dimensional video laparoscopy.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 14—Education (12:19

PM

– 12:30

PM)

140 Documentation of Patient’s Consent for Laparoscopy Giridhara V, Griffiths AN, Penketh R. University Hospital of Wales, Cardiff, Wales, United Kingdom Study Objective: Are the guidelines laid down for taking consent for laparoscopic operations relevant as of today? Design: Consent forms along with the operative notes were reviewed from January 2006 to April 2006 prospectively and retrospectively and compared with the RCOG guidelines. Setting: University Hospital of Wales, Cardiff, UK, Tertiary Referral Centre. Patients: Fifty patients chosen randomly. Measurements and Main Results: Of the 31/50 (62%) consents were taken by the Senior House Officers, 10/50 (20%) by Registrars, 6/50 (12%) by consultants and 3/50 (6%) by Clinical research fellows. The patients explained about the intended benefits were 50/50 (100%) and about damage to bowel, bladder and blood vessels were 47/50 (94%) each. None of them had been informed about the failure to gain entry, overall risk of 2/1000 and risk/figure of death. Only 10/50 (20%) had been informed about the failure to diagnose or treat and 7/50 (14%) about the uterine perforation. Only 1 patient was told about the shoulder tip pain and none about the bruising. 42/50 (84%) had been consented for laparotomy and 17/50 (34%) for repair of damage. Only 8/50 (16%) received the information leaflet and 4/50 (8%) were told about the type of anaesthesia they would be receiving. All the consent forms were signed by both the patient and the doctor. Conclusion: RCOG guidelines had not been followed and whether the guideline is appropriate is debatable. A change in the guidelines with respect to present scenario is necessary. Qualitative research regarding how much the patient wants to know before giving consent needs to be done.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 15—Pelvic Pain (2:45

PM

– 2:56

PM)

141 Severe Adhesion Related Disorder (ARD): Pattern of Bowel Dysfunction and Obstruction, Social and Physician Issues: An Internet Survey Wiseman D. Synechion, Inc., International Adhesions Society, Dallas, Texas Study Objective: To profile patients suffering with severe Adhesion Related Disorder (ARD). Previous studies have

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documented the incidence and cost of adhesions but none have profiled patients themselves. Design: Patients with abdominopelvic adhesions were asked about bowel obstruction, GI disturbance, nutrition, analgesia, employment and disability status, support structure and their physicians’ attitudes and abilities. Setting: Internet-based survey. Patients: Patients visiting an adhesions resource web site (www.adhesions.org) or subscribed to its mailing list. Measurements and Main Results: 466 patients (51 male, 415 female) reported having a diagnosis of adhesions for 7.0 ± 0.3 years. 68% of patients reported having had a population average of 9.5 ± 0.7 full or partial obstructions, and mean time (geometric) between obstructions of 1.0 years. 81% of respondents suffered from chronic pain for which 68% of whom took medication, which, in 68% of those, worsened their bowel symptoms. 71% of patients reported GI disturbances, including 24% with malabsorption. 42% of patients were unable to work; 47% of these could not obtain disability benefits. 26% of patients had tried physical/massage therapy, 29% of whom benefited. 44% of patients reported that their friends and family were not very supportive. 40% of patients reported that their physician was able to help somewhat, with another 51% reporting their physician’s acknowledged of the problem but inability to help. 9% of patients reported their physician’s denial of the problem and unwillingness to help. Conclusion: Despite caveats, this profile of severe ARD patients will help to formulate strategies for their medical, nutritional, social and financial support.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 15—Pelvic Pain (2:56

PM

– 3:07

PM)

142 Botulinum Toxin Type A for Chronic Pain and Pelvic Floor Spasm in Women: A Randomized Controlled Trial 1,2 Abbott JA, 2Jarvis SK, 1,2Thomson A, 1,2Lyons SD, 1,2 Vancaillie TG. 1University of New South Wales; 2Royal Hospital for Women, Sydney, Australia Study Objective: To estimate whether botulinum toxin type A is more effective than placebo at reducing pain and pelvic floor pressure in women with chronic pelvic pain and pelvic floor muscle spasm. Design: Double-blind randomized placebo-controlled trial. Setting: A tertiary referral centre, Sydney Australia. Patients: Sixty women with chronic pelvic pain of more than 2 years duration and evidence of pelvic floor muscle spasm. Intervention: Thirty women received 80U of botulinum toxin type A and 30 women had saline injected into the pelvic floor muscles. Measurements and Main Results: Dysmenorrhea, dyspareunia, dyschezia and non-menstrual pelvic pain were assessed by visual analogue scale at baseline and then monthly for 6 months. Pelvic floor pressures were measured by vaginal manometry. There was significant change from

baseline in the botulinum toxin type A group for dyspareunia (r2 = 25.78, p < 0.0001) and non-menstrual pelvic pain (r2 = 16.98, p = 0.009). In the placebo group only dyspareunia was significantly reduced from baseline (r2 = 2.98, p = 0.043). There was a highly significant reduction in pelvic floor pressure in the botulinum toxin type A group from baseline r2 = 39.53, p < 0.0001; with the placebo group also having lower pelvic floor muscle pressures r2 = 19.85, P = 0.003. Conclusion: Objective reduction of pelvic floor spasm reduces some types of pelvic pain. Botulinum toxin type A reduces pressure in the pelvic floor muscles more than placebo. Botulinum toxin type A is a useful agent in women with pelvic floor muscle spasm and chronic pelvic pain who do not respond to conservative physical therapy.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 15—Pelvic Pain (3:07

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– 3:18

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143 Pain Control and Quality of Life After Laparoscopic In-Block Resection of Deep Infiltrating Endometriosis versus Incomplete Surgical Treatment with or without Medical Therapy Angioni S, Mais V, Contu R, Milano F, Peiretti M, Santeufemia S, Melis GB. University of Calgliari, Cagliari, Italy Study Objective: To evaluate the efficacy, in terms of pain control, of laparoscopic in-block resection of retrocervical and/or rectovaginal endometriosis compared to incomplete surgical treatment followed by GnRH analogue (GnRHa) or no medical therapy. Design: Randomized, controlled study. Setting: Teaching hospital. Patients: Seventy five patients with deep infiltrating endometriosis of the cul-de-sac and of the rectovaginal septum with pelvic pain. Intervention: Laparoscopy was performed with complete separation of rectovaginal space and in-block resection of the diseased tissue in 25 patients without post-surgical medical treatment. Fifty patients underwent laparoscopic adhesiolysis of adnexae and/or uterus and eventual excision of endometriomas. In these patients deep infiltrating endometriosis nodules were only partially removed for refusal of patient consent to in-block resection as a potentially harmful surgical procedure. After surgery, these 50 patients were randomly assigned to GnRHa (n = 25) or no therapy (n = 25) groups for 6 months. Measurements and Main Results: Patients filled in a pain questionnaire before and 3, 6 and 12 months after surgical treatment. Quality of life was determined according to SF36 questionnaire before and 1 year after surgery. At 3 and 6 months follow-up patients treated with in-block resection of deep endometriosis showed the highest reduction of cumulative pain scores for chronic pelvic pain, dysmenorrhea and dyspareunia. However, pain control did not differ signifi-

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cantly when these patients were compared with the 25 patients undergoing incomplete surgery and post-surgical GnRHa treatment. Indeed, both groups obtained significantly lower pain scores than those achieved by the 25 patients undergoing incomplete surgical treatment and no post-surgical therapy. After interruption of GnRHa and restoration of menstrual cycles pain scores returned to pre-surgical levels in patients undergoing incomplete surgery and post-surgical medical treatment. At 1 year follow-up patients treated with in-block resection showed the lowest pain scores and the highest quality of life among the three groups. Conclusion: Complete surgical excision of deep endometriosis improves the quality of life with a long-lasting outcome. GnRHa administration is followed by a temporary improvement of pain in patients with incomplete surgical treatment although following discontinuation of treatment symptoms tend to recur.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 15—Pelvic Pain (3:18

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– 3:29

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144 Depression Reduces Improvement in Pain Symptoms After Surgical Excision of Endometriosis Remorgida V, Abbamonte LH, Giordano M, Parisi M, Ragni N, Ferrero S. San Martino Hospital, University of Genoa, Genoa, Italy Study Objective: To evaluate whether changes of pain symptoms reported by patients after surgical excision of endometriosis are correlated to the presence of depression. Design: Prospective study. Setting: University hospital. Patients: This study included 114 women who underwent surgical excision of endometriosis. No patient included in the study had used GnRH analogs in the 6 months before surgery. Intervention: All visible endometriotic lesions were excised at surgery; the diagnosis of endometriosis was histologically confirmed. Measurements and Main Results: Before surgery, the presence of depression was diagnosed by using the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD PHQ); the severity of depression was scored using the Beck Depression Inventory (BDI). The presence and intensity (measured on a 100-mm visual analogue scale, VAS) of pain symptoms were investigated. At 1 year from surgery, prevalence of depression and intensity of pain symptoms were evaluated. Before surgery, 45.6% (52/114) of women with endometriosis were classified as depressed; according to the BDI, one woman had extreme depression and 6 women had severe depression. At followup, absence (VAS < 30 mm) or improvement (> 40 mm in the VAS scale) in pain symptoms, was observed in 78.1% of women with endometriosis (77/105). Depressed women were significantly less likely to report absence or improvement in pain symptoms than non-depressed women

(p < 0.001). Improvement in pain symptoms was reported only by 2 out of 7 (28.6%) women with extreme/severe depression. No significant change in the BDI score was observed in subjects with severe and extreme depression (p = 0.212); the BDI was significantly decreased in subjects with borderline and moderate depression (p = 0.012). Conclusion: Severe depression may reduce the improvement in pain symptoms after surgical excision of endometriosis.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 15—Pelvic Pain (3:29

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– 3:40

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145 Possible Intergel Reaction Syndrome (pIRS): Mechanisms and General Consequences for Patients Undergoing Surgery Wiseman D. Synechion, Inc., International Adhesions Society, Dallas, Texas Study Objective: To determine if “possible INTERGEL Reaction Syndrome” (pIRS) is associated with risk factors for iron overload. Design: Participants entered the study if they suspected a postoperative reaction to iron-containing Intergel with at least one of: late onset postoperative pain, unexplained fever, infection, or unexplained peritoneal reaction. Medical and ethnic histories were taken along with a cheek swab to determine the presence of one of three main HFE mutations causing Hereditary Hematrochromatosis (HHC). Setting: Patient survey and genetic analysis conducted by a commercial lab. Patients: Visitors to adhesions.org reporting a reaction to Intergel. Seven patients were entered. Measurements and Main Results: Compared with about 25% of the population, 3/7 (43%) patients had one copy of one of the three HFE mutations. These patients, along with two others were of Irish/Scottish ancestry, known to have a high prevalence of HHC. With approximately 1/7 Americans claiming such descent, this finding is highly significant (p < 0.001). Three women who were HFE normal had had prior hysterectomies. The one male (normozygote) was of Irish descent. Conclusion: Disturbances in iron metabolism, as in HHC, are known to permit its local accumulation and participation in redox reactions leading to tissue damage, and even cancer. HFE heterozygotes may express an attenuated form of HHC and propensity to iron overload. Along with findings in animals, and clinical disturbances in calcium and leukocyte levels, our preliminary findings suggest that the combination of surgery (itself a mediator of iron imbalance), other risk factors for iron accumulation (HFE mutations, ethnic propensity for iron overload, prior hysterectomy, male gender) and the use of iron-containing Intergel resulted in pIRS. Our findings raise the possibility of long term effects of Intergel exposure and may explain intercontinental differences in adverse event rates to Intergel and differences in patients’ reactions to surgery or disease.

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WEDNESDAY, NOVEMBER 8, 2006 Plenary 16—Hysteroscopy (2:45

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– 2:56

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146 Role of Transvaginal Ultrasonography in Selecting Women With Abnormal Menopausal Uterine Bleeding to Further Invasive Assessment Cianferoni L, Franchini M, Ciatto S. Ospedale SM Annunziata, Florence, Italy Study Objective: We reviewed a consecutive transvaginal ultrasonography (TVUS) series of 1856 postmenopausal women with abnormal uterine bleeding (AUB) to assess the reliability of endometrial thickness measurement for selecting subjects worth invasive assessment. Endometrial cancers (EC) following TVUS were identified by cancer registry linkage. Design: Retrospective study. Setting: Hospital. Patients: Post menopausal women with AUB (1856). Measurements and Main Results: VUS and different endometrial thickness cut off sensitivity was determined. Sixty EC were identified in the first (56), second (2), third (1) or beyond the third year (1) following TVUS. EC was less frequent (2.3%) at age < 60 compared to age > 60 (4.3%). TVUS suspected EC in 59 of 60 EC (98.3%). Oneyear sensitivity was 98.2% (55/56). EC risk increased with thickness, from 0.1% for < 1 mm (half layer) to 14.6% for > 10mm. Receiver Operating Characteristic analysis of thickness accuracy showed a 0.8701 overall AUC. A cut off of > 1, > 2, > 3, > 4 or > 5 mm (half layer) would identify 98%, 96%, 89%, 78% or 63% of EC and would spare unnecessary invasive assessment in 54%, 68%, 79%, 85% or 89% of non-cancer cases, respectively. Conclusion: Postmenopausal AUB first episode should not prompt immediate invasive assessment: indication for hysteroscopy/curettage should be based on TVUS endometrial pattern and thickness.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 16—Hysteroscopy (2:56 pm – 3:07 pm)

147 Hysteroscopy in Endometrial Cancer: New Methods to Evaluate Trans-Tubal Leakage of Saline Distension Medium 1 Solima E, Brusati V, 1Ditto A, 1Kusamura S, 1Martinelli F, 1 Hanozet F, 2Carcangiu ML, 3Maccauro M, 1Raspagliesi F. 1 Department of Gynecologic Oncology; 2Department of Pathology; 3Department of Nuclear Medicine, National Cancer Institute, Milan, Italy Study Objective: This study was undertaken to evaluate trans-tubal fluid leakage after low pressure office saline solution hysteroscopy Design: From December 2002, we are carrying out a prospective case controlled study on the significance of sentinel node detection in endometrial cancer. Patients with pre-

viously untreated endometrial carcinoma, were submitted to office hysteroscopy. Distension of the uterine cavity was obtained by a 1000 mL saline solution bag, placed 50 cm above the patient’s plane. After visualization of uterine cavity, 111 MBq of technetium 99m-labeled human albumin colloid particles and 8 ml of patent blue dye in 4 ml saline were injected sub-endometrially around the lesion at 3, 6, and 9 hours, through a 18 gauge 30cm-long needle. Leakage of Tc99 and blue-dye from the injection sites into the uterine cavity was observed. Within three hours from hysteroscopy, patients underwent staging surgery. Peritoneal free fluid was collected when present and was visually analyzed to detect the presence of blue dye and scanned by a crystal scintillator-gamma probe to detect the presence of radioactive tracer. In case of absence of intra-peritoneal fluid, peritoneal washing was obtained and scanned. Subsequently abdominal hysterectomy, bilateral salpingooophorectomy, pelvic or pelvic and para-aortic lymphadenectomy were performed. Pathological examination of peritoneal washing was obtained after centrifugation at 3000 g for 10 minutes and pellets staining with May-GrunwaldGiemsa and Papanicolau. Setting: Oncology referral teaching hospital. Patients: Forty-five consecutive patients with an histological diagnosis of endometrial cancer were included in the present study. Measurements and Main Results: Technetium-99m and blue dye were detected on the peritoneal surface and in the peritoneal fluid only in two patients. In that cases uterine pressure was for some minutes increased by squeezing the saline bag by hands to wash-out intrauterine bleeding to enable hysteroscopic view. In one of that patients peritoneal cytology was negative for cancer cells. Peritoneal cytology was positive in 2 more cases. Conclusion: This study confirm the low risk of trans-tubal leakage of distension fluid throughout the fallopian tubes during hysteroscopy performed with a standardized intrauterine pressure of about 40 mm Hg and immediately before hysterectomy. When bleeding occurs during hysteroscopy, intrauterine pressure should not be increased to avoid the risk of tumor spread. If transtubal leakage occurs not always cancer cells pass throughout the fallopian tubes.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 16—Hysteroscopy (3:07

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– 3:18

PM)

148 Hysteroscopic Surgery Does Not Adversely Affect the Long-Term Prognosis of Women with Uterine Malignancies Vilos GA, Edris F, Al-Murbarak A, Ettler HC, HollettCaines J, Abu-Rafea B. The University of Western Ontario, London, Ontario, Canada Study Objective: To estimate the incidence of uterine malignancy encountered during routine resectoscopic surgery in women with abnormal uterine bleeding (AUB) and

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to determine the effect of hysteroscopic surgery on the longterm clinical outcome of those women diagnosed with uterine cancer. Design: Prospective cohort study (Canadian Task Force Classification II-3). Setting: University-affiliated teaching hospital. Patients: From January 1990 through December 2005, the principal author (GAV) performed primary hysteroscopic surgery in 3401 women with AUB. Amongst these women, there were 25 uterine malignancies. Intervention: All women underwent hysteroscopic evaluation and partial or complete rollerball electrocoagulation and/or endomyometrial resection. Following diagnosis of uterine malignancy, all women were counseled regarding their disease and management in accordance with established clinical practice guidelines. Follow-up of 1 to 14 years was conducted by office visits and telephone interviews. Measurements and Main Results: Among the 3401 women, there were 16 incidental cases of endometrial adenocarcinoma for an incidence of 0.47%. Three additional cases with known endometrial adenocarcinoma, were included. One woman refused hysterectomy and remains alive and well after total hysteroscopic endomyometrial resection. Two women wished to maintain fertility; one consented to hysterectomy after incomplete resection of her lesion. The other was treated with progestins, and although her cancer reverted to complex hyperplasia, she requested hysterectomy 4 years later. No residual cancer was found. After 5years follow-up, one patient had died from carcinoma of the gallbladder (2 years), and two died at 4 years; one at the age of 87 years and the other from acute renal failure unrelated to her cancer. Fourteen women remain alive and well. In addition to adenocarcinomas, three incidental uterine sarcomas underwent resectoscopic surgery (incidence 0.09%). At 5 years, one is A&W, one died accidentally at 1 year, and the third died from carcinomatosis from breast cancer and/or uterine malignancy (postmortem was declined). Three miscellaneous uterine malignancies were also encountered (incidence 0.09%); two atypical polypoid adenomyomas of the endometrium and one minimal deviation adenocarcinoma of the cervix. Following hysterectomy, all remain alive and well at 1 to 5 years of follow-up. Conclusion: 1) During resectoscopic surgery, uterine malignancy was encountered in 0.65% (n = 22) of women with AUB. 2) Resectoscopic surgery did not adversely affect the 5-year survival and the long-term prognosis of women with uterine malignancy.

WEDNESDAY, NOVEMBER 8, 2006 Plenary 16—Hysteroscopy (3:18

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– 3:29

PM)

149 A Randomized Trial of Hysterectomy versus Endometrial Ablation: Surgical Treatments Outcomes Project for Dysfunctional Uterine Bleeding (STOP-DUB) 1 Munro MG, 2Clark M, 2Langenberg P, 2Zhu Q, 2Nichols JE, 2Yalcinkaya TM, 2Scherer R, 2Frick K, 2Hallock L, 2 Dickersin K. 1David Geffen School of Medicine at University of Los Angeles, Los Angeles, California; 2 STOP-DUB Investigative Group Study Objective: To compare hysterectomy and endometrial ablation (EA) for effectiveness and associated morbidity in women with dysfunctional uterine bleeding (DUB) Design: A multicenter RCT with a minimum 2 years of followup. Setting: US and Canadian clinical centers and a coordinating center funded by the US Agency for Healthcare Research and Quality. Patients: Women with at least 6 months of chronic DUB unresponsive to medical therapy, a normal endometrial cavity, willing to undergo fertility-removing surgery. Intervention: Randomization to total hysterectomy or endometrial ablation (EA), either resectoscopic (REA) or balloon (NREA). Surgical approach (abdominal [AH], vaginal [VH], laparoscopic [LH]) and type of ablation (REA and NREA) were not randomized. Reoperation information was obtained for at least 2 and up to 5 years. Measurements and Main Results: Twenty-five centers enrolled 237 patients into the RCT with 123 assigned EA and 114 assigned hysterectomy. No patients receiving EA required readmission and surgery for complications within 42 days of study surgery compared to 3/118 (2.5%) receiving hysterectomy. There were two cystotomies, seven hematoma/seromas, and four wound infections in the hysterectomy group compared to one hematoma for those receiving EA. Hysterectomy rates were 22.5% and 27.5% for REA and 26.0% and 33.5% for NREA, at 2 and 4 years, respectively. Mean hospital stay in days was 2.3 (AH), 1.6 (VH), 1.3 (LH), and < 1 (EA). Symptom relief was similar in the two groups at 2 years. Thirty-four out of 110 patients receiving EA had reoperation for return of symptoms within 5 years, all but one a hysterectomy. Conclusion: STOP-DUB is the largest RCT to date comparing hysterectomy and EA for treatment of DUB in women with normal endometrial cavities. EA provides satisfactory control of DUB symptoms for most women, with less perioperative morbidity, however, a substantial minority undergo hysterectomy by 5 years.

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WEDNESDAY, NOVEMBER 8, 2006 Plenary 16—Hysteroscopy (3:29

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– 3:40

PM)

150 Patient Satisfaction with the Levonorgestrol-Releasing Intrauterine Device (Lng-Ius) as Treatment for Abnormal Uterine Bleeding 1 Quinlan DJ, 2Shaw I. 1Victoria General Hospital, Victoria, British Columbia, Canada; 2Freshwell Health Centre, Finchingfield, Essex, England Study Objective: To evaluate patient satisfaction with the LNG-IUS when used to treat premenopausal women referred with abnormal uterine bleeding. Design: Retrospective analysis. Setting: Referral gynecologic practice. Patients: All patients referred with abnormal uterine bleeding. Completed questionnaires were obtained form 82/104 (79%) women. Average age was 42 years (range 18–50). Body mass index > 25 in 39 (37%) women. Fifty seven (69%) had heavy cyclical bleeding, 25 (31%) had irregular/prolonged bleeding. Average time from LNG-IUS insertion to completion of questionnaire was 22 months (range 6–39). Intervention: Exclusion of pregnancy and lower genital tract disease. Transvaginal ultrasound performed in all women, 24 (29%) had fibroids. Eighty one endometrial biopsies revealed secretory or proliferative endometrium, one had complex hyperplasia with no atypia. Diagnostic hysteroscopy performed in 88% of women. Normal endometrial cavity in 58 women (70%). Intrauterine polyps or myoma resected in 12 (15%) women prior to LNG-IUS insertion. Transvaginal ultrasound at 6–8 weeks confirmed the location of the device. Measurements and Main Results: Fifty-five percent were very satisfied, 21% were satisfied, 17% were uncertain, 7% dissatisfied. Eighty-eight percent would choose the same treatment again. Eighty-nine percent still had the device present. LNG-IUS removed in 9 (11%) women. Conclusion: The LNG-IUS is an effective treatment for abnormal uterine bleeding with high patient acceptance.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 6—Pelvic Pain/Adhesions (3:50 PM – 3:56 PM)

151 Continued Chronic Pelvic Pain in Adolescent Women with Failed Treatment for Endometriosis: Identification and Treatment Outcome in Patients with Bladder Origin of CPP (Interstitial Cystitis) Grochmal S, Shulman L, Dell J, Sherry S, Howard University College of Medicine, Washington, DC Study Objective: To identify bladder origin of chronic pelvic pain and evaluate treatment response for interstitial cystitis in adolescent women after failed treatment for endometriosis.

Design: Ongoing, multi-center prospective investigation currently at 30 month mark. Setting: Gynecologic and urogynecologic practices located in New Jersey, Illinois, Tennessee and Minnesota respectively. Patients: 139 adolescent females, (ages 13 to 20 years), with persistent CPP. Intervention: Laparoscopic excision of endometriosis [biopsy confirmed] followed by medical therapy (average 13 months). After therapy completed, 89/139 (64%) still complained of symptoms of CPP. Urine and genital cultures were all negative. Pelvic Pain and Urgency/Frequency questionnaire, Potassium Sensitivity Test and in-office cystoscopy were used to identify/confirm the presence of IC. Subsequently, patients were treated with oral pentosan polysulfate sodium (PPS) 100 mg tid. Measurements and Main Results: Based on combined data, 77 patients were evaluated using PUF, PST and cystoscopy. Of these patients, 67/77 (87%) had findings suggestive of IC. Following initiation of oral therapy with PPS, 15 (22%) patients reported symptom relief within 4 to 6 weeks while 33/67 (49%) patients reported improvement within 7 to 10 weeks. The remaining 21/67 (31%) reported symptom improvement between 11 and 25 weeks. Utilizing the patients Overall Rating of Improvement of Symptoms (PORIS) questionnaire as an outcome measure, a 50% or greater improvement in IC symptoms was reported in 55/67 (82%) of patients after 12 months of PPS therapy and 63/67 (94%) reported 75% or greater improvement after 30 months. Conclusion: Ongoing study demonstrates that a possible explanation of CPP in adolescents with failed treatment of endometriosis is IC. Therefore, bladder origin pain should be included earlier in the initial evaluation of young women with CPP. Use of the PUF questionnaire as a screener would be prudent before considering more invasive surgical procedures and treatments. Satisfactory, prolonged relief of IC symptoms can be achieved with oral PPS in young women with CPP of bladder origin.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 6—Pelvic Pain/Adhesions (3:56 PM – 4:02 PM)

152 Post Cesarean Anterior Cul-de-sac Obliteration: A Potential Cause for Chronic Pelvic Pain Furlow ML, Advincula AP. University of Michigan, Ann Arbor, Michigan Study Objective: To evaluate the presentation, therapeutic management, and outcomes in patients with chronic pelvic pain and an obliterated anterior cul-de-sac. Design: Retrospective case analysis. Setting: University teaching hospital. Patients: Fourteen patients with chronic pelvic pain and an obliterated anterior cul-de-sac at time of surgical evaluation. Intervention: Adhesiolysis with or without hysterectomy. Measurements and Main Results: Mean age at presentation

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was 34.5 years (range 19–55 years). All patients had a history of Cesarean section (mean 1.8). Nine (64%) had onset of pain after multiple C-sections and 5 (36%) after first Csection. Mean time interval from c-section to development of pain was 8.7 months (range 0–32 months, n = 9). Nine patients (64%) presented with dyspareunia, 7 (50%) with incisional tenderness, 5 (36%) with dysmenorrhea, and 5 with (35%) lower quadrant pain. All patients failed medical management. One patient declined surgical management and had persistent pain. Thirteen underwent surgical management via either laparoscopy (5) or laparotomy (8). All patients had adhesiolysis and 8 (62%) also underwent hysterectomy. Eight patients (61.5%) had resolution or improvement of pain with mean follow-up of 12 months (range 1–26 months). Of the 8 patients with resolution of their pain, 6 (75%) also had a hysterectomy. Three patients (23%) had persistent pain and 2 (15%) had no follow-up. Of the 3 patients with persistent pain, 2 had further surgical evaluation demonstrating endometriosis. Conclusion: A history of previous cesarean delivery can be a predisposing factor in the development of chronic pelvic pain as a result of anterior cul-de-sac obliteration. Common presenting symptoms were dyspareunia and incisional tenderness. No patients had improvement of pain with medical management alone. Adhesiolysis with or without hysterectomy appeared to be an effective treatment. Long-term follow-up and a larger patient sample are needed.

of the vein at the inferior vena cava. The left ovarian vein was reached by incising the posterior peritoneum covering the abdominal aorta 2 cm below the duodenal fold. The ovarian vein was identified and freed from surrounding retroperitoneal areolar loose tissue paying attention to the presence of collaterals. Two or three titanium clips were placed near the origin of the vein at the renal vein. To investigate long-term outcome women were asked to keep their pain diary. Measurements and Main Results: All women were avaible for examination at the follow-up visits of 6 weeks, 6 and 12 months after operation. In all the patients pain was markedly decreased (VAS scale decreased more than 5 points). In more than 80% of women pain was totally eliminated (VAS scale = 0). None of the women had US signs of pelvic varicocele recurrence. None of the women showed symptoms of postoperative ovarian failure. Conclusion: Chronic pelvic paif is a common condition in women in their reproductive age. Pelvic congestion syndrome is a clinical entity which is often disregarded as demonstrated y the rarely reported laparoscopic finding of pelvic varices. Pelvic congestion syndrome was reported by 59% of women with ovarian varices. This in a report on the feasibility of high bilateral transperitoneal laparoscopic ligation of the ovarian veins by direct incision of the posterior peritoneum covering the inferior vena cava and abdominal aorta. Therefore this surgery remains investigational.

WEDNESDAY, NOVEMBER 8, 2006

WEDNESDAY, NOVEMBER 8, 2006

Open Communications 6—Pelvic Pain/Adhesions (4:02 PM – 4:08 PM)

Open Communications 6—Pelvic Pain/Adhesions (4:08 PM – 4:14 PM)

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154

Laparoscopic Management of Pelvic Congestion Syndrome 1 Gargiulo T, 2De Filippis G, 1Gargiulo M, 1Brokaj L, 1 Paoletti AM, 1Mais V, 1Melis GB. 1Universita de Cagliari, Cagliari, Italy; 2Ospedale Maria Vittoria, Turin, Italy

Vaginismus and Botulinum Toxin A: A Measure of Treatment Greenleaf BAB, McKinney TB, Hashemi EA. Athena Women’s Medical Center, Turnersville, New Jersey

Study Objective: This study was undertaken to evidence the effectivness of high bilateral closure of the ovarian veins in women with pelvic pain caused by pelvic varicocele. Design: Fifty-six women were included in a surgical retrospective study between 2000 and 2006. All women underwent surgical laparoscopic treatment of symptomatic pelvic varicocele. Setting: City’s public hospital in Turin and University hospital of Cagliari. Patients: Fifty-six women with pelvic pain due to pelvic congestion syndrome (pelvic varicocele). Intervention: Laparoscopy was performed in general anesthesia. The right ovarian vein was reached by incising the posterior peritoneum covering the inferior vena cava 2 cm below the mesentericoparietal fossa. The ovarian vein was identified and freed from surrounding retroperitoneal areolar loose tissue paying attention to the presence of collaterals. Two or three titanium clips were placed near the origin

Study Objective: To find measurable evidence to quantify vaginismus treatment. Design: Prospective case series. Setting: Advanced Gynecology and Urogynecology Office. Patients: Twelve patients with clinical evidence of vagismus and associated tenderness. Patients presented with the complaints of urgency, frequency, dysuria, pelvic pain, vaginal burning, and/or incontinence. None of these patients presented with the complaint of dyspareunia or vaginal tightening/spasm, but on review of systems admitted to these complaints. Dyspareunia was identified as pain with initial penetration or entry in all of these patients. Secondarily to their urinary complaints, all patients were worked up for concomitantly for urinary causes of their symptoms with cystoscopy, and urodynamics. It was found that 92% of these patients had urethral instability and high urethral pressures, 25% with detrussor sphincter dyssynergia, and 41.6% with interstitial cystitis. On physical exam, all of these patients were found to have significant spasm of the puborectalis

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and/ or levator muscles with associated tenderness with palpation. Once other urologic conditions were identified and treated patients were then treated for their vaginismus. Intervention: patients injected with 100–400 units of Botulinum Toxin A intramusclularly into multiple locations in the puborectalis and levator muscles. Measurements and Main Results: Anorectal manometry catheters (T-DOC) were employed for pressure measurements and perceived tolerable volume before and after injections. There was an improvement in tolerable volume. The catheter balloon was filled with air until the patient first perceived discomfort at the level of the puborectalis and levators. This was measured pre and post injection. Pre injection puborectalis tolerable volume measurements ranged between 30–50 cc, with post injection tolerable volumes ranged from 90–130cc. Pre injection levator tolerable volume measurements ranged between 30–70cc, with post injection ranges between 110–240cc. On average, there was a 207% increase in tolerable volume at the level of the puborectalis muscles and 285% increase at the level of the levators after injection of Botulinum Toxin A. Conclusion: This initial study demonstrated an adequate measurement of vaginismus treatment and success with Botulinum Toxin A injections. Botox A has a treatment length of 3–6 months. The majority of patients treated with Botox still experience relief of symptoms beyond this time after one treatment. This study will be continued with the development of vaginal pressure monitors, QOL questionnaires, EMG studies, and 3-month, 6-month, and yearly follow-up. In addition, correlations will be investigated between vaginismus, and other pelvic disorders such as urethral instability, chronic vaginitis, and interstitial cystitis

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 6—Pelvic Pain/Adhesions (4:14 PM – 4:20 PM)

155 Botox for the Treatment of Terminal Dysuria in Women with Chronic Pelvic Pain 1 Lyons SD, 2Millard RJ, 1Abbott JA, 1Vancaillie TG. 1Royal Hospital for Women; 2Urology Prince of Wales Hospital, Sydney, Australia Study Objective: In women with chronic pelvic pain, terminal dysuria may occur as part of a constellation of pain symptoms. Terminal dysuria is usually associated with bladder inflammation or infection and manifests as suprapubic or pelvic pain after voiding. Terminal dysuria in women with chronic pelvic pain, however, may have no obvious precipitant and adequate diagnosis and treatment of this condition remains elusive. Setting: Hospital. Patients: A case series of four women with chronic pelvic pain who either present with, or subsequently develop, terminal dysuria will be presented. Intervention: Following assessment and treatment of inter-

current pathology, women with terminal dysuria and objective evidence of post-void detrusor spasm were offered treatment with cystoscopic detrusor infiltration using 200 IU Botox. Measurements and Main Results: Four cases of terminal dysuria complicating chronic pelvic pain are presented. Two women opted for treatment of post-void spasm with Botox infiltration of the detrusor. Despite a double voiding regime, the first case was complicated by acute urinary retention, and a transient flu-like toxin reaction. Voiding dysfunction resolved after one week of clean intermittent self-catheterisation (CISC). CISC was taught pre-procedure for the second case and was necessary for prolonged post-treatment voiding dysfunction. Both patients experienced decreased severity of terminal dysuria as a result of treatment and this correlated with an objective decrease in post-void spasm. Conclusion: Cystoscopic detrusor infiltration using Botox is an efficacious treatment for terminal dysuria in women with chronic pelvic pain. Potential complications such as voiding dysfunction and transient toxin reaction should be addressed at pre-procedure counselling.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 6—Pelvic Pain/Adhesions (4:20 PM – 4:26 PM)

156 Chronic Pelvic Pain Due to Healed Endometriosis Malek SF. Lutheran Medical Center, Brooklyn, New York Study Objective: To review a ten year evaluation of pelvic pain due to endometriosis that had healed, leaving only a symptomatic scarred lesion. Design: Six hundred patients had laparoscopy between 3/1/96 and 3/1/2006, for chronic pelvic pain. Setting: Local teaching hospitals. Patients: Six hundred patients had laparoscopy for chronic pelvic pain, ages between 17–54 years, symptom duration 6 months –10 years, number of prior operations 0–9, number of lesions 2–8, mean operating time 100 minutes, mean blood loss 50cc. The laparoscopic appearance was white opacified focal lesions, with or without blind pouches, predominantly in the rectovaginal septum. Three hundred fortyeight patients (58%) had both active, and healed endometriotic lesions, 42 patients (7%) had all active endometriosis, 192 patients (32%) had all healed lesion, and only 18 patients in this series had no visible pathology. All procedures were performed by the same surgeon. Intervention: Laparoscopy was performed under general anesthesia, after complete inspection of the pelvis, and in particular the rectovaginal septum, and pararectal spaces, utilizing the use of a vaginal probe to expose the hidden lesions. All lesions were completely excised using peritoneal re-usable scissors, and bipolar coagulation when needed. Measurements and Main Results: Five hundred forty patients (90%) of all patients improved or became asymptomatic after the initial 6 weeks post-op. 12 patients (2%) with

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long history of pelvic pain remained symptomatic and required to seek pain management. 48 patients (8%) either failed to improve or improved slightly and required another laparoscopic excision. Conclusion: This long awaited large study proves that all focal lesions in the pelvis, in particular in the rectovaginal, and para-rectal spaces should be completely excised in all chronic pelvic pain patients.

WEDNESDAY, NOVEMBER 8, 2006

festation of external endometriosis and a possible presentation of primary or secondary endometriosis with a typical presentation that has little variation. Laparoscopic excision of endometrial tissue can result in inadvertent, iatrogenic seeding to the umbilicus. Historical and physical findings are pathognomonic, thus, justifying a formal name, after the initial reporting physician: Villar’s nodule. Surgical intervention is recommended, but medical therapy may result in long term symptom control and malignancy risk is minimal.

Open Communications 6—Pelvic Pain/Adhesions (4:26 PM – 4:32 PM)

WEDNESDAY, NOVEMBER 8, 2006

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Open Communications 6—Pelvic Pain/Adhesions (4:32 PM – 4:38 PM)

Villar's Nodule: A Case Report and Systematic Literature Review of Endometriosis Externa of the Umbilicus 1 Victory R, 2Saed GM, 2Diamond MP. 1Wayne State University, Windsor, Ontario, Canada; 2Wayne State University, Detroit, Michigan Study Objective: To report a case of umbilical endometriosis externa and systematically review the literature regarding this finding. Design: Case report and literature-review generated database. Setting: Harris Methodist Fort Worth Hospital and Medline. Patients: A 47–year-old woman with cyclic umbilical bleeding and pelvic pain and no previous umbilical surgery; 62 patients with documented umbilical endometriomas from 1966 – present and 109 cases reported prior to 1953. Intervention: Umbilical biopsy or resection, abdominal wall repair; diagnostic and/or operative laparoscopy, adhesiolysis, hysterectomy, bilateral salpingo-oophorectomy. Measurements and Main Results: Measures included patient age, race, past medical and surgical history, past use of oral contraceptives, history of umbilical pain, bleeding, or swelling, duration of signs and symptoms prior to presentation, size and colour of the lesion, evaluations, and medical or surgical management. Mean age of the study population was 31.7 +/- 1.0 years. Up to 34.1% of patients with extrapelvic endometriosis present with umbilical endometriomas, with symptoms occurring an average of 18.7 +/- 4.4 months prior to presentation. Lesions averaged 2.5 +/- 0.2 cm in diameter, were predominantly brown (18.0%), blue (13.1%) or purple (11.5%), and frequently presented with pain (80.3%), cyclical bleeding (50.8%), and swelling (91.8%). Most patients had no previous history of endometriosis (73.7%), and laparoscopic, umbilical trocar-related seeding was identified in only 5 patients. Medical management was limited to only 3 patients, and surgical management was invariably curative, though one patient required repeat surgical therapy. Conclusion: Umbilical endometriosis is a common mani-

158 Information and Consent Regarding Adhesions: An Internet Survey Wiseman D. Synechion, Inc., International Adhesions Society, Dallas, Texas Study Objective: To determine the extent to which patients are informed about adhesions and adhesion barriers prior to surgery. Design: Patients who had abdominal or pelvic surgeries were asked about information given them prior to surgery regarding adhesions and adhesion barriers. Setting: Internet-based survey. Patients: Patients visiting an adhesions resource web site (www.adhesions.org). Measurements and Main Results: Five hundred seventy (43 male, 527 female) patients completed the survey concerning 952 procedures. Patients reported being informed about adhesions prior to 27% (254/952) of the procedures they underwent. In only 122 (12.8%) of these were adhesions mentioned as part of the informed consent and in another 132 (13.9%) adhesions were discussed. Patients reported being given information about adhesions in 55% of procedures involving adhesiolysis and in 9.3% of procedures not involving adhesiolysis. Patients reported being provided with information about adhesion barriers, in 46% and 6% of procedures involving and not involving adhesiolysis respectively. Where adhesions were mentioned, barriers were mentioned in 46% of adhesiolysis procedures and 22% of nonadhesiolysis procedures. Conclusion: The frequency of information provided to patients about adhesions and adhesion barriers appeared remarkably low. Despite a number of obvious caveats involved in interpreting a study of this kind, preoperative consultation and consent procedures offers an ideal opportunity to educate patients about adhesions. There is an increasing trend regarding information about adhesions, but a decreasing trend regarding information about adhesion barriers. Whether this represents the adoption or rejection of barriers in surgical practice requires further study.

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WEDNESDAY, NOVEMBER 8, 2006 Open Communications 6—Pelvic Pain/Adhesions (4:38 PM – 4:44 PM)

159 Polychlorinated Biphenyl Congeners Enhancement of Type I Collagen Expression 1 Diamond MP, 2Wirth JJ, 1Saed GM. 1Wayne State University, Detroit, Michigan; 2Michigan State University, East Lansing, Michigan Study Objective: We have previously demonstrated that PCB-180 enhances expression of type I collagen, but not TGF-` or VEGF. To test the hypothesis that this is an effect of PCB’s as biomodulators, and not the effect of a single congener, we examined the effects of additional PCB’s in normal human peritoneal fibroblasts on expression of three adhesion markers, TGF-`1, VEGF, and type I collagen. Design: Cell culture. Setting: University research laboratories. Patients: Primary cultures of normal peritoneal fibroblasts were established from three patients. Intervention: Fibroblasts were treated with PCB-77, PCB105, and PCB-153, 20 ppm for 24 hours. Measurements and Main Results: Total RNA was extracted from each fibroblast treatment culture and subjected to real-time RT/PCR to quantitative relative change in mRNA levels of type I collagen, VEGF and TGF-`1. Exposure of normal human fibroblasts to each PCB congener did not affect mRNA levels of `-actin, nor did it affect cell viability as assessed by the trypan blue exclusion method. Compared to control, PCB-77, PCB-105, and PCB-153 each resulted in no significant change for TGF-`1 mRNA or VEGF mRNA levels. In marked contrast, type I collagen mRNA levels were increased many fold (p < 0.01) in response to the brief 24 hrs exposure to each PCB congener. Conclusion: The finding that PCB-77, PCB-105, and PCB-153 all increase the expression of type I collagen in human normal peritoneal fibroblasts confirms our prior finding with PCB-180, and thus enhances the demonstration of involvement of organochlorines in the pathogenesis of tissue fibrosis. This may implicate organochlorine exposure as a possible etiologic factor in fibrosis-characterized human disorders.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 6—Pelvic Pain/Adhesions (4:44 PM – 4:50 PM)

160 A New Polyethylene Glycol Polymer for Adhesion Prevention Dulemba JF, Medler-Pelzel C. North Texas Hospital, Denton, Texas Study Objective: To Decrease adhesion formation following laparoscopic surgery.

Design: One hundred twenty-three women undergoing laparoscopic surgery for pelvic pain. Setting: A community hospital in a private gynecologic practice. Patients: One hundred twenty-three patients with pelvic pain undergoing laparoscopic surgery. Only patients with adhesions noted at time of surgery were included in the evaluation. A questionaire was given 1 week post-op, and 6 months post-op. Intervention: Following laparoscopic surgery, and adhesiolysis, the polyethylene glycol polymer was sprayed onto the raw surfaces through a lower port. The polymer was not disturbed for at least one minute. Measurements and Main Results: The patients completed a survey describing the amount of pain relief one week, and 6 months after laparoscopic surgery. At one week, 86% of the patients felt pain relief as compared to before surgery. 74% of these patients felt significant pain relief at 6 months post-op. Only one patient had a second look procedure. Initially she had severe adhesions, but no adhseions were noted at the second look. When an appendectomy was performed during the surgery, and the spray was used, the patients seemed to experience a significant amount of post-op pain. One patient had to be readmitted for observation. Greater than 70% of patients had pain relief at 6 months after using the polyethylene glycol polymer. Conclusion: The new polyethylene glycol polymer appears to be safe and effective in reducing the pain of adhesions in patients with pelvic pain.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 6—Pelvic Pain/Adhesions (4:50 PM – 4:56 PM)

161 Ten Years of Experience With Seprafilm 1 Diamond MP, 2Dowd K, 2Eng D, 2Holmdahl L. 1 Wayne State University, Detroit, Michigan; 2 Genzyme Corporation, Cambridge, Massachusetts Study Objective: Over 1.9 million sheets of Seprafilm have been used worldwide since product introduction in 1996. To Review 10 years of Experience with Seprafilm, a Marketed Adhesion Barrier. Design: A systematic review of clinical trial literature, pharmacovigilance reports, and marketing data. Setting: Seprafilm is used in abdominal and pelvic surgery the United States, Europe, Canada, and Japan and in cardiothoracic surgery in Europe and Canada. Clinical trials have been conducted in abdominal, gynecological, obstetrical, cardiothoracic, ophthalmic, and orthopedic surgeries in the United States, Europe, Canada and Japan. Patients: Twenty-three clinical studies have been conducted with 2182 treatment patients receiving Seprafilm. Intervention: Seprafilm administration. Measurements and Main Results: Seprafilm has been used

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to reduce adhesions including colectomy, gastrectomy, appendectomy, splenectomy, bariatric procedures, bowel resection, hepatic resection, rectal resection, myomectomy, C-section, oophorectomy, salpingectomy, cystectomy, hysterectomy and debulking surgery. Its use has been reported in open and laparoscopic procedures, in cancer and benign disease. It has also been used to prevent adhesions following cardiac surgery including pediatric, coronary artery bypass graft and left ventricular assist device surgery procedures. The clinical trials were randomized controlled, cohort and retrospective studies of Seprafilm use in men, women and children. Seprafilm has consistently been shown to be effective in reducing adhesion formation where placed. Additionally, long-term data has shown that Seprafilm reduces the incidence of adhesive small bowel obstruction requiring reoperation. Seprafilm has been reported to be well tolerated throughout that body, but data suggests it should not be wrapped around a fresh bowel anastomosis. The reporting rate of adverse events in Medical Device Reports received from 1996 through 2005 is calculated as 0.06%. Conclusion: Seprafilm has been extensively studied in men and women, children, different ethnic populations, and a variety of surgical settings. It is well tolerated and efficacious where placed.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 7—Hysteroscopy/Oncology (3:50 PM – 3:56 PM)

162 Prevalence and Clinical Course of Endometrial Polyps in Asymptomatic Women Lieng M, Qvigstad E, Istre O. Ullevål University Hospital, Oslo, Norway Study Objective: To assess the prevalence of endometrial polyps in women aged 45–50 years and to evaluate the frequency of abnormal vaginal bleeding in women with incidentally diagnosed endometrial polyps. Furthermore, the eventual change in bleeding as well as polyp size during one year of observation will be recorded. Design: Prospective cohort study. Setting: One-centre study. University Hospital. Patients: Randomly selected (1000) women in the age 45–50 years. Intervention: Gynecological examination, vaginal sonography and hydrosonography were performed, as well as endometrial biopsy (pipelle) in women with endometrial polyps. Measurements and Main Results: Amount of bleeding (pbac) in women with endometrial polyps and controls were registrated. Registration of eventual change of size of endometrial polyps (volume) and amount of bleeding will be performed twelve months after inclusion. Persistent endometrial polyps one year after inclusion will be removed by hysteroscopic resection. Three hundred eleven out of 988 women (31%) responded. 271 out of 988 women (27%) agreed to be included in this study and by May 15, 2006,

246 women (91%) have been included. The prevalence of endometrial polyps so far in the study population is 11.4%. Further data from inclusion of women into the study will be presented. Conclusion: A prospective study evaluating the prevalence and clinical course of endometrial polyps in asymptomatic women. Preliminary data from the time of inclusion in the study will be presented.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 7—Hysteroscopy/Oncology (3:56 PM – 4:02 PM)

163 Endometrial Polyps and Risk of Hyperplasia and Neoplasia 1 Dolloff A, 2Kohn N, 2Fried-Oginski W, 2,3Nimaroff M. 1 Newton-Wellesley Hospital, Newton, Massachusetts; 2 North Shore University Hospital, Manhassett, New York; 3 New York University School of Medicine, Manhassett, New York Study Objective: With the increased use of pelvic sonography and sonohysterography, endometrial polyps are diagnosed with increasing frequency even in the asymptomatic patient. The objective of this study was to estimate the prevalence of endometrial hyperplasia and neoplasia in polyps resected at the time of operative hysteroscopy. Design: Retrospective chart review (Canadian Task Force II-3). Setting: Tertiary care center and two private gynecologic practices. Patients: Four hundred seven patients who underwent hysteroscopic polypectomy with a preoperative diagnosis of endometrial polyp between November 2003 and June 2005. Intervention: Dilatation and curettage with operative hysteroscopic loop excision of endometrial polyps. Measurements and Main Results: Of the 407 patients who underwent polypectomy, abnormal polyp pathology was identified in 64 patients (15.7%). Simple hyperplasia without atypia was found in 42 patients (10.3%), complex hyperplasia without atypia in 6 (1.5%), simple hyperplasia with atypia in 2 (0.5%), complex hyperplasia with atypia in 5 (1.2%), and endometrial cancer in 9 (2.2%) Age, weight, parity, menopause status, symptoms, and history of hormone use were not significantly associated with abnormal polyp pathology (Table 2). Polyp size on sonohysterogram measurement was significantly associated with polyp pathology. The average polyp size was 15.9 mm for benign polyps vs. 18.5 mm for polyps with abnormal pathology (p < 0.0391). The complication rate for operative hysteroscopy and polypectomy in this study was 2/407 (0.5%), with false passages created in two patients. Conclusion: In this study, the incidence of abnormal pathology in resected polyps was 15.7%, with 3.9% showing evidence of hyperplasia with atypia or neoplasia. Clinical risk factors, including symptoms and menopause status, were not significantly associated with an increased incidence of

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endometrial hyperplasia or cancer, with the exception of polyp size on sonohysterogram. Due to the high incidence of pathologic findings in polyps, combined with the low complication rate for operative hysteroscopy and polypectomy, patients with polyps who are appropriate operative candidates should be encouraged to undergo polypectomy.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 7—Hysteroscopy/Oncology (4:02 PM – 4:08 PM)

164 Intraperitoneal Spread of Endometrial Cells During Operative Office Hysteroscopy versus Conventional Hysteroscopy: Prospective Randomized Trial Taskin O, Sadik S, Simsek M, Onoglu A, Akar M, Seyhan S, Ispahi C, Mendilcioglu I. Akdeniz University School of Medicine, Antalya, Turkey Study Objective: Hysteroscopy is the gold-standard tool for the evaluation of endometrial cavity with the potential of disseminating endometrial cells into the peritoneum, which may affect the survival of patient with endometrial cancer. We aim to explore whether office hysteroscopy with a low and high intrauterine pressure settings will disseminate the peritoneal cells into the peritoneum. Design: Prospective randomized. Setting: Tertiary care center. Patients: Ten women (Gr 1, aged 22–25 years) undergoing infertility evaluation and 10 premenopausal patients (Gr 2, aged 43–48 years) scheduled for laparoscopy for non-uterine indications (adnexal mass/ pelvic pain). Intervention: Each group of patients was randomized to office hysteroscopy with 30- to 40-mm Hg intrauterine pressure (IUP40, Gr1 n: 5, Gr2 n: 5) or conventional hysteroscopy with 80–100 mmHg intrauterine pressure (IUP100, Gr1 n: 5, Gr2 n: 5). Before and after hysteroscopy peritoneal cytology was obtained by aspirating/or washing of Douglas pouch by laparoscopy. After centrifugation the pellets were stained with May-Grunwald Giemsa and Papanicolau stains. Measurements and Main Results: Patients with positive peritoneal cytology. None of the patients in IUP40 GR1/2 had positive peritoneal cytology following office hysteroscopy. However, among IUP100 patients 3 patients in Gr 1 and 4 patients in Gr 2 had positive peritoneal cytology. Conclusion: Our preliminary results denote that intra uterine pressure is important bin disseminating peritoneal cells into the peritoneum. Although clinical importance of peritoneal dissemination remains elusive particularly in patients with endometrial malignancy, we may conclude that low-pressure office hysteroscopy does not increase the risk of peritoneal spread of endometrial cells and could be safely used to evaluate such patients.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 7—Hysteroscopy/Oncology (4:08 PM – 4:14 PM)

165 Resectoscopic Surgery May be an Alternative to Hysterectomy in High-Risk Women with Atypical Endometrial Hyperplasia 1 Edris F, 1Vilos GA, 1Al-Mubarak A, 2Ettler HC, 1HollettCaines J, 1Abu-Rafea B. 1Department of Obstetrics and Gynecology; 2Department of Pathology, The University of Western Ontario, Ontario, Canada Study Objective: Atypical endometrial hyperplasia is found in 2% to 10% of women with abnormal uterine bleeding (AUB), and up to 25% of cases harbor coexisting adenocarcinoma. Approximately 25% of atypical hyperplasia, if untreated, progress to cancer. The conventional treatment is hysterectomy and bilateral salpingo-oophorectomy (BSO). The objective of this study is to evaluate the role of resectoscopic surgery in the management of women with AUB and atypical endometrial hyperplasia who refused or were at high risk for hysterectomy. Design: Prospective cohort study (Canadian Task Force Classification II-3). Setting: University-affiliated teaching hospital. Patients: From January 1990 through December 2005, the senior author (GAV) performed primary resectoscopic surgery in 3401 women with AUB. Amongst these, there were 19 women with atypical (14 complex, 5 simple) endometrial hyperplasia. Intervention: All women underwent hysteroscopic evaluation and partial or complete endomyometrial electrocoagulation and/or resection. Subsequently, six women had hysterectomy and BSO. Measurements and Main Results: The median (range) for age, parity, and BMI were 52 years (24–78), 2 (0–4), and 30 kg/m2 (21–52), respectively. Out of the 13 women who did not undergo hysterectomy and followed for 1.5 to 14 years (median 5 years), one died at year 2 from colon cancer, one died at year 4 from lung cancer and one developed endometrial cancer after 10.5 years of amenorrhea. She presented with atypical glandular cells in Papanicolaou smear and remains alive and well 3.5 years following hysterectomy and BSO. The remaining 10 patients are amenorrhic at a median follow-up of 4.5 years (1.5–12 years). Conclusion: Resectoscopic surgery detected 12 incidental cases of atypical endometrial hyperplasia among 3401 women with AUB. Skillful resectoscopic surgery may be an alternative to hysterectomy in women with AUB and atypical endometrial hyperplasia, who refused or are high-risk for hysterectomy and who are compliant with regular and longterm follow-up.

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WEDNESDAY, NOVEMBER 8, 2006

WEDNESDAY, NOVEMBER 8, 2006

Open Communications 7—Hysteroscopy/Oncology (4:14 PM – 4:20 PM)

Open Communications 7—Hysteroscopy/Oncology (4:20 PM – 4:26 PM)

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Accuracy in Detecting Benign Intracavitary Lesions in Postmenopausal Abnormal Uterine Bleeding: A Comparative Study Between Blind Biopsies and Outpatient Hysteroscopy Loddo A, Angioni S, Milano F, Contu R, Piras B, Melis GB. University of Cagliari, Cagliari, Italy

Hysteroscopic Resection: A Possible Treatment of Atypical Endometrial Hyperplasia Cianferoni L, Castellacci E, Franchini M. Ospedale SM Annunziata, Florence, France.

Study Objective: To evaluate the accuracy of blind biopsies in detecting benign intracavitary lesions as causes of postmenopausal bleeding in comparison to diagnostic hysteroscopy. Design: Prospective clinical study. Setting: University hospital. Patients: Three hundred nineteen patients with postmenopausal uterine bleeding. Intervention: All patients underwent both blind biopsy (Novak curette) and subsequently diagnostic hysteroscopy. All patients with benign intracavitary lesions underwent operative hysteroscopy to enable the removal of polyps and intracavitary myomas or endometrial ablation if required. Histopathologic findings from endometrial specimens obtained after operative hysteroscopy were used as a reference standard to establish the prevalence of pathology. Measurements and Main Results: Sensitivity, specificity and positive and negative predictive values of blind biopsies and hysteroscopy were assessed to distinguish benign intracavitary formations such as polyps, submucous myomas and endometrial hyperplasia in patients with AUB. Blind biopsy showed a sensitivity of 11% and a specificity of 93% in detecting endometrial polyps. A sensitivity of 13% and a specificity of 100% was displayed for submucous myomas; a sensitivity of 25% and a specificity of 92% for the diagnosis of hyperplasia. On the other hand, hysteroscopy demonstrated a sensitivity of 100% and a specificity of 97% in diagnosing endometrial polyps; sensitivity and specificity of 100% and 98% for submucous myomas. The worst result was obtained in the appraisal of hyperplasia, with values of 74% and 88%, respectively. Conclusion: Blind biopsy displayed a remarkably low sensitivity in the diagnosis of benign intracavitary lesions. Hysteroscopy should be considered the gold standard in the assessment of AUB after menopause. The latter averts the occurrence of false negative results in blind biopsies by allowing direct visualization of the uterine cavity and the performing of targeted biopsies in case of doubt.

Study Objective: To evaluate the efficacy and the safety of endometrial hysteroscopic resection in the treatment of selected cases of endometrial hyperplasia with atypia. Design: Retrospective analysis. Setting: Department of Gynecology at a general hospital. Patients: Fifteen women, 46 to 78 years old, with histologically proven endometrial hyperplasia with atypia. Intervention: Transcervical hysteroscopic endometrial resection under general or spinal anesthesia. Measurements and Main Results: Efficacy of treatment was based on hysteroscopic and histological regression of endometrial hyperplasia and absence of development of endometrial cancer. Safety was evaluated by adverse events. Thirteen post menopausal women had experienced complete remission of uterine bleeding, regression of hyperplasia and none developed endometrial cancer or recurrance of endometrial cell atypias during follow-up. Two underwent hysterectomy: one for the precence of endometrial cancer in the chips atere endometrial resection and one had a recurrance of hyperplasia although without atypias. Atrophic endometrium or absence of endometrium was present in all endometrial specimens at follow-up. Conclusion: Endometrial resection seems effective in treating endometrial hyperplasia with atypias and in preventing the occurrance of endometrial cancer during 24 months follow-up. It could be consider a possible treatment in selected cases of atypical hyperplasia.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 7—Hysteroscopy/Oncology (4:26 PM – 4:32 PM)

168 Improving Spillage Rate During Laparoscopic Management of Ovarian Teratoma Vittori G, Delfini R, Lena A, Chakargi A, Bassani A. Ospedale San Carlo, Rome, Italy Study Objective: To describe a surgical technique effective to minimize cystic spillage in the laparoscopic management of ovarian teratoma. Design: Review of cases of women with dermoid cysts who underwent cystectomy or annessectomy by laparoscopy. Setting: Dept of Gynecology. District General Hospital. Patients: Between January 1998 and May 2006, 136 women with a diagnosis of dermoid cysts by ultrasound required surgical management. Of these, 128 women with benign

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cysts underwent laparoscopic cystectomy and 8 underwent annessectomy for other reasons. Intervention: Laparoscopic technique was standardised. The ovary was grasped on the antemesenteric border. The ovarian cortex was lifted from the cyst to facilitate identification of the cleavage plane. A small incision was made (1–1.5 cm) and was extended in depth with sharp and blunt dissection was to establish the correct plane taking care to avoid rupture of the cyst — “Four wheel drive technique.” Measurements and Main Results: Using this method a small number of ruptures occurred. In fact, spillage was observed in 16 cysts (12%). In the spillage group no chemical peritonitis occurred. The mean size of dermoid cysts was 5.1cm (range 1.5–15cm) and no significant intra-operative blood loss occurred during laparoscopic ovarian cystectomy. The mean operation time was 40 minutes (range 25–100). Conclusion: This laparoscopic surgical technique of ovarian cystectomy should be considered as a valid method for the removal of benign ovarian cystic teratomas: it offers minimal spillage of cysts with consequent reduction in postoperative adhesions, reduced pain and shorter hospital stay. It should be performed by surgeons with considerable experience in advanced laparoscopic surgery.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 7—Hysteroscopy/Oncology (4:32 PM – 4:38 PM)

169 Laparoscopic Management of Ovarian Mature Cystic Teratomas Salem HA. Alexandria University, Alexandria, Egypt Study Objective: Check the postoperative complications after laparoscopic treatment of dermoids. Design: A prospective study. Setting: Shatby University Hospital, Alexandria, Egypt. Patients: Forty cases with mature cystic teratomas selected from attendants of the outpatient clinic of El-Shatby University hospital. All patients are married, 18–40 years, with unilateral or bilateral dermoid cyst not exceeding 10cm in diameter. Those patients with criteria suggesting malignancy (by u/s or laparoscopy) were excluded History taking, clinical examination, high resolution vaginal ultrasound, CA125, abdominal x-ray and written consent were all fulfilled. Intervention: Laparoscopic excision of the mature cystic teratoma through incision in the anti -mesenteric border of the ovary with hydrostatic dissection. The ovary left without suturing. Excessive lavage using 10 litres of normal saline were done in those cases with spillage. Measurements and Main Results: Laparoscopic resections were done in all patients. None was transformed into laparotomy. Mean operative time was (70 min). Mean blood loss (40 mL). Post operative fever (16%). Peritoneal spillage (80%). Duration of hospital stay (1 day). Bilaterality of the tumour (12%). Chronic post operative pelvic pain (none). Chemical peritonitis (none). Post operative fever (16%).

Peritoneal spillage (80%). Duration of hospital stay (1 day). Bilaterality of the tumour (12%). Chronic post operative pelvic pain (none). Chemical peritonitis (none). Conclusion: Laparoscopic resection of benign cystic teratoma is safe procedure and in presence of good preoperative preparation it must be the rule with exception only extensive pelvic adhesions and malignant suspicions. Advantages over laparotomy were diminished blood loss, hospital stay, postoperative fever, postoperative treatment. Although spillage had occurred in most of the cases none of them developed chemical peritonitis.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 7—Hysteroscopy/Oncology (4:38 PM – 4:44 PM)

170 Subcutaneous Laparoscopic Groin Lymphadenectomy for Vulva Malignancies Zhang Z, Guo S, Liu C, San C, Li Y. Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China Study Objective: To study the feasibility and safety of laparoscopic surgery for groin lymphadenectomy for vulva malignancies. Design: Retrospective analysis. Setting: Hospital. Patients: Two patients with vulva cancer. Measurements and Main Results: Subcutaneous laparoscopic groin lymphodenectomy for vulva malignancies was performed for 2 patients suffer from vulva cancer from September 2004 to November 2005. Age 74 and 65 years old, all squamous cell cancer, all T1N0M0 and T2N0M0. The later was companied by diabetes. The duration of the operation was 120 and 40 minutes. There was no obvious blood lose during the operation. Lymphonodes resected 0/13 (7,6) and 0/14 (6,8). The duration of groin healing was 28 and 60 days with evidence of infection. The two patients are survival without evidence disease. Conclusion: Subcutaneous laparoscopic groin lymphodenectomy is feasible for the surgical management of groin lymph note for vulva malignancies.

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WEDNESDAY, NOVEMBER 8, 2006 Open Communications 7—Hysteroscopy/Oncology (4:44 PM – 4:50 PM)

171 Total Laparoscopic Radical Hysterectomy and Bilateral Pelvic Lymphnode Dissection in Early Stage Cervical Carcinoma and Comparing the Final Results with Open Radical Hysterectomy Control Cases (The First Pilot Study in Scandinavia) Sert MBV, Abeler VM. University of Oslo,RikshospitaletRadiumhospitalet HF, Oslo, Norway Study Objective: The purpose of this study was to investigate the feasibility of total laparoscopic radical hysterectomy and bilateral pelvic lymph node dissection in patients with early stage cervical carcinoma. (St Ia1/Ia2 with LVSI and St Ib1 < then 2cm) Design: 17 women were included in a case control study. All women underwent a type II–III piver radical hysterectomy with bilateral pelvic lypmh node dissection. In Laparoscopic group the surgery was performed with conventional laparoscopic techniques and the adequacy of the operation was determined and documented on video and final histopathology results were compared with historical open traditional radical hysterectomies. Bilateral ureter stent, Unipolar/bipolar coagulation, vascular surgical clips, Argon-beam coagulation, Endo GIA stapling and uterine manipulator were used in all laparoscopic cases. Setting: Gynecologic oncology and comprehensive cancer center teaching hospital. Patients: Nine patients was taken as a historical control group who were operated with open radical hysterectomy. Between April 2004 and August 2005 only 8 patients were offered the total laparoscopic radical hysterectomy. Intervention: The operation was performed entirely by laparoscopy in 8 patients. One patient underwent laparotomy because of equipment failure. Nine patients who had been operated traditionally has taken as a control group (case-control study). Measurements and Main Results: All operations were performed by same surgeon. All the lymph nodes were negative after cytokeratine ultrastaging. There were no ureteral injuries or fistula formation. No patients were reoperated due to postoperative bleeding and non of the patients has complained postoperative voiding dysfunction or constipation. Peroperative one cystotomy was repaired by laparoscope and one patient has developed postoperative acute compartment syndrome and treated with bilateral anterior tibial, fasciotomy. All patients remain clinically tumor free. Mean follow-up was 14 months (range 9–25) in laparoscopic group and 30 months (range 19–38) in open group. There is no radicality differences between this two groups; regarding to parametrium size, vaginal edge and number of pelvic lymph nodes. Bleeding was significantly minimal and the operation time was significantly longer in the laparoscopic group.

Conclusion: Based on this preliminary pilot study results, total laparoscopic radical hysterectomy with bilateral pelvic lymph node dissection for early stage cervical carcinoma patients is feasible and safe and associated with a minimal intraoperative bleeding and does not require postoperative blood transfusion. Needs longer follow-up time for recurrence and survival analysis.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 7—Hysteroscopy/Oncology (4:50 PM – 4:56 PM)

172 Laparoscopic Para-Aortic Lymphadenectomy: Initial Experience Volpi E, Ferrero AM, Sismondi P. University of Turin, Turin, Italy Study Objective: Para-aortic lymphadenectomy has been introduced about 15 years ago. In this paper we want to report about our experience in para-aortic lympadenectomy and some modified steps in the technique Setting: University of Turin. Patients: Twenty-seven patients undergoing para-aortic lymphadenectomy. Measurements and Main Results: We reviewed the videos of 27 patients undergoing para-aortic lymphadenectomy as a bioptic procedure or as part of a larger intervention. Three patients had only right inframesenteric lymphadenectomy. Twelve patients had bilateral inframesenteric lymphadenectomy, and 12 an infrarenal procedure. Indication to paradortic lymphadenectomy were ovarian restaging in 13 cases, preoperative staging of cervical cancer in 3, staging or restaging in endometrial cancer in 6. Six patients underwent paradortic lymphadenectomy in lymphoma. As a first step we incise the peritoneum on the right common iliac vein. Then we dissect on the aorta to the inferior mesenteric artery and we prepare the left inframesenteric space. Lymphadenectomy is performed from the right side of the patient and both operators stay on the same side. The right lymphadenectomy is performed subsequently standing on the left side of the patient. Bipolar coagulation was used to accomplish hemostasis. The median duration of the procedures was 97 minutes (range 45–180). The mean number of lymph nodes was 18 (range 5–40). The mean body mass index of the patients was 21.35 (19.05–30.21). Two patients had laparotomy: one to control a perforating vessel from the vena cava, and one because of technical difficulty in dissection of the lymph nodes. One lesion of the inferior mesenteric artery was controlled by laparoscopy. Conclusion: We believe that the advantages of laparoscopic para-aortic lymphadenectomy greatly overcome the traditional approach. However, technically the procedure is difficult for all the team. Starting from the left side in our hand is better because all the first part of the procedure need dissection of arterial vessels.

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WEDNESDAY, NOVEMBER 8, 2006 Open Communications 8—Endoscopic Surgery (3:50 PM – 3:56 PM)

173 “To Be or Not to Be” a Laparoscopic Surgeon, That is the 2006 Question Pregenzer GJ. Somerset Medical Center, Warren, New Jersey Study Objective: To review the cost effectiveness of laparoscopy surgery and the illogical struggle for appropriate fair remuneration. Design: Retrospective analysis. Setting: Private practice, community hospital. Patients: Eighty-six patients, ages 26–52 years. Intervention: Comparison of laparoscopic cystectomies, myomectomy, hysterectomy was compared to laparotomy. Measurements and Main Results: In virtually all cases, the cost of performing laparoscopy was more cost saving. The cost of every aspect of a patient’s surgical case, from the time the patient entered the hospital to the time they left was calculated and analyzed. In virtually all laparoscopic cases, the surgeon was penalized for performing laparoscopy. The laparotomies were actually reimbursed at a higher level and required less operative time. Conclusion: Most gynecologic surgeons in our geographic area are no longer performing laparoscopic surgery due the penalties levied on then by our health care insurance industry. Most of us truly believe the best surgical route most often is the laparoscopic route. But with the realities of medicine today, that being the escalating malpractice premiums and escalating overhead costs along with the inability to pass the cost on to the consumer, we surgeons placed in an uncomfortable situation deciding between financial survival and performing the fastest and best compensating surgical procedure. Our health insurance industry has determined what type of surgery we are to perform, rather a decision between patient and her surgeon. We need to convince our esteemed politicians to help us care for our patients properly with fair compensation and change to the absurd legal malpractice environment.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 8—Endoscopic Surgery (3:56 PM – 4:02 PM)

174 Applying Lean Management Principles to Patient Flow: How to Increase Patient Throughput and Reduce Surgical Turnover Times 1 Leyland NA, 1Singh SS, 2Shek R, 1Tolomiczenko GS. 1 St. Joseph’s Health Centre, University of Toronto; 2 University of Waterloo, Toronto, Ontario, Canada Study Objective: To illustrate and describe principles of patient flow assessment and lean management principles in a gynecologic endoscopy practice setting.

Design: Medical quality improvement project and observational study. Setting: Gynecologic endoscopy practice in a community academic hospital with a fellowship in minimally invasive gynaecology. Patients: Medical staff including nursing, physicians, trainees, housekeeping and maintenance staff. Intervention: 1) Process Analysis: Observation of patient flow through the operating room was conducted by an independent observer from the time of admission to time of discharge/transfer to hospital bed. (2) Cycle Time Measuring time taken by key components of patient flow in this setting including turnover time, cleaning time and staff-patient interactions. Bottlenecks are identified that are amenable to simple Intervention to reduce turnover time to an average of 15 minutes. Measurements and Main Results: A patient flow intake sheet was developed through observation of 27 surgical cases including 13 laparoscopic, 10 hysteroscopic, 3 combined and 1 laparotomy. This information was translated into a wireless PDA format through IT consultation allowing for monitoring of patient flow through a paperless “anywhere, anytime” method. Conclusion: Utilizing manufacturing sector concepts of process analysis, “just in time” and the “theory of constraints,” turnover time can be radically improved and patient throughput increased in a day surgical setting without significant resource input.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 8—Endoscopic Surgery (4:02 PM – 4:08 PM)

175 Traditional Incision versus Mini-Lap: Which Is Better? Rogers TL. Drexel University College of Medicine, Philadelphia, Pennsylvania Study Objective: To determine if the length of the surgical skin incision alters hospital stay, length of surgery, postoperative complications and/or pain management. Design: Data was analyzed for all laparotomies over an 18 month time period. A mini-laparotomy (mini-lap) incision was defined as any low transverse incision 6 cm or less. A traditional laparotomy incision was defined as any low transverse incision greater than 6 cm. Setting: This study was conducted based on cases performed at a tertiary care center. Drexel University College of Medicine, Hahnemann Hospital. All cases were performed by generalists in the department of obstetrics and gynecology. Patients: All patients included in the study had benign surgical indications and pathology. A total of 173 patients were retrospectively evaluated. Intervention: Blood transfusions were required and given in 6 cases. Measurements and Main Results: Comparison was made between a traditional incision and a mini-lap incision. Two

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groups were developed: mini-lap and traditional. Each group was evaluated for length of stay, length of procedure, estimated blood loss, post operative complications, defined as fever (> 100.4, 2 episodes at least 6 hrs apart after the first 24 hrs postoperative period), bleeding, and infection (documented by positive blood cultures). The average length of stay for traditional incisions being 2.75 days and 1.83 days for mini laparotomies. The procedure time was slightly increased for mini-laps at 209.2 minutes versus 199.2 minutes for traditional incisions. The traditional incision group had increased rates of postoperative complications. These complications included fever, 31% for traditional group versus 20% for mini-lap group, wound separation, 1 for traditional group versus none for the mini-lap group. There was a need for transfusion on 6 occasions in the traditional group while there were 0 transfusions in the minilap group. Estimated blood loss in the traditional group was 298 cc versus 195 cc in the mini-lap group. Postoperative ileus was noted to have an impact on the length of stay in the traditional group, but not in the traditional group. Conclusion: The study concludes that in the proper situation a mini laparotomy may be a more appropriate and/or advantageous incision for the patient. The length of stay was decreased, blood loss was decreased, length of procedure was slightly increased, most likely due to decreased visibility. Postoperative complications (fever, wound separation, transfusion, ileus) were also decreased. Minilaparotomies have proven to be more cost-effective with less patient complications.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 8—Endoscopic Surgery (4:08 PM – 4:14 PM)

176 Simultaneous and Combined Surgery in Patients with Gynecologic and Associated Diseases Kiselev SI, Chuprynin VD, Makiyan ZN, Adamyan LV. Moscow State University of Medicine and Dentistry, Moscow, Russian Federation Study Objective: To evaluate efficacy of surgery for associations of gynecologic and extragenital conditions. Design: Retrospective analysis of 97 cases of associated gynecologic and extragenital conditions, managed by simultaneous surgery. Setting: Department of Reproductive Medicine and Surgery of Moscow State Medical-Stomatologic University, Moscow, Russia. Patients: One hundred twenty-one patients (aged 18–69 yrs) with associations of gynecologic (myoma, endometrial hyperplasia, adenomyosis, ovarian mass, endometriosis, pelvic floor relaxation) and extragenital pathology (appendicitis, cholecystitis, stress urinary incontinence, thyroid struma). Intervention: One hundred twenty-one patients underwent simultaneous laparoscopic and/or vaginal procedures: cho-

lecystectomy + hysterectomy, salpingoophorectomy or pelvic floor reconstruction (41 patients), appendectomy + hysterectomy, myomectomy, ovarian resection (36 patients); laparoscopic gynecologic surgery was combined with resection of thyroid gland in 21 women with TVT in 35 cases. Measurements and Main Results: Operating time, blood loss, postoperative hospital stay were evaluated and compared to the parameters of analogous procedures performed alone, showing reduction of total operating time by 1.5 times, blood loss by 1.4 times, hospital stay by 2 times with no intra- or postoperative complications occurred. Conclusion: Simultaneous surgery in patients with associated gynecologic and extragenital conditions allows to carry out treatment of all pathology within one procedure and anesthesia, thus reducing overall trauma, stress, and negative impact on the patient’s health and quality of life.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 8—Endoscopic Surgery (4:14 PM – 4:20 PM)

177 Laparoscopic Adnexal Surgery for Post-hysterectomy Patients Lee HW, Choi J, Kyung YS; Jung US; Lee KW; Han JS. Seoul Division of Gynecologic Oncology and Gynecologic Minimally Invasive Surgery, Seoul, Korea Study Objective: To evaluate the feasibility and effectiveness of laparoscopic adnexal surgery for post-hysterectomy patients. Design: Retrospective clinical study (Canadian Task Force Classification III). Setting: University teaching hospital. Patients: Fifteen post-hysterectomy patients with adnexal mass. Intervention: Operative laparoscopy. Measurements and Main Results: From February 2004 to April 2006, we reviewed the medical records of 15 post-hysterectomy patients who received laparoscopic adnexal surgery including age, parity, type of hysterectomy, operative indications, histopathological diagnosis, operating time, size of adnexal tumor, change in the hemoglobin level, hospital stay, and occurrence of any complications. Among 15 patients, 7 of them previously received TAH, 6 patients received TAH with unilateral adnexal surgery whereas one patient received LAVH and the other recieved TLH. The median age of patients was 47 years (range 36–51), and the median parity was 2 (range 0–3). The median operating time was 45 minutes (range 35–120), and the median size of the adnexal mass was 7.4 cm (range 4.3–11.2). The median change in hemoglobin level was 1.7 g/dL (range 0.6–2.8). The median hospital stay was 4.0 days (range 3–7). Median time of gas-out after operation was 31 hours (range 14–50). Histopathological diagnosis included 4 cases of mucinous cystadenoma of the ovary, 3 cases of serous cystadenoma of the ovary, 3 cases of functional cyst of the ovary, 3 cases of

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hydrosalpinx, 1 case of fibrothecoma, and 1 case of tuboovarian abscess. Pelvic adhesions were found in all patients. Post-TAH patients revealed more severe adhesion between omentum and peritoneum as well as adnexal mass and rectum than post-laparoscopic hysterectomy patients. If incision type of hysterectomy was low midline, patients revealed more severe adhesion of peritoneum and omentum than pfannenstiel incision. Particularly for left adnexal mass, adhesion with rectum was very extreme that longer operating time was necessary than the operation of right adnexal mass. There were no intraoperative or postoperative complications and no conversion to laparotomy. Conclusion: The specialist of laparoscopic surgery is capable of achieving successful result by performing laparoscopic surgery primarily to patients with adnexal mass such as post-hysterectomy patients who are expected to suffer severe adhesion. Furthermore, high expertise of surgical technique can significantly reduce occurrences of any operative complications and benefit from laparoscopic surgery for fast recovery of patients.

tracheal intubation and mechanical ventilation. Protocol 1: During the 1 hour procedure, PitO2 was continuously monitored using a polarographic oxygen electrode. Protocol 2: PitO2 was continuously monitored during anesthesia alone, CO2 or air pneumoperitoneum and laparotomy within the same mice. Measurements and Main Results: PitO2 was significantly higher in the low IPP-CO2 pneumoperitoneum group with CRS than in the other groups except the low IPP-CO2 pneumoperitoneum group without CRS. PitO2 during a CO2 pneumoperitoneum at the low IPP (104.2 ± 7.8 mm Hg, mean ± SEM) were elevated approximately two fold over the levels during laparotomy (49.8 ± 15.0 mm Hg). This elevation was not seen with air insufflation. Conclusion: This study provides a new insight on peri-operative peritoneal physiology. The use of a low IPP during laparoscopic surgery may, through minimization of hypoxia, reduce the incidence of complications such as postoperative adhesions formation.

WEDNESDAY, NOVEMBER 8, 2006 WEDNESDAY, NOVEMBER 8, 2006 Open Communications 8—Endoscopic Surgery (4:20 PM – 4:26 PM)

178 Peritoneal Tissue Oxygen Tension During a Carbon Dioxide Pneumoperitoneum in a Mouse Laparoscopic Model With Controlled Respiratory Support 1 Canis M, 1Matsuzaki S, 1Bourdel N, 1Pouly JL, 2Bazin JE, 1 Mage G. 1CHU – Polyclinique de l’Hôtel Dieu, Gynécologie Obstétrique Médecine de la Reproduction, Clermont-Ferrand, France; 2Département d’Anesthésie Réanimation, l’Hôtel Dieu, Clermont-Ferrand, France Study Objective: Animal experiments suggested that the laparoscopic peritoneal environment is hypoxic. Given that hypoxia has many adverse effects on biological systems, it is plausible that it may contribute to the formation of adhesions or to the growth of malignant cells. There is no study, however, that investigates the relationship between ventilation, intraperitoneal pressure (IPP) and the surgical peritoneal environment to the development of hypoxia. The objective of this study was to monitor the peritoneal tissue oxygen tension (PitO2) under various surgical peritoneal environment. Design: Protocol 1: Mice were randomly divided into four groups of 10 animals each: anesthesia alone, CO2 pneumoperitoneum at low (2 mm Hg) or high (8 mm Hg) IPP and laparotomy. Groups were further subdivided into those with or without CRS. Protocol 2: Mice anesthetized with CRS were randomly divided into two groups of three animals each: CO2 pneumoperitoneum and Air pneumoperitoneum at 2 mm Hg. Setting: Academic research center. Patients: Adult, female C57BL6 mice. Intervention: CRS was enabled by videoendoscopic endo-

Open Communications 8—Endoscopic Surgery (4:26 PM – 4:32 PM)

179 Torsion of Normal Adnexa in Post-Pubertal Women is Associated with a Significant Recurrence Rate: Possible Role for Preventive Oophoropexy Pansky M, Smorgick N, Herman A, Schneider D, Halperin R. Assaf Harofe Medical Center, Zerifin, Israel, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel Study Objective: Torsion of normal adnexa in young females is possibly due to excessive mobility of the ovarian supportive ligaments. The purpose of this study was to compare the incidence of recurrent torsion of normal compared to abnormal adnexa in pubertal women and question current patient management. Design: All cases of surgically confirmed adnexal torsion operated in our department from January 2002 to April 2006 (68 cases, 62 females) were retrospectively analyzed. The cases were classified as torsion of pathologic adnexa versus torsion of normal adnexa based on the pre and post operative pelvic sonogram, the operative findings and the pathologic diagnosis (where available). The torsion recurrence rate was estimated with data from medical records (in all patients) and from a telephone interview (in patients with torsion of normal adnexa). Setting: Obstetrics and gynecology department of a universityaffiliated medical center. Patients: Twelve women with torsion of normal adnexa were compared to 50 women with torsion of pathologic adnexa. Measurements and Main Results: The torsion recurrence rate was 58.3% (7 out of 12) in the group of patients with twisted normal adnexa, compared with 8% (4 out of 50) in the group of patients with twisted pathologic adnexa (p < 0.01). Recurrent torsion of normal adnexa involved the

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ipsilateral side (n = 4, 57.1%) as well as the contralateral side (n = 3, n = 42.9%). The group of patients with twisted normal adnexa was characterized by a younger mean age (25.5 ± 7.9 years vs. 31.4 ± 11.4 years, p = 0.04) and lower mean parity (0.33 vs. 1.1, p = 0.02). The clinical presentation (i.e., abdominal pain, nausea/vomiting, fever) of patients with twisted normal adnexa compared with twisted abnormal adnexa was similar, as was an elevated white blood cell count of > 11,000 cell/mL (26.7% vs. 33.9% respectively, p = 0.7), and the mean time from admission to surgery (18.2 hours vs. 17.5 hours respectively, p = 0.9). Conclusion: The current adnexa sparing laparoscopic management of adnexal torsion by simply untwisting them may predispose to recurrent torsion of normal adnexa. Oophoropexy procedures may prevent further torsion events and should be considered in patients with twisted normal adnexa.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 8—Endoscopic Surgery (4:32 PM – 4:38 PM)

180 Apple Peeling the Uterus: An Effective One Piece Uterine Vaginal Morcellation Technique during Total Laparoscopic Hysterectomy Mashiach R, Soriano D, Stockheim D, Zolti M, Shiff E, Goldenberg M. The Chaim Sheba Medical Center, Ramat Gan, Israel Study Objective: Total laparoscopic hysterectomy (TLH) is a safe procedure even for enlarged non prolapsed uteri. One of the major obstacles in the way of wider acceptability of this technique is its time consuming nature. The morcellation of the uterus has been determined as the rate limiting step of TLH, since precious minutes are often required to complete this procedure, especially in obese or nulliparous women. Many of the commonly employed methods for uterine morcellation are potentially dangerous, and slow. We describe a new “apple peel” method that is unique for TLH, and not adopted from vaginal hysterectomy. In this method the morcellation is done in the vagina, and not the abdomen, the scalpel is always directed at the posterior vaginal speculum blade, and the uterus is extracted in one piece. Setting: An academic referral center. Patients: Over 100 patients operated in our hospital since 2004. Intervention: Total laparoscopic hysterectomy. Measurements and Main Results: We found this method in over 100 consecutive patients to be safe and fast. No vaginal or other lacerations were encountered. Conclusion: We describe a new safe and fast morcellation technique. we believe that it requires less force and therefore may produce less trauma to the vaginal vault and suspension.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 8—Endoscopic Surgery (4:38 PM – 4:44 PM)

181 Current Update of Laparoscopic Uterine Suspension by the Elevest Technique Schwartz M. Lifeline Medical Associates, Piscataway, New Jersey Study Objective: To determine the short and long term effectiveness of the Elevest procedure for uterine prolapse, both symptomatically by patient assessment and objectively by POP-Q measurement. Design: Patients eligible and willing to follow-up over the course of the evaluation were entered. The intended duration of the study is 2 years. Setting: All evaluations were performed in the office. The procedure was performed at a private hospital on an outpatient basis. Patients: Eighteen patients with symptomatic uterine prolapse who desired uterine retention have been enrolled to date. Intervention: Laparoscopic suturing of the uterosacral and round ligaments by investing with permanent suture utilizing the Elevest procedure kit. Measurements and Main Results: Patients were assessed on several symptom and pain parameters preoperatively and at various predetermined times postoperatively. They also underwent POP-Q assessment in a similar manner. The results to date demonstrate a high success rate by both patient assessment and objective measurement. The patient symptom assessment revealed an average improvement in all symptoms of 67.8% at 3 months and 85.5% at 1 year. POP-Q scores improved 75.7% at 3 months and 49.8% at 12 months. To date, of the 18 patients, only one required hysterectomy subsequent to the Elevest procedure. Conclusion: This minimally invasive procedure effectively corrects uterine prolapse while using the patient’s own ligament support and offers women, who so desire, an alternative to hysterectomy. Results indicate a persistent benefit in most women at one year follow-up.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 8—Endoscopic Surgery (4:44 PM – 4:50 PM)

182 Pain and Quality of Life after Laparoscopic Presacral Neurectomy in Young Women 1 Nevin AC, 1,2Singh SS, 3Mansfield RW, 4Tolomiczenko G, 1,2 Leyland NA. 1University of Toronto; 2St. Joseph’s Health Centre, Department of Obstetrics and Gynecology,, Division of Gynecologic Endoscopy; 3Faculty of Medicine, University of Toronto; 4St. Joseph’s Health Centre, Research Department, Toronto, Ontario, Canada Study Objective: To determine whether LPSN for refractory or advanced pelvic pain improves pain and quality of life

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in young women. Design: Retrospective cohort study including follow-up telephone interviews. Setting: Advanced gynecologic endoscopy practice within a community academic hospital. Patients: Young women, defined as less than or equal to age 25 at the time of procedure, who underwent LPSN for pelvic pain between October 2003 and March 2006 by a single gynecologic endoscopic surgeon. Intervention: LPSN was performed with CO2 laser and diathermy to facilitate neural tissue excision. All eligible patients were contacted via telephone. Patients were asked to complete: (1) verbal pain scales for current and retrospectively for preoperative and 6 months postoperative status; (2) the SF-36v2™ Health Survey; and (3) an overall cure rate and level of satisfaction survey. Measurements and Main Results: Eleven patients were identified as meeting the study age criteria from a possible of 124 LPSN cases. Seven patients were successfully contacted and agreed to participate. Mean age and time since LPSN was 23.3 years ± 2.0 and 16 months ± 9, respectively. Concurrent endometriosis resection occurred in 5/7 patients. 3/7 patients were “very happy” with the results of their operation, while 1 subject was “unhappy” with the results. Subjective pain scale results (baseline, 6 months post and current) for dyspareunia (9.3 ± 0.8, 5.8 ± 1.0, 5.5 ± 3.4, respectively), dysmenorrhea (9.6 ± 0.8, 5.5 ± 3.4, 6.1 ± 3.2, respectively) and chronic pain (9.0 ± 1.2, 4.2 ± 3.7, 4.8 ± 4.3, respectively) all improved. Complete analysis of quality of life results will be presented. Conclusion: Preliminary results reported here for a small cohort of young women show a trend to improvement in pelvic pain parameters and overall patient satisfaction with LPSN. Current literature does not satisfactorily assess the role of aggressive surgical management of pelvic pain in young women including long-term quality of life issues. Larger cohort trials are needed to evaluate the young patient.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 8—Endoscopic Surgery (4:50 PM – 4:56 PM)

183 Alexithymia and Quality of Life in Gynecologic Surgery 1 Bruni R, 1Battista C, 1Angioli R, 1Muzii L, 1Zullo MA, 1 Marullo E, 1Terranova C, 1Cafà E, 1Sereni MI, 1Vulcano E, 2Benedetti Panici P. 1Università “Campus Bio-Medico” di Roma, Rome, Italy; 2Università degli Studi di Roma “La Sapienza,” Rome, Italy Study Objective: Most studies evaluating quality of life after surgical or medical treatment made use of questionnaires which considered the subjective perception of life quality. Nonetheless, only few studies took into consideration the variability introduced by personality factors. In order to verify the influence of the personality trait in the evaluation of life quality, we analysed the effect of alex-

ithymia on the outcome of gynaecological surgery. The purpose of the present study was to investigate the prevalence of alexithymia by using Toronto Alexithymia Scale20 (TAS-20) and to examine the relationship between alexithymia and self-reported descriptors of quality of life in gynaecological population. Design: Forty consecutive patients, suffering from a benign gynaecological pathology, were enrolled in the study; twenty of them underwent laparoscopy and twenty laparotomy. All patients were evaluated in a semi-structured interview in which personal, medical and social data were collected. They were provided with a set of questionnaires that included both measure of alexithymia (TAS-20) and quality of life perception (The Medical Outcomes Study shortform general health survey-36, known as the SF-36). The patients were assessed before the surgical procedure and 1 month postoperatively. Setting: University Hospital–Gynaecology Division. Patients: Forty consecutive patients (mean age 50 years). Intervention: Patients were provided with a set of questionnaires that included both measure of alexithymia and quality of life perception. Measurements and Main Results: Gynaecological patients were separated in two groups, with respect to the TAS questionnaire score: the high-level alexithymia group (HA), with scores above 61, and the low-level alexithymia group (LA), with scores below 51. Conclusion: We observed significant statistical differences between LA and HA in each surgical group. Our data reveals that the subjective QoL tested with SF36 in gynaecological patients undergoing surgery is clearly influenced by the level of alexithymia.

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184 Development of a Laparoscopic Mouse Model with Controlled Respiratory Support by Videoendoscopic Endotracheal Intubation and Mechanical Ventilation 1 Canis M, 1Matsuzaki S, 1Bourdel N, 1Pouly JL, 2Bazin JE, 1 Mage G. 1CHU – Polyclinique de l’Hôtel-Dieu, Gynécologie Obstétrique Médecine de la Reproduction, ClermontFerrand, France; 2CHU – Département d’Anesthésie Réanimation, Hôtel Dieu, Clermont-Ferrand, France Study Objective: Continued advancement of the field of laparoscopic surgery depends on the use of adequate animal models. A serious limitation of many of the laparoscopy experiments performed in rodents is the lack of attention paid to confounding factors including whether respiratory support was used, and what insufflation pressures were used. The objective of this study was to develop laparoscopic a mouse model to obtain results that are generalizable to the clinical setting. Design: Mice were randomly divided into four groups of 10 animals each: anesthesia alone, CO2 pneumoperitoneum at

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low (2 mm Hg) or high (8 mm Hg) intraperitoneal pressure (IPP) and laparotomy. Groups were further subdivided into those with or without CRS. Setting: Academic research center. Patients: Adult, female C57BL6 mice. Intervention: CRS was enabled by videoendoscopic endotracheal intubation and mechanical ventilation. A rigid 2 mm endoscope was used to visualize the vocal cords. Mice were ventilated with a tidal volume of 200 mL at 250 strokes (laparoscopy) or 220 strokes (laparotomy, control) per minute. Anesthesia was maintained by 2% isoflurane. Arterial blood gas analysis was performed at the end of the 1 hour procedure. Measurements and Main Results: Mice in the CO2 pneumoperitoneum groups without CRS developed a hypercarbic acidosis, regardless of the IPP (pH: low IPP: 7.260 ± 0.012; high IPP: 7.155 ± 0.027, mean ± SEM). In addition, mice in the high IPP-CO2 pneumoperitoneum groups without CRS developed mild hypoxemia (PaO2: 70.2 ± 17.7 mm Hg) and those with CRS were mildly acidemic (pH: 7.269 ± 0.041). Blood gas parameters for all of the other groups were within the normal range. Conclusion: This study demonstrates that both the use of an IPP in proportion to the animal’s size and mechanical ventilation, are necessary to obtain near physiological conditions in the rodent that are comparable to the clinical setting.

was used to collate participant opinions through a series of evaluation, reevaluation and feedback sessions. Consensus is reached once the final list of competencies has been agreed upon by participants. This anonymous process is realized through a combination of paper and online communications. Surveymonkey was utilized to create online surveys. Measurements and Main Results: Using a national group of endoscopy educators, a set of core competencies for gynecologic endoscopy was developed for Ob/Gyn resident education. The key competencies have been developed to conform to the CanMEDS 2005 format, under the heading Medical Expert and subheadings of “Knowledge” and “Technical Skills.” Conclusion: The document developed from this expert consensus represents the first national endeavor to build a standardized, contemporary and competency based curriculum for gynecologic endoscopy teaching. Ultimately, such initiatives may enhance ob/gyn residency education, improve resource allocation, and better utilize regional surgical skills laboratories. Moreover, inter-departmental national teaching projects foster participation and cooperation among academic ob/gyn units, resulting in shared ownership, teaching excellence, and commitment to patient safety.

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185 National Consensus and Collaboration to Determine Core Competencies for Gynecologic Endoscopy Education in Ob/Gyn Residency Training 1,2,3 Singh SS, 1,2,3Ternamian AM, 1,2,4Martin DK, 2,4 Shapiro H, 1,2,6Tolomiczenko GS. 1St. Joseph’s Health Centre; 2University of Toronto; 3Division of Gynaecologic Endoscopy; 4Department of Family Medicine; 5Mount Sinai Hospital; 6Department of Research, Toronto, Ontario, Canada Study Objective: To determine the core competencies for gynecologic endoscopy education in ob/gyn residency training by national expert consensus. Design: Expert consensus using the Delphi technique. Setting: Academic ob/gyn residency programs across Canada. Patients: Sixteen endoscopy educators, one from each ob/gyn residency training program, were identified by program directors to represent their department. A core group of education and curriculum development experts have also been recruited to aid in the development of the overall endoscopy curriculum. Intervention: Following a literature search and review of national and international specialty society guidelines, a comprehensive list of gynecologic endoscopy competencies was compiled. The Delphi Technique for consensus building

Collaboration in Academic Endoscopy: Building Bridges to Improve Education 1,2,3 Ternamian AM, 1,2,3Singh SS, 1,2,4Tolomiczenko GS, 1,2,3 Leyland N. 1St. Joseph’s Health Centre; 2University of Toronto; 3Division of Gynaecologic Endoscopy; 4 Department of Research, Toronto, Ontario, Canada Study Objective: (1) To discuss the importance of collaboration among academic gynecologic endoscopists. (2) To highlight techniques that may be used for consensus building among thought leaders and educators in the field. Measurements and Main Results: To foster an academic initiative at the national level, consensus among leaders in endoscopy training is required. This exercise demonstrates that collaboration among specialists across the country and internationally is required to further endoscopy education and research. A review of the medical and business management literature offers various techniques and approaches to encourage collaboration, promote partnerships and ensure ownership. This presentation highlights use of the Delphi Technique, for consensus building, as one option for improving academic endoscopy education. Whole Image Negotiation (WIN) and Walk in the Woods Conflict Resolution Methodology of Marcus are also described as mechanisms to achieve consensus. Conclusion: Through a better understanding of individual and team dynamics one may foster collaboration to further academic endoscopy education and practice. The multitude of practice types, approaches and opinions may be brought

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to the forefront to enhance our understanding of what is standard of care, evidence based medicine and how to best navigate the vast amount of knowledge in our field.

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Objective Measurement of Residents’ Laparoscopic Competency Using a Training Model Protocol Fanning J, Bell R, Maseelall P, Fenton B, Flora R. Summa Health System, Northeastern Ohio Universities College of Medicine, Akron, Ohio

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187 Does Model Laparoscopy Training Improve Surgical Dexterity and Economy of Movement During Virtual Reality Laparoscopy? Clevin L. University Hospital Copenhagen, Gentofte, Hellerup, Denmark Study Objective: Model laparoscopy trainers are difficult to validate, whereas virtual reality (VR) trainers offer a computer based analysis of several parameters instantaneously. The same validation of laparoscopic skills training on real models requires a complicated setup, with time and precision being the only objective parameters. These may be too crude to assess improvement. Our aim was to validate a low cost model trainer, using improvement in skill assessed by a VR system (LapSim, Surgical Science, Gothenburg, Sweden). Design: Randomised study of laparoscopic skill performance on LapSim before and after training on a model trainer. Setting: Gynaecological Division, Alpha Institute, University Hospital of Copenhagen, Frederiksberg, Denmark and Surgical Dept., University Hospital of Copenhagen, Glostrup, Denmark. Patients: Sixteen gynaecology registrars with no previous laparoscopic experience. Intervention: The participants were randomised into two groups, A and B. Both groups completed seven basic training tasks on LapSim and scores were obtained. Group A trained a further three hours on a low cost model trainer. Group B did no further training. One week later, both groups were re-assessed using the same parameters on LapSim. Measurements and Main Results: The following parameters were assessed: 1) Time and error score; 2) Drift, instrument path + angular length, camera path + angular length (economy of movement parameter); and 3) Tissue damage (error parameter). Group A performed significantly better in economy of movement (p = 0.001), time (p = 0.001) and tissue damage (p = 0.036) parameters. Conclusion: Basic laparoscopic skill training on a low cost model trainer improves performance as assessed using VR system LapSim. Trainees who used the model trainer showed significant improvements compared to those who did not. Further validation of model trainers is needed to assess where a transfer of skill to live surgery occurs.

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188

Study Objective: Development of a laparoscopic training model to be used as an objective measurement of residents’ laparoscopic competency. Design: A laparoscopic trainer was created. Three laparoscopic training procedures were developed: 1) bead/pompom drop, 2) checkerboard drill, and 3) bead manipulation. Setting: Community-based, university affiliated ob/gyn residency program Patients: Eight senior and fifteen junior residents were timed performing the three procedures. Intervention: All residents that underwent the training had their times measured and the best time was used. Median times for the senior residents and junior residents were calculated. Comparing the senior to junior residents, specific competency times were established. Measurements and Main Results: The median time (in seconds) for completion of the laparoscopic training procedures is shown below. Competency time was calculated at 120% of senior residents’ time. Table

Bead/pom-pom Checkerboard Bead Manipulation

Senior Residents

Junior Residents

Competency

86 50 95

139* 83* 268*

100 60 115

Values are median times in seconds * p < 0.05

Conclusion: The laparoscopic training model utilized in the study can provide objective measurement of resident laparoscopic competency. Our trainer can be manufactured for $275 in conjunction with existing laparoscopic equipment. Interns expected to accomplish drills in allotted time by end of PGYI year. We are now in the process of developing competencies for our senior residents.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 9—Education (4:20

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189 Effect of In-house Laparoscopic Skills Training at the Royal Women’s Hospital, Melbourne, Australia Ang WC, Thomas P, Mohamed-Noor K, Healey M. Royal Women’s Hospital, Melbourne, Australia Study Objective: An evaluation of the results of training resident medical officers in basic laparoscopic skills on a

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continuing basis in the year 2004–2005. Design: Prospective cohort study. Setting: Royal Women’s Hospital. Patients: Unaccredited and accredited trainees in the Australian obstetrics and gynaecology training programme at the Royal Women’s Hospital, Melbourne, Australia. Intervention: Trainees were given 6 laparoscopic tasks to perform. These included simple dominant hand tasks, alternating hand tasks, and tasks requiring simultaneous use of both hands. Each task was to be repeated a number of times, and performed with each hand. Trainees were also offered the option to return for further episodes or attendances of training. Each task was evaluated and recorded at the time it was performed. Measurements and Main Results: It was clearly demonstrated that repetitions significantly improved the performance of each task at each episode. However, beyond 3 episodes or attendances, there was a limit to the improvement in scores for most of these tasks. For half the tasks, tasks performed with the right hand consistently scored better than if performed with the left hand, despite repetitions. Advanced trainees performed better than junior trainees although the results were not consistent with each additional year of training. Conclusion: In-house laparoscopic skills can be a useful supplement to actual operating theatre sessions. Our results demonstrate improvement in performance in repetitions during each attendance, as well as cumulative number of attendances over time. Trainees approaching specialist qualification can still benefit from these exercises.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 9—Education (4:26

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190 Assessing the Learning Curve for Laparoscopic Supracervical Hysterectomy Ghomi A, Prasad A, Littman P. University at Buffalo, Buffalo, New York Study Objective: To assess the learning curve for laparoscopic supracervical hysterectomy (LSH). Design: Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2). Setting: University-affiliated teaching hospital. Patients: Fifty women who underwent LSH for benign gynecologic disease. Intervention: Laparoscopic supracervical hysterectomy. Measurements and Main Results: We analyzed the first 50 consecutive LSH procedures performed by a team of two gynecologic laparoscopists to examine whether there was a learning curve as defined by a decrease in operative time, complications rate and blood loss as sequence increased. There was a weak linearly decreasing trend in operative time; however, this did not reach a statistical significance (p = .14). In order to test whether there was a non-linear relationship between operative time and sequence, a second

regression was performed to include a quadratic effect, which was not statistically significant (p = .21). There was little evidence of a linear relationship between percentage drop in Hgb and sequence, linear (p = .058) and non-linear (p = .39). The complication rate was too small to lead to any conclusion. BMI, uterine weight and a history of Cesarean section did not seem to be cofounders with respect to the relationship between operative time and sequence. Conclusion: This study did not find any evidence to suggest that there is a learning curve for LSH when performed by skilled laparoscopic gynecologists.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 9—Education (4:32

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191 What is the Value of History Taking in Women with Suspected Endometriosis? Lam AM, Condous GS, Royal North Shore Hospital, University of Sydney, Centre for Advanced Reproductive Endosurgery, Sydney, New South Wales, Australia Study Objective: To determine whether there is any correlation between presenting complaints and the presence of endometriosis at laparoscopy in women who present to a tertiary referral unit. Design: Prospective observational ongoing study. All women who presented to Centre for Advanced Reproductive Endosurgery had thorough history taken. If symptoms were suggestive of endometriosis, these women underwent laparoscopy. Biopsies were taken at laparoscopy to confirm the presence of endometriosis histologically. The presence or absence of different presenting complaints was correlated with biopsy positive confirmation of disease. For example, if woman presented with lower back pain the number of positive biopsies was compared to the group who presented without lower back pain. The difference between the numbers of positive biopsies for a given symptom was evaluated using Mann-Whitney test. P values < 0.05 represented statistical significance. 21 different presenting complaints were evaluated. Site-specific pain (left iliac fossa, right iliac fossa, lower abdominal pain and lower back pain) was also compared to location of histology positive disease at laparoscopy. Setting: Centre for Advanced Reproductive Endosurgery. Intervention: Performing excisional biopsies of endometriosis. Patients: One hundred and four consecutive women who underwent laparoscopy and biopsy for endometriosis. Measurements and Main Results: 104 consecutive women presented and underwent laparoscopy. Mean age 34.3 years (range 20–52). 63.5% (66/104) had history of previous endometriosis. Menorrhagia was the only significant historical variable. If menorrhagia was present, the average % of positive biopsies for endometriosis was 63% compared to 81.5% if menorrhagia was absent (p = 0.025). Site-specific pain did not correlate with the location of the disease. Conclusion: Site-specific pain does not correlate with location

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of disease. History taking is of limited value in predicting the presence of endometriosis. Dysmenorrhoea and dyschezia do not correlate with the presence of endometriosis in our unit.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 9—Education (4:38

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192 Retrospective Analysis of 356 Cases of Hydrothermal Ablation, Dilitation and Curretage With Paracervical Block Garcia MA. North Florida OBGYN, Jacksonville, Florida Study Objective: To assess the efficacy, safety, and discomfort of hydrothermal ablation, D&C, with paracervical block in the evaluation and treatment of abnormal uterine bleeding. Design: Retrospective analysis of 356 cases of hydrothermal ablation, D&C, with paracervical block. Setting: North Florida private gynecology practice. Patients: Three hundred and fifty-six women (ages 27–61) with abnormal uterine bleeding. Intervention: No pretreatment and hydrothermal ablation, D&C with paracervical block. Measurements and Main Results: Ninety-seven percent reported significant improvements with 50% ammenorrhea; 45% hypomenorrhea and 2% eumorrhea; 3% failed to report improvement and in those half underwent hysterecomy. Another 10 patients also underwent hysterectomy for various reasons; mostly pain or cramping. Only 2 cases were not able to be completed for the full 10 minutes and both of these were satisfied with results. No definite perforations occurred nor was there any reported infection. Discomfort was minimal and all patients were observed and discharged the same day of surgery. D&C was done following the ablation and was not felt to alter the outcome nor hinder the pathologist in his interpretation of the curretings pathology. Conclusion: Hydrothermal ablation with Boston Scientific Instrumentation is a safe and effective treatment of abnormal uterine bleeding which can be done with minimal discomfort and recovery time.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 9—Education (4:44

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193 Global Endometrial Ablation Using the NovaSure Device Immediately Following Hysteroscopic Myomectomy Hopkins MR, El-Nashar SA, Famuyide AO. Mayo Clinic, Rochester, Minnesota Study Objective: To review the feasibility and efficacy of performing NovaSure endometrial ablation immediately following hysteroscopic myomectomy. Design: Retrospective Cohort Study (Canadian Task Force Classification II-2). Setting: Midwestern Academic Medical Center. Patients: Using a record linkage system, we identified 32

women who underwent concurrent hysteroscopic myomectomy and NovaSure endometrial ablation between January 2004 and May 2006. Three women were excluded on the basis of failing to provide authorization to their records. The final cohort included 29 women. Intervention: Hysteroscopic myomectomy followed immediately by endometrial ablation with the NovaSure Device. Measurements and Main Results: The mean age of the women was [45.2 + 4.9 years, 95%CI (43.4–47.1)], median parity was 2 (range 0–4), and the mean BMI was [26.3 + 6 kg/m2, 95%CI (23.8–28.7)]. In one patient (3%) the NovaSure device malfunctioned. In the remaining 28 women the fibroid was classified as class 0 in 8 (28%), class I in 20 (69%) and class II in one woman (3%) with an overall mean diameter of [2.4 + 0.83 cm, 95% CI (2.1– 2.8)]. The mean cavity length was [6 + 1 cm, 95% CI (5.6–6.4)], and the mean width was [4.2 + 0.7 cm, 95 % CI (4–4.3)]. The mean ablation time and power density were [66 + 19.6 seconds, 95%CI (59.2–74.4)] and [135.5 + 23.3 watt, 95%CI (126–144.9)], respectively. There were no intraoperative or early post operative complications encountered. The mean follow-up was [10.7 + 8.3 months, 95%CI (7.6–13.9)]. There were no hysterectomies or re-ablations performed for treatment failures during the study period. Conclusion: NovaSure endometrial ablation can be safely and reliably performed following hysteroscopic myomectomy in women with submucosal leiomyoma which distort the uterine cavity. Our preliminary data supports a favorable long-term outcome.

WEDNESDAY, NOVEMBER 8, 2006 Open Communications 9—Education (4:50

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194 Should Gynecologists Perform More Appendectomies During Laparoscopy? 1 El-Nashar SA, 1Hopkins MR, 2Pruthi RK, 3Barnes SA, 1 Gebhart JB, 1Cliby WA, 1Famuyide AO. 1Department of Obstetrics and Gynecology; 2Division of Hematology, 3 Division of Biostaticts, Mayo Clinic, Rochester, Minnesota Study Objective: Should gynecologists perform appendectomy when finding signs of chronic infection? Design: Retrospective study of laparoscopic appendectomies in patients with chronic abdominal pain in the past 5 years. Setting: Day clinic. Patients: Eighty patients. Intervention: Laparoscopic appendectomy. Measurements and Main Results: Two cases of a carcinoid of the appendix in an early stage and one case of a ruptured mucocele with beginning pseudomyxoma peritonei were found. No complications occurred. Do these findings justify removal of the appendix by gynecologists when an appendix with pathologic features are encountered. Three cases of potentially lethal appendix diseases were found after removal of the appendix for chronic pelvic pain. Two carci-

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noids were diagnosed in an early stage so that both patients can be considered cured after right side hemicolectomy was performed. One patient with the psudomyxoma peritonei remains without symptoms. Conclusion: Laparoscopic appendectomy is an easy procedure and has a low complication rate. It should be performed by gynecologists when signs of chronic infection are found. In some cases early appendectomy may be life-saving.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (12:35 PM – 12:41 PM)

195 Anesthesia for Office Procedures Glasser MH. Kaiser Permanente Medical Center, San Rafael, California Study Objective: To describe the office anesthesia regimens consisting of minimal oral sedation combined with paracervical/intracervical block used for in-office gynecologic procedures. These include HydroTherm Ablation (HTA), hysteroscopic sterilization using the Adiana and Essure systems, diagnostic and minor operative hysteroscopy and suction curettage for pregnancy termination and miscarriage. Design: A retrospective review of gynecologic procedures performed in the medical office over the last 20 years which were previously performed in the operating room. Setting: A suburban medical center which is part of a large prepaid health maintenance organization. Patients: Pregnancy terminations (10000) both elective and missed abortions over 20 years, 1200 diagnostic and minor operative hysteroscopies over 12 years, 265 HTAs over 5 years and 40 hysteroscopic steilizations using the Adiana and Essure systems over 2 years. Intervention: Minimal oral sedation using NSAIDs, diazepam and Hydrocodone/Acetaminophen in addition to intramuscular Ketorolac and paracervical/intracervical block. Measurements and Main Results: Only 1 procedure was discontinued because of pain. Conclusion: HTA, hysteroscopic sterilization, diagnostic and minor operative hysteroscopy (polypectomy), and suction curettage can be performed in the medical office using minimal oral sedation and paracervical block.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (12:41 PM – 12:47 PM)

196 Feasibility of the Administration of IV Conscious Sedation for Hysteroscopic Procedures in the Office Setting Kulbersh D, Davis J. Lexington Medical Center, West Columbia, South Carolina Study Objective: To evaluate the feasibility of conducting various hysteroscopic procedures (including D&C and/or

polyp removal), thermal endometrial ablation (TEA), tubal occlusion by Essure placement, and the combination of thermal endometrial ablation and tubal occlusion with the use of IV conscious sedation administered by a Certified Registered Nurse Anesthetist (CRNA). Design: Retrospective chart analysis. Setting: Urban private practice. Patients: Eighty patients treated with hysteroscopically supported procedures, 56 TEA, 7 tubal occlusion by Essure placement, 9 combined TEA and tubal occlusion, and 8 other. Intervention: Depending on patients’ medical history and physical status a regimen including midazolam, fentanyl, toradol and propofol was used to achieve adequate analgesia and conscious sedation in the office. Patients were directly supervised by a CRNA and monitored during the procedure with continuous EKG, pulse oximetry, BP and EtCo2 with continuation of both BP and pulse oximetry during the recovery period. Complete recovery was established by the patients’ ability to take fluids and light snacks, void, and experiencing no pain or nausea or their pain or nausea are controlled with medication by mouth. Measurements and Main Results: All patient treatments were completed without any requirement for conversion to alternative anesthesia or other setting. Interruption or delays in treatment procedure resulting from sedation administration were not experienced. Total IV administration time ranged from 15–60 minutes, with associated recovery time ranging from 15–45 minutes. Sedation times were shortest for the “other” (i.e., removal of polyp) with increasing length for thermal ablation, tubal occlusion and the combination of thermal ablation and tubal occlusion, respectively. Recovery time was not correlated with the sedation time. Conclusion: IV conscious sedation administered under the direct supervision of a CRNA allows for the conduction of these hysteroscopic procedures in the office setting by the physician and office clinical staff traditionally performed in the operating rooms of hospitals and surgery centers.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (12:47 PM – 12:53 PM)

197 Complete Compliance in Office Hysteroscopy Using a 4mm Hysteroscope: A Prospective Clinical Study Bettocchi S, Ceci O, Vicino M, Pinto L, Pontrelli G, Costantino A, Santoro A. University of Bari, Bari, Italy Study Objective: To verify complete patient compliance during office hysteroscopy performed with a 4mm hysteroscope using a Visual Analog Scale (VAS). Design: Prospective clinical study. Setting: University hospital. Patients: From January 2004 to January 2006, 3863 consecutive patients underwent office hysteroscopy (1102 operative and 2761 diagnostic procedures); 2802 patients were in the early proliferative phase, 1061 were in menopause.

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Intervention: All hysteroscopies were performed using the 4-mm, continuous flow operative hysteroscope based on the 1.9-mm rod lens scope (Karl Storz, Germany). The vaginoscopic approach was used without any analgesia or anesthesia. All the pathologies were treated with 5 Fr mechanical instruments or using the 5 Fr Versapoint electrode (Gynecare, USA). About 15 minutes after the procedure the patients were asked to fill out a questionnaire scoring the maximum amount of pain suffered during the procedure using a visual analogue scale, by marking a cross on a 10-cm line: 0 = no pain, 2.5 = low pain, 5 = moderate pain, 7.5 = severe pain and 10 = worst pain imaginable. In addition, the patients were asked whether, if they had to repeat hysteroscopy, they would prefer a general anaesthetic while the procedure was performed. Measurements and Main Results: For the 2761 diagnostic procedures, 1503 (54.44%) patients crossed the 0 (no pain); 1154 (41.8%) patients the 2.5 value (low pain); 98 (3.55%) patients between 5 and 7.5; 6 (0.21%) patients marked the 10 (worst pain). For the 1102 operative procedures: 484 (43.92%) patients marked the 0 (no pain); 408 (37.02%) patients marked 2.5 (low pain); 171 (15.52%) patients marked 7.5; 23 (2.09%) patients marked the 10 (worst pain). In sixteen cases (1.45%) the procedures were interrupted and performed in the operative theatre in general anesthesia. No statistically differences were found in the two groups. As to the second question, 3847 women (99.58%), all the women in which the procedure was completed, answered that they would undergo a repeat procedure in the same manner. No difference was noted between fertile and menopausal women or between nulliparous and uni/multiparous women. Conclusion: Thanks to the improvement of office hysteroscopy, in skilled hands, this highly technologic procedure has become a simple and painless procedure that can easily be performed without any discomfort for the patient, yielding immediate results.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (12:53 PM – 12:59 PM)

198 Office Hysteroscopy in Infertile Women: The Role of Instrument Diameter, the Distention Medium and Surgeon Experience on Patient Discomfort Pluchino N, Cela V, Genazzani AR. University of Pisa, Pisa, Italy Study Objective: To assess the role of the instrument diameter (5.0 or 3.5 mm external sheath), the uterine distention medium (CO2 or saline) and the surgeon experience on discomfort produced by diagnostic hysteroscopy in infertile women. Design: Prospective randomized controlled trial. Setting: Department of Reproductive Medicine and Child Development, Division of Obstetrics and Gynecology, University of Pisa, Italy.

Patients and Intervention: One hundred and sixty women attending the infertile clinic, were randomly assigned to undergo conventional hysteroscopy (group 1, n = 80) or mini-hysteroscopy (group 2, n = 80), using CO2 or saline as distention medium and performed by surgeons with different experience. Measurements and Main Results: Patient discomfort was analyzed throughout the 10 mm visual analogue score (VAS). Procedure complication and patient satisfaction rate were also recorder. Less pain, complications and higher satisfaction rates were observed with mini-hysteroscopy independently of surgeon experience. In addiction, procedures using saline medium scored less pain, complications and better patient satisfaction respect to CO2 only when performed by inexperienced surgeons. Conclusion: Instrumental diameter and surgeon experience, more than the medium distention appear to be the main variables affecting the perception of discomfort during office hysteroscopy.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (12:59 PM – 1:05 PM)

199 Goserelin for Small Myomas: Avoiding Resectoscope and Favoring Office Hysteroscopy Rincon AG, Belkys CP. Maternidad Santa Maria, University of Los Andes, Merida, Venezuela Study Objective: To determine the efficacy of Goserelin in reducing the size of small myomas, 3 months prior to surgery and it’s a capacity to turn over an operative room procedure (resectoscope) to an office procedure (hysteroscopy). Design: Tweleve female patients were included in this experimental study, they have been diagnosis with submucosos myomas and need to be treated with resectosocopy under anesthesia in the operating room, prior to intervention they receive 3 monthly doses of Goserelin (Zoladex) then re evaluated and decided the need of using resectoscope or small diameter hysteroscope. Setting: Private medical center affiliated with a University. Patients: Twelve women with genital bleeding due to sub mucosa myomas (Type 0) requiring myomectomy with resectoscope. Intervention: Sub cutaneous Goserelin (Zoladex) 3 monthly doses prior to momectomy. Measurements and Main Results: Patients average age was 35 years old, all with symptomatic submucous myomas (1–3 myomas per patient), average size myoma was 2.6 cm of diameter. After the third month of treatment a new ultrasound evaluation was performed, resulting in a decrease of 60% of the size of myomas and a totally disappearance of myoma related symptoms in all patients. Eight patients were treated with office histeroscopic using and 4 remain to be treated as first planned with resectoscope under anesthesia in the operating room. All 4 had two or more myomas.

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Conclusion: Goserelin administration is effective in reducing the size and volume of myomas, thereby can be treated with office hysteroscopy rather than resectoscope in operating room.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (1:05 PM – 1:11 PM)

200 Feasibility of NovaSure Endometrial Ablation in the Office Setting Kreuze D. West Michigan Ob/Gyn Grand Rapids, Michigan Study Objective: To assess compatibility of NovaSure ablation procedure with an office setting under local anesthesia protocols. Design: Prospective, single-arm. Setting: Private Ob/Gyn office. Patients: Thirty patients with refractory menorrhagia secondary to DUB. Intervention: Endometrial ablation using NovaSure system. Measurements and Main Results: Patients treated with NovaSure endometrial ablation with no endometrial pretreatment of any kind. Patients were instructed to take Valium 5 mg and Vicoden prior to coming to the office, the morning of then received Toradol 60 mg IM 45 in the office prior to procedure. Para cervical block of 20cc 1% Xylocaine plain administered equally at 3 and 9 o’clock. An additional 4 cc were then injected into each U-S ligament. All patients were treated successfully only reporting minor discomfort and all would do it again in the office following the anesthesia guidelines. All patients were released within 30 minutes of the procedure and no patient required any additional recovery considerations. Conclusion: NovaSure is a viable endometrial ablation procedure in the office setting without the need for IV sedation due to its short treatment time of 90 seconds, demonstrated low intra- and postoperative level of discomfort, and short recovery time.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (1:11 PM – 1:17 PM)

201 Hysteroscopic Placement of Essure Device in an Office Setting under Local Anesthesia: Successful Placement and Occlussion Rates Levie M, Chudnoff SG, Weiss G. Albert Einstein College of Medicine, Montefiore Medical Center, Centennial Women’s Center, Bronx, New York Study Objective: To assess the rates of successful Essure placement and bilateral tubal occlusion in patients undergoing the procedure in a office setting under local anesthesia.

Design: This is an ongoing prospective study of women seeking tubal sterilization. Setting: A private office setting associated with a teaching hospital. Patients: To date 177 patients have undergone the Essure procedure in our office. Intervention: Micro-inserts were placed into the proximal fallopian tube lumens under hysteroscopic visualization, under local anesthesia and nonsteroidal anti-inflammatory drugs. Successful placement and reasons for failed attempts were recorded. A hysterosalpingography was performed after 12 weeks to determine tubal occlusion. Patient demographics, medical and surgical history, procedural data, pain assessment and satisfaction data were also collected. Measurements and Main Results: 162/177 (92%) of patients had successful placement on initial attempt. The overall successful placement rate was 93% in patients opting for a second attempt. All patients tolerated the procedure well. Total procedure time averaged 11.7 minutes. There were no adverse reactions or hospitalizations, and average in-office recovery time was under 30 minutes. To date hysterosalpingographies were performed on 136 patients and revealed bilateral occlusion in 132 patients (97%). Two patients aborted the devices into the uterine cavity, one was lost to follow-up, and one patient had a device perforation. Of these patients, two had repeat successful procedures and one opted for laparoscopic tubal ligation. Conclusion: The Essure procedure can be readily performed in an office setting, with excellent success rates.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (1:17 PM – 1:23 PM)

202 Historical Risk Factors: Are They a Contraindication for Office Essure? Levie M, Chudnoff SG, Weiss G. Albert Einstein College of Medicine, Montefiore Medical Center, Centennial Women’s Center, Bronx, New York Study Objective: To determine the impact that historical risk factors have on successful Essure device placement. Design: One hundred ninety-one women were included in this prospective IRB approved study. Patients were questioned prior to the Essure procedure regarding historical risk factors which may potentially affect tubal cannulation. Data including history of prior sexually transmitted diseases, pelvic inflammatory disease, termination of pregnancy, and caserean sections were collected. All women underwent office-based hysteroscopic sterilization between 2004 and 2006. Procedural information was collected and documented. Succesful placement rates were calculated for the overall population and correlated with patients with historical risk factors. Setting: General Ob/Gyn faculty office practice at an academic teaching hospital. Patients: One hundred ninety-one women desiring perma-

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nent contraception who underwent office-based placement of Essure. Intervention: Office hysteroscopic placement of the Essure device. Measurements and Main Results: The overall successful placement rate for this cohort was 92% on initial attempt ant 94% in patients undergoing a second attempt. 3/191 patients reported prior pelvic inflammatory disease all of whom had successful placement. 21/191 had a prior chalmydial infection. 20/21 had successful placement on initial attempt with 1 patient successfully placed on a second attempt. Gonorrhea was reported in 7/191 patients with successful placement in 6/7 patients. 107/191 patients had at least 1 prior termination of pregnancy (range 1–10). 101/107 had initial successful placement with 1 patient undergoing a second procedure with success. 57/191 had at least 1 prior caserean section 54/57 had successful placement. Conclusion: This study supports that office-based Essure placement can be accomplished effectively irrespective of historical risk factors. The majority of patients can have this minimally invasive office procedure and can avoid having a laparoscopic sterilization procedure under general anesthesia in an operating room.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (1:23 PM – 1:29 PM)

203 Hysteroscopic Sterilization with Essure in an Office Setting under Local Anesthesia: Patient Assessment of Procedural Pain and Satisfaction 1 Weiss G, 1Chudnoff SG, 1Levie M, 2Levy BS, 1Snyder D. 1 Albert Einstein College of Medicine, Montefiore Medical Center, Centennial Women’s Center, Bronx, New York; 2 Women’s Health Center, Franciscan Health Systems, Federal Way, Washington Study Objective: To assess the pain associated with hysteroscopic sterilization under local anesthesia, as well as patient satisfaction. Design: Prospective analysis of patients undergoing hysteroscopic sterilization. Setting: Offices of three gynecologists: 1) An urban academic practice in Bronx, N.Y., 2) A private practice in Greenfield, Indiana, 3) A private practice in Federal Way, Washington. Patients: To date 149 patients undergoing in office hysteroscopic sterilization have been enrolled in this ongoing study. Intervention: All patients were surveyed immediately after completion of the procedure. Pain was assessed on a scale of 0–10. Patients were asked to assess the pain they experience during their menstrual cycle using the same scale. This gave perspective to the pain encountered during the procedure. Patients were also contacted after their 12-week Hysterosalpingogram (HSG) to evaluate satisfaction with the procedure.

Measurements and Main Results: One hundred forty-nine patients were surveyed immediately post-procedure. Patients said that the average pain of their menstrual cycle was 3.1. The average pain encountered during the procedure was 2.5, and the most pain encountered was 3.2. 128 patients had reached the 12-week HSG and were surveyed. 98% of patients would recommend the procedure to a friend, and on a scale of 1-5 the average satisfaction rating was 4.6. Conclusion: Office hysteroscopic sterilization using the Essure system is well tolerated under local anesthesia. Patients felt that the pain during the procedure was less than or equal to a menstrual cycle. Patients were extremely satisfied with their choice and would recommend it to a friend.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (1:29 PM – 1:35 PM)

204 Management of 273 Patients for Essure Sterilization in the Outpatient Department without Any Anesthesia Vleugels M. Rivierenland Hospital, Tiel, Netherlands Study Objective: The benefit of the hysteroscopic sterilization (Essure) is the possibility to be performed on OPD without anaesthesia. A new patient management, for doctors/personnel has been developed and evaluated. Design: Prospective describing study. Setting: Out patient department with office hysteroscopic facility of a Dutch general hospital. Patients: Two hundred seventy-three women seeking permanent contraception. Intervention: Hysteroscopic sterilisation without any anaesthesia. This sterilisation was performed according a strict protocol concerning Information, Instruction and Instrumentation. The outcome was evaluated by the VAS, QLF, procedure time, failure rates. Measurements and Main Results: Patients will be aware of impressions never experienced before since she has chosen the advantages of this sterilization without anaesthesia; non admission, rapid recovery, no scar. She gives her commitment under the condition that the surgeon respects her limits. Her limits will be extended to perform the sterilization by this management; Information; Instruction to personnel; Instrumentation by small hysteroscopes, introduced without dilatation. Some highlights are: the consulted surgeon has to operate, plan procedure straight after her period, premedication NSAID sup few hours before, company of husband, screen for patients, background music, vaginal approach according Bettocchi, normal saline at body temperature, no pressure bags. Once both tubes have been localized, the devices have to be introduced rapidly to be ahead of any spasm. During the procedure never show any stress. After the sterilisation patients go home. This management of patients (n = 273) resulted in an overall pain score 2.7 (SD: 2.5; median 2.0, range 0–8), procedure time 9.8 minutes. Failure rate of placement 5.9%. Almost all woman (98.9%)

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mentioned on the quality life questionnaire that they would advocate this method to anyone else, even those who had failure of placement (20/22). Conclusion: Essure sterilisation can be done on the OPD without any anaesthesia with this new management of patients/doctors and personel.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (1:35 PM – 1:41 PM)

205 The Impact of Obesity on Office-Placement of Essure Chudnoff SG, Levie M. Albert Einstein College of Medicine, Montefiore Medical Center, Centennial Women’s Center, Bronx, New York Study Objective: To determine the impact of obesity on successful placement of the Essure device in an office-based setting. Design: One hundred ninety-one women were included in this prospective study. Eighty-one of the women met our definition for obesity of body mass index (BMI) > 30. All of the women underwent office-based hysteroscopic sterilization between 2004 and 2006. Data relating to various demographic characteristics as well as procedural information was collected. Setting: General Ob/Gyn faculty office practice at an academic teaching hospital. Patients: One hundred ninety-one women desiring permanent contraception who underwent office-based placement of Essure. Intervention: Office hysteroscopic placement of the Essure device. Measurements and Main Results: The average BMI in the obesity group was 36.2 (SD ± 5.7) with the largest BMI being 51. In the obese group 74/81 (91%) had successful placement of the device, compared to 101/110 (92%) in the non-obese group. The average procedural time in the obese group was 11.6 minutes and in the non-obese group it was 11.8 minutes. In one patient obesity may have played a role in the inability to place the device. Conclusion: This study supports that office-based Essure placement can be accomplished effectively irrespective of BMI. Patients with obesity may be better served being counseled for the office procedure as less potential complications are likely with an office procedure without anesthesia, compared to laparoscopic procedures with general anesthesia.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (1:41 PM – 1:47 PM)

206 Cost Effectiveness Analysis of the Essure Tubal Sterilization Procedure in an Ambulatory Setting. Thiel JA, Carson G. Regina Qu’Appelle Health Region, Regina, Saskatchewan, Canada Study Objective: To analyze the financial and patient care implications of establishing an hysteroscopic sterilization program using the Essure micro-insert in an ambulatory women’s clinic setting. Design: Retrospective case control (Canadian Task Force classification Type II-2). Setting: Ambulatory women’s health clinic in a tertiary hospital. Patients: One hundred twenty-two women undergoing Essure coil insertion for permanent sterilization. Intervention: The Essure procedure was completed using a 4 mm single channel operative hysteroscope with the aid of conscious sedation using fentanyl and midazolam. Measurements and Main Results: Costs associated with the procedure, necessary follow-up and management of complications were tabulated. These costs were compared with those that would be generated if a similar number of procedures were done as laparoscopic tubal sterilization with clips. A comparison of the costs of the two procedures was used to calculate the incremental cost-effectiveness ratio. The Essure coils were demonstrated to be adequately placed in the tubal cornua in 111 women (90%). Eight-six (70%) were confirmed with ultrasonography, 25 (20%) also required hysterosalpingography. Four (3%) women had unsuccessful placement of the coils and elected to have laparoscopic tubal with clips. Seven (5%) were lost to follow-up. The total cost associated with the 122 Essure procedures was $CA160,985. The cost to complete 122 laparoscopic tubals with clips would be $CA106,140; assuming no complications with the laparoscopic procedures. The cost per Essure procedure was $CA1319 and per laparoscopy would be $CA870. The incremental cost-effectiveness ratio was $CA449. Conclusion: Completion of the Essure procedure in an ambulatory setting resulted in an additional cost to the system of $CA449. This additional cost provides a safer procedure with no failures reported at 5 years. The Essure procedure can be completed in an ambulatory setting, allowing OR time to be directed to other types of cases, improving access to care for more patients.

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THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (1:47 PM – 1:53 PM)

207 Body Sculpting for Gynecologists: A New Technique for Liposuction Turner DJ. Santa Barbara Cottage Hospital, Santa Barbara, California Many physicians are looking for ways to expand their practices and take better care of their patients. Aesthetic procedures are an example. LipoSelection by VASER is a refined ultrasound technique that utilizes the laparoscopists skills and knowledge of minimally invasive procedures and ultrasound to sculpt the abdomen. It is an ideal fit into the gynecologist’s practice. Technology, training, certification and malpractice insurance are presented.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (1:53 PM – 1:59 PM)

208 Integrating Vaser Aesthetic Based Procedures into the Gynecologic Practice Taylor EB. Stone Mountain, Georgia Study Objective: Report successful integration of VASER LipoSelection into a gynecological practice and the resulting patient satisfaction. Design: Case report summarizing one gynecological practice’s initial experience with VASER over 4 months. Setting: A private practice in Atlanta, Georgia. Procedures performed in an office procedure room. Patients: Three female patients ranging from 35-57 years of age, with undesired abdominal fat deposits. Patient followup stages range from 2 weeks–3 months. Intervention: SoundVASER System was utilized for the fragmentation, emulsification and aspiration of soft tissue in the abdominal area to achieve aesthetically pleasing contours. Measurements and Main Results: VASER abdominal procedures were performed in a gynecological office procedure room using local anesthesia. Aspirate volume ranged from 700–1500 cc. Patients walked unassisted immediately after the procedure. Patients reported minimal pain for 3–5 days post-op, were prescribed 7.5 mg Lortab and 800 mg Motrin as needed. Patients returned to work within 3–5 days. Bruising was minimal and not visible 7–14 days post-op. Overall results produced flattened and smoothed abdominal contours. Three months post-op, the first patient was satisfied with results and inquired about additional procedures. Patient demand for VASER aesthetic procedures in a gynecological practice is evidenced by the scheduling of 4 additional procedures and several patient consultations. Conclusion: Case study indicates VASER aesthetic procedures can be integrated into Gynecological practices with

ease. It suggests Gynecologists can effectively perform aesthetic abdominal contouring, due to existing abdominal and surgical expertise. This case study also suggests significant patient demand for abdominal contouring exists within a gynecological setting. Initial results show the procedure is minimally invasive, can be done in office using local anesthesia, and patients experience minor pain during recovery. Patient follow-ups confirm the relatively gentle nature of the procedure and continued satisfaction with physical results.

THURSDAY, NOVEMBER 9, 2006 Open Communications 10—Changing Office Practice (1:59 PM – 2:05 PM)

209 Implementation of VASER Technology and the Possible Impact on Overall Health LaRoche ER. Anti-Aging Body & Face Medical Cosmetic Center, Murfreesboro, Tennessee Study Objective: Report the use of VASER and introduce potential to encourage healthy lifestyle maintenance through diet and exercise Design: A case report overview of the implementation VASER procedures over 11 months and the possible effect on patient lifestyle and overall health. Evaluations were done pre-op, and 48 hours, 2 weeks, 2 months post-op to evaluate diet and exercise habits. Setting: A private multidisciplinary practice in Tennessee, procedures performed in-office by Ob/Gyn. Patients: Fifty females aged 17–65 (average 50) years reporting undesirable fat deposits underwent VASER outpatient procedures to reduce fat deposit bulk. Intervention: VASER Ultrasonic fragmentation, emulsification and aspiration of fat tissue, predominantly in abdominal area to produce preferred body contours. Measurements and Main Results: Overall health gauged by body weight, BMI, blood pressure, pre-existing conditions, and surveying diet, exercise, and lifestyle habits. Three groups of patients were evaluated. Group I: Exercise regularly, good nutritional habits, healthy body weight. Results indicate group is likely to continue healthy habits after surgery. Group II: Near preferred weight, overall health could benefit from exercise and nutritional changes. Group referred to nutritionists, put on low-fat diets, and asked to increase exercise 3 months prior to re-evaluation for VASER procedures. Approximately 80% was more likely to maintain healthy lifestyle post-op than pre-op. Group III: Overweight, require increased exercise and nutrition for improved health. Results show approximately 70% felt more committed maintaining healthy diet and exercise habits post-op than pre-op. Conclusion: Study indicates after undergoing VASER procedures, Group I patients were likely to maintain healthy lifestyle habits. Group II and Group III patients may be more likely to adopt or continue a healthy lifestyle through diet and exercise than they would have without VASER procedures.

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THURSDAY, NOVEMBER 9, 2006 Open Communications 11—Endometriosis (12:35 PM – 12:41 PM)

210 Detection of VEGF Expression in Pericystic Endometrioma is Associated with a Higher Incidence of Disease Recurrence Bettocchi S, Vicino M, Ceci O, Pinto L, Pontrelli G, Costantino A, Santoro A. University of Bari, Bari, Italy Study Objective: Several studies on angiogenesis of endometrioma have suggested that Vascular Endothelial Growth Factor (VEGF) seems to play a key role locally in the development of endometriotic lesions. Recently, a strong correlation was reported between diffuse VEGF expression in epithelial cells and cyst diameters greater than 5 cm. A high VEGF expression was shown in capsular fibroblasts, suggesting that neoangiogenesis and the fibrosis process leading to adhesions affect the outer cyst wall during cyst growth. This study was carried out to investigate VEGF expression in endometrioma and its clinical prognostic value on recurrence of the disease. Design: Prospective clinical study. Setting: University hospital. Patients: From January 2002 to December 2003, 78 women of ages ranging between 18 and 25 years, with ovarian endometrioma, were enrolled. Mean diameter of the endometriotic cyst was 4.6 ± 1.9 cm. None of the patients underwent medical therapy after surgery. Patients have been followed up for three years, by ultrasound and CA125 serum levels, in order to detect recurrence of endometrioma, and a laparoscopic 2nd look was performed in presence of an endometriotic cyst. Intervention: Laparoscopic surgery was done in mid-luteal phase in all patients and ovarian cystectomy was performed by the stripping procedure. Specimens were evaluated by pathologists to confirm the presence of endometrioma. Immunohistochemical stains on formalin-fixed paraffinembedded samples using monoclonal antibodies for CA125 (clone M11) and for VEGF (clone C1) were assessed. A semiquantitative analysis was performed by evaluating the expression of the reported markers in the different cell populations: epithelium, macrophages, fibroblasts, and endothelial cells. Measurements and Main Results: At first surgery, CA125 expression was noted in all epithelial cells lining the endometrial cysts, with a cytoplasmic pattern; CA125 tissue positivity was not correlated with the CA125 serum levels or the size of the cyst. VEGF expression had aheterogeneous distribution pattern: a predominantly epithelial expression was observed in a minority of cases and a diffuse stromal expression (histiocytes and endothelial cells) in 25 out of 78 patients. In these cases VEGF stromal expression was associated with a weak or focal epithelial positivity. A recurrence of the endometriotic cyst occurred during the followup in 19 out of the 25 patients with high VEGF expression

in stromal pericystic tissue. In these cases immunochemistry at the second surgery revealed a persistent, strong VEGF expression in the stromal tissue of the cyst. Conclusion: These preliminary data suggest that immunohistochemical evaluation of angiogenesis in the pericystic tissue by studying VEGF expression could be helpful to identify patients at high risk of recurrence. Active angiogenesis inside the endometriotic tissue presents a major risk of recurrence of the disease even if correct surgery was performed in the first instance. Medical therapy after surgery in these conditions could be helpful to reduce the disease recurrence rate.

THURSDAY, NOVEMBER 9, 2006 Open Communications 11—Endometriosis (12:41 PM – 12:47 PM)

211 Sonographic Evaluation of Posterior Deep Pelvic Endometriosis: Role of Three Dimensional Ultrasound to Assess the Extension of the Disease Exacoustos C, Zupi E, Amoroso C, Amadio A, Szabolcs B, Romanini ME, Arduini D. University of Rome “Tor Vergata,” Rome, Italy Study Objective: Magnetic Resonance Imaging (MRI) has emerged to be the best diagnostic imaging to evaluate the extent posterior pelvic deep infiltrating endometriosis (DIE). Two dimensional transvaginal sonography (2D TVS) shows some diagnostic limits in the evaluation of the extension of DIE. Three dimensional (3D) ultrasound by using sectional image analysis such as tomographic ultrasound imaging (TUI) could be very similar to MRI. The aim of this study was to evaluate the accuracy of 3D TVS and TUI in the assessment of posterior DIE extension. Design: Patients with DIE underwent 2D and 3D TVS evaluation, using a GE Voluson 730 Expert ultrasound system. An accurate mapping of the extension of the disease was performed at 2D and 3D sonographic examination and during laparoscopy. A detailed list of locations, which described the endometriotic/fibrotic infiltrating tissue on different sites of the posterior pelvis, was done. Setting: University hospital. Patients: Sixteen patients with DIE underwent 2D and 3D sonographic evaluation. Measurements and Main Results: A comparison between 2D and 3D sonographic and laparoscopic findings was performed. The TUI mode analyzing volumes in different parallel planes with the possibility to adjust distance between planes and number of slices, seems to be very useful in the evaluation of rectal or sigmoid wall infiltration. In fact the concordance rate in the diagnosis of endometriotic nodes of the pouch of Douglas and uterosacral ligaments was similar for 2D and 3D sonography (94% vs 96%). Whereas the accuracy in the diagnosis of nodes infiltrating the rectal or sigmoid wall, is higher with 3D TUI (85% vs 94%). Conclusion: 3D TVS and TUI may provide accurate infor-

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mations about the extension of posterior DIE. In particular it improves the diagnosis of the infiltration of the rectal and sigmoid wall and could be useful in the management of these patients.

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Diagnosis of Douglas Cul-de-sac Obliteration(CDSO) by the MRI Jelly Method Kikuchi I, Takeuchi H, Kitade M, Shimanuki H, Koizumi K. Juntendo University School of Medicine, Tokyo, Japan

Open Communications 11—Endometriosis (12:47 PM – 12:53 PM)

212 Accuracy of Transvaginal Sonography in the Diagnosis of Deep Posterior Endometriosis Manuzzi L, Savelli L, Pollastri P, Guerrini M, Villa G, Firinu L, Seracchioli R, Venturoli S. Center of Reconstructive Pelvic Surgery, Reproductive Medicine Unit, S.orsola-Malpighi Hospital, University of Bologna, Bologna, Italy Study Objective: To evaluate the accuracy of transvaginal sonography (TVS) in the diagnosis of deep infiltrating endometriosis of the posterior compartment (rectovaginal septum, rectosigmoid) when undertaken by sonographers of differing experience. Design: Retrospective analysis. Setting: University hospital. Patients: Three hundred eighty-one patients with suspected pelvic endometriosis. Measurements and Main Results: Sonographic, surgical and histopathologic data from 381 patients operated between January 2002 and December 2005 for suspected pelvic endometriosis were retrospectively obtained. Preoperative TVS were carried out by physicians of varying experience. The presence and size of the endometriotic lesions located on the posterior compartment were compared with the surgical and histological findings. One hundred thirty-six patients underwent removal deep endometriotic lesions of the posterior compartment. Sensitivity, specificity, positive and negative predictive value and overall diagnostic accuracy of expert operators were 77%, 95%, 90%, 87% and 88% respectively. Corresponding features for first-level operators were: 45%, 98%, 92%, 79% and 81%. In patients with positive findings at TVS, the mean diameter of the endometriotic nodule was of 4.7 ± 3.4 cm, while in cases with negative findings the average diameter was 2.6 ± 1.1 cm (p < 0.05). An intestinal resection upon removal of the nodule was unnecessary in any of the patients who recorded a false negative result. Conclusion: Diagnosis of deep infiltrating endometriosis is difficult when the nodules are small in size. In experienced hands TVS can reveal the presence and the location of deep endometriosis when its diameter is > 1 cm. Operators with less experience in TVS have a lower sensitivity in comparison to expert physicians. To minimise operating times, rates of complication and optimize the efficacy of surgery, sonography should be carried out by adequately trained personnel with good experience.

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Study Objective: We evaluated the usefulness of MRI jelly method (jelly method). Design: Retrospective. Setting: University school of medicine. Patients: Thirty patients (32.7 ± 5 years old) participated in this study, who had undergone preoperative examination by the jelly method and then laparoscopic surgery between January and March 2005. Intervention: In imaging by the jelly method, 50 mL of jelly used for ultrasound was injected into the vagina, and 150 mL of jelly diluted twice with tap water was injected into the rectum. MR images were inspected for the following 6 features: 1) position of the uterus (anteflexed, retroflexed), 2) thickness of the posterior uterine wall, and 3) ascites in T2-high Douglas, which could be evaluated without injection of jelly, and 4) tethered appearance of the posterior vaginal fornix, 5) tethering of the anterior rectum, 6) thickness of fat on the anterior rectum shown by T1-high image, which were detected only by injection of jelly. Correlation between these imaging data and CDSO in laparoscopic surgery findings was investigated. Measurements and Main Results: CDSO was present in 20 of 30 patients. Sensitivity and specificity of the above MR image features for CDSO were respectively 1) 45%/80% (obliteration present if retroflexed), 2) 60%/90%, 3) 90%/60% (obliteration present if no ascites), 4) 85%/20%, 5) 75%/90%, and 6) 95%/60%. Features relatively high in both sensitivity and specificity were tethering of the anterior rectum and thickness of fat on the anterior rectum shown in T1-high image. Both features were made clear only by the jelly method. Conclusion: By combining this finding with tethering of the anterior rectum, it became possible to evaluate CDSO. These findings could not be obtained except by the jelly method, which indicated the usefulness of the jelly method in diagnosis of CDSO.

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Open Communications 11—Endometriosis (12:59 PM – 1:05 PM)

Open Communications 11—Endometriosis (1:05 PM – 1:11 PM)

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Sonovaginography: A New Way of Diagnosing Rectovaginal Endometriosis in Women with Pelvic Pain Lam AM, Condous GS. Royal North Shore Hospital, University of Sydney Centre for Advance Reproductive Endosurgery, Sydney, New South Wales, Australia

Histologic Confirmation of Endometriosis may not be Clinically Useful Martin DC, Webb TL, Lazarus EJ. University of Tennessee Health Science Center, Memphis, Tennessee

Study Objective: To determine the value of pre-operative sonovaginography in predicting rectovaginal endometriotic disease. Secondary aim was to establish normative values for the normal rectovaginal septum. Design: Prospective observational ongoing pilot study. Women underwent intra-operative sonovaginogram prior to the laparoscopy being performed. Saline was installed into the vagina to act as an acoustic window between the probe and the vaginal channel – this is sonovaginography. This scan facilitates the visualisation of the rectovaginal septum. The rectovaginal septum was then measured in the sagittal plane at three levels: posterior fornix, mid rectovaginal septum and just above the perineal body. The presence or absence of rectovaginal disease was predicted using sonovaginography and then laparoscopy with biopsy was performed as the gold standard to confirm or refute the diagnosis. Setting: Centre for Advanced Reproductive Endosurgery Intervention: Performing sonovaginography to predict rectovaginal disease. Patients: Eleven women to date have been recruited to this pilot study. Measurements and Main Results: 11 women have undergone both sonovaginography and laparoscopy. Mean age – 38.8 years (range 26–48 years). 72.7% had history of endometriosis. 9/11 had normal rectovaginal septum and 2/11 had rectovaginal nodule according to sonovaginogram. Mean rectovaginal thickness at posterior fornix, mid rectovaginal septum and just above perineal body were 5.4 mm (3.6–8.6), 3.4 mm (1.7–6.6) and 4.6 mm (2.8–6.9), respectively. At laparoscopy, 9/11 had normal rectovaginal septum and 2/11 had rectovaginal nodule 63.5% confirmed. Conclusion: Sonovaginography may be the pre-operative tool of choice in the future to predict rectovaginal disease. Sonovaginography may also be the tool of choice to delineate normative data for rectovaginal septum.

Study Objective: This purpose of this study is to point out the difficulties of histologic documentation. Design: Laparoscopic cases were analyzed and compared to historic cases. Setting: Retrospective review of clinical charts. Patients: One hundred one consecutive laparoscopic cases were compared to historic cases from the literature. Intervention: None Measurements and Main Results: Endometriosis was diagnosed in 72 (71.3%) of 101 patients. 63 (88%) were confirmed by histology. 57 (79.2%) were diagnosed at laparoscopy and 6 (8.3%) were diagnosed by histology. The 88% confirmation is lower than that the 99% of the last 69 of my 495 patients ending in 1986. However it is higher than the 45% of 44 cases reported by Walters (2001). My confirmation began at 62% in 1982. Stratton (2003) and Stegmann (2005) of the NIH analyzed by specimen and had an increased confirmation of individual specimens from 61% of lesions in their first 46 cases to 68% of lesions in next 56 cases. A separate consideration the use of biopsy results. Chapron (1998) noted no statistically significant difference in the response of dysmenorrhea in histologically positive and negative patients. With the exception of Chapron’s paper, other studies are based on appearance or history. Conclusion: At present biopsy is clinically useful in determining diagnosis in confusing lesions and ruling out cancer. Histology and requiring a specific diagnosis or description by the pathologist appear useful for those groups. On the other hand, biopsy may have more risk than benefit in patients with puckered pigmented lesions when a physician plans to observe or to treat a patient medically.

THURSDAY, NOVEMBER 9, 2006 Open Communications 11—Endometriosis (1:11 pm – 1:17 pm)

216 Rectovaginal Septum Endometriosis: A New Rectal Probe to Assist with Surgery Van der Wat JI. University Witwatersrand, Parklane Clinic, Johannesburg, South Africa Study Objective: To demonstrate the use of a newly designed rectal probe to facilitate the resection of rectovaginal septum endometriosis and other rectal pathology. A description of this probe and its use in colorectal and rectovaginal septum endometriosis will be presented.

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Setting: Operating Room, Park Lane Clinic Endoscopic Surgery Unit, Johannesburg, South Africa. Patients: Patients presenting with palpable rectovaginal septum endometriosis and rectosigmoid pathology. Intervention: Endoscopic resection of rectovaginal septum endometriosis using the transilluminating rectal probe. The transilluminating probe is attached to conventional endoscopic equipment like 10 mm laparoscope, camera and light source. The probe is manufactured from a transilluminating nylon which allows light from the laparoscope to be transmitted through the nylon into the adjacent tissues. This ability makes for the identification of tissue planes and margins of the pathology like endometriosis. The probe also has a 5 mm port that will allow for the passage of a 5 mm instrument for minor surgical procedures like excision of polyps and biopsies. It will also make insufflation of the rectum possible to asses for bowel damage after surgery. Dye can also be instilled through this port to asses whether the bowel muscularis is intact after surgery. It will be a useful instrument for both the gynaecologist and general surgeon interested in rectal and para rectal surgery. Conclusion: The transilluminating rectal probe will be of benefit in the surgical resection of rectovaginal septum endometriosis for the following reasons, it: 1) allows for the transillumination of the rectum and rectovaginal septum to asses the margins and extent of the endometriotic lesion in this region, 2) accurately defines the anatomical position of the rectum to assist with surgery, 3) provides for the visual inspection of the rectal mucosa, 4) makes for the easy inflation of the rectum and sigmoid to asses for untoward damage to bowel wall, 5) will allow for the instillation of dye to adequately diagnosis rectal wall injury, and 6) can be used for diagnosing rectal and lower sigmoid pathology being attached to conventional endoscopic equipment. This gives it the ability to display images of the rectum and rectal mucosa on a monitor.

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217 Laparoscopic Approach in Endometriosis of the Urinary Tract Viscomi FA, Pastore M, Silva AS, Silva EA, Borges PC, Freire CH, Inacio W, Jr, Fonseca LL, Rios LAS, Lenci B. Viscomi Institute, São Paulo, Brazil Study Objective: This study was undertaken to describe the role of laparoscopy in the approach of the urinary tract endometriosis. Design: From May 1990 to December 2005, 1181 women were submitted to laparoscopy with the diagnosis of endometriosis. Nineteen women showed involvement of urinary tract (15 bladder and 4 ureter). Setting: Viscomi Institute – Minimally Invasive Surgery, São Paulo, Brazil. Patients: Nineteen women complaining urinary symptoms

were submitted to pre- operative evaluation including ecography of urinary tract, cistoscopy and in selected cases intravenous urography. Intervention: Laparoscopic excision of endometriosis nodule of the bladder in 11 women, laparoscopic partial cystectomy in 4 women and ureteral reimplant in 4 women. Measurements and Main Results: Laparoscopy confirmed the location of endometriosis lesions. Laparoscopic excision of the nodule was performed in 11 patients when the lesion was located in the vesico-uterine space infiltrating the detrusor muscle. Partial laparoscopic cystectomy was done in 4 women when the nodule infiltrate the lumen of the bladder. Ureteral reimplant was done in four cases. No intra-operative complications occurred. Deeply endometriosis was confirmed on histologic evaluation. In eleven cases endometriosis infiltrated the detrusor muscle, four cases infiltrated the bladder lumen, and four cases the ureter. In one case hystologic evaluation diagnosed vesical mullerianosis and in another case endometriosis and endosalpingiosis was diagnosed in the same nodule. Conclusion: Laparoscopic approach in endometriosis of the urinary tract is feasible and offers the benefits of minimally invasive surgery.

THURSDAY, NOVEMBER 9, 2006 Open Communications 11—Endometriosis (1:23

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218 Effect of Site and Size of Bladder Endometriotic Nodules on Severity of Dysuria Villa G, Pollastri P, Manuzzi L, Mabrouk M, Mignemi G, Guerrini M, Venturoli S, Seracchioli R. Center of Reconstructive Pelvic Surgery, Reproductive Medicine Unit, S.orsola-Malpighi Hospital, University of Bologna, Bologna, Italy Study Objective: To evaluate if the site and dimensions of bladder endometriotic lesions are correlated with the severity of dysuria and if laparoscopic excision of these lesions would have significant effect in reduction of this symptom. Design: Between 2001 and 2005, 526 patients underwent laparoscopic treatment for pelvic endometriosis: 41 patients diagnosed intra operatively as having bladder endometriosis were included in a retrospective study. Size and site of bladder endometriotic lesions were assessed intra operatively. Further follow up was done, in comparison with preoperative data, to evaluate reduction of dysuria using 10 point Verbal Analog Scale (VAS). Setting: Centre of Reconstructive Pelvic Endo-surgery, University of Bologna. Patients: Forty-one women with intra operative diagnosis of bladder endometriosis who underwent laparoscopic excision of pelvic endometriotic lesions. Intervention: Laparoscopic excision of suspected bladder lesions. Pathological examination confirmed the endometriotic nature in all cases. Measurements and Main Results: Comparing intra opera-

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tive findings, pre operative data with post operative followup results, it was found that 22 patients out of 41 (53.7%) had pre operative dysuria while 19 (46.3 %) were asymptomatic. Mean lesion diameter in symptomatic patients was 24.76 mm versus 17.05 mm in asymptomatic patients. Endometriotic lesions at the base of the bladder were observed in 18 patients (43.9%) versus 23 (56.1%) at the dome. Out of the patients with basal lesions, 14/18 patients (77.78%) had pre operative dysuria (with median VAS 8.5 ± 2.37) versus 8/23 patients (34.78%) with dome lesions (median VAS 5.75 ± 1.91). Median pre operative VAS in symptomatic patients was (7.59 ± 2.44) while post operatively it became (3.67 ± 1.37). Conclusion: Basal bladder endometriotic lesions are more symptomatic than those of the dome. There is a significant positive correlation between the size of bladder endometriotic lesions and severity of pre operative dysuria. Laparoscopic excision of bladder lesions decreases significantly the severity of dysuria post operatively.

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219 Ureteral Deviation in Patients with and without Endometriosis Webb TL, Martin DC, Batt RE, Portera G. University of Tennessee Center for Health Sciences, Memphis, Tennessee Study Objective: The primary purpose of this study was to evaluate ureteral position in patients with endometriosis, pelvic pain and/or infertility. Design: This is a case series study using retrospective chart review. Setting: The review was of private patient charts. Patients: Private patient charts. Measurements and Main Results: One hundred three charts were identified and reviewed. Specified landmarks were identified in 39 of 103 patients. This yielded measurements on a total of 78 sites. The 78 sites included 21 in the area of the right hilum, 32 in the area of the right infundibulo-pelvic ligament, 13 in the area of the left hilum, and 12 in the area of the left infundibulo-pelvic ligament. Sites were more likely to be seen in patients with endometriosis. 32 of 39 patients with sites seen had endometriosis. Although medial position of the ureter was seen in 15 of 66 patients with endometriosis and 0 of 12 patients without endometriosis, this was not statistically significant using ANOVA single factor testing. Moreover, there was an inability to standardize the measurements obtained in this retrospective review of surgical Polaroid pictures, which rendered us unable to quantify the ureteral deviation present in this select population of patients. Conclusion: Ureteral deviation was identified both clinically by the surgeon and visually on a retrospective review of Polaroid pictures taken routinely during surgery. Deviation was identified both toward the uterosacral ligament as well

as toward the ovarian hilar and infundibulo-pelvic vessels. Those deviations put the ureter at risk both in operations that involve suturing of the uterosacral ligament and in operations that require hemostasis of the hilar and infundibulopelvic vessels.

THURSDAY, NOVEMBER 9, 2006 Open Communications 11—Endometriosis (1:35

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220 Ureteral Suspension Facilitates Surgery for Deep Pelvic Endometriosis Ferrero S, Alessandri F, Lijoi D, Mistrangelo E, Ragni N, Remorgida V. San Martino Hospital and University of Genoa, Genoa, Italy Study Objective: To describe a technique of ureteral suspension which may facilitate its identification during excision of deep endometriotic lesions. Design: Description of surgical technique. Setting: University hospital. Patients: One hundred twenty-six women with deep endometriotic lesions of the ovarian fossa, the uterosacral ligaments, and the rectovaginal septum. Intervention: Before excision of deep endometriotic lesions, ureterolysis was started high on the pelvic sidewall in normal peritoneum overlying the ureter and then continued in the direction of the uterosacral ligament. When the ureter was completely free, a 40 cm biocompatible silicone sling (Medical Biomaterial Products, Neustadt-Glewe, Germany) was introduced in the pelvis through the ipsilateral trocar by using atraumatic forceps. The sling was applied around the ureter; the two ends of the sling were brought out of the pelvis via the ipsilateral trocar sleeve. The sleeve was removed and it was replaced in the peritoneal cavity next to the sling. The sling was secured outside the abdomen. The operation continued with an easy identification of the ureter which was pushed outwards by placing an extracorporeal traction on the slings. At the end of the surgical procedure the sling was removed. Measurements and Main Results: Efficacy of the technique. Ureteral suspension was performed monolaterally in 70.6% of the patients (n = 89) and bilaterally in 29.4% of the subjects (n = 37). In one case (0.8%), the muscolaris of the ureter was invaded by endometriosis; resection of a portion of the ureter was required and laparoscopic uretero-ureterostomy was performed. No complication resulting from the ureteral suspension was observed. The technique was easy to perform and normally took less than 5 minutes to be completed on both sides. Conclusion: Ureteral suspension facilitates the identification of the ureter.

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Open Communications 11—Endometriosis (1:47 PM – 1:53 PM)

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Conservative Laparoscopic Treatment of Ureteral Endometriosis 1 Pollastri P, 2Vianello F, 1Villa G, 1Manuzzi L, 1Mabrouk M, 1Mignemi G, 1Venturoli S, 1Seracchioli R. 1Center of Reconstructive Pelvic Surgery, Reproductive Medicine Unit, S.orsola-Malpighi Hospital, University of Bologna, Bologna, Italy; 2Pieve di Coriano Hospital, Mantova, Italy

Laparoscopic Management of Ureteral Endometriosis: Our Experience Frenna V, Ohana E, Santos L, Wattiez A. IRCAD/EITS, Strasbourg, France

Study Objective: We sought to explore intra operative findings and results of conservative laparoscopic treatment of ureteral endometriosis. Design: Between 2002 and 2005, 452 patients underwent laparoscopic treatment for stage IV pelvic endometriosis: 22 patients diagnosed intra operatively as having ureteral endometriosis were included in this observational study. Intra operative findings were registered. Post operative clinical and radiological follow-up was performed. Setting: Centre of Reconstructive Pelvic Endo-surgery, University of Bologna. Patients: Twenty-two women with intra operative diagnosis of ureteral endometriosis who underwent laparoscopic excision of pelvic endometriosis Intervention: Conservative laparoscopic treatment of 26 ureteral stenosis was performed. Pathological examination confirmed the endometriotic nature of the lesions in all cases. Measurements and Main Results: In 12/22 patients (54.5%), lesions were left sided while right sided in 6 patients (27.3%) and bilateral in 4 (18.2%). In 25 ureteral units (96.1%), lesions were in the distal third of the ureter and in 1case (3.9%) in the middle third. Hydronephrosis was observed in 7 patients (31.8%) with monolateral ureteral endometriosios in wich a ureteral stent was inserted preoperatively. In 20/22 patients (90.9%) endometriotic lesions in recto-vaginal septum were observed. In 21 cases, conservative laparoscopic excision of ureteral lesions and adhesiolysis were performed with no intra operative complications. In one case, due to extensive involovement of the distal ureter, laparotomic conversion in which distal ureterectomy with ureterocystoneostomy was performed by urologists. During follow up (range 6-48, mean 17 months), no complications were detected and no recurrences were reported by urography. Conclusion: In our experience, conservative laparoscopic surgery may provide a good choice for treatment of ureteral endometriosis. We can suppose that ureteral endometriosis derives from enlargement of recto-vaginal septum endometriosis.

Study Objective: To evaluate the prevalence of extrinsic ureteral endometriosis and the place of ureterolysis in women undergoing laparoscopic surgery for severe endometriosis. Design: A retrospective analysis was carried out of fiftyfour patients who underwent laparoscopic surgery for severe endometriosis between November 2004 and January 2006. Patients were examined to assess anatomic cure at 6 weeks after surgery and 6 months later. Setting: University hospital in France. Patients: Fifty-four patients with severe endometriosis underwent laparoscopic surgery. Intervention: In all patients ureterolysis was performed by laparoscopy. The adenomyotic lesion and the vaginal pouch were removed in cases of rectovaginal endometriotic nodule. When the bowel wall was affected either superficial, discal excision or segmental bowel resection were performed. Bladder nodules were removed at the end of the surgery. Measurements and Main Results: Patients had a mean age of 31 years and a mean BMI 21.9. Reported symptoms were: dysmenorrhea (88%), severe dyspareunia (88%), severe pelvic pain (38.8%), infertility (74%); 5 woman presented with dysuria, frequency, recurrent urinary tract infections and pain in the renal angle, 2 patients had hydronephrosis. We observed 3 cases of ureteral stenosis (5.6%), 35 cases (64.8%) with adenomyotic tissue surrounding the ureter without stenosis and 16 (29.6%) with adenomyotic tissue adjacent to the ureter. It was on the left side in 47.4% of cases, on the right-side 31.6% and bilaterally in 21% of cases. In 9 patients, ureteral involvement was associated with bladder endometriosis (16.7%). There were: one case of ureteral injury during the procedure, two of transitory urinary retention and one of uretero-vaginal fistula postoperatively. Conclusion: Conservative laparoscopic surgery to relieve ureteral obstruction and remove pathological tissue is the management of choice. Resection of part of the ureter should only be performed in exceptional cases. Ureterolysis should be performed in all patients before endometriotic nodule resection, to recognize and prevent any ureteral damage.

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Open Communications 11—Endometriosis (1:59 PM – 2:05 PM)

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Combined Endoscopic Treatment for the Conservative Management of Ureteral Endometriosis Vittori G, Lena A, Giovannini P, Delfini R, Russo PL, Zeloni R, Camilli FM. Ospedale San Carlo, Rome, Italy

Letrozole does not Prevent Pain Symptoms in Women With Rectovaginal Endometriosis Remorgida V, Abbamonte LH, Parisi M, Ragni N, Fulcheri E, Ferrero S. San Martino Hospital and University of Genoa, Genoa, Italy

Study Objective: The object of the study is to propose a combined endoscopic treatment (ureteroscopic and laparoscopic) for conservative management of ureteral endometriosis. Design: Case report. Setting: Dept. Gynaecology Ospedale San Carlo, IDI, IRCSS–Rome Patients: Urinary tract endometriosis represents 1–4% of all localizations and ureteral involvement is very rare (0.1–0.4 %) and may be caused by extrinsic or intrinsic disease with a clear prevalence of the extrinsic form.R We report three cases of extrinsic ureteral endometriosis observed between 2002 and 2006. Symptoms included pelvic pain refractory to medical therapy, hydronephrosis and hydroureter shown by ultrasonography and pyelography. Intervention: Combined ureteroscopic and laparoscopic surgery. Surgery was divided into two different stages. The first was diagnostic laparoscopy associated with retrograde ureteroscopy and dilatation of the ureteral stenosis by passing a balloon probe followed by ureteral stenting. Laparoscopic ureterolysis was performed one month later and at the time of this second procedure hydronephrosis had been resolved in all cases. In one case of combined extrinsic and intrinsic endometriosis endoscopic ureteral dilatation was not possible, conservative management was not indicated and partial ureteral resection and re-implantation was performed. . Measurements and Main Results: All extrinsic cases were treated ureteroscopic dilatation and laparoscopic conservative ureterolysis associated with the removal of other sites of endometriosis (ovary, peritoneum, rectum). No operative complications occurred. The post-operative course was normal in all cases. The ureteral stent was removed three months after the procedure as the patients were well and remission of symptoms was observed. One patient become pregnant after surgery and at the moment is at 19 weeks of gestation. Conclusion: Ureteral endometriosis is rare but it can be a severe disease. Organ damage with potentially life threatening complications is possible. Conservative management is feasible and recommendable in extrinsic disease. Retrograde ureteral stenting and dilatation is necessary before surgery in order to preserve renal function and facilitate ureteral identification during surgical procedure.

Study Objective: To evaluate the effectiveness of letrozole for the treatment of rectovaginal septum endometriosis. Design: Open label prospective study. Setting: University hospital. Patients: Nine women of reproductive age with rectovaginal endometriosis confirmed by the histological examination of a biopsy in the posterior vaginal fornix. All patients had pain symptoms (dysmenorrhea, dyspareunia, and/or chronic pelvic pain) that persisted or recurred after one or more previous medical treatments. Women with ovarian endometriomas were excluded from the study. No patient had previously undergone surgical treatment of endometriosis. Intervention: The treatment protocol included the daily administration of letrozole 2.5 mg (Femara®, Novartis Farma), noretisterone acetate 2.5 mg (Primolut-Nor®, Schering), elemental calcium 1000 mg and vitamin D 880 I.U. for 6 months. Measurements and Main Results: Pain symptoms were evaluated before starting the treatment, at the completion of treatment, and at 6 and 12 months after treatment. The intensity of each pain symptom was measured on a 100-mm visual analogue scale (VAS). Quality of life was evaluated using the Short Form (SF)-36 questionnaire. All the 9 women completed the 6 months treatment; a significant improvement in dysmenorrhea (p < 0.001), dyspareunia (p < 0.001), and chronic pelvic pain (p < 0.01) was observed at the completion of the 6 months treatment. Pain symptoms recurred at 6 months follow-up, no significant difference was observed in their presence and intensity when compared with baseline values; no significant change in the SF-36 score was observed. Three patients requested surgical excision of endometriosis before the 12 months follow-up, histological examination of the specimens removed at surgery demonstrated the presence of active endometriosis. Conclusion: Letrozole is not effective in the long-term prevention of pain symptoms in women with rectovaginal endometriosis.

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THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (2:10 PM – 2:16 PM)

225 Novasure Impedance Controlled Endometrial Ablation System in the Office Setting: A Comparison of Anesthesia Considerations Bertrand JD. University Texas Southwestern Medical School, Dallas, Texas Study Objective: Assess the safety, tolerability, efficacy of the NovaSure system in the office setting under different anesthesia protocols. Design: A retrospective study reviewing and comparing endometrial ablation using the NovaSure system in the office and the efficacy and tolerability of different anesthesia regimens. Setting: Private practice office. Patients: Eighty-seven pre-menopausal women with menorrhagia. Intervention: Endometrial ablation using NovaSure Impedance Controlled Endometrial Ablation System. Measurements and Main Results: The NovaSure System was used to treat 87 patients with menorrhagia .No endometrial pre-treatment was used in this group of patients. Cervical softening with laminaria or misoprostol was utilized. All patients received either oral and paracervical, or IV anesthesia in the office setting. Patient’s average pain scores on a scale of one to ten are reported and results averaged from one to eight during the procedure depending on the type of anesthesia used. NovaSure efficacy rate was determined by amenorrhea rates of 52%, hypomenorrhea rates of 43%. Overall satisfaction rates averaged 96%. Conclusion: NovaSure is safe, effective, and well tolerated in the office setting. The type of anesthesia utilized the office setting can vary depending on patient needs and physician choices.

THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (2:16 PM – 2:22 PM)

226 Efficacy of Hydrothermal Ablation in Patients With Abnormal Uterine Bleeding Kahn BS, Flinn A. Scripps Clinic & Research Institute, La Jolla, California Study Objective: The purpose of this study was to assess the changes in menstrual pattern and patient satisfaction after hydrothermal ablation for abnormal uterine bleeding. Design: Two hundred patients who underwent hydrothermal ablation in our institution initially had their charts reviewed for demographics, procedure data, clinical history and follow-up. Thereafter, a telephone interview was conducted to assess post-procedural menstrual pattern, quality of life and

patient satisfaction. Data were compared with the use of appropriate tests for categorical or continuous variables and logistic regression analysis. Setting: Obstetric and gynecology multi-specialty group practice in an academic teaching hospital. Patients: Two hundred women (ages 28–77 yrs) with abnormal uterine bleeding. Intervention: Endometrial ablation via hydro-thermal ablation Measurements and Main Results: The median follow-up time was 27 months, and a telephone interview was obtained of 160 of 200 patients. A reduction in days per cycle (9.7 days vs. 2.1 days) and in pads per day (8.0 vs.1.8), and an improvement in self-reported quality of life score (2.8 vs. 8.0) were observed after Hydrothermal Ablation. Hysterectomy was required in 22 of 200 (11%) patients. Assessment of the level of satisfaction showed that 92% of patients were satisfied or very satisfied with the procedure. No major complications or deaths were related to Hydrothermal ablation. Conclusion: Hydrothermal ablation is a safe and efficient method to treat abnormal uterine bleeding. It reduces menstrual flow, improves quality of life, and remarkably fulfills expectations in selected patients.

THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (2:22 PM – 2:28 PM)

227 Five Year Clinical Experience with the HTA Endometrial Ablation System Talvacchia J, Iddenden DA. Thomas Jefferson University, Methodist Hospital Division, Philadelphia, Pennsylvania Study Objective: This study was undertaken to look at patient outcome following HTA endometrial ablation as defined by patient assessment of menstrual bleeding at 3, 6, 12 and 24 months post procedure. In addition, we wanted to see if the success rate differed among patients with or without uterine fibroids. Design: The charts of 139 patients were retrospectively reviewed who underwent HTA Endometrial Ablation by one of two physicians from 2001 through 2005. 27 patients were lost to follow-up. 4 patients required repeat procedures. Thus a total of 116 procedures were analyzed. Setting: Hospital owned gynecology practice in a urban community based teaching hospital Patients: One hundred twelve women between the ages of 31 and 57 who presented with menorrhagia or dysfunctional uterine bleeding Intervention: HTA endometrial ablation was performed in a hospital outpatient OR using saline heated to 90 degrees C for10 minutes. All but one patient received pre-treatment with either Lupron depot or hormonal suppression. Measurements and Main Results: A total of 116 procedures were performed, 4 of which were repeat procedures.

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54 patients had uterine fibroids (46.55%). 12 patients had subsequent hysterectomies, 8 for pelvic pain and 4 for excessive bleeding. One patient underwent a subsequent myomectomy for pelvic pain. At 3 months, the reports of minimal or no improvement vs. hypo or eumenorrhea vs. amenorrhea was 15 (13.16%), 49 (42.99%), and 50 (43.86%) respectfully. At 6 months the results were 12 (11.65%), 48 (46.6%), and 43 (41.75%). At 12 months the results were 7 (9.86%), 38 (53.52%), and 26 (36.62%). At 24 months the results were 4 (12.9%), 13 (41.94%), and 14 (45.16%). In patients with uterine fibroids, the results were 6 (11.11%), 21 (38.88%), and 27 (50%) at 3 months. 6 (12.24%), 20 (40.82%), and 23 (46.94%) at 6 months. 4 (11.11%), 19 (52.78%), and 13 (36.11%) at 12 months. And 4 (30.77%), 2 (15 38%), 7 (53.85%) at 24 months. Conclusion: This study supports numerous earlier works showing the HTA endometrial ablation procedure to be very effective in treating women with abnormal uterine bleeding. In addition it appears to be equally effective in patients with and without uterine fibroids.

THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (2:28 PM – 2:34 PM)

228 Inadequacy of Blind Preoperative Endometrial Biopsy when Compared with Hysteroscopy in 173 Patients Undergoing Endometrial Ablation Young DS. BEST CAREmed, Logan, Utah Study Objective: Understand the importance of focal lesion assessment before endometrial ablation despite normal preoperative biopsy. Design: Retrospective long-term data analysis (Canadian Task-Force Classification III). Setting: Cache Valley Specialty Hospital/Logan Regional Hospital. Patients: One hundred seventy-three premenopausal or postmenopausal women with menorrhagia treated between 1993 and 2005. Intervention: Preoperatively, pipelle and/or med-gyne endometrial biopsies were performed. Intraoperatively, focal lesions consisting of polypoid endometrium and/or polyps were sampled and/or excised at hysteroscopy. Measurements and Main Results: Hysteroscopy identified 24% (42/173) total abnormalities versus preoperative pathology of 12% (21): 15% (26) postop hyperplasia versus 9% (15), 8% (13) hyperplasia with atypia post op versus 4% (6) and 2% (3) cancer. No cancers were identified preoperatively. 18% (31) normal biopsies were abnormal intraoperatively. Only 6% (11) had abnormal pre and postop path. 6% (10) abnormal biopsies were normal intraoperatively. Conclusion: Standard of care requires normal preoperative biopsy. In 173 patients, approximately one in four patients had abnormal pathology identified postoperatively in polypoid endometrium and/or polyps. Approximately 50% of the

time, abnormal pathology had been missed by preoperative biopsy. Pathology included a 2% incidence of cancer which would have been missed if focal lesion sampling at the time of pre-ablation hysteroscopy and/or ablation had not been performed. Therefore, these data support that blind biopsy should not be relied on in the presence of intracavitary pathology.

THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (2:34 PM – 2:40 PM)

229 Chemical Ablation of Endometrium with Trichloroacetic Acid: A Major Contribution in Minimal Invasive Treatments in Patients with Abnormal Uterine Bleeding 1 Birlain M, 2Menocal G, 3Leroy Y, 2Gudino J. 1Centro Mexicano de Ginecologia y Pediatria S:C, Queretaro, Mexico; 2Hospital Angeles de Queretaro, Queretaro, Mexico; 3Hospital Angeles del Pedregal, Mexico, DF, Mexico Study Objective: This is an evidence based Category 1 study that evaluates the difference between the therapy offered: Trichloroacetic acid instillation for endometrial ablation with or without use of a GnRH agonist prior to therapy for endometrial ablation in patients with dysfunctional uterine bleeding (AUB). Design: This is a prospective study that was performed in 36 patients with AUB in a private practice of three gynaecologists in Mexico, from May 2004 to May 2006, based on a randomised trial that was published by the group of Turkey. Setting: Private practice. Patients: Thirty-six patients with AUB. Intervention: AUB was evaluated using history, age (36–54 years) transvaginal sonography (TVS) to evaluate in both groups: the endometrial lining, the size of the uterus and the appearance of the endometrial cavity. In group I, 18 patients received intrauterine instillation of trichloroacetic acid, 95% solution and underwent dilatation and curettage before endometrial chemical ablation. In-group II received the same therapy after a single dose of a gonadotropin releasing hormone (GnRH) analogue 1 month before the procedure, we included 2 patients with intramural fibroids. Patients were evaluated 3, 6, 9, and 12 months, respectively, after TCA application. Measurements and Main Results: After 12 months of treatment, hypomenorrhea, and amenorrhea rates of 93.6% and 97.8%, respectively, our results are similar to the Turkish group. There were no observed negative effects or related complications of the treatment. Histology of tissue changes with TCA was observed in uterus that was obtained after hysterectomy not only in AUB but also with abnormal cavity in benign conditions to prove the extent and depth of ablation. Conclusion: This study gives us a new, easy, cost-effective office procedure for treatment of endometrial ablation in the

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management of AUB. More specific study of the safety of this procedure appears to be indicated. Evaluation of reflux to the fallopian tubes, and absorption of the TCA in previous scared tissue (C-section) has to be proved. If the procedure becomes more widely used, it is likely that only ultrasound examination would be use to rule out intrauterine pathology, and this practice might affect the overall outcome in places were sophisticated methods in diagnostic and treatment of AUB are not provided.

THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (2:40 PM – 2:46 PM)

230 Endometrial Ablation Prior to Myomectomy Is a Safe and Effective Approach 1 Miller CE, 2Zinger M, 1Johnston MT. 1University of Illinois, Chicago, Illinois, Lutheran General Hospital, Park Ridge, Illinois; 2Edward Hospital, Naperville, Illinois Study Objective: To assess combining endometrial ablation using Hydro ThermAblator (HTA, Boston Scientific, Natick, MA) or NovaSure (Cytyc Surgical Products, Mountain View, CA) and laparoscopic myomectomy for menorrhagia and pain. Design: Retrospective cohort analysis of all women consented to undergo myomectomy and HTA or NovaSure from February 2005 through March 2006 by the same surgeon. Novasure was utilized during the initial study period, while HTA was utilized following November 2005. Assessment of menstruation was by pad count and subjective pain score. Setting: Outpatient surgery center in a community hospital. Patients: Twelve women with uterine myomas, menorrhagia, and desire for uterine conservation underwent combined endometrial ablation and laparoscopic myomectomy. Intervention: Each patient underwent transvaginal HTA or Novasure endometrial ablation. Hysteroscopic bipolar endometrial resection was necessary as specified. Immediately following endometrial ablation, laparoscopic myomectomy was performed with a three-layer repair by laparoscopic suturing. Measurements and Main Results: Two of five patients were able to complete NovaSure ablation. Three failed the cavity integrity check, thus underwent hysteroscopic resection. All seven HTA patients completed ablation successfully. Uterine sounding and size was 7–10 cm and 8–12 weeks in Novasure patients versus 7–16 cm and 8-–20 weeks in HTA patients. All three NovaSure-failure and one HTA patient had type II submucous myomas, while the remainder had only intramural. Postoperatively, all patients had hypomenorrhea except one Novasure patient had amenorrhea. Three HTA patients and one NovaSure patient had preoperative dysmenorrhea, noting 40%–100% versus 20% improvement respectively. The only complication was a five-day hospital stay with transfusion related to resection of a 7.5 cm adenomyoma in an HTA patient.

Conclusion: The addition of ablation does not alter the healing and rapid recovery that is expected with laparoscopic myomectomy. The combination consistently results in hypomenorrhea or amenorrhea. While submucous myomas preclude NovaSure usage, HTA can be performed in uteri with submucous myomas and cavities greater than 10 cm.

THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (2:46 PM – 2:52 PM)

231 Placement of Essure Device Immediately Following NovaSure Endometrial Ablation Thiel JA, Ciaran G. Regina Qu’Appelle Health Region, Regina, Saskatchewan, Canada Study Objective: To determine the success of placement of Essure coils immediately following NovaSure endometrial ablation for dysfunctional bleeding. Design: Retrospective case control study (Canadian Task Force Type II-2) Setting: Ambulatory women’s health clinic in a tertiary care hospital. Patients: Twenty-one women undergoing NovaSure ablation for dysfunctional bleeding with concomitant Essure coil placement for sterilization. Intervention: After administration of conscious sedation with IV narcotic and benzodiazepine, the endometrial cavity and tubal ostia were hysteroscopically visualized. Novasure endometrial ablation was completed. Immediately following ablation, the Essure procedure was completed. Follow-up at 3 months was by ultrasound localization of the coils, those with an unsatisfactory ultrasound underwent hysterosalpingography to determine tubal occlusion. Measurements and Main Results: Age, parity, gravidity and indication for ablation was recorded. Success of the ablation and the Essure procedure was noted as well as the procedure and recovery time. Follow-up results included success of the ultrasound or if necessary, the hysterosalpingogram. The mean age of the patients was 38.8 years, the mean gravidity was 1.89, the mean parity was 1.68. The average time to complete both procedures was 17 minutes, the mean time in the recovery area was 141 minutes. Seventeen patients required a single dose of Ibuprofen 400 mg following the procedure. Nineteen of 21 patients (90%) had successful placement of the Essure coils immediately following NovaSure ablation. Sixteen women were first evaluated with ultrasound 3 months following the procedure, 9 (42%) had satisfactory localization of the coils in the uterine cornua, 7 (33%) were unsatisfactory. Five (23%) patients were taken directly to hysterosalpingogram without completing an ultrasound. Two of the 12 women undergoing HSG had patent tubes at 3 months and underwent laparoscopic tubal coagulation. Both unsuccessful procedures were completed early in the series, resulting from poor visualization of the tubal ostia secondary to debris after the

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NovaSure. This problem is now overcome with the use of suction curettage if excessive endometrial debris is encountered. Twenty women (95%) reported satisfactory results following the NovaSure procedure. One patient continued to have dysfunctional uterine bleeding following the Novasure procedure and requested total laparoscopic hysterectomy. At the time of the hysterectomy the coils were noted to be well positioned in the uterine cornua. One patient was lost to follow-up. Conclusion: Satisfactory improvement of dysfunctional uterine bleeding symptoms and successful bilateral placement of the Essure coils was noted in 17 (81%) women. Placement of Essure coils after NovaSure ablation can be satisfactorily completed, with ultrasound localization of the coils 3 months following the procedure successful in 42% of patients. Hysterosalpingogram was successful in the remainder of patients in determining tubal occlusion.

THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (2:52 PM – 2:58 PM)

232 Essure Tubal Sterilization Associated With Concomitant Operative Hysteroscopic Procedure: Technical Specificities and Outcomes Deffieux X, Donnadieu AC, Gervaise A, Chevalier N, Bonnet K, Frydman R, Fernandez H. APHP, Antoine Beclere Hospital, Clamart, France Study Objective: Permanent sterilization is desired by many of these patients, and hysteroscopic sterilization with the Essuri System offers a transvaginal approach similar to the endometrial ablation techniques. Furthermore, the need for contraception is a concern for both patients and their physicians after endometrial ablation, since reported pregnancies after endometrial ablation are complicated by a high risk of abnormal placentation and cesarean hysterectomy. The aim of this study was to assess the feasibility and to describe the technical specificities of hysteroscopic tubal sterilization during associated operative hysteroscopy, and to assess outcomes. Design: Retrospective study. Setting: University Hospital (Department of Obstetrics and Gynecology). Patients: Twenty-two women who have undergone an hysteroscopic tubal sterilization during an associated hysteroscopic procedure. Intervention: Hysteroscopic tubal sterilization was performed using Essuri System. Associated procedure included balloon therapy (n = 14) (ThermaChoice UTB System, Gynecare), hot circulating saline (n = 1) (Hydro ThermAblator HTA System, BEI Medical/Boston Scientific), endometrial resection using bipolar impedance technology (n = 2) (Versapoint System, Gynecare), and microwave (n = 3) (NovaSure System, Novacept), resection of endometrial polyp using monopolar technology (n = 2).

Successful device placement was assessed after 3 months by volume-contrast three-dimensional (3D) ultrasound imaging 3 months after the procedure. Measurements and Main Results: Successful bilateral placement was obtained in 19 (86%) patients, and in 3 (14%) the procedure failed (endometrial bleeding at the beginning of the procedure). The Essure procedure has been performed immediately before (n = 12/14, 85%) or immediately after (n = 2/14, 14%) the ThermaChoice uterine balloon ablation system. It has also been done immediately after—but not immediately before—using the NovaSure radiofrequency ablation system. Volume-contrast (3D) ultrasound showed proper positioning of the coils within the proximal fallopian tube in all women. After 18 womanmonths of exposure to intercourse, no pregnancies have been recorded. Conclusion: The placement of Essure Micro-Insert System is feasible during an associated operative hysteroscopic procedure. This method may be offered to all women undergoing an hysterosocpic operative procedure and who ask for permanent tubal sterilization. The tubal ostia could reliably be found, and the tubes cannulated, after each technique of endometrial ablation.

THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (2:58 PM – 3:04 PM)

233 The Essure Micro-insert System for Hysteroscopic Sterilization in Women With Cardiac Disease: 19 Cases El-Nashar SA, Hopkins MR, Driscoll DJ, Famuyide AO. Mayo Clinic, Rochester, New York Study Objective: To report on the feasibility, safety and short-term efficacy of Essuri hysteroscopic sterilization method for women with cardiac disease including adult congenital heart disease (ACHD) and valvular or ischemic heart disease (V/IHD). Design: A retrospective cohort study (Canadian Task Force classification II-2). Setting: A Midwestern academic medical center. Patients: Using a record linkage system, 19 women with documented heart disease (9 ACHD & 10 V/IHD) were identified out of a total of 100 women (19%) who had Essure placement (January 2003 – December 2005). Intervention: Essuri hysteroscopic sterilization. Measurements and Main Results: Two subgroups of cardiac patients were identified; adult CHD and V/IHD. The adult CHD group included younger women [median age = 24 years (range 17–29); median BMI = 22 kg/m2 (range 19–28)]. One had a heart transplant, while the other 8 had definitive cardiac operation for complex cyanotic heart disease (3), single ventricle with pulmonary hypertension (2), tetralogy of Fallot (1), and atrial septal defect (1). All except one were nulliparous. Previous contraception included abstinence (1), oral contraceptive pills (OCP) (3) and Depo-Provera (5). The V/IHD

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group included 10 women [median age = 38 years (range 25–50); median BMI = 25 kg/m2 (range 21–39)]. Median parity was 2 (range 0–3). Previous contraception included abstinence (1), rhythm (1), barrier (1), OCP (4), Depo-Provera (2), & Mirena (1). All women had a successful placement with no reported intra-procedural complications [median operation time of 14 min (range 5- 36)]. Sixteen (84%) had I.V. sedation ± regional block and general anesthesia was needed in 3 (16%). Sixteen 16 (84%) completed the requisite hysterosalpingogram. All showed bilateral tubal block. Conclusion: In high risk women with cardiac disease; the micro-insert system (Essure) is a safe and feasible procedure which can provide a permanent, reliable, and non-hormonal method of contraception.

THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (3:04 PM – 3:10 PM)

234 Case Presentation of Novasure Endometrial Ablation in Women with Platelet Disorder: Review of Endometrial Ablations in Women with Hemostatic Disorders Lukes A, Sobolewski CJ, Arepally G. Duke University Medical Center, North Carolina Study Objective: To present a case of a successful Novasure endometrial ablation in a woman with a platelet disorder, as well as review the evidence of endometrial ablations in women with bleeding disorders. Design: A case review will be presented of a 34-year-old black female who was identified with an underlying bleeding disorder. A comprehensive review of all evidence on endometrial ablations in women with underlying bleeding disorders will be presented. Setting: Women’s Hemostasis and Thrombosis Clinic at a tertiary medical center. Patients: A 34-year-old black female with a platelet disorder. Her hemostatic disorder was discovered during adulthood by a pediatric hematologist who cared for her son who also has a bleeding disorder. The woman failed multiple medical treatments for heavy menstrual bleeding, including hormonal medication, tranexamic acid, and Stimate nasal spray. Intervention: A NovaSure endometrial ablation was performed without complications, combined with a bilateral tubal ligation. Measurements and Main Results: The procedure was uncomplicated. Given the planned tubal ligation, the ablation was done with laparoscopic visualization. At three month follow-up, she was had significant improved quality of life and was amenorrheic. A review of all published data on endometrial ablations in women with hemostatic disorders will be presented. Conclusion: Evidence has shown that endometrial ablations are safe and effective treatments for abnormal uterine bleeding. Females with underlying hemostatic disorders are good candidates for this minimally invasive treatment for heavy

menses. There is little evidence reviewing this important area of abnormal uterine bleeding.

THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (3:10 PM – 3:16 PM)

235 Initial Sydney Experience in Hysteroscopic Sterilization Using the Adiana Complete Permanent Birth Control Device Vancaillie TG. Royal Hospital for Women, Randwich, Australia Study Objective: To present our initial experience in the use of the Complete™ permanent birth control device in Sydney Australia. Design: A prospective study. Setting: Royal Hospital for Women, Sydney, Australia Patients: Eighty-three women seeking permanent birth control. Intervention: From 12 January 2004 to 27 April 2005, women who sought sterilization were counseled with regards to the various options of permanent birth control. Informed consent for hysteroscopic sterilization was obtained only after the woman met the criteria for the Adiana permanent birth control. The sterilization procedure was carried out without the need for general anesthesia in a day surgery center using the Adiana permanent birth control device. Measurements and Main Results: After screening, 69 patients were brought to hysteroscopy and had attempted catheter placement with bilateral success in 66 patients (95.7%). Local anesthesia was used in 100% of patients. No patients received IV sedation; however, 12% of patients received supplemental nitrous oxide by inhalation. Mean procedure time (“scope in to scope out”) was 10 minutes + 5 minutes. All 66 patients had successful documented bilateral tubal occlusion by HSG and entered the 1 year efficacy follow-up. No serious adverse events related to the use of the Adiana device were reported. No pregnancies have been reported in our series to date. Conclusion: The results show that the procedure is well tolerated under local anesthesia and that the devices can be successfully placed in a high percentage of cases. Patient follow-up continues.

THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (3:16 PM – 3:22 PM)

236 Essure Localization after Successful Placement 1 Veersema S, 2Vleugels MPH, 1Timmermans A, 3Brolmann HAM. 1St. Antonius Hospital, Nieuwegein, Netherlands; 2 Rivierenland Hospital, Tiel, Netherlands; 3VU University Medical Center, Amsterdam, Netherlands Study Objective: The aim of this study is to evaluate the reliability of pelvic X-ray and transvaginal ultrasound (TVU) to

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localize the Essure micro-inserts three months after a successful bilateral placement. In Europe, pelvic X-ray is recommended, while in the US an HSG is required. Design: Prospective cohort study. Setting: Gynaecology outdoors department of two Dutch clinics. Patients: One hundred and fifty women who underwent a successful bilateral Essure sterilization between August 2002 and August 2004. Intervention: All women were scheduled for TVU after three months. TVU was followed by HSG in the same session. HSG was started with a blank pelvic X-ray. After the micro-inserts were localized, the position of the reflections of the insert in relation to the outer line of the uterus were described. Measurements and Main Results: In 148 patients both tubes were occluded. With TVU 291/300 Essure devices were visualized. In one case the Essure device could not be seen on TVU nor was it seen with X-ray. A complete expulsion of the microinsert. In another case the micro-insert was present on TVU and X-ray, but the HSG showed patency beyond the micro-insert. The pre-test probability that a patient still has a patent tube 3 months after a successful Essure placement is 1,3 % ( 0.5%–3.1). The positive predictive value for incorrect placement is 0.11 (6.0%–16%) for TVU and 1 for X-ray. The sensitivity for both X-ray and TVU is 50% (42%–58%). The specificity of X-ray is 100% and for the TVU 94.6% (91%–98.2%). Conclusion: Ultrasonography appears to be a reliable non-radiation alternative diagnostic tool for pelvic X-ray or HSG following a successful bilateral Essure placement. X-ray and HSG can be reserved for those patients whose micro-inserts are not localised by TVU.

THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (3:22 PM – 3:28 PM)

237 Evaluation of Contrast Infusion Sonogram for Use in the Post Essure Setting 1 Connor V, 2Asaad R, 3Hammoud A, 2Khani MR, 2 Diamond MP. 1Cleveland Clinic Florida, Weston, Florida; 2Wayne State University, Detroit, Michigan; 3 University of Utah, Salt Lake City, Utah Study Objective: To evaluate the use of Contrast Infusion Sonography (CIS), an adaptation of Hysterosalpingo Contrast Sonography, to determine microinsert placement and tubal occlusion three months after Essure placement. Design: Pilot Study. Patients were evaluated at one or two, and three month intervals after bilateral Essure microinsert placement. Setting: Academic multispecialty clinic. Patients: Nine women desiring permanent sterilization. Eleven studies were performed within 90 days of hysteroscopic sterilization. Intervention: IRB approval and informed consent were obtained. Patients underwent Contrast Infusion Sonogram

with Definity microsphere contrast agent, followed by an HSG at 30 or 60, and 90 day intervals after bilateral Essure placement. Premedication was given with an oral prophylactic antibiotic and Toradol. Measurements and Main Results: With Contrast Infusion Sonography microinsert location was determined by ultrasound, and tubal status was determined using either the presence or absence of real time flow along the microinsert, or unequivocal presence of contrast agent in the cul de sac or adnexa. A sequential HSG was performed and interpreted as recommended by the manufacturer of the Essure system. In all cases microinsert location was accurately assessed by ultrasound when compared to HSG. In six patients bilateral occlusion was confirmed by both CIS and HSG. In two patients contrast agent was visualized in the cul de sac during CIS, and HSG confirmed tubal patency. One patient had real time flow with CIS and patency confirmed on HSG. Two patients had real time flow on CIS and bilateral occlusion on the sequentially performed HSG. Conclusion: These preliminary results indicate Contrast Infusion Sonography may be an attractive in-office, ultrasound based alternative to HSG in the post Essure setting. Further investigation is warranted.

THURSDAY, NOVEMBER 9, 2006 Open Communications 12—Hysteroscopy EA/TL (3:28 PM – 3:34 PM)

238 Post-operative Compliance with a 3-month hysterosalpingogram after Essure Hysteroscopic Tubal Occlusion 1 Tagoe UJ, 2Della Badia C, 3Chaudhari A. 1Graduate Hospital, Philadelphia, Pennsylvania; 2Drexel University School of Medicine, Philadelphia, Pennsylvania; 3 University of Utah Medical School, Salt Lake City, Utah Study Objective: The Essure sterilization system is a method of permanent birth control that utilizes hysteroscopic placement of micro-inserts to achieve tubal occlusion. The purpose of this study is to describe and compare patient compliance rates with the three-month post-operative hysterosalpingogram (HSG) required to confirm tubal occlusion after Essure hysteroscopic sterilization among patients in a resident clinic population compared to a private patient population. Design: A retrospective chart review was performed to identify all patients who had undergone Essure hysteroscopic tubal sterilization between January 1, 2003 and December 31, 2005. Demographic data, hospital service, and follow-up HSG data was collected and analyzed. Setting: An academic teaching hospital. Patients: One hundred and sixty-two patients were identified who had undergone Essure hysteroscopic tubal sterilization. Thirteen patient records were incomplete; 149 patients were included in the analysis. Measurements and Main Results: There was a significant difference in the percentage of private patients who under-

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went the 3-month HSG, 81%, compared to 39% in the clinic patient population (p < 0.001). There was no significant difference between the two groups with regard to mean time from Essure procedure to HSG follow-up between the clinic and private patients (124 days and 112 days, respectively, p = 0.19). Conclusion: This study supports that a resident clinic population is significantly less likely to be compliant with the 3month HSG than a private patient population. Possible explanations for this include younger age, inadequate counseling on the importance of confirming tubal occlusion, system barriers which hinder efficient scheduling and coordination of the HSG in a clinic setting, and lapses in insurance coverage. Given this lack of follow-up, future studies focused on safety and efficacy of Essure sterilization in a resident clinic population are needed.

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239 Hydro Thermablator (HTA) and Essure Hysteroscopic Sterilization-Physician Retrospective Review Berman JM, Elhamady E, Berman J, Detti L. Wayne State University School of Medicine, Detroit, Michigan Study Objective: Hydro-thermal endometrial ablation (HTA) with Hydro Thermablator System and hysteroscopic sterilization with Essure are two well-established operative techniques. Our objective was to assess the immediate risks, benefits, and indications of performing HTA and hysteroscopic sterilization with Essure as combined procedures during the same operative session or in close proximity. Design: Retrospective assessment of the outcome of the combined procedures, HTA/Essure placement, as reported by 2 general gynecologists-obstetricians to whom a comprehensive questionnaire was sent. Our main outcome measures were combined procedure feasibility, best operative order based on the success rate of Essure coil implantation, and complications. Setting: Multicenter retrospective study. Patients: Four patients underwent HTA/Essure placement during 2 years (from 2003 to 2005). Intervention: HTA and Essure placement were performed in multiparous women following two different operative sequences. Measurements and Main Results: A total of 4 combined procedures were performed by 2 physicians. Demographics of the 4 patients are similar. One patient underwent HTA before Essure placement (sequence 1), and 3 underwent Essure before HTA (sequence 2). The overall success rate of Essure coil implantation when performed before or after HTA was 4. We found 0 Essure failures (0 monolateral, 0 bilateral) in sequence 1 and 0 (0 monolateral, 0 bilateral) in sequence 2, respectively. Uterine perforation during HTA was reported in 0 patients in sequence 1 and 0 patients in

sequence 2, respectively. Overall success was reported in 1 for sequence 1 and 3 for sequence 2. The overall success rate of Essure coil implantation when performed before or after HTA was 4. Conclusion: HTA and Essure are safe to perform together or with a short interval between. Most procedures were done with the Essure placed face followed by the HTA. The operative sequence did not appear to affect the outcomes. It is expected that when all the data is collected there will be approximately 100 patients.

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240 Use of Dye to Enhance Visualization Aids Placement of Essure Device Immediately Following Novasure Endometrial Ablation Howell TG. Mayo Health System, Cannon Valley Clinic, Fairbault, Minnesota Study Objective: To prospectively evaluate a unique catheter marking the tubal ostia and subsequently ability to place Essure devices after Novasure Endometrial Ablation. Design: Seventeen consequetive patients undergoing endometrial ablation and tubal occlusion were involved. Data collection is ongoing but is complete in 12 of 17 subjects. Follw-up was complete after HSG confirms tubal occlusion at least 3 months after procedure. Setting: Community Hospital one-day surgery area. Patients: Seventeen consecutive patients requesting Global Endometrial Ablation and needing permanent sterilization. 12 patients have completed and 5 are waiting for HSG to confirm tubal occlusion. No patients have been lost to follow-up to date. Intervention: Tubal ostia were marked with methylene blue dye using a unique catheter (patent pending: Mayo Medical Ventures) prior to performing Endometrial Ablation with Novasure device. Ostia were then cannulated with Essure Tubal Occlusion device. Patients returned after 3 months for follow-up HSG to confirm placement and tubal occlusion. Measurements and Main Results: Measurement was number of attempts with successful placement and confirmation of occlusion at HSG. Seventeen patients were scheduled. One patient’s ostia could not be visualized, ablation was performed but dye placement and Essure not done. She underwent a laparoscopic sterilization. All other patients had successful dye placement followed by bilateral Essure Occlusion. One patient had only one remaining tube so unilateral procedure performed. Ninety-four percent of patients had successful placement. 65% (12) are confirmed on HSG. 29%(5) are pending HSG. 6%(1) were not successful. Tubal were not visualized on one patient prior to ablation. She would not have been a candidate for Essure independent of herablation. Conclusion: Use of Methylene blue dye to enhance visualization of tubal ostia was shown to be feasible, simple and helpful. Placement of Essure after Novasure ablation was easier to perform as the ostia were more reliably located. This enabled the procedure to be done quickly and with more confidence.

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All patients who have had follow-up to date are satisfied with the procedure and have bilateral occlusion demonstrated. This technique should make it easier for the general hysteroscopist to perform this combined procedure using minimal anesthesia. This enhances patient recovery and comfort while minimizing costs. This technique should also aid those just learning the procedures.

THURSDAY, NOVEMBER 9, 2006 Open Communications 13—Myomas (2:10 pm – 2:16 pm)

241 Preoperative Ultrasound for Uterine Leiomyomas: Is It Trustworthy? A Preliminary Study 1 Battista C, 1Angioli R, 1Sereni MI, 1Cafa E, 1Marullo E, 1 Sadun B, 1Vitale M, 1Terranova C, 1Muzii L, 1Zullo MA, 2 Benedetti Panici P. 1Universita “Campo Bio-Medico” di Roma, Rome, Italy; 2Universita degli Studi di Roma “La Sapienza,” Rome, Italy Study Objective: To correlate the preoperative ultrasound examination with anatomo-pathological findings with regard to estimating the number and the size of myomata. Design: We performed a prospective study on 43 patients who underwent surgical operation for uterine leiomyoma between March 2005 and May 2006. Ultrasound scans (US) were performed within 1 day of admission to the operating theatre always by the same experienced operator, using a Siemens Sonoline Antares sonographic scanner equipped with a 7, 5 MHz transvaginal probe. Number and size of myomata at ultrasounds were compared with anatomopathological (AP) findings. Patients were divided into three groups: one submitted to hysterectomy, one submitted to laparoscopic myomectomy and another submitted to laparotomic myomectomy. Furthermore, each surgical procedure was performed by the same team. Setting: University Hospital-Division of Gynaecology. Patients: Forty-three patients, aged 29–73 years (mean 51years). Intervention: Ultrasound scans (US) were performed within 1 day of admission to the operating theatre. Measurements and Main Results: Preliminary results show that there is no significant difference between the number of leiomyomata at US and at AP in the three groups if the number of myomata is less than or equal to six, while a significant difference exists if the number of myomata is more than six (P = 0.0269).The analysis of the size of myomata shows that there’s no significant difference between US and AP in the laparoscopic and the hysterectomy groups, while there is significant difference in the laparotomic group (P = 0.0339). Conclusion: Our data shows that US is a good method to identify the size of myomata in laparoscopy and hysterectomy.US is also a good method to evaluate the number of uterine fibroids if they are less than or equal to 6, while it downstages when the number is above 6; is this the cut-off of US for uterine leiomyomas?

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242 New Submucous Fibroid Classification – STEP-W Classification 1,2 Lasmar RB, 2Barrozo PR, 1Oliveira MAP, 2Dias R. 1 Departmento de Ginecologia – Sector de Endoscopia Ginecologica da Faculdade de Medicina de Botucatu – UNESP, SP; 2Departmento de Ginecologia da Faculdade de Medicina da Universidade Estadual do Estado do Rio de Janeiro, Rio de Janeiro, Brazil Study Objective: To develop a new submucous fibroids classification for evaluating the viability and the degree of difficulty and complexity of a hysteroscopic myomectomy. Design: Retrospective study (Canadian Task Force classification II-3) Setting: University teaching hospitals. Patients: Sixty two patients who underwent hysteroscopic myomectomy. Intervention: We have included more four parameters in addition to penetration the fibroid into the myometrium. The extra-parameters were: size of the fibroid, it topography, it extension of the base in relation the wall was set and the wall it was set. The fibroids were classified according to the Classification of the European Society for Gynaecological Endoscopy (ESGE) and to the new classification (STEP-W) in patients who were submitted to hysteroscopic resection of submucous fibroids. The possibility of total resection of the fibroid, the operating time, the fluid deficit and the frequency of any complications were considered. The Fisher test, the Student t test and the analysis of variance test were used in the statistical analyses. It was considered statistically significant when the p-value was less than 0.05 in the twotailed test. Measurements and Main Results: In group which the hysteroscopic surgery was considered complete there was no significant difference between the three ESGE levels (0, 1 and 2). Using the STEP-W, the difference between the numbers of complete surgeries was significant (p < 0.001) for the two levels (groups I and II). The difference between the operating times was significant for the two classifications. In relation to the fluid deficit, only the STEP-W showed significant differences between the levels (p = 0.02). Conclusion: The STEP-W classification gives more clues to the difficulties and complexities of a hysteroscopic myomectomy than the ESGE classification. Table.1 – Table used to classify each fibroid Size

Topography Extension Penetration Lateral Base wall <1/3 0 0 )<2 cm lower +1 1 >2 to 5 cm middle >1/3 to 2/3 <50% +1 2 >5cm upper >2/3 >50% +1 Score + + + + =

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Score Group

Suggested Treatment Process:

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Laparoscopic Myomectomy. Surgical Anatomy Based Technique Vittori G, Lena A, Delfini R, Giovannini PL, Russo PL, Camilli FM, Zeloni R. Ospedale San Carlo, Rome, Italy

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Recommend an alternative non- hysteroscopic technique.

Table 2 – Table showing the group and the suggested treatment according to the highest score obtained

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243 Effect of Uterine Myomas on Pregnancy Complications 1 Asaad R, 2Hammoud A, 1Khani MR, 1Diamond MP. 1 Wayne State Univesity, Detroit Michigan; 2University of Utah, Salt Lake City, Utah Study objective: To study the effect of uterine myomas on pregnancy complications. Design: Historic cohort. Setting: Tertiary care center. Patients: Patients diagnosed with myomas during pregnancy and have complete records. Intervention: Medical records were reviewed to extract data relating to the course of pregnancy, delivery and post partum period. Early postpartum hemorrhage (PPH) was defined as estimated blood loss during delivery of > 500 cc for vaginal and > 1000 cc for cesarean deliveries. Measurement and main results: From September 1998 to June 2005, 155 patients met our inclusion criteria. The frequency of pregnancy complications were as follow: first trimester loss 7.7%, second trimester loss 5.8%, Premature rupture of membranes16.1%, preterm labor 17.4%, growth restriction 17.4%, malpresentation at delivery 22% (breech 16.8%, transverse 3.9%, and oblique 1.3%). Fibroid degeneration occurred in 22.6% of patients. The mode of delivery was as follow: 45% vaginal and 55% cesarean deliveries. The type of cesarean was as follow: Low transverse 74%, classical 18.2%, T incision 5.2%, and J incision 2.6%. The mean EBL was 309 ± 150 for vaginal delivery and 1081 ± 563 for cesarean. The risk of PPH was 27.3% in cesarean compared to 2.6% in vaginal deliveries (p<0.001). During cesarean: a low anterior position of at least one fibroid increased 8 times the risk of PPH (OR=8.8, CI: 2-38). There was no correlation between the number of fibroid and risk of PPH. Anterior location of placenta was associated with 27.7% risk of PPH compared to 25.0% if the placenta was posterior (p=0.811). Myomectomy was performed in 9% of cesarean. Myomectomy was not associated with increased risk of PPH. Conclusion: Uterine myomas during pregnancy are associated with high incidence of pregnancy complications. A cesarean delivery in the presence of low anterior myoma is associated with a high incidence of PPH. offer an effective alternative to conventional resectoscopy.

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Study Objective: To demonstrate safety, effectiveness of a surgical anatomy based technique for laparoscopic myomectomy. Design: Retrospective analysis of 703 cases of laparoscopic myomectomy. Setting: Dept. of Gynecology, Ospedale San Carlo, IDI IRCSS, Rome. Patients: More than 700 laparoscopic myomectomies were performed at our institution between 1996 and 2005. Intervention: A 10 mm umbilical trocar and only two ancillary trocars (5 mm and 10 mm) were inserted in all cases. No pre-operative GnRH agonists, or intra-operative vasoconstrictor uterine injections were used. Surgical anatomy rationale was based on a vascular architectural optical microscopydemonstrated pseudocapsule, which surrounds myomas. Myomas lack a single vascular pedicle and are anchored by several small fibrovascular bridges to the myometrial pseudocapsule. Blunt dissection of these connections inside the pseudocapsule dramatically minimizes blood loss and allows complete enucleation of the myoma. Uterine incision is carried out until myoma is exposed enough to be grasped by a laparoscopic Collins forceps in order to apply traction. Countertraction is achieved using an Endopath Uterine Manipulator (Ethicon®) which results in exposure of the cleavage plane and of the pseudocapsule fibrous bridges which are dissected by a harmonic scalpel or mechanical traction. Closure of incision is performed in multiple layers with Monocryl extracorporeally-tied interrupted suture. The myoma is then removed by morcellation. Peritoneum is closed with the intrabdominal closing technique (IACT) for incisions of 10 mm or larger to prevent of Richter’s hernia. Measurements and Main Results: We removed 1298 myomas laparoscopically in 703 patients. Mean number of myomas removed/patient was 1.85 ± 1.37 (range 1–8); 201 women (28.7%) had multiple myomectomy. The largest myoma removed was 17 cm. Mean operating time was 103 ± 39 minutes (range 68–197 min). Mean hemoglobin decrease was –1.4 ± 1.2 g/dL. One patient recived a blood transfusion, four patients developed a broad ligament hematoma, one developed postoperative fever and five needed laparoconversion. Mean length of stay was 2.9 ± 1.4 days. Conclusion: Myomas have been reported in 20%–40% of fertile women and represent the most common solid tumors of female pelvis. Laparoscopic myomectomy provides a minimally invasive alternative to laparotomy for the removal of intramural and subserosal myomas. We describe the surgical technique used in our large series experience. Advances in endoscopic surgery have improved the feasibility and safety of

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laparoscopic myomectomy which involves no particular risk of short term complications and offers encouraging results in terms of fertility, complication rate and remission of symptoms.

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245 Laparoscopic Myomectomy for Treating Symptomatic Uterine Myomas 1,2 Hsu WC, 1Torng PL, 1Chang WC, 1Sheu BC, 1Chang DY, 1 Huang SC. 1National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; 2Buddhist Tzu-Chi College of Medicine, Buddhist Tzu-Chi General Hospital, Taipei, Taiwan Study Objective: To evaluate the feasibility, complications, and conversion rate of laparoscopic excision of myomas. Design: Prospective evaluation of women with myoma underwent laparoscopic myomectomy. Setting: Gynecology department of a university-affiliated teaching hospital. Patients: One hundred nine patients receiving laparoscopic myomectomy between March 2003 and December 2005. Intervention: Surgical technique, operation time, myoma weight, estimated blood loss, clinical course, length of stay and complications were all reviewed to evaluate the effects of laparoscopic excision of myomas. Measurements and Main Results: Every patient had adequate preoperative ultrasonography and was used for the analysis. The uterine weight, postoperative complications, and patient outcomes, including hospital stay, operation time, and blood loss during operations were analyzed. The average age of patients included for laparoscopic myomectomy was 38.5 + 6.22 years old (range 24–50 y/o). In the course of these operations 203 myomas were removed. The average number of fibroids removed per patient was 1.86 ± 1.27 (range 1–8). The average mean size of the largest fibroid removed was 6.34 ± 1.92 cm (range 2–12.7). The average myoma weight removed per patient was164.20 ± 132.51g (range 10–760). In 85% of cases, the largest fibroid measured was between 4–9 cm and we carried out laparoscopic myomectomy. The total mean operation time was 125 ± 41 min with an average blood loss of 31.1 ± 22.4 ml (range 20–200). The average length of hospital stay was 3.37 ± 0.8 days (range 2–9). The total complication rate was 1 . 8 % (2/109). One patient had postoperative fever (> 38.00C) after 48 hours. Postoperative ileus occurred in one case and she had a stay of 9 days. No other complications were found in these cases. During our study eight patients conceived, three of them underwent Caesarean section at term at NTUH without complication of uterine rupture. Conclusion: Myomectomy by laparoscopy is a safe alterative to laparotomy in well-selected patients.

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246 Surgical Approach and Case Selection in Myomectomy Waters NV, Thoma V, Wattiez A. IRCAD, Hopitaux Universitaires, Strasbourg, Cedex, France Study Objective: To retrospectively analyse the surgical case selection process for laparoscopic or open myomectomy in order to optimize the selection process of the best treatment modality. Design: Single center retrospective study. Setting: University hospital, France. Patients: Forty-three women were included in the study. There were 22 laparotomies, mean age 34 (22–43). There were 21 laparoscopic myomectomies, mean age 37 (27–55). Most patients desired fertility in the future (83%), but statistically equal number of patients desired fertility in both groups. The commonest indication for the procedure was menorrhagia (41%). Intervention: All myomectomies performed laparoscopically or by laparotomy from January 2004 to December 2005. Measurements and Main Results: The main parameters influencing surgeon’s choice of mode of surgery were the size of fibroids preoperatively, number of fibroids (single vs. multiple), rapid growth and suspected malignancy, strategies to reduce intraoperative blood loss (uterine artery ligation, preoperative uterine artery embolization) and preoperative use of LHRH analogs. The main outcomes analysed were post-operative hemoglobin drop, length of hospital stay and the weight of the fibroids on histology. In the laparotomy group the fibroids were bigger on clinical examination or by ultrasound, and were predominantly multiple. All patients with rapid growth or suspicion of malignancy were selected for laparotomy. Both groups had similar utilization rates of uterine artery occlusion strategies and of LHRH analogs. Blood loss as reflected by actual haemoglobin drop was similar between the two groups, but the length of stay was 1.9 times longer in the laparotomy group (p < 0.05), with a mean of 5 days in the laparoscopic group compared to 7 days in the laparotomy group. The mean histological weight in the laparotomy group was 595 grams compared to 121 grams in the laparoscopic group. Conclusion: Appropriate preoperative patient selection avoids unnecessary conversion of laparoscopy to laparotomy. Information that aides appropriate patient selection is the fibroid size on clinical examination and their number. If the fibroid is more than around 8 cm and especially if they are multiple, surgeons tend to select patients for laparotomy. This decision making process works well in terms of postoperative blood loss since hemoglobin drop between the two groups is not significantly different.

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Laparoscopic Assisted Abdominal Myomectomy— A Safe, Effective, Minimally Invasive Method for the Management of Uterine Fibroids 1 Shah JP, 2Vaught JM, 2Mackoul PJ. 1Wayne State University, Karmanos Cancer Institute, Detroit, Michigan; 2 George Washington University, Washington, DC

Recurrence of Leiomyoma After Laparoscopic Myomectomy Kitade M, Takeuchi H, Koizumi K, Kumakiri J, Shimanuki H, Kikuchi I, Shimanuki H, Kikuchi I, Juntendo University School of Medicine, Hongo, Bunkyo-, Tokyo, Japan

Study Objective: To evaluate the feasibility, complications, and conversion rate of laparoscopic assisted abdominal myomectomy. Design: Seventy-eight consecutive cases of laparoscopic assisted abdominal myomectomy with either uterine artery ligation or uterine artery tourniquet performed by one surgeon with resident assistant at a teaching institution from January 2004 to August 2005 were reviewed. Duration of follow-up extended to 6 months. Setting: A community based teaching hospital, Holy Cross Hospital, Silver Spring, Md. Patients: There were a total of 78 consecutive patients analyzed with an average age of 36, average BMI of 27, and 21% had a history of prior abdominal surgery. The indications for myomectomy included leiomyoma, pelvic pain, symptomatic anemia, or infertility. Intervention: Laparoscopic assisted abdominal myomectomy accomplished with either laparoscopic uterine artery tourniquet or uterine artery ligation and completion of myomectomy through mini-laparotomy incision. Measurements and Main Results: Following a retrospective chart review the average operating time was 94 minutes, average estimated blood loss was 180 ml, average length of stay was 1.2 days, and average weight of fibroids removed was 399 grams (range 35–3411). Overall, rate of complication was 12.8%. Complications included blood transfusion (6.4%), pelvic abscess (3.8%), wound infection (5.1%), partial small bowel obstruction (1.2%), and fascial dehiscence (1.2%). No patients had a lower urinary tract injury. No patients required conversion to hysterectomy. Conclusion: Laparoscopic assisted abdominal myomectomy is a safe alternative with many of the inherent advantages of both a laparoscopic and abdominal approach to myomectomy. Laparoscopic control of the uterine blood supply combined with mini-laparotomy ensures minimal blood loss with a strong multi-layered closure. In our experience, this minimally invasive approach has few complications and provides for rapid patient recovery.

Study Objective: To assess recurrence of leiomyoma after laparoscopic myomectomy (LM) and evaluate the factors associated with recurrence. Design: Retrospective analysis of 262 consecutive cases performed LM. Setting: Department of Obstetrics and Gynecology, Juntendo University School of Medicine. Patients: Two hundred sixty-two women (age 22-47, median 37 yrs) with mean follow up of 19 months range 6-36 after LM. Intervention: laparoscopic myomectomy. Measurements and Main Results: Diagnosis of recurrence was performed transvaginal ultrasound investigation every 6 months postoperatively, and patients with myomas less than 2cm in diameter were excluded. Recurrence was observed in 46 patients (21.3%) but no one required additional surgery. Predictive factors for recurrence were the number of myomas, patient age, and the use of gonadotrophin-releasing hormone agonists preoperatively (logistic analysis). Patients with previous myomectomy also had a significantly higher cumulative recurrence rate, versus patients without previous surgery. The mean time before recurrence was 14.6 months. Cumulative risk of recurrence (Kaplan-Meier curve) was 12% after 1 year and 33% after 3 years. Conclusion: According to our results, the cumulative rate of myoma recurrence within 3 years after LM was similar as after laparotomy reported previously.

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249 Predictors of Leiomyoma Recurrence after Laparoscopic Myomectomy 1 Yoo EH, 2Lee PI, 3Huh CY, 4Kim DH, 5Lee BS, 6Lee JK. 1 Department of Obstetrics and Gynecology, East West Neo Medical Center, KyungHee University Medical College; 1,2 Cheil General Hospital; 3KyungHee University Medical Center, KyungHee University Medical College; 4ChungAng University Medical Center, Chung-Ang University Medical College; 5YoungDong Severance Hospital, Yonsei University, College of Medicine; 6Korea University Medical Center, Korea University, College of Medicine, Seoul, Korea Study Objective: The purpose of this study was to assess recurrence of leiomyoma and evaluate the risk factors that influence the recurrence of leiomyoma after laparoscopic myomectomy Design: Multicenter retrospective cohort study.

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Setting: Five university hospital and a university affiliated teaching hospital. Patients: Five hundred thirty-eight women underwent laparoscopic myomectomy between 1995 and 2004. All women had a minimum of 1 year of post-operative follow up after laparoscopic myomectomy. Intervention: Laparoscopic myomectomy. Measurements and Main Results: Recurrence of leiomyoma was defined as the presence at the clinical examination and appearance of a myoma 2 cm or larger on ultrasound examination or subsequent surgery. Cox regression (full model) analysis of the possible risk factors for recurrence followed by a stepwise variable selection were performed to eliminate confounding factors. The cumulative risk of recurrence (Kaplan Meier curve) was 11.7% after 1 year, 36.1% after 3 years, and 52.9% after 5 years. Significant factors that were independently associated with cumulative recurrence were age (hazard ratio = 1.051, 95% confidence interval (95%CI) = 1.010–1.093, p = 0.0133), preoperative number of myoma (hazard ratio = 1.252, 95% CI = 1.143–1.371, p = 0.001), preoperative uterine size by pelvic examination(hazard ratio = 1.074, 95%CI = 1.020–1.132, p = 0.0073) and delivery after laparoscopic myomectomy (hazard ratio = 1.737, 95%CI = 1.096–2.753, p = 0.0188). Conclusion: Age, preoperative number of myoma, preoperative uterine size by pelvic examination and subsequent parity are associated with a higher cumulative recurrence of leiomyoma.

Setting: Three surgery centers. Patients: Twenty patients with severe symptomatic uterine fibroids. Measurements and Main Results: No adverse events occurred and all patients were discharged from hospital within 24 hours. Patients reported no significant post-treatment pain. Median fibroid volume reduction was 57.1% and 81.6% at 3 and 6 months, respectively. Median SSS-UFSQoL score improvement is 43.8%, and 69.2 at 3 and 6 months, respectively. One patient underwent hysterectomy three months following the cryoablation procedure due to persistent menorrhagia and anemia. Conclusion: Our preliminary data indicates that Percutaneous Laparoscopically-Assisted Cryomyolysis (PLC), using GalilMedical’s 17 gauge Argon-based cryogenic needles, is a safe and effective alternative for the management of symptomatic uterine fibroids in pre-menopausal women, who completed their family planning yet wish to preserve their uterus.

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Study Objective: To review the various techniques available to perform myolysis. Design: A metanalysis review and evaluation of published techniques for the performance of myolysis. Setting: Outpatient facilities. Patients: Multiple patients from published data. Intervention: Evaluation of Bipolar, Cryo, Radiofrequency, Laparoscopic and Focused high energy MRI guided Ultrasound Myolysis, MRI guided Laser Myolysis Measurements and Main Results: Meta-analysis Evaluation. Discuss results, complications, cost, efficiency of procedures. Conclusion: All procedures claim significant improvement of Myoma status. The question to be answered is “At what cost in both time and money?”

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250 US Guided Laparoscopically-Assisted Cryomyolysis. Preliminary Safety and Efficacy Results Using Galil-Medical’s 17-G Argon-Based Cryogenic Needles Zimberg S. Cleveland Clinic Florda, Fort Lauderdale, Florida Study Objective: To evaluate the safety and efficacy of percutaneous laparoscopically assisted cryomyolysis (PLC) for the treatment of symptomatic uterine fibroids in women who completed childbearing, yet wish to preserve their uterus, using Galil-Medical’s 17-gauge (1.47 mm) Argon-based cryogenic needles. Design: Twenty patients in three centers: Cleveland Clinic Florida, Mississippi University Medical Center, and Assaf Harofeh Medical Center (Israel) with severe symptomatic uterine fibroids were treated in a percutaneous laparoscopic-assisted approach using Galil-Medical’s ultra-thin cryogenic needles, with TVUS guidance. Procedures were performed according to a predetermined freezing and thawing protocol using real-time temperature and US monitoring. Cryoneedles were inserted percutaneously directly to the fibroid using US guidance. Thermal sensors provided continuous temperature monitoring of the tissue for efficacy and safety. Safety was evaluated by intra-operative and post-operative adverse events. Efficacy was measured by uterine fibroid volume reduction and by a validated fibroid related symptom severity questionnaire (SSS-UFSQoL; Spies, 2002).

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251 Laparoscopic Myolysis Revisited Goldfarb HA. New York Downtown Hospital, New York, New York

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252 CESAM: Combined Embolization and Surgery after MRI. A New Approach in Treating Fibroids in Women of Child Bearing Age 1 Fazel A, 1Ledref O, 1Daaloul W, 1Jacob D, 2Pelage JP. 1 Centre Hospitalier Universitaire Lariboisiere, Paris France; 2Centre Hospitalier Intercommunal de Poissy – Saint Germain en Laye, Poissy, France Study Objective: To evaluate a new method of treating fibroids by combined embolization and selective minimally access myomectomy.

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Design: Prospective study (Canadian Task Force classification II-3). Setting: University-affiliated hospital. Patients: Twenty patients with large uterus and multiple fibroids. Intervention: In the department where the first fibroid embolization was performed, the first cases of combined embolization and selective myomectomy, starting in 2002, are described. After clinical examination, MRI and pre-operative multidisciplinary decision, referred patients were admitted for selective embolization of uterine fibroids at day1, with single or multiple myomectomy (up to 4) performed by laparoscopy or hysteroscopy at day 1 or 2. Only large sub-serosal, or sub mucosal fibroids were removed when embolization alone was supposed to be ineffective or dangerous. Measurements and Main Results: Clinical examination and MRI were performed at day 3 and 6 months after the combined procedure. Intra-operative and post-operative complications were assessed, up to 48 months. No major complication occurred. Heavy bleeding disappeared after 6 months when the MRI at day 3 was showing a total devascularization of the remaining fibroids. Pelvic pain had disappeared or markedly improved after 6 months. The remaining fibroids shrunk an average of 60% in volume after 6 months. No major complication was notified in long term follow up (up to 48 months). Pregnancy rates are discussed. Conclusion: Combined embolization and selective myomectomy after MRI is a new approach to treat large uteri with multiple fibroids. When embolization alone is dangerous due to the risk of necrosis, or ineffective, due to the localization of certain fibroids, and when single or multiple myomectomies can be performed by minimally invasive surgery, this new approach is an alternative, markedly improving symptoms. Pregnancy rates are discussed when some patients were offered an abdominal hysterectomy previously to this technique.

Intervention: A diagnostic laparoscopy was scheduled. A mass arising from the uterus developed into the left abdominal cavity. The mass, in the resemblance of a very large myoma, had a smooth surface without vegetations. On the uterine surface and on the anterior abdominal wall irregular vegetations with an aspect of vesicles were present. A peritoneal washing and multiple biopsies were performed. Histological examination failed to make a correct diagnosis although orienting toward a possible leyomiomatosis peritonealis disseminata (LPD) with high invasive potentiality while lacking necrosis and atypias. Given the age of the patient and her desire for maintaining the uterus, a conservative intervention was planned. At laparotomy the pelvic mass turned out to be the left tube completely invaded by hundreds of irregular vesicles. The irregular vegetations on the uterine surface continued with a fibromatous nodule of the uterine fundus that did not presented any cleavage plane. Left salpingectomy, nodulectomy and revomal of peritoneal implants were performed. Measurements and Main Results: Histological examination confirmed leyomiomatosis peritonealis disseminata with high invasive potentiality. Negative immunohistochemical (IHC) staining for p53 protein was found. Conclusion: Cases of LPD without exogenous or increased endogenous estrogen exposure without uterine leiomyomas, and without ER and PR expression in the nodules may represent a different entity and should be regarded as cases with a high malignant potential. The risk of malignant degeneration justifies a close follow-up based on radiologic and ultrasonographic evaluations and periodic laparoscopic evaluations to identify any eventual sarcomatous degeneration of disease

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253 A Case of Leiomyomatosis Peritonealis Disseminata Rossetti A, Sizzi O, Spagnuolo R, Castagnola D, Florio G. Villa Valeria Hospital, Rome, Italy Study Objective: To describe an unusual case of Leyomiomatosis Peritonealis Disseminata. Design: Case report. Setting: Private endoscopic center. Patients: A 30-year-old nulliparous patient was referred to our division for rapid abdominal swelling in absence of other pelvic symptoms. Gynaecologic examination revealed the presence of an abdominal mass occupying the left quadrant from the pouch of Douglas to the spleen. Cancer markers were negative. Sonographic and RMN findings showed a non specific solid and complex soft tissue mass with intralesional vegetations.

Laparoscopic Adenomyoma Resection 1,2 Patel SS, 1,2Jhala YM, 1Patel RR, 1Vaghashiya HP. 1 Mayflower Women’s Hospital, Ahmedabad, Gujarat, India; 2Steriling Hospital, Ahmedabad, India Study Objective: There were two objectives of this study, 1) To assess the symptomatic relief in menorrhagia and dysmenorrhoea after conservative surgery in those women who did not wish hysterectomy, and 2) To report the pregnancy rate following the surgery. Design: Retrospective study of laparoscopic adenomyoma resection of two hundred and fifty six cases. Resection was done in elliptical strip manner in diffuse adenomyosis group. Some of the cases had uterine debulking up to hemihysterectomy. Large defect resultant of the adenomyosis resection was sutured by intra-corporeal slip knot endosuturing technique. Those who conceived were delivered by elective caesarian section at 37 weeks of pregnancy. Setting: Tertiary referral center for Gynaec endoscopic surgery in India.

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Patients: Total 256 cases (age group 25–35) between years 1996–2005. Intervention: Laparoscopic adenomyoma resection. Measurements and Main Results: In the study group of 256 cases, 210 cases had localized adenomyoma and 46 cases had diffuse adenomyosis. Conclusion: There is significant improvement in the dysmenorrhea (92%) & menorrhagia (84%) noted after laparoscopic adenomyoma resection. Good pregnancy outcome (34%) when the adenoma was localized and less than 3 cm in size. Pregnancy rates are very low (8%) in cases of diffuse adenomyosis. Recurrence of the disease was 38% noted after five years if patient did not conceive after the resection. No incidence of scar dehiscence in the antenatal period in study group.

We observed a significant decrease in uterine volume (716.9 ± 213.8 mL vs. 520.6 ± 148.3 mL). However, sonographic signs of adenomyosis such as myometrial cystic areas, asymmetric myometrium, or presence of myometrial hyperechoich striation does not disappear, some decrease in size but not significantly. Conclusion: After insertion of the LNG-IUS in patients with adenomyosis, uterine volume decrease and symptoms relieved or were significantly alleviated. However, sonographic sign of adenomyosis seems not to disappear completely. A long-term follow-up during and after treatment could be useful to understand the therapeutic role on adenomyosis of LNG-IUS.

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255 Symptomatic Adenomyosis: Sonographic Findings before and after Insertion of Levonorgestrel Intrauterine System Zupi E, Exacoustos C, Amoroso C, Amadio A, Szabolcs B, Marconi D, Romanini ME, Arduini D. University of Rome “Tor Vergata,” Rome, Italy Study Objective: Recently it has been reported that levonorgestrel intrauterine system could be an effective and safe method in the treatment of adenomyosis. The aim of this study is to assess whether the sonographic detectable morphological alterations of the myometrium induced by adenomyosis changed after the insertion of levonorgestrel intrauterine system (LNG-IUS). Design: Symptomatic (menorrhagia, severe dysmenorrhea) premenopausal patients with sonographic findings typical for adenomyosis were enrolled into the study. All the patients underwent before and at least three months after insertion of the LNG-IUS, a detailed transvaginal sonography (TVS) which evaluates: uterine diameters and volume, endometrial thickness, presence and dimension ofmyometrial cystic areas, asymmetric myometrium, presence of myometrial hyperechoich striation, vascolarization of the myometrial lesions and accurate mapping of the localisation of the myometrial alterations. A comparison between dimensions and presence of these different signs of adenomyosis before and after insertion of LNG-IUS was performed. Setting: University hospital. Patients: Twelve symptomatic premenopausal patients with sonographic findings typical for adenomyosis. Intervention: TVS before and at least three months after insertion of the LNG-IUS. Measurements and Main Results: Seven patients (58.3%) become amenorrhoic and the other patients referred a significantly reduction in menstrual bleeding. Dysmenorrhea was completely relieved or significantly alleviated in all patients.

How Many Hysterectomies Could Be Performed with Minimally Invasive Surgery? McCracken GR, Robertson D, Lefebvre GG. Saint Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada Study Objective: Across North America the majority of hysterectomies are still performed by laparotomy despite consensus that a minimally invasive surgery (MIS) approach would be preferable if feasible. This study is to determine the proportion of abdominal hysterectomies which could have been attempted by MIS, i.e., vaginally or laparoscopically, using evidence-based criteria. The second objective was to evaluate the trend in proportion of MIS hysterectomies performed at our site over a four-year period. Design: A retrospective chart review was conducted of all hysterectomies performed from January 1, 2004 to December 31, 2004. Clinical characteristics and OR data were collected from the patient record. Data was analyzed using ANOVA and chi-square analysis, Cohen’s Kappa was calculated to express the percent agreement between the clinical criteria and the actual surgery. We compared the results to a review of the year 2000. Setting: University-affiliated tertiary gynecology centre for advanced pelvic surgery. Patients: Two hundred and seventy five patients with benign gynecological indications for hysterectomy. Intervention: One hundred and seventy seven patients had an open abdominal approach; ninety eight patients MIS for their hysterectomy in 2004. Measurements and Main Results: In 2004, 35.5% of cases were MIS and 64.5% were by laparotomy either as total or subtotal hysterectomy. In 2000, 89.3% were performed via laparotomy. The vaginal group were older (p = < 0.0001) and higher in parity (p = 0.03) than patients in all other surgery groups. The frequency of uteri greater than 12 weeks is smaller in the MIS group (p = 0.0001) whereas the frequency of previous surgery does not differ (p = 0.11). Applying different combinations of evidence-based criteria, there was

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no recorded contra-indication to an MIS approach in up to 95% of the laparotomies, with a Kappa statistic of 0.02. Conclusion: Using clinical data obtained from the chart, we could potentially offer an MIS approach to the majority of our patients. Although MIS has increased from 11% to 35.5% of hysterectomies in 4 years, there is ongoing opportunity to improve. Sharing this evidence along with preceptorship of surgeons in practice is key to future success.

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257 Intention to Treat with Total Laparoscopic Hysterectomy: Ongoing Prospective Trial Lam AM, Condous GS. Royal North Shore Hospital, University of Sydney, Centre for Advanced Reproductive Endosurgery, Sydney, New South Wales Study Objective: To evaluate the effectiveness and safety of hysterectomy in women selected for total laparoscopic hysterectomy (TLH). Design: Prospective observational ongoing study: May 2005–February 2006. It was the intention to treat all women with TLH prior to surgery. TLH was carried out using a combination of harmonic scalpel and bipolar grasping forceps. Data collected included complications, both intra- and post-operative, conversion rate, operating time, estimated blood loss (EBL), length of stay (LOS) in hospital and weight of uterus. Setting: Centre for Advanced Reproductive Endosurgery. Patients: Seventy-three consecutive women undergoing TLH. Intervention: Performing TLH. Measurements and Main Results: 73 consecutive women to date have been enrolled in the study. Mean age 47.2 years (range 36–71 years). 89% (65/73) of women successfully underwent TLH, 5.5% (4/73) of the TLH group underwent sub-total LH and 5.5% (4/73) of the TLH group were converted to LAVH–three for difficult access and one as a result of bleeding from the right uterine artery. Mean operating time was 111 minutes (60–210); mean EBL 107 mL (20–1000); mean LOS 2.9 days (2–7); mean weight of uterus 248 g (52–1032). Post-operative febrile morbidity was noted in 8.2% (6/73) (three urinary tract infections, one vault haematoma, one sepsis, one paralytic ileus); 2.7% (2/73) had haemorrhage requiring transfusion (one intraand one post-operation—the latter for a vaginal wall tear secondary to forced delivery of the uterus); 8.2% (6/73) were re-hospitalised (four infection, one bleeding vault, one paralytic ileus). There were no bladder perforations, ureteric injuries or life threatening events. Conclusion: In this intention to treat study, 89% of this group successfully underwent TLH. This approach is safe and associated with few complications.

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258 Laparoscopic Hysterectomy with Retroperitoneal Dissection and Uterine Artery Occlusion 1 Vaught JM, 2Shah JP, 1MacKoul PJ. 1George Washington University, Washington, DC; 2Wayne State University, Karmanos Cancer Institute, Detroit, Michigan Study Objective: To describe the technique and results of retroperitoneal dissection and uterine artery occlusion as a valuable approach to laparoscopic hysterectomy. Design: A retrospective chart review performed from January 1, 2004 to April 15, 2006 included 300 consecutive patients who underwent laparoscopic hysterectomy by 3 participating surgeons. Setting: Community-based hospital with academic affliation. Patients: Three hundred consecutive patients were selected with benign pathology and early stage endometrial cancer. Advanced stage endometrial cancer patients undergoing laparoscopic hysterectomy were excluded. Intervention: Total laparoscopic hysterectomy was performed using retroperitoneal approach to identify the ureter and transect the uterine arteries with or without bilateral or unilateral salpingoophorectomy. Measurements and Main Results: Three hundred consecutive laparoscopic hysterectomies were performed at a single institution. Average BMI was 31 kg/m2 and 56% had prior abdominal surgery. Average estimated blood loss was 194 mL and average operating time including morcellation was 92 minutes. The average uterine weight was 372 g with a range of 14 g to 3283 g. The average length of hospital stay was 1.09 days, with 27 patients discharged the same day of surgery. The readmission rate was 3.0% (9 of 300), blood transfusion rate of 2.7% (8 of 300), rate of urinary tract injuries of 1.0% (3 patients with intraoperative laparoscopic cystotomy repairs), and 1.6% rate of bowel related complications. The conversion to laparotomy rate was 1.0% (1 conversion due to complete obliteration of the posterior cul-desac, the other two were conversions to mini-laparotomy secondary to undiagnosed incisional hernias and need for small bowel resection). Conclusion: Retroperitoneal dissection provides isolation and transection of the uterine artery as it diverges from the internal iliac artery and excellent visualization of the ureter. It has been our experience that this technique allows patients to have a safe and efficient laparoscopic hysterectomy regardless of uterine size with minimal blood loss, short hospital stay and a low rate of complications.

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259 Laparoscopic-Assisted Vaginal Hysterectomy for the Massive Leiomyomatous Uterus by Uterine Artery Ligation through Retrograde Tracking of Umbilical Ligament 1 Chang WC, 1Sheu BC, 1,2Hsu WC, 1Torng PL, 1Chang DY, 1 Huang SC. 1National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei,Taiwan; 2Buddhist Tzu-Chi College of Medicine, Buddhist Tzu-Chi General Hospital, Taipei, Taiwan Study Objective: To evaluate the feasibility, complications, and conversion rate of laparoscopic-assisted vaginal hysterectomy with large uteri heavier than 700 g. Design: Prospective study (Canadian Task Force classification II-3). Setting: A University-affiliated hospital. Patients: A total of 49 patients with large uteri heavier than 700 g between October 2002 and December 2005. Intervention: LAVH with uterine artery identification and ligation through retrograde tracking of umbilical ligament (RUL). Measurements and Main Results: The average age of patients was 45.3 years and the extirpated uterine weight was 905 g, with 32.7% above 1000 g. Intraoperatively, the mean operative time was 194 min and the average blood loss was 188 mL. The mean intramuscular meperidine requirements were 1.3 ampoules (1 ampoule = 50 mg) and the average hospital stay was 3.3 days. Five patients had blood loss more than 500 mL, but only one needed blood transfusion. One case had the uterine artery rupture related to RUL and was converted to laparotomy. One bladder injuries related to severe pelvic adhesion with endometriosis occurred. It took approximately 10 minutes from identification of the umbilical ligament to ligation of the uterine artery. Uterine weight >700 g required significantly longer operative time [194 min vs. 128 min, P <0.001] and more blood loss [188 mL vs. 73 mL, P <0.001] than uterine weight < 700 g. There were no differences in the mean intramuscular meperidine requirements and hospital stay between the two groups. Conclusion: Minimal blood loss and a low complication rate are noted in large uteri heavier than 700 g with LAVH by uterine artery ligation through RUL.

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260 Total Laparoscopic Hysterectomy in the Grossly Enlarged Uterus 1 Ang WC, 2Canis M, Rabischong B, 2Botchorishvili R, 2 Jardon K, 2Pouly JL, 2Mage G. 1Royal Women’s Hospital, Melbourne, Victoria, Australia; CHU – Polyclinique de l’Hôtel Dieu, Gynécologie Obstétrique Médecine de la Reproduction, Clermont-Ferrand, France Study Objective: A retrospective study was carried out to examine the outcomes of total laparoscopic hysterectomy

performed in patients with an enlarged uterus. Design: Retrospective cohort study. Setting: Tertiary care hospital. Patients: Patients attending for routine care at a tertiary care hospital with university affiliation. Intervention: Patients who had undergone TLH for benign conditions whose uterus weighed at least 500 g at histopathology were identified in the database during the period 2000–2003. The patient characteristics were examined. Each woman underwent TLH in a standardized manner. The perioperative and postoperative complications were analysed. The follow-up results were evaluated. Measurements and Main Results: Sixty-eight of a possible 615 patients (11.0%) were identified with an enlarged uterus greater or equal to 500 g at histopathology. The average age of the patients was 47.1 (± 4.7) years. Of these, 59 patients (86.8%) had their hysterectomy completed entirely through the laparoscopic route. Of the remaining 13.2%, 6 patients (8.8%) were converted to laparotomy and 3 patients (4.4%) were converted to laparoscopic-assisted vaginal hysterectomy. The average duration of the procedure was 136.0 min (± 41 min). The mean uterine weight was 671 g (range 500–1500 g). There was 1 (1.5%) urinary tract injury and 2 bowel injuries (2.9%). There were no other major postoperative complications. One month later, 97.1% of patients were entirely satisfactory at consultation. Problems included persistent pelvic pain (1 patient) and de novo urinary incontinence (1 patient). Conclusion: Our analysis of our procedure and technique in this group of patients revealed that patients with a clinically enlarged uterus appear to be at higher risk of bowel injury. However, total laparoscopic hysterectomy is still feasible when appropriate surgical technique is followed.

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261 Total Laparoscopic Hysterectomy with Early Discharge: Feasibility Study Rabischong B, De Lapasse C, Canis M, Pouly J, Botchorishvili R, Jardon K, Mage G. CHU – Polyclinique de l’Hôtel Dieu, Gynécologie Obstétrique Médecine de la Reproduction, Clermont-Ferrand, France Study Objective: To assess the feasibility, the safety and patient satisfaction with total laparoscopic hysterectomy and discharge the day after the procedure, in a French university hospital. Design: Prospective feasibity study. Setting: Large university hospital with tertiary care facilities. Patients: Twenty-seven total laparoscopic hysterectomies were performed with the same procedure. All the patients are selected. They arrive the day of the surgery and leave twenty-four hours later if the Post Anaesthetic Discharge Scoring System (PADSS) authorizes it. All the patients had a phone call the second and the seventh day after the surgery.

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Measurements and Main Results: Of twenty-seven procedures, twenty-six patients leave the hospital (96.3%) the day after the surgery. One patient was not discharge because of the technical difficulties during the procedure. Two patients required readmission because of complications (7.4%). The first required hospitalization for a vesicovaginal fistula at the tenth day. She has to undergo a new surgical operation. The second consulted for a hyperthermia at the fourth day with suspicion of infection of the vaginal dome. After two days of a double antibiotic treatment, she could go home. Twentysix women were satisfied with the procedure (96.3%) and all would recommend it to others. Conclusion: Total laparoscopic hysterectomy with early discharge (twenty-four hours after the surgery) is safe and feasible in a French university hospital. Development of a protocol with patient selection, preoperative teaching, and phone call at home, seem to be essential for the success of the procedure.

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262 A Multicentered Series of 400 Daycase Laparoscopic Subtotal Hysterectomies in the UK and Greece: The New Approach to Hysterectomy Chandakas S, Hill N, Erian J. Princess Royal University Hospital, London, UK and Iaso Hospital, Athens, Greece Study Objective: To demonstrate the safety, feasibility and morbidity of laparoscopic subtotal hysterectomies in a daycare setting. Design: Retrospective, descriptive, non randomized study. Setting: Princess Royal University Hospital, London, UK and Iaso Hospital, Athens Greece. Patients: For the patients who underwent a laparoscopic subtotal hysterectomy in 40 months (November 2002–March 2006), data were collected from medical records on how the intervention was performed, followed for 12 months. 400 subtotal hysterectomies were performed by two surgeons. Intervention: Indications included 21.6% cases for endometriosis, 66.2% for menorrhagia, 12.05% for endometrial pathology. Median follow-up was 48 weeks. Measurements and Main Results: Duration of operation and of hospital stay, safety (morbidity and mortality), and patient satisfaction were assessed Estimated blood loss was 90 mL (range 50–2000 mL) Intraoperative complications: 0.5% had significant complications, 0% vascular injuries and 0% nerve or ureter injuries, 2.5% had cyclic bleeding. Early postoperative morbidity included 0.5% deep vein thrombosis, 0% pulmonary embolism, 2% bladder infection and dysfunction. The overall complication rate was 1.5%. One of them required drainage for intra-abdominal abscess Hospital stay of these 400 patients, 91% were discharged to home the same day with an average length of stay for these patients of 8 hours. Conclusion: Laparoscopic subtotal hysterectomy can be safely performed as a day-care procedure.

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263 A Safer Laparoscopic-Assisted Vaginal Supracervical Hysterectomy Technique Liu WM. Taipei Medical University Hospital, Taipei, Taiwan Study Objective: The aim of this study was to introduce a safe and less hemorrhagic approach in doing laparoscopic and vaginal procedures through the posterior cul-de-sac for supracervical hysterectomy. Design: Prospective study (Canadian Task Force Classification II). Setting: University-affiliated hospital. Patients: Women with symptomatic uterine leiomyomata or adenomyosis who wish to preserve their cervix and have a relatively appropriate vaginal capacity when compared to enlarged uterus. Intervention: Bilateral laparoscopic uterine arteries ligation was carried out, followed by the dissection of bilateral round ligments, adnexa and parametrium down to the uterosacral ligaments. Subsequently, the uterine fundus was pulled out step-by-step using Alis or Tenaculun under hand compression upon uterus through the posterior cul-de-sac and vagina via a posterior colpotomy. Supracervical hysterectomy was performed thereafter trans-vaginally by conventional techniques. Cervix was then restored to its original position followed by a repair of the colpotomy wound. Measurements and Main Results: From October 2002 through March 2006, we performed 54 consecutive supracervical hysterectomy by these newly developed procedures. Records were kept at the discharge of all patients and statistics show that the mean operative time, blood loss, and length of hospital stay were 53.4 ± 13.7 minutes, 78.2 ± 36.5 mh, and 2.4 ± 0.3 days, respectively. No major complications or re-operation were noted except for one patient who developed an 8 cm hematoma between rectum and right parametrium and was put on observation, although eventually discharged without further procedures. Conclusion: The addition of uterine artery ligation procedure prior to laparoscopic and vaginal approach in performing supracervical hystectomy through the posterior cul-desac is a safe and less hemorrhagic treatment modality in women with diffuse adenomyosis or multiple uterine leiomyomas, who wish to retain their cervices.

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264 Our 16 year Evolution with Laparoscopically Assisted Vaginal Hysterectomy Pregenzer GJ, Perl FL. Somerset Medical Center, Somerville, New Jersey Study Objective: To describe our sixteen year progress with laparoscopically assisted vaginal hysterectomy.

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Design: Retrospective analysis of over eight hundred ten laparoscopically assisted vaginal hysterectomy noting modification in techniques and new technologies. Setting: Private practice at a teaching hospital. Patients: Eight hundred ten patents underwent hysterectomy for benign conditions: refractory menorrhagia, disabling chronic pelvic pain, fibroids and endometriosis. Intervention: We first started performing laparoscopically assisted vaginal hysterectomy by using vascular clips and unipolar instruments. We then progressed to Endoscopic stapler, then Endoscopic stapler with initial vaginal dissection, then Kleppinger bipolar instrument. With the introduction of vessel sealing technology we used the Ligasure and subsequently the next generation instruments namely the Enseal instrument. Measurements and Main Results: The first twenty five cases involved the utilization of the vascular hemoclips and unipolar instruments; specimen range 60–120 grams. The next twenty eight cases involved the use of the endoscopic stapler; specimen range 60–240 grams. The next modification in technique was the introduction of initial vaginal dissection and preparation while still using the Endoscopic stapler. Twenty four cases were performed in this fashion; specimen range 66–260 grams. The next six hundred and eighty four cases involved the use of the Kleppinger bipolar instrument; specimen range 48–1820 grams. The most recent modification has been the introduction of vessel sealing technology. One hundred fourteen cases performed in this fashion; specimen range 120–1440 grams. With the advance of technology and modification of techniques, more challenging cases are performed quicker, less blood loss and impressive recovery. There were two cuff hematomas and one cuff cellulites, all in the first 25 cases. One patient was transfuses 2 units of packed red blood cells for blood loss (case # 120). No major complications occurred. Conclusion: With advancement of technology and the accumulation of experience, we have seen dramatic improvements in already established impressive recuperation and convalescence with laparoscopically assisted vaginal hysterectomy. Currently, the blood loss is truly negligible. Pain is also likewise minimized. When matched for pathology, the operative times are also dramatically reduced. We believe it has been well established that laparoscopically assisted vaginal hysterectomy is a much safer procedure than it was even a few years ago. Unfortunately, the majority of the gynecologic surgeons in our geographic area are no longer performing any major laparoscopic operative procedures due to the financial penalties levied by our health care insurance industry. It is our hope that with conferences such as this AAGL conference, we can pressure both government and our health insurance industry to enable our surgeons to perform the procedures we all believe to be best for our patients.

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265 Laparoscopic-Assisted Vaginal Hysterectomy versus Laparoscopic Supracervical Hysterectomy for the Non-Prolapsed Uterus Ghomi A, Lithman P. University at Buffalo, Buffalo, New York Study Objective: To compare laparoscopic-assisted vaginal hysterectomy (LAVH) with laparoscopic supracervical hysterectomy (LSH) for the non-prolapsed uterus. Design: Retrospective chart analysis (Canadian Task Force classification II-2). Setting: University-affiliated teaching hospital. Patients: Two hundred fifty-three women undergoing LAVH or LSH for benign gynecologic disease. Intervention: Laparoscopic hysterectomy. Measurements and Main Results: A total of 253 patients receiving LAVH or LSH by 29 gynecologists were retrospectively studied between January 2001 and September 2004. The exclusion criteria were documented uterine prolapse or a concomitant procedure to correct any type of pelvic organ prolapse. 165 patients had LAVH and 88 patients had LSH. The two groups were compared with regard to operative time, hospital stay, peri-operative complications, conversion rate to laparotomy, blood loss, uterine weight, and patient characteristics. Patients who underwent LSH experienced a significantly shorter hospital stay, 27.4 ± 10.4 hours compared to 37.1 ± 13.3 hours (p < 0.01). The LSH group had a slightly longer operative time, 155 minutes vs. 150 minutes (p = .28). There was a linear correlation between uterine weight and operative time in both groups. The LAVH group had a higher number of parity, 1.8 vs. 1.5 (p < .01). Other parameters were similar between the two groups. Conclusion: Our study shows that LSH offers the benefits of a shorter hospital stay as compared to LAVH when performed in patients without uterine prolapse. In view of a shorter hospital stay and comparable operative time, LSH may prove to be at least as cost-effective as LAVH for the non-prolapsed uterus despite using a disposable tissue morcellator.

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266 Total Laparoscopic versus Vaginal Hysterectomy: A Retrospective Comparison Morton M, Cheung VYT, Rosenthal DM. University of Toronto, Toronto, Ontario, Canada Study Objective: To compare surgical outcomes of patients undergoing total laparoscopic and vaginal hysterectomy. Design: One hundred fifty-two patients who underwent either total laparoscopic or vaginal hysterectomy, between

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January 1, 2001 and December 31, 2004 were retrospectively analyzed. Information was obtained via chart review. Patients undergoing concomitant surgery for urogenital prolapse or urinary stress incontinence were excluded. A separate subgroup analyses of uterine weights < 300 g was performed. Setting: North York General Hospital, a teaching hospital affiliated with the University of Toronto. Patients: One hundred fifty-two patients who underwent total laparoscopic hysterectomy (109) and vaginal hysterectomy (43). Measurements and Main Results: There was no statistically significant difference between groups with respect to patient’s age, estimated blood loss, mean postoperative hemoglobin change, or incidence of intraoperative and postoperative complications. Preoperative body weight was greater in the TLH group (67.7 vs. 60.6 kg, p = 0.01). Mean parity was significantly less in the TLH group (1.84 vs. 2.57, p < 0.01). TLH took significantly longer to perform (104.4 vs. 54.4 min, p < 0.0001; diff 50.0, 95%CI 41.3–58.7; ranges TLH 70–195 min, VH 33–105 min), however, mean postoperative hospitalization was greater in the VH group (2.21 vs. 1.14 days, p < 0.0001; ranges TLH 0–3 d, VH 1–4 d). Mean uterine mass was significantly greater in the TLH group (290.9 vs. 151.6 g, p < 0.0001; diff 139.3, 95%CI 77.5–201.3; ranges TLH 52–930 g, VH 42–356 g). One patient in the TLH group required conversion to laparotomy. Previous Cesarean section did not confer an increased operating time or an increased risk of intraoperative complications in either group. In the subgroup comparison of uterine weights < 300 g (n = 71 TLH, 43 VH; mean uterine mass 176.9 g vs. 151.6 g; p = 0.06), results were similar as above. Conclusion: We retrospectively compared the surgical outcomes of women who underwent TLH and VH over a given period of time. We hypothesized that surgical outcomes of TLH could approximate those of vaginal hysterectomy. The objective of this study was to test this hypothesis and to perhaps help properly select patients for TLH. Findings of our study are similar to others with respect to increased operating time in the TLH group, however, we demonstrated a shorter hospitalization in the TLH group. Intraoperative complications in both groups appeared similar. Issues such as patient satisfaction, post-operative analgesic requirements, return to work/baseline functional activity were not considered due to the retrospective nature of this study. These parameters could be properly addressed with a future study prospectively comparing total laparoscopic and vaginal hysterectomy. This retrospective study does not clearly demonstrate one technique’s superiority over the other. Future prospective trials comparing vaginal and total laparoscopic hysterectomy may accomplish this, and could potentially help guide clinicians in selecting the optimal surgical approach to hysterectomy.

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267 Advantages of Early Discharge after Laparoscopic Assisted Vaginal Hysterectomy Park SH, Lim JE, Jung NH, Lee NW, Kim T, Kim HJ, Kim SH, Lee KW. Korea University Ansan Hospital, Ansansi, Kyungki-Do, Korea Study Objective: To determine whether early discharge after laparoscopic assisted vaginal hysterectomy (LAVH) has advantages compared with conventional discharges. Design: Retrospective study. Setting: Department of Obstetrics and Gynecology, Korea University, Ansan Hospital. Patients: One hundred twenty-five patients who underwent LAVH from July 2001 to July 2002 for leiomyomas. Intervention: Patients were divided into three groups (A group is two days of hospital stay: B group is three days of hospital stay: C group is four days or more of hospital stay) according to hospital stay and compared clinical results. Measurements and Main Results: Duration of operation time, mean decreased hemoglobin level, mean time of gas out, mean weight of uterus, pathologic findings, number of antibiotics and analgesics, total cost, and complication rate were compared among three groups. A group was 59 patients (47.2%), B group was 48 patients (38.4%), and C group was 18 patients (13.6%). The mean hospital stay was 2.9 ± 1.4 days. Duration of operation time, mean decreased hemoglobin level, mean time of gas out, mean weight of uterus, and pathologic findings were not different among three groups. The number of antibiotics were 5.1 ± 0.30 vials in group A, 8.27 ± 0.44 vials in group B, and 11.22 ± 2.16 vials in group C (p = 0.005). The number of analgesics was 3.9 ± 0.18 vials in group A, 6.41 ± 0.61 vials in group B, and 11.02 ± 0.67 vials in group C (p = 0.005). Total cost in group A was less than that of B or C group. There were no differences in complication rate among three groups. Conclusion: Early discharge (postoperative first day) after LAVH has many advantages and no more complication rate compared with conventional discharges. So it is suggested that discharges at the postoperative first day after LAVH is recommended if there are no side effects.

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268 The Need for Indwelling Catheter after Total Laparoscopic Hysterectomy 1 Pollard RR, 2Ahluwalia PK. 1Case School of Medicine, MetroHealth Medical Center, Cleveland, Ohio; 2 St. Elizabeth Medical Center, Utica, New York Study Objective: To determine the necessity of indwelling after total laparoscopic hysterectomy.

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Design: Retrospective case study (Canadian Task Force Classification 3). Setting: Private Practice and an AAGL Fellowship site. Patients: Eighty-nine consecutive patients undergoing total laparoscopic hysterectomy. Intervention: Total laparoscopic hysterectomy. Measurements and Main Results: The catheter was removed in the operating room in 87 patients following completion of the surgery. Two patients continued with catheterization because one was converted to a laparotomy and one patient sustained a bladder injury. 85 patients (98%) were able to void without difficulty. One patient required intermittent catheterization in the recovery room and one patient presented later that evening with urinary retention. Conclusion: Routine use of indwelling catheter after total laparoscopic hysterectomy may not be necessary.

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269 Role of Vaginal Packing Post-Vaginal Hysterectomy 1 Jamal W, 1Krishnamurthy S, 2Correa JA. 1McGill University Obstetrics and Gynecology, Royal Victoria Hospital; 2Department of Mathematics and Statistics, Montreal, Quebec, Canada Study Objective: About 20,000 vaginal hysterectomies are done each year in Canada. Although post-operative vaginal packing is very often utilized, there is no published evidence on its efficacy. Study aim is to compare short and intermediate term complications between the routine use of vaginal packs versus no packs post vaginal hysterectomy. Design: Retrospective cohort study. Setting: Analysis of all vaginal hysterectomies performed at the Royal Victoria Hospital (McGill University tertiary center, Montreal, Canada) from October 2002 to September 2004. Patients: One hundred eight patients had vaginal packing (VP) post operatively and 62 had no packing (NP), very similar baseline characteristics of both cohorts except more post menopausal in (VP) and more pre menopausal women in (NP) groups. Intervention: Vaginal pack placement post vaginal hysterectomy. Measurements and Main Results: Post operative complication categorized into minor (e.g. persistent low grade fever, therapeutic antibiotic use) and Major complications (e.g. Blood transfusion, vault haematoma). Univariate analyses including Student t-tests for continuous variables and chi square tests for categorical variables were used and multivariate logistic regression was used to adjust for potential confounders. On Univariate analysis, there were more requests for transvaginal ultrasound to rule out postoperative haematoma in the NP group (p = 0.006). However, on multivariate analysis only persistent low grade fever was found to be significantly higher in the VP group (p = 0.01). Conclusion: This is the first study exploring the risks and

benefits of vaginal packing post vaginal hysterectomy; it showed higher low grade fever in the VP group on multivariate analysis, and no demonstrable benefit from packing. A randomized controlled trial is warranted to determine if the routine use of vaginal packs is worthwhile.

THURSDAY, NOVEMBER 9, 2006 Open Communications 14—Hysterectomy (3:34 PM – 3:40 PM)

270 Cyclic Bleeding after Laparoscopic Supracervical Hysterectomy: A Comparison of Two Surgical Techniques 1 Morris SN, 2Ferland RJ, 1Isaacson KB. 1Newton-Wellesley Hospital, MIGS Center, Newton, Massachusetts; 2Women and Infant’s Hospital, Rhode Island, Rhode Island Study Objective: The purpose of this study is to determine and compare the rate of cyclic bleeding after laparoscopic supracervical hysterectomy (LSH) using two different surgical techniques. Design: This is a retrospective cohort study, examining 72 women who underwent LSH between January 2002 and October 2005. The exposure being studied is desiccation of the cervical canal with bipolar cautery after removal of the uterine corpus. The outcome being studied is the persistence of cyclic bleeding 6 or more months after LSH. Data were gathered through medical record review and phone questionnaire. Setting: Two advanced pelvic surgery teaching hospitals Patients: Seventy-two women who underwent LSH. Intervention: In one group of patients, the cervical canal was desiccated using bipolar cautery after removal of the uterine corpus. In the other group, the cervical canal was not treated with any additional energy source. Measurements and Main Results: The presence of cyclic bleeding 6 months or more after LSH was the main outcome being studied. Of the women who had their cervical canals desiccated at the time of LSH 19% reported cyclic bleeding. 14% of the women who did not have their cervical canal desiccated at the time of LSH reported a cyclic bleeding. This is not a statistically significant difference. In all women, the amount of bleeding either required only a pantiliner or no sanitary protection at all. Overall patient satisfaction was high (93%). Even among women with cyclic bleeding, 86% were either “very satisfied” or “satisfied” with the outcome of the procedure. This is preliminary data. Conclusion: Cyclic bleeding after LSH occurs in 14%-19% of our patients. However, even women who report cyclic bleeding post-LSH have a high level of satisfaction with the procedure. Larger sample sizes (and ideally, a randomized trial) are needed to determine if one technique is superior to the other with regards to post-operative cyclic bleeding.