Didactic: No More Fibs: The Truth about Fibroids · 2020-01-30 · Broad Ligament, and Cervical...

Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Didactic: No More Fibs: The Truth about Fibroids

PROGRAM CHAIR

Hye-Chun Hur, MD, MPH

PROGRAM CO-CHAIR

Stephanie N. Morris, MD

Togas Tulandi, MD

GLOBAL CONGRESSON MINIMALLY INVASIVE GYNECOLOGYNOV. 17-21, 2014 | Vancouver, British Columbia

43rd AAGL

Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 Which Fibroids Should You Treat? Understanding Fibroid Anatomy, Range of Diagnoses, and Associated Clinical and Reproductive‐Sequelae to Tailor the Plan H‐C Hur .......................................................................................................................................................... 3 Simplifying Laparoscopic Myomectomy: Setting the Stage for Effective Suturing and General Tips and Tricks S.N. Morris .................................................................................................................................................... 9 Robot‐Assisted Laparoscopic Myomectomy: Different Strategies Compared to Conventional Laparoscopic Myomectomy H‐C Hur ........................................................................................................................................................ 14 When to Opt for Laparotomy: Minimally Invasive Techniques for Open Myomectomy, Strategies for Minimizing Blood Loss and Adhesions T. Tulandi ..................................................................................................................................................... 20 Strategies for Safe and Effective Tissue Removal, Controversies of Fibroid Morcellation S.N. Morris .................................................................................................................................................. 25 Hysteroscopic Myomectomy: How to Approach the Type 2 Submucosal Fibroid S.N. Morris .................................................................................................................................................. 29 How to Tackle the Challenging Fibroid Presentation: Adenomyomas, Deeply Intramural, Broad Ligament, and Cervical Fibroids H‐C Hur ........................................................................................................................................................ 34 Other Fibroid Treatment Options: Single‐Port Myomectomy, Uterine Artery Embolization, and Myoma Ablation Procedures (MRI‐focused US, Radiofrequency Ablation) T. Tulandi ..................................................................................................................................................... 40 Cultural and Linguistics Competency ......................................................................................................... 46

FIBR-‐711 Didactic: No More Fibs: The Truth about Fibroids

Hye-‐Chun Hur, Chair

Stephanie N. Morris, Co-‐Chair

Faculty: Togas Tulandi This course will provide participants with a systematic approach to managing symptomatic patients with both simple and complex fibroid presentations. An algorithm for deciding routes of surgical treatment (conventional laparoscopy, robot-‐assisted laparoscopy, laparotomy, or hysteroscopy) will be discussed. Radiologic imaging as well as nonsurgical treatment options will be addressed. Techniques and specific approaches for the treatment of more challenging fibroids, such as broad ligament, cervical, deep intramural, and submucosal fibroids, will be presented. Tips and tricks for laparoscopic suturing, minimizing blood loss, and tissue extraction techniques will be reviewed. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Summarize currently available treatment options for conservative fertility-‐sparing fibroid management; 2) apply strategies, tips and tricks for resecting various fibroid presentations, including submucosal, deeply intramural, broad ligament, and cervical fibroids; 3) describe strategies to minimize blood loss; and 4) describe laparoscopic suturing and tissue extraction techniques essential for laparoscopic myomectomy.

Course Outline 12:30 Welcome, Introductions and Course Overview H-‐C Hur

12:35 Which Fibroids Should You Treat? Understanding Fibroid Anatomy, Range of Diagnoses, and Associated Clinical and Reproductive-‐Sequelae to Tailor the Plan H-‐C Hur

1:00 Simplifying Laparoscopic Myomectomy: Setting the Stage for Effective Suturing and General Tips and Tricks S.N. Morris

1:25 Robot-‐Assisted Laparoscopic Myomectomy: Different Strategies Compared to Conventional Laparoscopic Myomectomy H-‐C Hur

1:50 When to Opt for Laparotomy: Minimally Invasive Techniques for Open Myomectomy, Strategies for Minimizing Blood Loss and Adhesions T. Tulandi

2:15 Questions & Answers All Faculty

2:25 Break

2:40 Strategies for Safe and Effective Tissue Removal, Controversies of Fibroid Morcellation S.N. Morris

3:05 Hysteroscopic Myomectomy: How to Approach the Type 2 Submucosal Fibroid S.N. Morris

3:30 How to Tackle the Challenging Fibroid Presentation: Adenomyomas, Deeply Intramural, Broad Ligament, and Cervical Fibroids H-‐C Hur

3:55 Other Fibroid Treatment Options: Single-‐Port Myomectomy, Uterine Artery Embolization, and Myoma Ablation Procedures (MRI-‐focused US, Radiofrequency Ablation) T. Tulandi

4:20 Questions & Answers All Faculty

4:30 Adjourn

Page 1

PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor* Kimberly A. Kho* Frank D. Loffer, Medical Director, AAGL* Linda Michels, Executive Director, AAGL* M. Jonathon Solnik* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: Blue Endo, Intuitive Surgical, SurgiQuest Other: Royalties: CooperSurgical William M. Burke* Rosanne M. Kho* Ted T.M. Lee Consultant: Ethicon Endo-‐Surgery Javier F. Magrina* Ceana H. Nezhat Consultant: Karl Storz Other: Medical Advisor: Plasma Surgical Other: Scientific Advisory Board: SurgiQuest Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Other: Stock Ownership: Titan Medical Robert K. Zurawin Consultant: Bayer Healthcare Corp., CONMED Corporation, Ethicon Endo-‐Surgery, Hologic, Intuitive Surgical FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Hye-‐Chun Hur Other: Author: UpToDate Stephanie N. Morris* Togas Tulandi Consultant: Actavis Asterisk (*) denotes no financial relationships to disclose.

Page 2

A teaching hospital of Harvard Medical School

Which Fibroids Should You Treat?Understanding fibroid anatomy, range of diagnoses, and associated clinical & reproductive sequelae to tailor the plan.

Hye-Chun Hur, MD, MPHAssistant Professor, Harvard Medical SchoolDirector, Division of Minimally Invasive GynecologyBeth Israel Deaconess Medical Center


Disclosures

Other: Author: UpToDate


Objectives

• Review process for selecting which fibroids to treat surgically.

• Review fibroid anatomy, diagnoses and clinical sequelae.

• Algorithm for planning fibroid treatment.


Fibroid Consult

35yo G2P0020 (SAB x1, TAB x1) female newly diagnosed with fibroid uterus during elective pregnancy termination.

• PUS: Uterus 9.5 x 3.3 x 4.1 cm, exophytic fundal fibroid 5.1 x 4.1 x 3.5 cm, EMS 5 mm. Normal ovaries bilaterally.

• Denies menstrual abnormalities or dysmenorrhea. Increasing dyspareunia, urinary frequency, LLQ pain.

• Exam revealed 12 wk sized uterus with anterior fibroid slightly crowding bladder area (mobility).

How do you advise the patient? Should you operate?


Selecting Which Fibroids to Treat

Symptomatic Asymptomatic

• Bleeding abnormalities

• Compression symptoms

• Reproductive problems

• Anatomic problems


Which Fibroids Should beTreated Surgically?

Symptoms

Reproductive goals

Page 3


Fibroid Treatment Algorithm

Symptomatic

Asymptomatic

ReproductiveGoals

No ReproductiveGoals

Myomectomy All Therapies

No treatment?A teaching hospital of Harvard Medical School


Symptomatic

Asymptomatic

ReproductiveGoals



No treatment?


Symptomatic, No Reproductive Goals

All therapies available.

If surgical treatment,

Hysterectomy preferable to myomectomy

• for definitive treatment

• if childbearing complete

Hysterectomy without BSO

• To permit natural menopause

• unless BSO indicated



Symptomatic

Asymptomatic

ReproductiveGoals



No treatment?


Symptomatic, Reproductive Goals

Patients actively trying to conceive have only 1 option:

Myomectomy

• Timingo Immediate myomectomyo Interval myomectomy

• Surgical Approacho Numbero Fibroid location o Size



Symptomatic

Asymptomatic

ReproductiveGoals



No treatment?

Page 4


Asymptomatic, Reproductive Goals

Known risk of myomectomy scar

with future pregnancies

Unknown risk of intramural fibroids

on pregnancy outcomes


Risk of Uterine Rupture

• 10% risk of uterine rupture with trial of labor after myomectomy.


Question

How do you decide when to operate

on asymptomatic fibroid patients?


Selecting Which Fibroids to Treat

Symptomatic Asymptomatic

• Bleeding abnormalities

• Compression symptoms

• Reproductive problems

• Anatomic problems

o Infertilityo Pregnancy complications

o Hydronephrosiso Thrombosis


Question

How do you decide when to operate

on asymptomatic fibroid patients

before a bad obstetric outcome?



• Age

• Fibroid location

• Fibroid burden (size, #)

• Findings, “silent” (hydronephrosis, thrombosis)

Page 5


Age

Source: Management of the Infertile Woman by Helen A. Carcio and The Fertility Sourcebook by M. Sara Rosenthal

Patients age >40 are offered a lower threshold for timely fibroid surgery.


Myomas and Pregnancy Outcomes

• Increased risk of malpresentation (OR 2.9)

• Increased risk of cesarean delivery (OR 1.5)

• Increased risk of spontaneous miscarriage (OR 1.6)

• Bleeding in pregnancy

• Placental abruption

• Premature rupture of membranes

References:Klatsky AJOG 2008Rice et al. AJOG 1989Muram D AJOG 1980


Fibroid Location

• Cavitary Fibroids

• Submucosal Fibroid

• Intramural fibroids

• Subserosal fibroids

• Exophytic Fibroids

• Pedunculated Fibroids

Like real estate, location matters for fibroids.


Fibroid Burden

• 5 cm

• Interestingly, weight of existing literature suggests

o Fibroid size does not affect miscarriage rates

o Fibroid # (multiple fibroids) and fibroid location does

o Mechanism for miscarriage unknown



Summary:

• Age (> 40)

• Fibroid location (determine approach, submucosal)

• Fibroid burden (size, #)

• “Silent” findings (hydronephrosis, thrombosis)

• History of bad pregnancy outcome (SAB, PTL, abruption)


Importance of Fibroid Anatomy

• Knowledge of fibroid anatomy optimizes the myomectomy dissection.

• The fibroid pseudocapsule is a structure which surrounds the uterine fibroid, separates it from the uterine tissue and contains a vascular network rich in neurotransmitters like a neurovascular bundle.

• Identification of the pseudocapsule planeo minimizes blood losso preserves the integrity of the myometriumo better for fertility

Page 6


Fibroid Anatomy


Fibroid Anatomy


Fibroid Anatomy: Video


Which Fibroids Should beTreated Surgically?

Symptoms

Reproductive goals

Age



• Symptoms

• Reproductive goals (preserve uterus)

o Immediate myomectomy

o Interim medical treatment with interval myomectomy

• Age (esp > 40)

• Location (determine approach, submucosal)

• Fibroid burden (#, size > 5 cm)

• “Silent” findings (eg. hydronephrosis)


Recommendations

• Fibroid surgery just to rule out the possibility of malignancy is not advised as routine practice.

• Frozen section is not reliable for excluding uterine sarcoma (multiple areas must be sampled).

References:Up to Date, Eliz SterwartLeibsohn et al. AJOG 1990Schwartz et al. AJOG 1993

Fibroid treatment plan should be based on:

• Symptoms

• Reproductive goals

• Findings (eg. hydronephrosis)

• Patient preferences, Age

Page 7


References• Butram VC et al. Uterine Leiomyomata: etiology, symptomatology, and management. Fertility and

Sterility 1981;36:433-5.

• Donnez et al What are the implications of myomas on fertility? A need for a debate? Hum Reprod 2002;17:142-30.

• Farhi J et al. Efect of uterine leiomyomata on the results of in-vitro fertilization treatment. Hum Reprod 1995;10:2576-8.

• Surrey et al. Impact of intramural leiomyomata in patients with normal endometrial cavity on in vitro fertilization enbryo transfer cycle outcome. Fertil Steril 2001;75:405-10.

• Somigliana E et al. Fibroids and female reproduction: a critcal analysis of the evidence. Hum Rprod Update 2007;13:465-76.

• Kolankaya A et al. Myomas and assisted reproductive technologies: when and how to act? Obstet Gynecol Clin North Am 2006;33:145-52. (>5cm)

• Klatsky PC et al. Fibroids and reproductive outcomes: a systematic review from conception to delivery. Am J Obstet Gynceol 2008;198:357-66.

• Rice JP et al. The clinical significance of uterine leiomyomas in pregnancy. AJOG 1989;160:1212-6.

• Muram D et al. Myomas of the uterus in pregnancy: ultrasonographic follow-up. AJOG 1980;138:16-9.

• Leibsohn et al. Leiomyosarcoma in a series of hysterectomies performed for presumed uterine leiomyomas. AJOG 1990;162:968

• Schwartz et al. Leiomyomsarcomas: clincal presentation. Am J Obstet Gynecol 1993;168:180.

Page 8

Stephanie Morris, MD

Clinical Instructor, Harvard Medical School

Associate Medical Director, MIGS Center

Newton Wellesley Hospital, Newton, MA

Disclosures

I have no financial relationships to disclose.

Objectives

Demonstrate steps to simplify laparoscopic myomectomy Pre-operative planning

Ways to reduce intra-operative blood loss

Suturing and surgical techniques

Tips for removing different types of fibroids

Planning:Patient selection Number of fibroids

Size of fibroids How big is too big?

Planning: Patient selection Number of fibroids

Size of fibroids How big is too big?

Location

Planning:Pre-Operative Imaging Ultrasound

Limited when numerous fibroids

9cm

Page 9

Planning:Pre-Operative Imaging MRI

Great for mapping fibroid location and number

Planning:In the OR

Port placement Higher lateral ports

Higher midline ports

LUQ port

5mm and 10mm

Trocar Placement

Planning:In the OR

Energy SourceBipolar

Monopolar

Ultrasonic Energy

Laser

Planning: In the OR Myoma manipulators

Specimen removal

Reducing Blood Loss:Pre-operative use of GnRH Agonists

Improves pre- and post-op hgb/hct

Decreases uterine volume and fibroid size 35-65%

Decreases procedure related blood loss Does not change need for blood transfusion

+/- Decrease in OR time Studies vary

Several individual RCT studies show less OR time

Meta-analysis, no difference in OR time (Cochrane)

? Affect surgical planes

Cochrane Review 2011; Lethaby A. 2002; Zullo F 1998; Gutmann, 2005;

Reducing Blood Loss:Vasopressin Blood loss:

Cochrane: 300 cc less EBL

Need for transfusion

Dilute vasopressin (0.05-0.3 units/ml)

Most studies for openmyomectomies

Kongnyuy E. Cochrane Review, 2007 (2011); Zhao F 2011; Fletcher H. 1996;

Page 10

Vasopressin/20mL NS

Roeder knot using 1-0 vicryl suture Reducing Blood Loss:Tourniquet/Clips

VIDEO TOURNIQUET

Reducing Blood Loss:Barbed suture Decreased OR time (approx 10 miin)

? Decreased blood loss – studies vary

VIDEO BARBED SUTURE

Angioli 2012; Einarsson 2011.

Reducing Blood Loss:Other

Direction of myometrialincision

The “Pedicle”

Electrocautery vs. suture for hemostasis

Walocha JA Hum Reprod 2003

Suturing techniques and aides

Same technique as open

Multiple layer closure

Suturing aides Unidirectional barbed suture – Quill, VLock

Suture clips – Lapra-Ty

Reducing Blood Loss:Closure of defect VIDEO OF MULTI

LAYER CLOSURE VIDEO V LOCK

VIDEO SEROSA

Page 11

Pedunculated fibroids

Fibroid

Pedunculated fibroids: Using a loop ligasure

Intramural and subserosal fibroids Multi-layered closure

Suture clips Submucosal fibroids

Page 12

Broad ligament fibroid References Angioli R et al. A new type of absorbable suture for use in laparoscopic myomectomy. Inter J Gyn Obstet

2012; 117: 220-223.

Einarsson, J. Use of bidirectional barbed suture in laparosocpic myomectomy: evaluation of perioperative outcomes, safety and efficacy. J Min Invas Gyn 2011; 18: 92-5.

Fletcher H et al. A randomized comparison of vasopressin and tourniquet at hemostatic agents during myomectomy. Obstet Gyencol 1996; 87: 1014-8

Gutmann J et al. GnRH agonist therapy before myomectomy or hysterectomy. JMIG 2005; 12: 529-537.

Kongnyuy E, Wiysonge S. Interventions to reduce hemorrhage during myomectomy for fibroids. Cochran Database System Rev, 2007. Updated 2011

Lethaby A. Pre-operative GnRH analogue therapy before hysterectomy or myomectomy for uterine fibroids. Cochran Database System Rev, 2001. Updated 2011

Walocha JA et al. Vascular system of intramural leimyomata reviewed by corrosion casting and scanning electron microscopy. Hum Reprod 2003; 18: 1088.

Zhao F et al. Evaluation of loop ligation of larger myoma pseedocapsule combined with vasopressin on laparoscopic myomectomy. Fertility and Sterility 2011; 95: 762-766

Zullo F et al. A prospective randomized study to evaluate lueprolide acetate treatment before laparoscopic myoectomy: Efficacy and ultrasonographic predictors. Am J Obstet Gyencol 1998; 178 (1): 108-12.

Page 13

Hye-Chun Hur, MDAssistant Professor, Harvard Medical SchoolDirector, Division of Minimally Invasive Gynecologic SurgeryBeth Israel Deaconess Medical Center, Boston , MA

Robotically-assisted Laparoscopic Myomectomy


Disclosures



Objectives

• Review factors for patient selection for robotically-assisted laparoscopic myomectomy (RA-LSC MMY).

• Identify the basic steps of laparoscopic myomectomy.

o Discuss differences between robotic vs conventional LSC MMY approach

o review practical tips specific for robotic method

• Video Demos


Patient Selection: RA-LSC MMY

Any patient who is a candidate for a

conventional laparoscopic myomectomy

is also a candidate for a

robotically-assisted myomectomy.

Who is a good candidate for a robotically-assisted laparoscopic

myomectomy?


Patient Selection: LSC MMY


Patient Selection

• Poor candidates for beginners:o Multiple fibroids (> 3)o Large uterine/fibroid size (e.g. well-above umbilicus) Ideal: place camera port 8-10 cm above pathologyo Adenomyosis (loss of distinct parameters).

• Consider preoperative imaging too determine myoma size, number, location, and

characteristics (degeneration, central necrosis).o exclude adenomyosis.

Page 14


Objectives

• Review factors for patient selection for robotically-assisted laparoscopic myomectomy (RA-LSC MMY).

• Identify the basic steps of laparoscopic myomectomy.

o Discuss differences between robotic vs conventional LSC MMY approach

o review practical tips specific for robotic method

• Video Demos


Robotic Approach

Advantages

• Surgeon comfort (obese patients)

• Myometrial incision (any direction)

• Magnification (identifying pseudocapsule planes)

• More comfortable when suturing


Robotic Approach

Disadvantages

• Larger trocar incision size (8 mm vs 5 mm)

• Additional trocar (4 vs 3 accessory trocars)

• Lack of tactile feedback (visual haptics)

• Space limitations (upper abdomen vs lower pelvis)


Differences

Robotic Approach

• 8 mm trocar size

• 4 accessory trocars

• Higher trocar placement (M configuration)

• Visual haptics

• Small movements with lots of clutching

• Surgeon sitting

Conventional Laparoscopy

• 5 mm trocar size

• 3 accessory trocars

• Lower trocar placement (diamond configuration)

• Tactile feedback

• Large movements with sweeping gestures

• Surgeon standing


Port Placement

Accessory Port (5-10 mm)10-12 mm port direct needle delivery

5 mm port back load the needle

Rainbow Configuration

8 mm port

10-12 mm port

M- Configuration


Port Placement: L-sided Docking

Left-sided Docking

Camera

Arm #1: Scissors or Harmonic

Arm #3: Teneculum

Arm #2:Bipolar

Accessory Port (suction irrigator)

Page 15


Port Placement: R-sided Docking

Right-sided Docking

Camera

Arm #1: Scissors or Harmonic

Arm #3: Teneculum

Arm #2:Bipolar

Accessory Port (suction irrigator)


Right-sided Docking


Right-sided Docking


Right-sided Docking


Basic Steps of LSC Myomectomy

Myomectomy Procedure (4 basic steps):

1. Myometrial incision

2. Fibroid enucleation

3. Myometrial closure

4. Fibroid morcellation

5. (Adhesion barrier)

Adhere to same surgical principles as open myomectomy.

Apply different techniques to achieve these principles

robotically.


Step 1: Myometrial IncisionWhat direction is best for

myometrial incision?

• Transverse • Vertical • Oblique incision

Anatomy

Page 16


Step 2: Enucleation

• Pseudocapsule

o Identify and dissect within pseudocapsule plane

o Diminishes blood loss

o Preserves normal myometrium

o Avoids entry into endometrial cavity

• Push, don’t pull

o push myometrium away from fibroid, rather than pull fibroid out towards you.


Video: Incision, Enucleation


Video: Harmonic


Step 3: Myometrial Closure

• Adhere to same surgical principles as abdominal myomectomy closure

• Check for adjacent myomas prior to closure

• Multi-layer closure is essential

• If endometrial cavity is entered, avoid endometrium in suture line (target endomyometrial junction) o IU dye (methylene blue, indigo carmine)o Uterine manipulator

• Consider adhesion barrier over suture line (esp if you use barb suture)


Suture SelectionUnidirectional Barb Suture Bi-directional Barb Suture

• e.g. V-Loc (Covidien)

• Pre-formed loop

• Polyglyconate (~Maxon)

• e.g. Quill (Angiotech)

• Needle on both ends

• Polydioxanone (~PDS)

Advantages:No knots

Maintains tissue tension by itselfEasy to achieve multi-layer closure


Video: Myometrial Closure

Page 17


Step 4: Morcellation

• Options:o Mechanical morcellatorso Laparoscopic scalpelo Manual morcellation via mini-laparotomy

• Must account for all removed fibroids (string myomas together w/ long suture using Keith needle if necessary)

• Perform thorough survey to prevent iatrogenic disseminated leiomyomatosis


Video: Morcellation


Morcellation Tips

• Grab an edge to start

• Avoid swiss cheeseo Place coreguard at 12 o’clock o Pulse the blade and adjust direction of tip

• Tissue tensiono Don’t pull too hard (pops off or morsel breaks off)o Regrasp tissue outside of body when it gets really long

• Avoid helicopter effecto Pulse the blade, then pull tissue, oro Truncate specimen


Port Placement: Morcellation

M- configuration


Hybrid Procedure

• Combined approach with conventional laparoscopic and robotic myomectomy techniques

o Myometrial incision and myoma enucleation performed laparoscopically

o Robot docked for myometrial closure only

o Attempt only when robotic learning curve well-established (ie. efficient docking)


Hybrid Procedure

Benefits of combined approach • May preserve tactile sensation• May allow faster enucleation of myoma• Fewer accessory ports

Page 18


Conclusions

• Adhere to the same surgical principles for all myomectomies regardless of mode of incision

• Use pre-operative imaging to aid surgical planning

• Allow anatomy to guideo port placement (let fundal height guide trocar locations)o location and direction of myometrial incision (for ergonomic

closure, to minimize risk to adjacent structures)

• Always dissect within pseudocapsule plane

• Push myometrium away from fibroid, rather than pull fibroid out

• Barbed suture is an excellent tool for both beginners and advanced laparoscopic surgeons alike


Questions?

Page 19

When to Opt for Laparotomy: What Limits a Laparoscopic Approach, and Strategies for a

Minimally Invasive Approach to Open Myomectomy

Togas Tulandi MD, MHCM

Professor and Academic Vice Chairman of Obstetrics and Gynecology, Milton Leong Chair in Reproductive Medicine

McGill University

Conflict of interests

Consultant: Actavis

Educational objectives

At the conclusion of this session, the participant should be able to:

1. Describe when to opt for laparotomy and the reasons.

2. Describe strategies for minimally invasive approach to open

myomectomy.

3. Describe the concept of laparoscopically assisted myomectomy.

Case:

• A 30 year old woman with symptomatic uterine myomas and skin lesions.

• Aunt: leiomyomasarcoma and a renal cyst, and her mother underwent a hysterectomy due to

uterine fibroids.

• CT scan and MRI demonstrated uterine myomata, a right renal simple cyst of 3x3.2 cm and left

adrenal adenoma.

• Hereditary leiomyomatosis and renal cell cancer (HLRCC), Multiple cutaneous and uterine

leiomyomatosis syndrome (MCUL1) or Reed's syndrome

• Genetic testing revealed a c. 139C>T, p.Gln47Stop mutation in the fumarate hydratase (FH)

gene, consistent with the diagnosis of HLRCC syndrome.

When to opt for a laparotomy?

• size, and number of leiomyomas

• surgical expertise

• Myomectomy by laparotomy or laparoscopically assisted myomectomy (LAM)?

• Preoperative GnRHa or ullipristal

Page 20

LAM (laparoscopically assisted myomectomy)

• First introduced in 1994

• Less difficult than laparoscopic myomectomy and faster

• Indications: large or multiple myomata not suitable to laparoscopic myomectomy or morcellation

Page 21

Buchs et al, 2012

Oxidized Regenerated Cellulose (Surgicel) Imitating Pelvic Abscess

Behbehani & Tulandi, Obstet Gynecol 2013

Page 22

Adhesion reducing substance

• Oxidized regenerated cellulose

• Expanded polytetrafluoroethylene

• Hyaluronic acid and carboxymethylcellulose

• Polyglactin

• Icodextrin?

LAM (laparoscopically assisted myomectomy)

Advantages

• Good visualization of the entire abdominal cavity

• The laparoscopic part allows identification and treatment of concomitant pathology.

• Allows conventional suturing

• No need to morcellate

• Thorough irrigation of the abdominal cavity and secruredpositioning of adhesion barrier.

• Short hospital stay

Case:

A 30 year old woman with HLRCC (hereditary leiomyomatosis and renal cell cancer).

GnRHa 4 months before myomectomy

Preop. And Postop. Hgb and Hct with GnRHa higher than without.400 microgram misoprostol vaginally 1 hour prior to surgery

Decreases blood loss

Page 23

• 20 iu Vasopressin per 100 mL saline

Decreases blood loss and operating time

50 mL bupivacaine 0.25% and 0.5 ml epinephrine

Tourniquet does not decrease blood loss

Oxytocin does not decrease blood loss.

Loop ligation plus vasopressin

Decreases blood loss and the operating time

Quality of evidence in reducing blood loss

• Moderate:

– misoprostol

– vasopressin

• Low:

– tranexamic acid

– Gelatin-thrombin matrix

– tourniquet

– loop ligation

• No evidence:

– Oxytocin

– Uterine artery ligation

Page 24

Concerns with GnRHa before myomectomy

• Side effects of GnRHa: Addback with estradiol 0.5 mg daily x 3 mths.

• Poor cleavage plane?

• Myoma degeneration

• Delay in diagnosis of sarcoma

• Missed smaller myoma at surgery?

1. Behbehani S, Tulandi T. Oxidized Regenerated Cellulose Imitating Pelvic Abscess. Obstet Gynecol 2013;121:447-9.

2. Benassi L, Lopopolo G, Pazzoni F, et al. Chemically assisted dissection of tissues: an interesting support in abdominal myomectomy. J Am Coll Surg 2000; 191:65.

3. Caglar GS, Tasci Y, Kayikcioglu F, Haberal A. Intravenous tranexamic acid use in myomectomy: a prospective randomized double-blind placebo controlled study. Eur J Obstet Gynecol Reprod Biol 2008; 137:227.

4. Campo S, Garcea N. Laparoscopic myomectomy in premenopausal women with and without preoperative treatment using gonadotrophin-releasing hormone analogues. Hum Reprod 1999; 14:44.

5. Celik H, Sapmaz E. Use of a single preoperative dose of misoprostol is efficacious for patients who undergo abdominal myomectomy. Fertil Steril 2003; 79:1207.

6. Deligdisch L, Hirschmann S, Altchek A. Pathologic changes in gonadotropin releasing hormone agonist analogue treated uterine leiomyomata. Fertil Steril 1997; 67:837.

7. Fletcher H, Frederick J, Hardie M, Simeon D. A randomized comparison of vasopressin and tourniquet as hemostatic agents during myomectomy. Obstet Gynecol 1996; 87:1014.

8. Frishman G. Vasopressin: if some is good, is more better? Obstet Gynecol 2009; 113:476. 9. Ginsburg ES, Benson CB, Garfield JM, et al. The effect of operative technique and uterine size on blood loss

during myomectomy: a prospective randomized study. Fertil Steril 1993; 60:956. 10. Helal AS, Abdel-Hady el-S, Refaie E, et al. Preliminary uterine artery ligation versus pericervical mechanical

tourniquet in reducing hemorrhage during abdominal myomectomy. Int J Gynaecol Obstet 2010; 108:233. 11. Hobo R, Netsu S, Koyasu Y, Tsutsumi O. Bradycardia and cardiac arrest caused by intramyometrial injection of

vasopressin during a laparoscopically assisted myomectomy. Obstet Gynecol 2009; 113:484. 12. Kongnyuy EJ, Wiysonge CS. Interventions to reduce haemorrhage during myomectomy for fibroids. Cochrane

Database Syst Rev 2011; :CD005355. 13. Lurie S, Mamet Y. Transient myocardial ischemia may occur following subendometrial vasopressin infiltration.

Eur J Obstet Gynecol Reprod Biol 2000; 91:87. 14. Nezhat F, Admon D, Nezhat CH, et al. Life-threatening hypotension after vasopressin injection during operative

laparoscopy, followed by uneventful repeat laparoscopy. J Am Assoc Gynecol Laparosc 1994; 2:83. 15. Raga F, Sanz-Cortes M, Bonilla F, et al. Reducing blood loss at myomectomy with use of a gelatin-thrombin

matrix hemostatic sealant. Fertil Steril 2009; 92:356. 16. Stovall TG, Muneyyirci-Delale O, Summitt RL Jr, Scialli AR. GnRH agonist and iron versus placebo and iron

in the anemic patient before surgery for leiomyomas: a randomized controlled trial. Leuprolide Acetate Study Group. Obstet Gynecol 1995; 86:65.

17. Taylor A, Sharma M, Tsirkas P, et al. Reducing blood loss at open myomectomy using triple tourniquets: a randomised controlled trial. BJOG 2005; 112:340.

18. Tomlinson IP, Alam NA, Rowan AJ, et al. Germline mutations in FH predispose to dominantly inherited uterine fibroids, skin leiomyomata and papillary renal cell cancer. Nat Genet 2002; 30:406.

19. Tulandi T, Béique F, Kimia M. Pulmonary edema: a complication of local injection of vasopressin at laparoscopy. Fertil Steril 1996; 66:478.

20. Tulandi T, Einarsson JI. The use of Barbed Suture for Laparoscopic Hysterectomy and Myomectomy: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2014;21:210-6

21. Tulandi T, Youssef H. Laparoscopy Assisted Myomectomy of Large Uterine Myomas. Gynaecol Endos 6:105-8, 1997.

22. Vercellini P, Trespìdi L, Zaina B, et al. Gonadotropin-releasing hormone agonist treatment before abdominal myomectomy: a controlled trial. Fertil Steril 2003; 79:1390.

23. Wei MH, Toure O, Glenn GM, et al. Novel mutations in FH and expansion of the spectrum of phenotypes expressed in families with hereditary leiomyomatosis and renal cell cancer. J Med Genet 2006; 43:18.

24. Ylisaukko-oja SK, Kiuru M, Lehtonen HJ, et al. Analysis of fumarate hydratase mutations in a population-based series of early onset uterine leiomyosarcoma patients. Int J Cancer 2006; 119:283.

25. Zhao F, Jiao Y, Guo Z, et al. Evaluation of loop ligation of larger myoma pseudocapsule combined with vasopressin on laparoscopic myomectomy. Fertil Steril 2011; 95:762.

Zullo F, Palomba S, Corea D, et al. Bupivacaine plus epinephrine for laparoscopic myomectomy: a randomized placebo-controlled trial.

Page 25

Strategies for Safe and Effective Tissue Removal

Stephanie N. Morris, MDAssociate Medical Director, MIGS

Newton Wellesley HospitalClinical Instructor, Harvard Medical School

Disclosure:


Objectives

• Plan tissue removal using multiple different techniques

• Picture: Large fibroid

• Picture: L/S incisions

FDA Safety Communication

• April 2014

• Laparoscopic Uterine Power Morcellation in Hysterectomy and Myomectomy: FDA Safety Communication

• When used for hysterectomy or myomectomy in women with uterine fibroids, laparoscopic power morcellationposes a risk of spreading unsuspected cancerous tissue, notably uterine sarcomas, beyond the uterus. Health care providers and patients should carefully consider available alternative treatment options for symptomatic uterine fibroids. Based on currently available information, the FDA discourages the use of laparoscopic power morcellationduring hysterectomy or myomectomy for uterine fibroids.

National/International Organizations weight in….

Page 26

SGO Position Statement: Morcellation• December 2013• power morcellation or other techniques that cut up the uterus in the abdomen

have the potential to disseminate an otherwise contained malignancy throughout the abdominal cavity. For this reason, the Society of Gynecologic Oncology (SGO) asserts that it is generally contraindicated in the presence of documented or highly suspected malignancy, and may be inadvisable in premalignant conditions or risk‐reducing surgery.

• Patients being considered for minimally invasive surgery performed by laparoscopic or robotic techniques who might require intracorporeal morcellationshould be appropriately evaluated for the possibility of coexisting uterine or cervical malignancy. Other options to intracorporeal morcellation include removing the uterus through a mini‐laparotomy or morcellating the uterus inside a laparoscopic bag.

• Uterine leiomyomas are a common indication for power morcellation. Fewer than one out of 1000 women who undergo hysterectomy for leiomyomas will have an underlying malignancy. The SGO recognizes that currently there is no reliable method to differentiate benign from malignant leiomyomas (leiomyosarcomas or endometrial stromal sarcomas) before they are removed. Furthermore, these diseases offer an extremely poor prognosis even when specimens are removed intact.

• Patients and doctors should communicate about the risks, benefits and alternatives of all procedures so that a patient is able to make an informed and voluntary decision about accepting or declining medical care.

ACOG

• Power Morcellation and Occult Malignancy in Gyn Surgery: A special report. May 2014

• MIS, including power morcellation continues to be an option for some patients.

• Critical to minimize risks for patients with occult malignancy

ACOG: Power Morcellation and Occult Malignancy in Gyn Surgery: A special report

• Pre‐op Dx and Eval– Cervical Cytology– Depending on clinical presentation, may include pelvic imaging and endometrial assesment

– NO pre‐op dx tests can reliable detect sarcoma

• Risk factors to consider– Increasing age– Menopausal status– Uterine size and rapid growth (may increase concern, but not been shown to be predictive of leiomyosarcoma)

– Certain treatments (tamoxifen, pelvic radiation)– Certain hereditary conditions

AAGL: Morcellation During Uterine Tissue Extraction. May 2014

• Pre‐op Eval• H&P, noting patient menopause status• Rapid uterine growth NOT a reliable predictor• Cervical cancer screening• AUB – sampled according to ACOG guidelines (PB • Imaging as indicated clinically

– US amd MRI discussed

• Risk Factors– Age: mean diagnosis age 60– Black race: 2x higher incidence of LMS– Tamoxifen (5+ years)– Pelvic Irradatiation– Hx retonoblastoma or HLRCC

Focus on technique….String of pearls:

keeping track of your fibroids

• VIDEO

Page 27

Power Morcellation

• VIDEO

In‐Bag Morcellation

• Endocatch VIDEO

In‐bag morcellation

• Ecosac VIDEO

In‐bag, minilap

• VIDEO

Posterior colpotomy

• VIDEO

References

• Laparoscopic Uterine Power Morcellation in Hysterectomy and Myomectomy: FDA Safety Communication. April 17, 2014

• Morcellation During Uterine Tissue Extraction. AAGL. May 2014.

• Power Morcellation and Occult Malignancy in Gynecologic Surgery: A Special Report. ACOG. May 2014.

• SGO Position Statement: Morcellation. December 2013.

Page 28

Hysteroscopic Myomectomy: How to Approach the Type 2

Submucosal Fibroid

Stephanie N. Morris, MDAssociate Medical Director, MIGS

Newton Wellesley HospitalClinical Instructor, Harvard Medical School

Disclosure


Objectives

• Identify characteristics of a submucosal fibroid during pre‐operative evaluation that can aide in surgical planning

• Plan surgical approach and describe surgical technique for resection of a large submucosalfibroid

Types of submucosal fibroids

• Type 0

– 100% w/in cavity

• Type I

– >= 50% w/in cavity

– < 50% myometrial extension

• Type II

– < 50% w/in cavity

– >= 50% myometrial extension

ESGE Classification

deBlok S, et al: Gynaecol Enosc 4:243-246, 1995 AAGL Practice Report, JMIG 2012

FIGO Classification of Fibroids

Copyright © 2012 AAGL; AAGL Practice Report, JMIG 2012.

Page 29

Pre‐op Planning

• Type 0, I, II

– Predicts ability to completely resect fibroid

‐ Type 0 96‐97%

‐ Type I 86‐90%

‐ Type II 61‐83%

Wamsteker K, 1993Van Dongen H, 2006

Decrease chance of complete resection

Pre‐op Planning

• Type 0, I, II


– Predicts fluid deficit

• Type 0 450ml

• Type I 957ml

• Type II 1682ml

Increasing fluid deficit

Emanuel, 1997AAGL Practice Guidelines for mgmt of hysteroscopic distending media, 2013

Pre‐op Planning

• Women with larger submucosalfibroids (> 3 cm) have higher risk of fibroid related surgery in the future

– <= 3 cm 10%

– > 3 cm 60%

• Risk of fluid overload increases with larger fibroid diameter

• Type 0, I, II


– Predicts fluid deficit

• Size matters

Hart, R. 1999

AAGL Practice Report: Practice Guidelines for the Management of Hysterscopic Distention Media, 2013

Patient Consent

• Risk of incomplete resection of fibroid

• Possible need for a second procedure

Office Eval OH Mult fibroids OH

Page 30

Intra‐op planning: Equipment

• Resectoscope– Monopolar

• using electrolyte free media

– Bipolar • using isotonic electrolyte‐rich solution (Normal saline)

– Diameter (typically 21/22 Fr and 26/27 Fr)

• Hysteroscopic Morcellator• using isotonic electrolyte‐rich solution (Normal saline)

• RF Vaporization electrodes• using isotonic electrolyte‐rich solution (Normal saline)

Intra‐op Planning: Fluid Deficit

– Electrolyte free media

• Use with monopolarresectoscope

• Sorbitol/Glycine

• Fluid deficit max 1000 ml

Intra‐op Planning: Fluid Deficit

– Monopolar

• using electrolyte free media (sorbitol/Glycine)


– Bipolar/Mechanical Morcellator

• using physiologic fluid (Normal saline or LR)

• Isotonic electrolyte‐rich solution


AAGL Practice Report: Practice Guidelines for the Management of Hysterscopic Distention Media, JMIG 2013

Intra‐op planning:Minimizing intravasation

• Intracervical Vasopression

– Decreased fluid deficit

– Dilute vasopression works well (0.05 U/ml)

– RCT

• Phillips DR. 1996

• 106 women – dilute vasopressin (8 ml of 0.05U/ml) vs. placebo

• Less fluid intravasation (450 ml vs. 820 ml)

Intra‐lesion vasopressin

• VIDEO


• Intrauterine pressure – Higher the pressure, the more the fluid absorption

• Especially when exceeds mean arterial pressure• Typical mean arterial pressure 70‐110 mmHg

– Uterine distention ‐ 45‐60 mmHg

– Venous pressure ‐ 8‐10 mmHg

– Pressure > 75 mmHg increases fluid loss into peritoneal cavity via fallopian tubes

• Use lowest pressure that provides good visualization


Page 31


• Avoid venous sinuses

– Encounter in deep myometrial resection

– Resect intracavitary portion first

– Cauterize if needed

• RF Vaporizing electrodes

– Less fluid absorption than cutting loop


Surgical Technique

1. Do complete survey of endometrial cavity first2. Resect intracavitary portion first3. Don’t resect yourself into a hole4. Only remove chips when you need to5. Move whole resectoscope, not just the loop to maintain

visualization6. Don’t leave pieces hanging7. When getting deeper into myometrium

a. Expect fluid deficit to rise more quicklyb. Identify the pseudo‐capsulec. Desiccate bleeders as neededd. Reduce pressure to help more fibroid protrude into cavity

Type I resectionRemove resected pieces under direct visualization

Type II Resection Reducing pressure

Page 32

Managing Post‐operative Bleeding

•Intra-uterine balloon

•Intrauterine pitressin soaked gauze

•Embolization

•Hysterectomy

•Rollerball ablation mostly ineffective

Consider laparoscopic myomectomy References

• AAGL Practice Guidelines for mgmt of hysteroscopicdistending media. JIMG 2013; 20: 137‐148.

• AAGL Practice Report: Practice Guidelines of the Diagnosis and Management of Submucosal Leiomyomas. J Minim Invas Gynecol 2012. 19:152‐171.

• deBlok S, et al: Gynaecol Enosc 1995. 4:243-246.• Van Dongen H. Follow-up after incomplete hysterscopic

removal of uterine fibroids. Acta Obstet Gynecol Scand. 2006; 85: 1463-7.

• Wamsteker K. Transcervical hysterscopic resection of submucous fibroids for AUB: results regarding the degree of intrmural extension. Obstet Gynecol. 1993. 82: 736-40.

A Type II submucosal fibroid

• A. Is almost entirely in the endometrial cavity

• B. Cannot be safely removed in its entirety hysteroscopically

• C. Is less than 50% in the endometrial cavity

• D. Is associated with less fluid deficit than a Type 0 submucosal fibroid at the time of hysteroscopic resection

Page 33


How to Tackle the Challenging Fibroid: Adenomyomas, Deeply intramural, Broad ligament and Cervical Fibroids.

Hye-Chun Hur, MD, MPHAssistant Professor, Harvard Medical SchoolDirector, Division of Minimally Invasive GynecologyBeth Israel Deaconess Medical Center


Disclosures



Objectives

• Discuss different fibroid presentations that pose unique surgical challenges

o Broad ligament fibroidso Cervical fibroidso Ectopic Fibroids (bowel, abd wall, pelvic sidewall)o Deep intramural fibroidso Adenomyomas

• Review tips and tricks for optimizing minimally invasive surgical techniques for challenging fibroids.


Case #1



Case #1

Page 34


Broad Ligament Fibroid


Broad Ligament Fibroid: Video


Broad Ligament Fibroid: Video


Case #2



Cervical Fibroid

Page 35




Case #3: Ectopic Fibroids

• Disseminated Peritonalis

• Uterine Fibroids

• Adenomyosis

• Endometriosis

• Infertility


Disseminated Peritonalis

Ectopic Fibroids

• Abdominal Wall

• Left rectosigmoid bowel

• Right rectosigmoid bowel

• Left Pelvic Sidewall, Ureteral

• Right IP ligament



Page 36







Page 37



Disseminated Peritonalis

Ectopic Fibroids

• Abdominal Wall x 2 (1.7 cm, 1.6 cm)

• Left rectosigmoid bowel (3.2 cm)

• Right rectosigmoid bowel (2.6 cm)

• Left Pelvic Sidewall, Ureteral (1.2 cm)

• Right IP ligament (5.2 cm)


Case #4: Deep Intramural Fibroids


Type 2 Submucosal Myoma



Case #5: Adenomyomas

• Video

Page 38


Questions

Page 39

Alternatives to myomectomy

Togas Tulandi MD, MHCMProfessor & Academic Chairman of Obstetrics and Gynecology

Milton Leong Chair in Reproductive MedicineMcGill University

Disclosure

Consultant: Actavis

Educational objectives

At the conclusion of this session, the participant should be able to:

• Describe different alternatives to myomectomy

• Describe medical treatment of uterine myoma

• Describe new techniques of surgical treatment of myoma

• Summarize advantages and disadvanatages of different treatments of

uterine myoma

Case presentation

• 35 yrs, G0, uterine myoma of 16 gestational weeks

• Ultrasound: multiple intramural myomata

• PH: intestinal obstruction due to volvulus at 1 year old

• “What are my options?”

• Type and severity of symptoms

• Size of the myoma(s)

• Location of the myoma(s)

• Patient age

• Reproductive plans and obstetrical history

Page 40

Non-surgical management

• Expectant mgmt.

• Medical mgmt.

• Uterine Artery Embolization

• MRgFUS

Medical management

• OCP: no good evidence

• L-norgestrel intrauterine system: may decrease the myoma size

• GnRHa: – most effective

– addback

• GnRH antagonist: daily dose

• SPRM (selective progesterone receptor modulators)

Amino acid composition of native GnRH and GnRHa

Amino acid position 1 2 3 4 5 6 7 8 9 10

GnRH Analog

pGlu His Trp Ser Tyr Gly Leu Arg Pro Gly-NH2

Leuprolide pGlu His Trp Ser Tyr D-Leu6 Leu Arg N-ethyl Pro

Nafarelin pGlu His Trp Ser Tyr D-Nal(2)6 Leu Arg Pro Gly-NH2

Goserelin pGlu His Trp Ser Tyr D-Ser(tBu)6

Leu Arg Pro Aza-Gly-NH10

Buserelin pGlu His Trp Ser Tyr D-Ser(tBu)6

Leu Arg Pro

Histrelin pGlu His Trp Ser Tyr Imbzl-D-His6

Leu Arg Pro

Mifepristone (RU-486)

10

SPRMs

New Class: SPRM

● Ulipristal acetate—1st in a new class—Selective Progesterone Receptor Modulator (SPRM)

● Partial progesterone antagonist effect

ProgesteroneOnapristoneMifepristone

Ulipristal acetate Asoprisnil

Telapristone acetate

AgonistsAntagonists 11 12

Page 41

Time to Control of Bleeding (PBAC < 75)

0

20

40

60

80

100

0 10 20 30 40 50 60 70 80 90 100

Time (days)

Pa

tien

ts (

%) UPA 5 mg

UPA 10 mgLeuprolide 3.75 mg

7 days 30 days

Donnez J, et al. N Engl J Med 2012;366:421‐32

PEARL II

Rates of amenorrhea:

• 73.4% of UPA 5 mg patients (50% in 10 days)

• 81.7% of UPA 10 mg patients

● UPA shows a superior safety profile to GnRHa

● UPA does not induce menopausal symptoms

Pat

ient

s w

ith m

ode

rate

and

sev

ere

hot f

lush

es (

%)

45

Leuprolide0

40

35

30

25

20

15

10

5

UPA 5 mg

UPA 10 mg

Estradiol Hot flushes70

0

60

50

40

30

20

10

Med

ian

seru

m e

stra

diol

(pg/

mL)

LeuprolideUPA 5 mg

UPA 10 mg

Co-primarysafety

endpoints(superiority)

UPA Has a Superior Safety Profile vs. GnRHa as It Does Not Induce Menopausal Symptoms

Safety, Week 13


PEARL II

Effects of UPA on bone• Urinary marker C‐Terminal telopeptide of type I collagen (CTX)


PEARL II

UPA 5 mg

UPA 10 mg

50

100

150

200

250

300

Leuprolide

*

Endometrial effects of SPRMs

Images courtesy of Professor A. Williams

Edinburgh University Medical School

Novel and benign endometrial changes represent a new morphological category whichhas been referred to as

PRM-Associated Endometrial Changes (PAEC).

Hallmark features of PAEC are: ● Low mitotic activity in both glands and stroma

● Abortive subnuclear vacuoles

● Apoptosis

● Absence of stromal breakdown and glandular crowding

● Cystically dilated glands that are linedby flattened epithelium without nuclear pseudostratification

Key features of PAEC

Mutter GL, et al. Modern Pathol 2008;21:591–8

RCT GnRHa vs. aromatase inhibitor

• RCT of women with fibroids of > 5 cm– Letrozole (n: 33) vs. triptorelin (n: 27)x 12 weeks

– Total volume of myoma decreased by 45.6% in letrozole group and 33.3% in GnRHagroup.

Testosterone Estradiol

Androstendione EstroneAromatase

Pituitary gland

Ovary

EstradiolFSH

AromataseInhibitor

Ovary:Androgens ↑FSH receptors ↑IGF I ↑Sensitivity to FSH ↑↑↑

Tulandi, NEJM 2007

Page 42

Both hysterectomy and UAE affect ovarian reserve.

Partial recovery of AMH suggests restoration of follicle cohort from the primordial follicle pool.

AMH remained low in the UAE group suggests irrepairable damage of the primordial follicle pool.

It indicates loss of ovarian reserve that may affect future fertility.

Pregnancy after uterine artery embolization for

leiomyomata: A series of 56 completed pregnancies

56 total pregnancies

33 pregnancies among 108 women trying to conceive

miscarriage rate 30.4%

preterm delivery rate 18.2%

postpartum hemorrhage 18.2%

Walker & McDowell, AJOG 200

Intra-abdominal Adhesions after Uterine Artery Embolization

Case-control study

UAE group (n:30), control group (72)

Intraabdominal adhesions: UAE group (20%) vs. control group (1.4%) P: 0.002, odds ratio 17.2.

Agdi, Valenti, Tulandi, AJOG 2008

From Fennessy & Tempany, 2006

MRgFUS

Funaki et al, 2009

Results

• Stewart et al, 2007: 359 women

Max. shrinkage: 25%Sustained relief: up 24 mths

Page 43

Safety Measures

• No beam passes through or near bowel loops

• No beam passes through the bladder or major scar tissue

• No distal beam passes within 4 cm of the sciatic nerve or branches in front of the sacrum

• Constant communication with the patient

Tempany, 2007

Vilos et al, 2005

Lichtinger et al, 2005

Brucker et al, 2014

Radiofrequency volumetric thermal ablation (RFVTA)

Decreased in myoma volume at 3 and 12 mths: 39.8% and 45.1%

Chudnoff et al, 2013 and 2014

Robot assisted vs. laparoscopic myomectomyGargiulo et al, 2012

P<0.001 P<0.04

Page 44

Goebel & Goldberg, 2014

Page 45

CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

Page 46

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

Didactic: No More Fibs: The Truth about Fibroids · 2020-01-30 · Broad Ligament, and Cervical...

Documents

Transcript of Didactic: No More Fibs: The Truth about Fibroids · 2020-01-30 · Broad Ligament, and Cervical...