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AAGLAdvancing Minimally Invasive Gynecology Worldwide
Didactic/Simulation Lab:Hysteroscopy 360° Beyond the Basics – Maximize Treatment, Minimize Failures
PROGRAM CHAIR
Aarathi Cholkeri-Singh, MD
AAGL acknowledges that it has received educational grants from the following companies: Bayer HealthCare, Boston Scientific, CooperSurgical, Hologic, Medtronic, Minerva Surgical,
Olympus America Inc, Karl Storz Endoscopy-America, Inc., Richard Wolf Medical Instruments Corporation.
AAGL acknowledges that it has received in-kind support from the following companies: Durable Equipment: Bayer HealthCare, Boston Scientific, CooperSurgical, Hologic, Medtronic, Minerva Surgical,
Olympus America, Inc, Karl Storz Endoscopy-America, Inc., Richard Wolf Medical Instruments Corporation; Disposable Supplies: Bayer HealthCare, Boston Scientific, Hologic, Medtronic, Minerva Surgical,
Karl Storz Endoscopy-America, Inc., Richard Wolf Medical Instruments Corporation.
Stefano Bettocchi, MD Amber Bradshaw, MD Angela Chaudhari, MDScott G. Chudnoff, MD, MS Amy L. Garcia, MD Matthew R. Hopkins, MDGretchen E.H. Makai, MD Stephanie N. Morris, MD Nigel Pereira, MD, FACOG
Kirsten J. Sasaki, MD S. Sony Singh, MD, FRCSC, FACOG Courtney Steller, DOMaria Teresa Tam, MD Kelly N. Wright, MD
Professional Education Information Target Audience This educational activity is developed to meet the needs of surgical gynecologists in practice and in training, as well as other healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) 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 ...................................................................................................................................................... 3 Hysteroscopy Overview: Indications and Instrumentation A. Cholkeri‐Singh .......................................................................................................................................... 5 Approaching Difficult Anatomy, Minimizing False Tracts S. Bettocchi ................................................................................................................................................ 12 Tips and Tricks for Difficult Essure Placement and Removal A.L. Garcia .................................................................................................................................................. 17 Endometrial Ablation and Long‐Term Outcomes M.R. Hopkins .............................................................................................................................................. 19 Managing Large Intracavitary Fibroids S.S. Singh .................................................................................................................................................... 30 Hysteroscopy Complications: Prevention, Recognition and Management A. Cholkeri‐Singh ........................................................................................................................................ 39 Cultural and Linguistics Competency ......................................................................................................... 67
HSC-700 Didactic/Simulation Lab: Hysteroscopy 360° Beyond the Basics – Maximize Treatment, Minimize Failures
Aarathi Cholkeri-Singh, Chair
Faculty: Stefano Bettocchi, Amy L. Garcia, Matthew R. Hopkins, S. Sony Singh
Lab Faculty: Amber Bradshaw, Angela Chaudhari, Scott G. Chudnoff, Gretchen E.H. Makai, Stephanie N. Morris, Nigel Pereira, Kirsten J. Sasaki, Courtney Steller,
Maria Teresa Tam, Kelly N. Wright Hysteroscopy is an important skill for all gynecologists. It is a skill set that continues to evolve due to
improving optics, instrumentation and fluid monitoring systems. It can be a straightforward surgical
solution to diagnose and treat pathology, thus improving patients’ quality of life. However, anticipated
as well as unexpected clinical situations can arise, and the outcome of your case and your patient’s
experience may depend on your ability to manage these events. What can we, as surgeons, do to
ensure completion of our hysteroscopic cases and improve patient outcomes? In this course, a
combination of didactics and hands-on simulation will allow the participant to expand their knowledge
beyond the basics of hysteroscopy. The participant will apply prevention and management techniques
to overcome intraoperative difficulties in order to minimize short-term risks and long-term
complications that can occur in every day practice.
Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Identify difficult case
scenarios and implement strategies to achieve optimal surgical outcomes; 2) prevent and manage
complications; and 3) compare and identify best utilization of various instrumentation.
Course Outline
12:30 Welcome, Introductions and Course Overview A. Cholkeri-Singh
12:35 Hysteroscopy Overview: Indications and Instrumentation A. Cholkeri-Singh
12:50 Approaching Difficult Anatomy, Minimizing False Tracts S. Bettocchi
1:05 Tips and Tricks for Difficult Essure Placement and Removal A.L. Garcia
1:25 Endometrial Ablation and Long-Term Outcomes M.R. Hopkins
1:45 Managing Large Intracavitary Fibroids S.S. Singh
2:00 Hysteroscopy Complications: Prevention, Recognition and
Management A. Cholkeri-Singh
2:20 Questions & Answers All Faculty
2:35 Hands-on Lab Introduction A. Cholkeri-Singh
2:40 LAB I: Hysteroscopy Ergonomics A. Chaudhari, S.G. Chudnoff, N. Pereira
• Perform diagnostic hysteroscopy
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• Perform operative hysteroscopy with scissors and graspers for polypectomy and septum
transection models
• Perform tubal occlusion with Essure placement
LAB II: Hysteroscopic Morcellators K.J. Sasaki, M.T. Tam, K.N. Wright
• Perform operative hysteroscopy for polyps, fibroids, retained products of conception and
visual D&C utilizing hysteroscopic morcellators
LAB III: Resectoscopy S. Bettocchi, A.L. Garcia, S.N. Morris, C. Steller, G.E.H. Makai
• Review proper ergonomics of resectoscopy to perform myoma resection or
endometrial ablation
• Review role of 5 FR electrodes
• Review principles of electrosurgery
LAB IV: Endometrial Ablation A. Bradshaw, M.R. Hopkins
• Proper use of endometrial ablation devices; reinforcing indications
and contraindications
4:25 Questions & Answers All Faculty
4:30 Adjourn
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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* R. Edward Betcher* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Aarathi Cholkeri-Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Sarah L. Cohen Consultant: Olympus Erica Dun* Joseph (Jay) L. Hudgens Contracted Research: Gynesonics Frank D. Loffer, Medical Director, AAGL* Suketu Mansuria Speakers Bureau: Covidien Linda Michels, Executive Director, AAGL* Karen C. Wang* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Sawsan As-Sanie Consultant: Myriad Genetics Lab Jubilee Brown* Aarathi Cholkeri-Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Jon I. Einarsson* Suketu Mansuria Speakers Bureau: Covidien Andrew I. Sokol* Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Stock Ownership: Titan Medical Karen C. Wang* 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). Stefano Bettocchi Consultant: Karl Storz Amber Bradshaw Speaker Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical
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Angela Chaudhari* Aarathi Cholkeri-Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Scott G. Chudnoff* Amy L. Garcia Consultant: Gynesonics, Minerva Surgical, NVision Matthew R. Hopkins* Gretchen E.H. Makai* Stephanie N. Morris* Nigel Pereira* Kirsten J. Sasaki* S. Sony Singh Speakers Bureau: AbbVie, Allergan, Bayer Healthcare Corp. Courtney Steller* Maria Teresa Tam Consultant: Bayer Healthcare Corp. Contracted Research: Smith & Nephew Endoscopy Other: Clinical Trainer: Merck Kelly N. Wright Other: Proctor: Applied Medical Content Reviewer has no relationships. Asterisk (*) denotes no financial relationships to disclose.
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DIAGNOSTIC AND OPERATIVE HYSTEROSCOPY: INDICATIONS AND INSTRUMENTATION
AARATHI CHOLKERI-SINGH, M.D., FACOG
Clinical Assistant Professor of Obstetrics and Gynecology at UIC
Associate Director of Minimally Invasive Gynecologic Surgery
Director of Gynecologic Surgical Education at ALGH
DISCLOSURE
Consultant: Smith & Nephew Endoscopy
Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic
Other: Advisory Board: Bayer Healthcare Corp., Hologic
OBJECTIVE
Explain diagnostic and operative hysteroscopy and instrumentation.
HYSTEROSCOPY INDICATIONS
Vaginal or Cervical examination
Evaluation of abnormal uterine bleeding
Infertility evaluations
Pre- and post-surgical evaluation
Surgical procedures
HYSTEROSCOPY INDICATIONS
Vaginal or Cervical examination
Evaluation of abnormal uterine bleeding
Infertility evaluations
Pre- and post-surgical evaluation
Surgical procedures
VAGINAL OR CERVICAL EXAMINATION
Diagnostic Inadequate speculum exam – pediatric, obese, postmenopausal with severe
atrophy
Vaginal endometriosis
Pelvic floor mesh erosions
Vaginal fistulas
Cervical pathology
Operative
Excision of vaginal or cervical lesions
Vaginal septums
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HYSTEROSCOPY INDICATIONS
Vaginal or Cervical examination
Evaluation of abnormal uterine bleeding
Infertility evaluations
Pre- and post-surgical evaluation
Surgical procedures
ETIOLOGY OF AUB
Pregnancy
Infection
Hormonal
Hematologic
Structural
Retained products of conception
Fibroids
Polyps
Adenomyosis
Endometritis
Hyperplasia
Cancer
HYSTEROSCOPY INDICATIONS
Vaginal or Cervical examination
Evaluation of abnormal uterine bleeding
Infertility evaluations
Pre- and post-surgical evaluation
Surgical procedures
CONDITIONS OF THE UTERINE CAVITY AFFECTING FERTILITY
Endometrial polyps
Uterine fibroids
Intrauterine synechia
Congenital defects
HYSTEROSCOPY INDICATIONS
Vaginal or Cervical examination
Evaluation of abnormal uterine bleeding
Infertility evaluations
Pre- and post-surgical evaluation
Information changes management & expectations
Surgical procedures
PREOPERATIVE PLANNING
Wamsteker, K, Emanuel, M H, & de Kruif, J H. (1993). Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstetrics and gynecology, 82(5), 736-40.
Type 0 – 100% within cavity Type I – > 50% within cavity Type II - < 50% within cavity
2 surgeries may be required for Type II or larger fibroids
Avoid resecting opposing fibroids
6
HYSTEROSCOPY INDICATIONS
Vaginal or Cervical examination
Evaluation of abnormal uterine bleeding
Infertility evaluations
Pre- and post-surgical evaluation
Surgical procedures
SURGICAL PROCEDURES
Biopsy/D&C
Retrieval of foreign body/IUD
Insertion of tubal occlusion device
Metroplasty
Adhesiolysis
SURGICAL PROCEDURES
Polypectomy
Myomectomy
Ablation
Evacuation of retained products of conception
Embryoscopy
CONTRAINDICATIONS
Viable intrauterine pregnancy
Active pelvic infection
Known cervical or uterine cancer
INSTRUMENTATION
DIAGNOSTIC HYSTEROSCOPY
Flexible Hysteroscope
Fiber-optic
0o lens with 240o range of visual field
Single channel
3-4mm diameter
IV tubing/cysto tubing or syringe
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DIAGNOSTIC HYSTEROSCOPY
Rigid
Rod lens – 12º, 25º, 30º
Single-flow
OD - 2.8 mm, 4.1 mm or 5.2 mm
Can perform vaginoscopy to avoid use of speculum and tenaculum
Continuous flow
OD - 3.6 mm, 4.5 mm or 6.2 mm
Able to proactively flush the uterine cavity
OPERATIVE HYSTEROSCOPY
Rigid scope
Rod lens
0º, 12º, 25º, 30º
Single sheath
OD - 5.5mm
Can perform vaginoscopy to avoid use of speculum and tenaculum
5-7 Fr instrument channel
Continuous flow
OPERATIVE HYSTEROSCOPY
Operative Instruments
5-7 Fr
35cm in length
Semirigid
Greater stability for direction and cutting
Biopsy Forceps Scissors Alligator Forceps
OPERATIVE HYSTEROSCOPY
Bipolar electrodes
5 Fr
40cm in length
Flexible
Vaporization, Cut and Desiccation
Normal saline distension medium
HYSTEROSCOPY GENERAL PEARLS
Open inflow and outflow valves with insertion of hysteroscope. The saline flow will aid insertion and assist in achieving good visualization quickly. The fluid will flush blood and clots and assist in the exchange of fluid.
Consider vaginoscopy, aka No Touch hysteroscopy
Insert the hysteroscope sheath with the obturator in place for larger scopes (curved edge – less cervical trauma)
Increasing uterine pressure setting at start of procedure will aid in achieving good visualization rapidly but then uterine pressure can be reduced.
Maintain pressure at the lowest setting that maintains adequate distention and provides good visualization. Lower pressure, lower intravasation.
Pressure to open tubal ostia > 75 mmHg
OPERATIVE HYSTEROSCOPY
Electrosurgical Resectoscope
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RESECTOSCOPY ADVANTAGES
Long experience
Suitable for pedunculated and sessile abnormalities
Suitable for endometrial ablation
Coagulation
Histology specimen available
RESECTOSCOPY CHALLENGES
Difficult
Time consuming tissue removal
Perforation risk
Long learning curve
Multiple insertions
Visibility disturbing elements Cervical mucus
Gas bubbles
Tissue fragments
Blood clots
RESECTOSCOPE ELECTRODES RESECTOSCOPY PEARLS
Activate electrode before contact
Never extend an activated electrode
Allow spark to generate energy
If bubbles obscure field, increase outflow to remove
VAPORIZATION DESICATION
9
RESECTION HYSTEROSCOPIC MORCELLATORS
Continuous flow hysteroscopy
Use of saline
Regulation of intrauterine pressure and liquid flow
Cutting device with suction
Mechanical tissue removal – instant
Shorter learning curve
Less risk of perforation
HYSTEROSCOPIC MORCELLATOR PROCEDURES
Polypectomies Myomectomies Retained Products of Conception (RPOC) Evacuation Diagnostic Visual Dilatation & Curettage (D&C) Hysteroscopic Adhesiolysis Endometrial Biopsy
HYSTEROSCOPIC MORCELLATORS
Instructions
• Two handed technique: hold the hand piece in your dominant hand and scope in the other hand
• May try holding scope & handpiece in vertical vs. horizontal position
• Position the scope close to the intracavitary lesion to clearly visualize
• Move the scope and device as one; activate footswitch while maintaining good contact with tissue
HYSTEROSCOPIC MORCELLATORS
Confirm the cutting window has a good “bite” of tissue inside
• If you can see inside the inner tube, you are only resecting fluid out of the uterine cavity
36
Video - Dr. Charles E. Miller, 2012
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HYSTEROSCOPIC MORCELLATORS
Running the morcellator in open cavity for a short time will aid in clearing visual field of debris. Remove clots by activating morcellator.
Keep pathology between morcellator blade opening (black line on morcellator is in line with blade opening) and optics of camera.
When morcellating pathology, work from the periphery to the base.
DISTENSION MEDIA
Diagnostic hysteroscopy
CO2 gas
Normal saline
Operative non-electrosurgical hysteroscopy
Normal saline
Resectoscopy
Bipolar - Normal Saline
Monopolar – Glycine, Sorbitol or Mannitol
FLUID MANAGEMENT
11
Dept. of OB. / GYNUniversity of Bari, Italy
OFFICE HYSTEROSCOPY
Anatomical Impediments
Prof. Stefano BettocchiDept. of Ob./Gyn., University of Bari, Italy
Chief: Prof. Ettore Cicinelli
Dept. of OB. / GYNUniversity of Bari, Italy
Dept. of OB. / GYNInt.U.S.Gyn.E
University of Bari, Italy www.hysteroscopy.org
Disclosure
Consultant: Karl Storz
Dept. of OB. / GYNUniversity of Bari, Italy
Dept. of OB. / GYNInt.U.S.Gyn.E
University of Bari, Italy www.hysteroscopy.org
Objective
Describe how to approach difficult anatomy
Dept. of OB. / GYNUniversity of Bari, Italy
Dept. of OB. / GYNInt.U.S.Gyn.E
University of Bari, Italy www.hysteroscopy.org
WHAT DOES IT MEAN DIAGNOSTIC HYSTEROSCOPY TODAY?
Current Opinion 2003, 15 (4): 303-308
Dept. of OB. / GYNUniversity of Bari, Italy
The most difficult part of the procedure…?
TO GET INTO THE UTERINE CAVITY…!!
Dept. of OB. / GYNUniversity of Bari, Italy
NO uterine cavity ? NO Party !
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Dept. of OB. / GYNUniversity of Bari, Italy
E.U.O
Less than 0,5 mm!
5 Fr. = 1.6 mm
Dept. of OB. / GYNUniversity of Bari, Italy
I.U.O.
Dept. of OB. / GYNUniversity of Bari, Italy
18 years in 2 Italian Universitary Centers
Dept. of OB. / GYNUniversity of Bari, Italy
CLASSIFICATION
• Type 1: Stenosis of the E.C.O.• Type 2: Combined stenosis of distal third of the cervical canal and I.C.O.
• Type 3: Stenosis of the I.C.O.• Type 4: Combined stenosis of E.C.O. & I.C.O.
Dept. of OB. / GYNUniversity of Bari, Italy
STRATEGIES FOR OVERCOMING STENOSIS
• TECHNIQUE #1: Adhesiolysis with the tip of the hysteroscope
Dept. of OB. / GYNUniversity of Bari, Italy
STRATEGIES FOR OVERCOMING STENOSIS
• TECHNIQUE #2: Adhesiolysis with 5Fr grasping forceps with teeth (grasp & rotate)
13
Dept. of OB. / GYNUniversity of Bari, Italy
STRATEGIES FOR OVERCOMING STENOSIS
• TECHNIQUE #2: Adhesiolysis with 5Fr grasping forceps with teeth (grasp & rotate)
THE LIMITS of OFFICE “MECHANICAL” SURGERY WITHOUT ANESTHESIA or ANALGESIA (4.863
cases) JAAGL, Febr. 2004
Dept. of OB. / GYNUniversity of Bari, Italy
THE LIMITS of OFFICE “MECHANICAL” SURGERY
WITHOUT ANESTHESIA or ANALGESIA (4.863 cases)
JAAGL, Febr. 2004
I.U.O. Anathomical Impediments
Dept. of OB. / GYNUniversity of Bari, Italy
STRATEGIES FOR OVERCOMING STENOSIS
• TECHNIQUE #3: Adhesiolysis with 5Fr scissors
Dept. of OB. / GYNUniversity of Bari, Italy
STRATEGIES FOR OVERCOMING STENOSIS
• TECHNIQUE #3: Adhesiolysis with 5Fr scissors
Dept. of OB. / GYNUniversity of Bari, Italy
MOST OF THE IMPEDIMENT TO THE CORRECT EXECUTION OF THE HYSTEROSCOPIC PROCEDURE CAN BE SOLVED IN THE OFFICE
Dept. of OB. / GYNUniversity of Bari, Italy
STRATEGIES FOR OVERCOMING STENOSIS
• TECHNIQUE #4: Adhesiolysis with 5Fr bipolar electrodes
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Dept. of OB. / GYNUniversity of Bari, Italy
RESULTS10.156 Cervical Stenosis
over31.052 procedures (32,7%)
• Type 4 stenosis the most common one (44.3% - p=<.001)
• All the CS more frequent in menopausal patients (70,1% - p=<.001), except Type 1 (64,6% - p=<.001)
Dept. of OB. / GYNUniversity of Bari, Italy
TREATMENT• Successful: when access to and visualization of the entire uterine
cavity (including both tubal ostia) was possible during the same procedure
• Incomplete: when access to uterine cavity was possible, but the entire uterine cavity could not be examined due to patient’s reaction or anatomical problems. The uterine cavity was then visualized during a second access, days or weeks after
• Failed: when access to uterine cavity was not possible. Failedhysteroscopies were then referred for an ultrasound-guidedhysteroscopy under loco-regional or general anaesthesia
Dept. of OB. / GYNUniversity of Bari, Italy
TREATMENT10.004 C.S. (98,5%)
MANAGED SUCCESFULLY
• Successful: 8.724 procedures, 85.9%• Incomplete: 1.280 procedures, 12.6%• Failed: 152 procedures, 1,5%
Dept. of OB. / GYNUniversity of Bari, Italy
TREATMENT10.004 C.S. (98,5%)
MANAGED SUCCESFULLY
• Technique #1 the more used strategy to overpass allCS (39,8% - p=<.001)
• Bipolar electrode more used in Type 1 & Type 4 CS (39,7% - p=<.001)
Dept. of OB. / GYNUniversity of Bari, Italy
WE PERFOMED A SURGICAL ACT BEFORE BEING DIAGNOSTIC
Dept. of OB. / GYNUniversity of Bari, Italy
CAN WE WORK BETTER AND FASTER?CAN WE IMPROVE THE RESULTS?
Measurement of the I.U.P.Size of the
Hysteroscopes
New Energies
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Dept. of OB. / GYNUniversity of Bari, Italy
THANK YOU!
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Tips and Tricks for Difficult Essure Placement and
Removal Amy Garcia, MD
AAGL/SRS Fellowship-Trained in MIGS
Director, Center for Women’s Surgery
Clinical Assistant Professor, University of New MexicoDepartment of Obstetrics and Gynecology
Albuquerque, New Mexico
Disclosure
• Consultant: Gynesonics, Minerva Surgical, NVision
Objectives
Identifying the difficult procedure
Observe video demonstration difficult procedures management
Incorporate troubleshooting techniques for successful outcomes
©2012 All rights reserved. For internal distribution only. CC-3001 13JAN12F
Change Entry Angle
Video presentations of difficult Essure procedures with trouble shooting techniques
“Now that a less complicated and more effective method has been established, our credo as obstetricians and gynecologists to optimize outcome by reducing risk and maximizing efficacy, really compels our specialty to critically re-examine the laparoscopic paradigm for tubal sterilization.”
Dr. Andrew Brill
2011 ACOG Update Clinical Data BulletinHysteroscopic Sterilization
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http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/EssurePermanentBirthControl/ucm452254.htm
2016
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©2016 MFMER | slide-1
Endometrial Ablation and Long Term OutcomesMatthew R Hopkins, MDChair of Education – OB/GYNAssistant Professor OB/GYN Mayo Clinic, Rochester MN
©2016 MFMER | slide-2
Disclosure
• I have no financial relationships to disclose
©2016 MFMER | slide-3
Objectives
• Define heavy menstrual bleeding
• Discuss treatment indications for endometrial ablation
• Discuss rates and reasons for treatment failure of endometrial ablation
• Review and manage common sequelae of endometrial ablation
©2016 MFMER | slide-4
Outline
• Indication
• Goal of Treatment
• Device Selection
• Patient Selection
• Post Ablation Events
©2016 MFMER | slide-5
Treatment Indication
• Heavy Menstrual Bleeding• “for clinical purposes, heavy menstrual blood
loss (HMB) should be defined as excessive menstrual blood loss which interferes with the woman’s physical, emotional, social and material quality of life”
• Not• Irregular Bleeding• Dysmenorrhea• PMDD
NICE clinical guideline 44, January 2007
©2016 MFMER | slide-6
What is Heavy Menstrual Bleeding?
19
©2016 MFMER | slide-7 ©2016 MFMER | slide-8
©2016 MFMER | slide-9Roy SM et al, Drug Safety 2004 ©2016 MFMER | slide-10
Comparison of Non-resectoscopic Endometrial Ablation Devices
Energy/Delivery system
Trade Name Device Outside Diameter (mm)
Single Use (S) / Reusable (R)
Pre-treatment
Max Uterine Sounded Length (cm)
Submucous Myomas Allowed?
Myoma Size / Type‡
Endpoint Determination Device (D) Surgeon (S)
Typical Treatment Time (min)
Heated fluid (balloon)
ThermaChoice 5.5 S Mechanical or medical
10 Yes++ ≤ 3 cm / type II
D 8.0
Cryogenic Her Option 4.5 S Medical 10 No N/A S 10
Heated Fluid (free)
HTA 7.8 S Medical 11 Yes+ Not known D 14
Microwave MEA 8.0 R/S Medical 14 Yes ≤ 3 cm/type II; selected type I
S 2.4
RF* (bipolar)
NovaSure 7.2 S None 10 Yes++ ≤ 2 cm D 1.5
*RF = radiofrequency alternating current.‡ Type O myomas are entirely intracavitary, on a stalk; type I are sessile but have a 50% or more of their maximum circumference within the
endometrial cavity; type II myomas have less than 50% of their maximum circumference within the endometrial cavity.+ There is insufficient data to determine the type and dimension of myomas treatable with HTA.++ Myomas 2 cm or less allowed, but no data available regarding clinical outcomes at this time.
Adopted from: Munro MG. Clin Obstet Gynecol 49;4:736-766
©2016 MFMER | slide-11
By treating HMB with endometrial ablation……
What are we trying to accomplish?Reduce menstrual blood flow
Improve quality of life
Improved utilization of resources
Initially, GEA has similar efficacy compared to Hysterectomy with lower cost and complication rates
These favorable outcomes diminish with time because 30% of patients required hysterectomy within 4 years after ablation.
Dickersin et al, Obstet Gynecol. 2007Aberdeen Endometrial Ablation Trials Group, Br J Obstet Gynaecol 1999
©2016 MFMER | slide-12
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©2016 MFMER | slide-13
Probability of Hysterectomy After Endometrial Ablation
0
5
10
15
20
25
30
0 1 2 3 4 5 6 6.5 8
Years after endometrial ablation
Pro
ba
bilit
y o
f hys
tere
cto
my
(%)
OverallHydrothermalFirst GenerationRadiofrequencyThermal balloonUnclassified
Fig. 1. Probability of hysterectomy by endometrial ablation technique: life-table method. Log rank test, P=.63.
Longinotti. Hysterectomy After Endometrial Ablation. Obstet Gynecol 2008.
Longinotti MK et.al. Obstet Gynecol 2008;112:1214-20©2016 MFMER | slide-14
Data Synthesis
• Despite knowledge of the prognostic factors, the outcome of endometrial ablation cannot be predicted for an individual
Parkin DE Lancet1998;351:1147-48
©2016 MFMER | slide-15
Are there predictors of failure of endometrial ablation?Bongars MY et al. Obstet Gynecol 2002.
Gervaise A et al. Human Reprod. 1999.
Shelly-Jones D et al. J Gynecol Surg. 1994
Molnar BG et al. Acta Obstet Gynecol Scand. 1997.
Phillips G et al. Br J Obstet Gynaecol. 1998.
Dutton C et al. Obstet Gynecol. 2001.
Shaamash AH, Sayed EH. J Obstet Gynaecol Res. 2004.
Hart R, Magos A. Lancet. 1998.
Parkin DE. Lancet. 1998.
Longinotti MK et al. Obstet Gynecol. 2008.
©2016 MFMER | slide-16
What are the reported predictors of failure?
• Young age
• Retroverted Uterus
• Endometrial Thickness >4mm
• Prolonged duration of menstruation
• Dysmenorrhea
• Atypical Pain
• Previous Tubal Ligation
• Large Uterus
• Hormonal Pretreatment
• Uterine Polyp
• Submucous Leiomyoma
• Cesarean Section
©2016 MFMER | slide-17
Previous Tubal Ligation Is a Risk Factor for Hysterectomy After Endometrial Ablation
0
0.2
0.4
0.6
0.8
1
0 20 40 60 80 100 120 140 160
Follow Up Time (Months)
Pro
bab
ilit
y o
f N
o H
yste
rect
om
y
No Tubal Ligation
Figure 1. Kaplan-Meier curve for the probability of not having a hysterectomy after rollerball ablation stratified by history of tubal ligation.
Mall. Tubal Ligation and Ablation. Obstet Gynecol 2002.Mall A et al. Obstet Gynecol 2002;100:659-64
Tubal Ligation
©2016 MFMER | slide-18
0
5
10
15
20
25
30
35
40
45
0 1 2 3 4 5 6 7 8
Years after endometrial ablation
Pro
ba
bili
ty o
f hys
tere
cto
my
(%)
40-44
45-49.9
Younger than 40
Older than 50
Age as a Risk Factor for Hysterectomy After Endometrial Ablation
Fig. 2. Probability of hysterectomy by age group: life-table method. Log-rank test, P<.001.
Longinotti. Hysterectomy After Endometrial Ablation. Obstet Gynecol 2008.
Longinotti MK et.al. Obstet Gynecol 2008;112:1214-20
21
©2016 MFMER | slide-19El Nashar et al Obstet Gynecol 2009;110:97-106
Preoperative Dysmenorrhea Is a Risk Factor for Treatment Failure
©2016 MFMER | slide-20
©2016 MFMER | slide-21
TBA (vs. RFA)
Previous CS
Predictors
Uterine length > 9 cm
Retro-verted uterus
Hemoglobin ≥ 12 g/dL
Endo. thick ≥4 mm
Uterine polyp
Submucous fibroid
Pre-op dysmenorrhea
Metrorrhagia
Accidents/clots
Tubal ligation
BMI ≥ 30 kg/m2
Parity ≥5
0.270
P value
0.003
0.010
<0.001
0.008
1.5 (0.8,2.9)
-
Multivariate HR
-
-
-
-
-
-
3.7 (1.6,8.5)
-
-
2.2 (1.2,4.0)
-
6.0 (2.5,14.8)
2.6 (1.3,5.1)
1.5 (0.8,2.9)
0.7 (0.3,1.6)
Univariate HR
1.0 (0.5,1.8)
1.0 (0.3,3.3)
1.8 (0.9,3.6)
0.8 (0.3,2.4)
0.6 (0.3,1.4)
1.0 (0.3,3.1)
3.9 (1.7,8.7)
1.5 (0.8, 2.7)
1.6 (0.8,3.1)
2.5 (1.4,4.5)
0.6 (0.3,1.3)
4.8 (2.0,11.4)
0.260
0.400 ‡
P value
0.940 ‡
0.970 ‡
0.084 †
0.730 ‡
0.220 ‡
0.940 ‡
0.001 †‡
0.180 †
0.160 †
0.002 †‡
0.200 †
<0.001 †
0.013 †2.4 (1.2,4.7)Age <45 years
Pre-treatment predictors of treatment failure
† Univariate P<0.2 ‡ Previously reported in the literature©2016 MFMER | slide-22
0.0038.51.63.7 Dysmenorrhea
0.0104.01.22.2 Tubal ligation
<0.00114.82.56.0 Parity ≥ 5
0.0085.11.32.6 Age < 45 years
UpperLower
P value**95% CIAdjustedHR
Predictors
The final multivariate Cox proportional hazards model for the predictors of treatment failure after GEA*
* Adjusted for the type of the ablation procedure** The C-statistics of this model is 0.755
©2016 MFMER | slide-23
HR= 2.6, P=0.008 HR= 6.0, P<0.001
HR= 3.7, P=0.003HR= 2.2, P=0.010©2016 MFMER | slide-24
Table 6. Examples of the expected probability of treatment failure based on pretreatment variables*
10% (3,17) 7% (2,12)3% (1,5)+--
17% (0,31)11% (0,22)5% (0,10)-+-
32% (2,54)23% (1,40)10% (0,20)++-
12% (6,18)8% (4,12)3% (1,5)--+
24% (12,35)17% (8,24)7% (3,12)+-+
37% (4,59)26% (3,44)12% (1,22)-++64% (18,84)49% (12,70)24% (4,40)+++
5 years3 years1 yearTubal ligation
DysmenorrheaAge < 45
5% (1,8)3% (1,5)1% (0,2)---
Probabilities of failure are presented with their 95%CI based on Cox regression Modeling* Excluding those who are para >5
22
©2016 MFMER | slide-25 ©2016 MFMER | slide-26
©2016 MFMER | slide-27
Criteria for Patient Selection
• Pivotal Trial Criteria
–Age 30 upwards–Childbearing is• complete–Normal sized• uterus
• Outcomes Data
–Age 40 or older–History of tubal• ligation–Premenstrual• dysmenorrhea
….and….low risk for developing endometrial hyperplasia…and…treatment aligns with patient expectation
©2016 MFMER | slide-28
Postablation Events
• Treatment Failure• “Late Onset Endometrial Ablation Failure*”• Bleeding +/- Pain
• Postablation Uterine Synechiae• Subsequent Evaluation• Post Ablation-Tubal Ligation Syn.
• Post GEA cancer
• Post GEA pregnancy
*Wortman M, Cholkeri A et al. JMIG 2015
©2016 MFMER | slide-29
Probability of Hysterectomy After Endometrial Ablation
0
5
10
15
20
25
30
0 1 2 3 4 5 6 6.5 8
Years after endometrial ablation
Pro
ba
bilit
y o
f hys
tere
cto
my
(%)
OverallHydrothermalFirst GenerationRadiofrequencyThermal balloonUnclassified
Fig. 1. Probability of hysterectomy by endometrial ablation technique: life-table method. Log rank test, P=.63.
Longinotti. Hysterectomy After Endometrial Ablation. Obstet Gynecol 2008.
Longinotti MK et.al. Obstet Gynecol 2008;112:1214-20©2016 MFMER | slide-30
Indications for Hysterectomy After Endometrial Ablation
N (754) %
Vaginal bleeding 389 51.6
Pelvic pain
Pain and bleeding
166
153
22
20.3
OtherPrecancerAdnexal massProlapse
77 6.1
Longinotti MK et.al. Obstet Gynecol 2008;112:1214-20
23
©2016 MFMER | slide-31
Case Presentation
• 31yo G2P2 (LTCS, BTL) presented with heavy menstrual bleeding, “significant” dysmenorrhea that required Ibuprofen every 6 hours for 4 days, monthly. Despite counseling, she requested endometrial ablation stating her neighbor had one and loved it.
©2016 MFMER | slide-32
Case Presentation
• Pelvic examination was normal, as was pelvic ultrasound
• RF ablation; uterine sound 9cm, global ablation documented
©2016 MFMER | slide-33
Case Presentation
• 3 years post ablation, presented with worsening cyclic pelvic pain, amenorrhea. Managed with NSAID
• 6 months later, no improvement, pain 8/10, now constant
• Pelvic US ordered
©2016 MFMER | slide-34
©2016 MFMER | slide-35
Post Ablation Synechiae
• Cornual Hematometra
• Central Hematometra
• Adenomyosis
©2016 MFMER | slide-36
Post-Ablation-Tubal Sterilization Syndrome
DUANE e. Townsend, MD VANCE McCAUSLAND, ARTHUR McCAUSLAND, GARY FIELDS, MD AND KEVIN KAUFFMAN, RN
Objective: To determine the cause of unilateral or bilateral pelvic pain associated with vaginal spotting in women who had previously undergone tubal ligation followed by rollerball endometrial ablation.
Methods: Women who had undergone previous tubal sterilization followed by rollerball endometrial ablation were evaluated laparoscopically and hysteroscopically when they presented with a symptom complex of intermittent vaginal bleeding associated with severe cramping pain in the lower abdomen.
Results: During a 1.5-year observation period, six women with the symptom complex had laparoscopy and hysteroscopy. In all cases, marked endometrial scarring was noted. In every case, the proximal portions of either one or both fallopian tubes were swollen, and two cases had the appearance of an early ectopic pregnancy. In the remaining cases, the fallopian tubes were rubbery and swollen to a much as twice normal size. Symptoms in five of six patients subsided after laparoscopic removal of the oviduct.
Conclusion: It appears that women who have had a tubal sterilization followed by endometrial ablation are at risk of developing an ectopic-like symptom complex. Salpingectomy appears to be effective in relieving symptoms. Whether this represents a new syndrome or just an unusual association between tubal sterilization and endometrial ablation remains to be seen.
Obstet Gynecol 1993;82:422-4
24
©2016 MFMER | slide-37 ©2016 MFMER | slide-38
©2016 MFMER | slide-39 ©2016 MFMER | slide-40
©2016 MFMER | slide-41
McCausland AM, McCausland VM. Am J Obstet Gynecol, 1999.
©2016 MFMER | slide-42
Papadakis EP et al. JMIG 2015
25
©2016 MFMER | slide-43
Post Endometrial Ablation Pain• Other causes
–Leiomyoma–Adenomyosis–Pelvic floor myalgia–Endometrial cancer
©2016 MFMER | slide-44
Pathologic Characteristics of Hysterectomy Specimens in Women Undergoing Hysterectomy after Global Endometrial Ablation
Table 3Pathologic characteristics of hysterectomy specimens according to indication for surgery a
Indication for surgery ____________________________________
Characteristic Bleeding (n = 34) Pain (n – 19) p Value
Uterine weight 145 (65.6) 173.2 (139.6)Endometrial finding
Proliferative 17 (50) 7 (37)Secretory 11 (32) 3 (16)Atrophic 4 (12) 4 (21)Ablative necrosis 2 (6) 4 (21)
Adenomyosis 10 (29) 6 (32) .87Endometriosis 6 (18) 2 (11) .49Endosalpingiosis 4 (12) 0 .12Hematometra 1 (3) 5 (26) .03Leiomyoma 18 (53) 10 (53) .98
Submucosal 0 0Intramural 11 (61) 6 (60)Subserosal 2 (11) 1 (10)Intramural and submucosal 3(17) 1 (10)Intramural and subserosal 1 (6) 1 (10)Submucosal, intramural and 1 (6) 1 (10)
subserosalA Values are given as mean (SD) or No. (%).
Carey E et al J Minim Invasive Gynecol. 2011;18:96-99
©2016 MFMER | slide-45
Pathologic Findings of Hysterectomy Specimens After Endometrial Ablation
N (728) %
Leiomyoma
Adenomyosis
Leiomyoma + Adenomyosis
Cancer/Precancer
243
172
163
12
33.4
23.6
22.4
1.6
Longinotti MK et.al. Obstet Gynecol 2008;112:1214-20©2016 MFMER | slide-46
Treatment Options
• Symptom relief
• Endometrial suppression
• Endometrial recanalization• “reoperative hysteroscopic surgery”*
• Bilateral salpingectomy
• Hysterectomy
*Wortman M et al. J Am Assoc Gyn Laparoc 2001.
©2016 MFMER | slide-47
Case Presentation
• 47yo G2P2 with a history of hypertension and obesity (BMI 36kg/m2) presented with vaginal spotting of 6 months duration. She RF ablation 5 years ago, with complete cessation of menses. Endometrial biopsy was benign at the time of ablation.
©2016 MFMER | slide-48
What to do Next?
1. Reassure, bleeding sometimes resumes after EA
2. Draw FSH to ascertain postmenopausal status
3. Order pelvic US
4. Attempt office biopsy with hysteroscopy
5. Schedule for a hysterectomy
26
©2016 MFMER | slide-49
Case Presentation
• ORIGINAL REPORT -08-Dec-2009 18:47:00
• Slightly heterogeneous echotexture of the myometrium which may be due to small fibroids. Endometrial stripe measures 3mm. Nabothian gland cyst. 1.8 x 2.0 x 2.2cm simple cyst in the right ovary. Left ovary looks normal with some very small follicles.
©2016 MFMER | slide-50
What to do Next?
1. Reassure, US showed normal ES 3mm
2. Attempt office biopsy with hysteroscopy
3. Schedule for a hysterectomy
©2016 MFMER | slide-51
Office Hysteroscopy and Biopsy
The patient was placed in the dorsolithotomy position. The cervix was
prepped with Betadine. A 3-mm flexible hysteroscope was introduced
through the cervical os into the endometrial cavity. The endometrial
cavity was distended with normal saline. The endocervix was inspected and
normal appearing. At the point where one would expect the lower uterine
segment, there was some contraction of the cavity. We were able to gently
probe this area with the hysteroscope, and it did open up some into a
small cavity. There was a copious amount of tissue within this cavity.
We were only able to advance the hysteroscope to approximately 5 cm. The
hysteroscope was withdrawn. The endometrial biopsy catheter was inserted
to 4.5 cm. Endometrial biopsy was performed. A large amount of tissue
was obtained. Given this, this was submitted for frozen section. Frozen
section returned demonstrating at a minimal atypical complex hyperplasia.
They feel there was likely a grade 1 endometrial adenocarcinoma present
but are going hold on until the permanent sections before making this
diagnosis.
©2016 MFMER | slide-52
Case Presentation
©2016 MFMER | slide-53
Vaginal Bleeding After Endometrial Ablation
• Avoid ablating patients at high risk for endometrial cancer
• Intramural leiomyoma
• Investigate any interval bleeding or change in pattern
©2016 MFMER | slide-54
Vaginal Bleeding After Endometrial Ablation
• Office Hysteroscopy
• Endometrial Biopsy
• Sonohysterogram• Ultrasound indeterminate*
• Must evaluate endometrial cavity
• Assess the adequacy of evaluation
• Low threshold for hysterectomy
*AlHilli MM et al. Ultrasound Quarterly 2012
27
©2016 MFMER | slide-55
Post-Ablation Endometrial Cancer
• Retrospective Cancer Registry Cohort Study
• 509 post ablation patients
• 2 cases of EC vs. 1.66 expected
Neuwirth RS, Loffer FD, Trenhaile T, Levin B. J Am Assoc Gynecol Laparosc. 2004 Nov;11(4):492-4.
©2016 MFMER | slide-56
Endometrial Cancer After Endometrial Ablation; A Systematic Review
N (17) %
High risk for EC 14 82.4
Bleeding as PC
Stage 1 @ Diagnosis
13
13
76.5
76.5
Endometrial BxNot performedBx not possibleAbnormal pap
11321
64.7
Al Hilli, M et al. J Minim Invasive Surg. 2011
©2016 MFMER | slide-57
Pregnancy Following Endometrial Ablation
• 70 pregnancies• 31 Viable
• Perinatal mortality 12.9%
• Preterm delivery 42%
• Placenta accreta 26%
Hare AA, Olah KS. J Obstet Gynaecol. 2005 Feb;25(2):108-14
©2016 MFMER | slide-58
Pregnancy After Endometrial Ablation
Gervaise et al Fertil Steril 2005;84:1746-7
Contraceptive information after endometrial ablationWe reviewed the records of the patients considered “fertile” in a consecutive series of 206 patients treated by intrauterine balloon ablation for dysfunctional uterine bleeding, and three pregnancies were observed among 58 patients (5.2%), with two spontaneous abortions and a placenta accreta at 26 weeks. These findings lead us to conclude that balloon ablation is not contraceptive and that use of a supplemental contraceptive method should be planned. Hysteroscopic endometrial ablation and nonhysteroscopicendometrial thermal ablation are the first-line conservative surgical treatments for dysfunctional uterine bleeding. Their use reduces the rate of hysterectomies for this common problem. Because of their effects on the endometrium and uterine cavity (synechiae), these treatments are indicated only for patients who do not wish to remain fertile. (Fertil Steril® 2005;84:1746-7. ©2005 by American Society for Reproductive Medicine)
©2016 MFMER | slide-59
Pregnancy After Endometrial Ablation
• Poor obstetric outcomes–Spontaneous miscarriage–Ectopic pregnancy–Antepartum hemorrhage–IUGR–PPROM–Placenta accreta–Fetal anomalies (Synechia)
©2016 MFMER | slide-60
Lo JSY.,Pickersgill A. J Minim Invasive Surg 2006;13:88-91
28
©2016 MFMER | slide-61
Pregnancy After Endometrial Ablation
• Counsel for additional contraception
• Permanent sterilization
• Avoid concomitant hysteroscopic sterilization (FDA, ACOG)
©2016 MFMER | slide-62
ReferencesNICE clinical guideline 44, January 2007
Munro MG. Clin Obstet Gynecol 49;4:736-766
Lethaby A et al. Cochrane Database Syst Rev 2013
Longinotti MK et.al. Obstet Gynecol 2008;112:1214-20
Parkin DE Lancet1998;351:1147-48
Mall A et al. Obstet Gynecol 2002;100:659-64
El Nashar et al Obstet Gynecol 2009;110:97-106
Townsend et al Obstet Gynecol 1993;82:422-4
McCausland AM, McCausland VM. Am J Obstet Gynecol, 1999.
Papadakis et al JMIG, 2015
Carey E et al J Minim Invasive Gynecol. 2011;18:96-99
Neuwirth RS, Loffer FD, Trenhaile T, Levin B. J Am Assoc Gynecol Laparosc. 2004 Nov;11(4):492-4.
Al Hilli, M et al. J Minim Invasive Surg. 2011
Gervaise et al Fertil Steril 2005;84:1746-7
Roy SM et al, Drug Safety 2004
Lo JSY.,Pickersgill A. J Minim Invasive Surg 2006;13:88-91
Bongars MY et al. Obstet Gynecol 2002.
Gervaise A et al. Human Reprod. 1999.
Shelly-Jones D et al. J Gynecol Surg. 1994
Molnar BG et al. Acta Obstet Gynecol Scand. 1997.
Phillips G et al. Br J Obstet Gynaecol. 1998.
Dutton C et al. Obstet Gynecol. 2001.
Shaamash AH, Sayed EH. J Obstet Gynaecol Res. 2004.
Hart R, Magos A. Lancet. 1998.
Al Hilli MM et al. Ultrasound Quarterly 2012.
Wortman M et al. J Am Assoc Gyn Laparoc 2001
Hare AA, Olah KS. J Obstet Gynaecol. 2005 Feb;25(2):108-14
Dickersin et al, Obstet Gynecol. 2007
Aberdeen Endometrial Ablation Trials Group, Br J Obstet Gynaecol1999
Woolcock JG et al. Fert and Sterility. 2008
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1
www.ottawahospital.on.ca | Affiliated with • Affilié à
MANAGING LARGE INTRACAVITARY FIBROIDS
AAGL 45TH GLOBAL CONGRESSORLANDO, FLORIDA
SUKHBIR S. SINGH MD, FRCSC, FACOGASSOCIATE PROFESSORVICE-CHAIR GYNECOLOGYDIRECTOR, FELLOWSHIP IN MIG
NOVEMBER 2016
Affiliated with • Affilié à
▶ Speakers Bureau: AbbVie, Allergan, Bayer Healthcare Corp.
SPEAKER DISCLOSURES
OBJECTIVES
At the conclusion of this activity, participants will be better able to:
▶ Identify the “Large” Intracavitary Fibroid
▶ Apply an approach to minimizing risk and maximizing benefit at Hysteroscopic Myomectomy
▶ Recognize red flags for surgical risks and how to prepare for them
** SYLLABUS Materials are provided for reference and may not be covered during the presentation*** Affiliated with • Affilié à
▶ How to Optimally Prepare for HysteroscopicMyomectomy?
▶ Are there intraoperative tips/suggestions for increasing success while reducing morbidity?
▶ Do I need to consider postoperative follow up?
3 QUESTIONS
Affiliated with • Affilié à
WHAT IS “LARGE”?
31 Oz
IT’S WHAT’S INSIDE THAT COUNTS…
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2
WHAT IS LARGE?
▶ Type I fibroids > 5-6cm
▶ Type II Fibroids > 4-5cm
▶ Alternative Definitions?
Di Spiezio et al 2008
What is the Calculation for the Volume of an Elipsoid?
Volume = 4/3πabc
Fibroid Volume
3 cm
5 cm
10 cm
DiameterVolume(4πr3/3)
14.1 cm3
65.5 cm3
523.6 cm3
APPROACHES TO “LARGE” UTERINE FIBROIDS
Locate Fibroid(s)
Hysteroscopy Laparoscopy Open
US, SIS, MRI
Normal Uterine Size Does Not Preclude an Intrauterine Lesion: Cavity Assessment
Hysterectomy for Failed Medical Management of
Bleeding
Intrauterine Type 0 Fibroid FoundAfter Surgery
R.L.Reid
Leiomyoma Subclassification System
S M‐ Submucosal 0 Pedunculated Intracavitary
1 <50% Intramural
2 ≥ 50% Intramural
O ‐ Other 3 Contacts endometrium; 100% Intramural
4 Intramural
5 Subserosal ≥50% Intramural
6 Subserosal < 50% Intramural
7 Subserosal Pedunculated
8 Other (specify eg, cervical, parasitic)
00
22
33
11
44
5566
77
00
2-52-5
0
2
3
1
4
56
7
0
2-5
Polyp
Adenomyosis
Leiomyoma
Malignancy & Hyperplasia
Coagulopathy
Ovulatory Dysfunction
Endometrial
Iatrogenic
Not Yet Classified
Submucosal
Other
Munro MG, et al. Int J Gynaecol Obstet 2011;113:3‐13
PALM‐COEIN Classification ofAUB
AUB = Acute uterine bleeding
PALM = Visually objective structural criteria
COEI = unrelated to structural anomalies N = entities not yet classified
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Hysteroscopic Fibroid Classification ESH Classification
Wamsteker K, et al. Obstet Gynecol 1993;82:736‐40ESH = European Society of Hysteroscopy
Serosa to Fibroid Distance!
SCORING TO PREDICT SUCCESS/RISK OF HYSTEROSCOPIC MYOMECTOMY TECHNIQUE DECISION
Hysteroscopy
Hysteroscopy Alone + Laparoscopy + Ultrasound
Optimize
Factors Affecting Myomectomy
Surgeon ExperienceSurgeon
ExperiencePathologyPathology
Equipment AvailabilityEquipment Availability
Patient FactorsPatient Factors
Patient PreferencePatient
Preference
Medically Modifiable
Vilos G, et al. J Obstet Gynaecol Can 2015;37:157–81
Medical Preoperative Optimization
Heavy Menstrual Bleeding/Anemia
• Amenorrhea
• Reduced need for transfusion
Fibroid Shrinkage
• Improve access, may allow minimally invasive surgery
• Reduce blood flow, less intraoperative blood loss
Pelvic Pain/Pressure Symptoms
• Improve QoL
• Treatment while waiting for surgery
Vilos G, et al. J Obstet Gynaecol Can 2015;37:157–81
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4
Fibroid Volume Reduction
3 cm
5 cm
10 cm
DiameterVolume(4πr3/3)
Volume reduction
30% 40% 50% 70%
14.1 cm3
9.9 cm3
d = 2.7 cm(‐11.3%)
8.5 cm3
d = 2.5 cm(‐15.7%)
7.1 cm3
d = 2.4 cm(‐21.7%)
4.23 cm3
d = 2.0 cm(‐33.1%)
65.5 cm3
45.8 cm3
d = 4.4 cm(‐11.3%)
39.3 cm3
d = 4.2 cm(‐15.7%)
32.7 cm3
d = 4.0 cm(‐21.7%)
19.7 cm3
d = 3.3 cm(‐33.1%)
523.6 cm3
366.5 cm3
d = 8.9 cm(‐11.3%)
314.2 cm3
d = 8.4 cm(‐15.7%)
261.8 cm3
d = 7.9 cm(‐21.7%)
157.1cm3
d = 6.7 cm(‐33.1%)
Fibroid Volume Reduction
3 cm
5 cm
10 cm
DiameterVolume(4πr3/3)
Volume reduction
30% 40% 50% 70%
14.1 cm3
9.9 cm3
d = 2.7 cm(‐11.3%)
8.5 cm3
d = 2.5 cm(‐15.7%)
7.1 cm3
d = 2.4 cm(‐21.7%)
4.23 cm3
d = 2.0 cm(‐33.1%)
65.5 cm345.8 cm3
d = 4.4 cm(‐11.3%)
39.3 cm3
d = 4.2 cm(‐15.7%)
32.7 cm3
d = 4.0 cm(‐21.7%)
19.7 cm3
d = 3.3 cm(‐33.1%)
523.6 cm3
366.5 cm3
d = 8.9 cm(‐11.3%)
314.2 cm3
d = 8.4 cm(‐15.7%)
261.8 cm3
d = 7.9 cm(‐21.7%)
157.1cm3
d = 6.7 cm(‐33.1%)
MEDICAL OPTIMIZATION OPTIONS
VolReduction
VolReduction
GnRHaGnRHa +/- Add back
+/- Add back
UPAUPA 1 or >1 courses1 or >1 courses
Other (Danazol)
Other (Danazol)
‐45.5‐50.0
‐44.8
‐55.7
‐43.2
‐16.5
‐70
‐60
‐50
‐40
‐30
‐20
‐10
0
UPA vs GnRHagonist: Fibroid Volume Reduction
Median change from baseline in fibroid volume* in PEARL II
*Volume of 3 largest fibroids
Week 13 Week 26 Week 38
Med
ian change in
fibroid volume (%
)
GnRHa (n = 44)
UPA (n = 45)
PEARL II
Donnez et al. N Engl J Med. 2012;366:421–32
Week 13 Week 26 Week 38
1. Donnez et al. N Engl J Med. 2012;366:409–20; 2. Donnez et al. N Engl J Med. 2012;366:421–32; 3. Donnez et al. Fertil Steril. 2014;101:1565–73.e1‐18; 4. Donnez et al. Fertil Steril. 2016;105:165–73.e4
‐75
‐50
‐25
0
UPA vs GnRHagonist: Fibroid Volume Reduction
Median change from baseline in fibroid volume* after each treatment course
*PEARL I: total fibroid volume; PEARL II, III, IV: combined volume of 3 largest fibroids; †10‐mg UPA dose not licensed
Treatment course 2
Treatment course 3
Treatment course 4
3‐monthfollow‐up
Treatment course 1
n 130 119 106 96 97207 189 173 160 158
Med
ian change in
fibroid volume (%
)
UPAPEARL IV
UPA†PEARL III
GnRHa (n = 93)
UPA (n = 93)
PEARL II
Placebo (n = 48)
UPA (n = 95)
PEARL I
ENDOMETRIUM PREPARATION
Endometrium Preparation
Endometrium Preparation
GnRHaGnRHa
ProgestinsProgestins
Other (Danazol)
Other (Danazol)
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Hysteroscopic Myomectomy
What’s your practice?
Emerging data on pre‐surgical use of ulipristal acetate
Design: 3 months of UPA vs. no medical treatment prior to hysteroscopic myomectomy (retrospective analysis)
UPA, ulipristal acetate; tx, treatment; SD, standard deviation
Fererro et al. The Journal of Minimally Invasive Gynecology (2016).
Outcome No pre‐tx(n=25)
UPA pre‐tx(n=25)
P‐value
Complete resection 68% 92% 0.034
Operative time (mean ± SD) 37.4 ± 17.6 min 28.6 ± 13.0 min 0.048
Fluid infused (mean ± SD) 14300 ± 5311ml 15156 ± 4103ml NS
Fluid absorbed (mean ± SD) 637 ± 481ml 498 ± 329ml NS
Patient satisfaction 3 months post‐op
50% 81% 0.041
Emerging data on pre‐surgical use of ulipristal acetate
Design: 3 months of UPA vs. GnRH analog prior to hysteroscopicmyomectomy of pts with submucous fibroids >2.5 cm diameter
“The subjective opinion of the three surgeons was that feasibility was similar in both groups.”
“No serious complications were reported in either group. “
UPA, ulipristal acetate; tx, treatment; SD, standard deviation
Sancho et al. EJOGRB 2016
Outcome GnRHa pre‐tx(n=24)
UPA pre‐tx(n=26)
P‐value
Complete resection 98% 93% NS
Operative time 37 min 38 min NS
Fluid deficit 350ml 200ml NS
Systematic ReviewGnRH agonist versus nothing…
• “inadequate evidence to support routine use of preoperative GnRH analogues before Hysteroscopic resection of Submucosal fibroids”
• Only 2 trials with 86 women!
Complete Resection and Time
Kamath et al. 2014
Fluid absorption
Kamath et al. 2014
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Hysteroscopic MyomectomyOptimization
Surgical optimization day of procedure1
Reduce fluid absorption
Thin the endometrium and improve visualization
Reduce bleeding
Submucosal fibroids > 3.0 cm
Consider 3 months GnRH agonist2 to maximize volume reduction (reduction in volume 30% to 60%)3 and thin endometrial lining
< 3.0 cm - 1 month (4 weeks preoperation)
1. Donnez J, et al. Fertil Steril 2001;75:620‐22. Vilos GA, et al. J Obstet Gynaecol Can 2015;37:157‐81
3. Stewart EA, et al. Lancet 2001;357:293‐8
GnRH Agonists and/or SPRMs for Fibroids?
Benefit of reduced fluid absorption at hysteroscopy and visualization1
Suggestion (expert consensus opinion)
Start UPA for immediate symptom relief and anemia correction
Prior to hysteroscopy utilize GnRH agonists for optimal intraoperative harm reduction
2014 Systematic Review: insufficient evidence to recommend GnRHa for routine use
1. Donnez J, et al. Fertil Steril 2001;75:620‐22. KamathMS et al. Eur J obstet gynecol reprod biol. 2014 Jun;177:11‐8.
Photo courtesy of Dr. Philippe Laberge
PATIENT BLOOD MANAGEMENT
Amenorrhea• Continuous
OCP• Progestins• GnRHa• UPA
Amenorrhea• Continuous
OCP• Progestins• GnRHa• UPA
Iron replacement• Oral• IV
• CHECK FERRITIN!
Iron replacement• Oral• IV
• CHECK FERRITIN!
Bleeding Disorders• Evaluate • Treat,
Prepare
Bleeding Disorders• Evaluate • Treat,
Prepare
UPA: Time to Amenorrhea
Kaplan‐Meier projection of time to amenorrhea
*Median time for treatment courses 1, 2, and 4. Median time to amenorrhea for treatment course 3 was 6 days.
Days
PEARL IVTreatment course 1Treatment course 2
Treatment course 3Treatment course 4
Patients (%)
0
20
40
60
80
100
0 10 20 30 40 50 60 70 80 90 100
Donnez et al. Fertil Steril. 2016;105:165–73.e4
Median*
5 days
Preoperative Anemia Contributes to Increased Mortality and Morbidity in Women Undergoing Gynecological Surgery
0.1
2.5
0.1
0.5
0.0 0.1
1.3
0.60.4
0.20.5
5.1
0.2
1.5
0.20.5
2.1
1.7
1.0
0.5
0.0
1.0
2.0
3.0
4.0
5.0
6.0
Mortality Composite morbidity
Cardiac Respiratory CNS Renal Wound Sepsis Venous thrombosis
Major bleeding
No preoperative anemia (n = 9,765)
Preoperative anemia (n = 3,071)
Inciden
ce (%)
p < 0.001
p < 0.001
p = 0.144
p < 0.001
p = 0.001p < 0.001
p = 0.001
p < 0.001
p < 0.001
p = 0.008
Richards T, et al. PLoS One 2015;10:e0130861.
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7
SOGC Guidelines: Correction of Anemia Prior to Surgery
Anemia should be corrected prior to proceeding with elective surgery. (II-2A). Selective progesterone receptor
modulators and gonadotropin-releasing hormone analogues are effective at correcting anemia and should
be considered preoperatively in anemic patients. (I-A)
Vilos G, et al. J Obstet Gynaecol Can 2015;37:157–81 Affiliated with • Affilié à
Patient Blood ManagementPatient Blood Management
Fibroid Volume ReductionFibroid Volume Reduction
Symptom controlSymptom control
BEFORE THE OR
INTRAOPERATIVE RISK REDUCTION - BLEEDING
TranexamicAcid IV
TranexamicAcid IV PGE1 analogPGE1 analog
Vasopressin*Vasopressin* Other ideas?Other ideas?
*Wong AS et al. Obstet Gynecol. 2014 Nov;124(5):897-903
INTRAOPERATIVE RISK REDUCTION
ULTRASOUND*ULTRASOUND* LAPAROSCOPYLAPAROSCOPY
FLUID BALANCE!
FLUID BALANCE!
KNOW WHEN TO STOP
KNOW WHEN TO STOP
• Korkmazer E, Tekin B, Solak N. Eur J Obstet Gynecol Reprod Biol 2016 Aug; 203:108‐11.• Wortman M. Surg Technol Int. 2013 Sept:23:181‐9.
Hysteroscopic Myomectomy
Resectoscope
TECHNIQUES
▶ Complete fibroid excision of SUBMUCOSAL fibroids
• Avoid “just the surface”
▶ Single versus multiple steps?
• Timing
▶ Tools
• Resectoscope versus hysteroscopic morcellators?
• Bipolar versus monpolar
▶ Cold Loop (Mazzon)
▶ OPPIuM Technique (Cicinelli E et al)
▶ Multiple Slicing 1 Step (Zayed et al)Mazzon et al Int J Surg 2015.
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8
Slicing technique to treat totally intracavitary and partially intramural submucous fibroid in office setting with 5Fr bipolar electrodes ‘a’ refers to the first half-sphere and ‘b’ to the
second.
Attilio Di Spiezio Sardo et al. Hum. Reprod. Update 2008;14:101-119
© The Author 2007. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Excision of intramural component by slicing: the electrosurgery is used to slice the neoformation, included into the thickness of the uterine wall (Image kindly donated by I.
Ardovino).
Attilio Di Spiezio Sardo et al. Hum. Reprod. Update 2008;14:101-119
© The Author 2007. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
(A) The rectangular loop is inserted into the plane between the fibroid and myometrium to progressively dissect it from the myometrial wall (B) Connective bridges which join the
fibroid and the adjacent myometrium are hooked by the single tooth cold loop (Images by I. Mazzon).
Attilio Di Spiezio Sardo et al. Hum. Reprod. Update 2008;14:101-119
© The Author 2007. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
COMPLICATIONS
▶ Uterine Perforation
▶ Intravasation and electrolyte imbalance
▶ Intrauterine adhesions
▶ Risk of Uterine Rupture (?)
▶ VIDEO
VIDEOS
Affiliated with • Affilié à
POSTOPERATIVE CHECK ALWAYS!
37
10/13/2016
9
Affiliated with • Affilié à
OBJECTIVES
At the conclusion of this activity, participants will be better able to:
▶ Identify the “Large” Intracavitary Fibroid
▶ Apply an approach to minimizing risk and maximizing benefit at Hysteroscopic Myomectomy
▶ Recognize red flags for surgical risks and how to prepare for them
REFERENCES• Cicinelli E et al. Minerva Ginecol. 2016 Jun; 68(3):328-33.
• Di Spiezio Sardo A et al. Hysteroscopic myomecotmy: a comprehensive review of surgical techniques. Hum Reprod Update. 2008 Mar-Apr;14(2):101-9.
• Donnez et al. N Engl J Med. 2012;366:409–20; 2. Donnez et al. N Engl J Med. 2012;366:421–32;
• Donnez et al. Fertil Steril. 2014;101:1565–73.e1-18; 4. Donnez et al. Fertil Steril. 2016;105:165–73.e4
• KamathMS et al. Eur J obstet gynecol reprod biol. 2014 Jun;177:11‐8.
• Korkmazer E, Tekin B, Solak N. Eur J Obstet Gynecol Reprod Biol 2016 Aug; 203:108‐11.
• Mazzon I. Int J Surg 2015 Oct;22:10‐4.
• Munro MG, et al. Int J Gynaecol Obstet 2011;113:3‐13
• Richards T, et al. PLoSOne 2015;10:e0130861.
• Stewart EA, et al. Lancet 2001;357:293‐8
• VilosG, et al. J ObstetGynaecol Can 2015;37:157–81
• Wamsteker K, et al. Obstet Gynecol 1993;82:736‐40
• *Wong AS et al. Obstet Gynecol. 2014 Nov;124(5):897-903
• Wortman M. Surg Technol Int. 2013 Sept:23:181‐9.
• Zayed M et al. JMIG 2015; 22(7):1196‐202.
www.ottawahospital.on.ca | Affiliated with • Affilié à
MANAGING LARGE INTRACAVITARY FIBROIDS
AAGL 45TH GLOBAL CONGRESSORLANDO, FLORIDA
SUKHBIR S. SINGH MD, FRCSC, FACOGASSOCIATE PROFESSORVICE-CHAIR GYNECOLOGYDIRECTOR, FELLOWSHIP IN MIG
NOVEMBER 2016
38
Aarathi Cholkeri-Singh, M.D., FACOG
Clinical Assistant Professor of Obstetrics and Gynecology at UIC
Associate Director of Minimally Invasive Gynecologic Surgery
Director of Gynecologic Surgical Education at ALGH
Disclosure
Consultant: Smith & Nephew Endoscopy
Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic
Other: Advisory Board: Bayer Healthcare Corp., Hologic
Objective
Discuss complications of hysteroscopy.
Complications of Hysteroscopy -Predisposing factors
Contraindications ignored
Improper surgical technique
Improper use of equipment
Incorrectly chosen patient
Complications of Hysteroscopy - Early
Cervical trauma
Uterine perforation
Hemorrhage
Distension media complication
Air or gas embolism
Complications of Hysteroscopy - Late
Adhesion formation
Infection
Hematometra
Nerve injuries
39
Cervical Laceration & Uterine Perforation - Prevention
EUA with an empty bladder
Adequate cervical dilation
Gentle insertion of instruments
Introduce under direct visualization or palpation
Advance only during unobstructed view
Cervical Laceration & Uterine Perforation & - Prevention
Misoprostol – 200-400mcg buccal or vaginally prior to procedure
Dilute Vasopressin –
20 units in 100ml saline
inject 20mL total
Cervical Laceration & Uterine Perforation - Prevention
Misoprostol Greater initial cervical dilation
Dilation required less often
Less time required for dilation
Less cervical laceration
Abd cramps, diarrhea, bleeding, fever .
Batukan, Cem, Ozgun, M T, Ozcelik, B, et al. (2008). Cervical ripening before operative hysteroscopy in premenopausal women: a randomized, double-blind, placebo-controlled comparison of vaginal and oral misoprostol. Fertility and sterility, 89(4), 966-73.
Lee, Y, Kim, T, Kang, H, et al. (2010). The use of misoprostol before hysteroscopic surgery in non-pregnant premenopausal women: a randomized comparison of sublingual, oral and vaginal administrations. Human Reproduction, 25(8), 1942-8.
Cervical Laceration & Uterine Perforation - Prevention
Vasopressin RCT – double blinded
Dilute vasopressin vs placebo into the cervical stroma at 4 and 8 o’clock
Peak linear force was measured
Mean total peak was 1 vs 2 lbs, P<0.001
“Definitive explanation of the mechanism awaits further investigation”
Phillips, D R, Nathanson, H G, Milim, S J, et al. (1997). The effect of dilute vasopressin solution on the force needed for cervical dilatation: a randomized controlled trial. Obstetrics and gynecology, 89(4), 507-11.
Uterine Perforation
Most common complication (~1%)
Occurs most often during cervical dilation
Highest risk patients – Ashermans and cervical stenosis
Munro, M G. (2010). Complications of hysteroscopic and uterine resectoscopic surgery. Obstetrics and gynecology clinics of North America, 37(3), 399-425.
Uterine Perforation -Risk Factors
Cervical stenosis
Acutely flexed uterus
Postmenopausal atrophy
Lower segment myoma
Intrauterine adhesions
Uterine anomaly
40
UTERINE PERFORATION
=TERMINATION!
Uterine Perforation -Management
Fundal perforation without RF energy Discontinue case and observe
Fundal with RF energy Laparoscope to inspect for visceral injury
Lateral perforation Laparoscope to assess for broad ligament
hematoma
Anterior perforation Cystoscopy
Complications of Hysteroscopy - Early
Cervical trauma
Uterine perforation
Hemorrhage
Distension media complication
Air or gas embolism
Hemorrhage
Foley catheter 25cc saline-filled balloon
Leave in cavity for 4-6 hours, deflate 50%, observe,
and then remove if no bleeding
○ If bleeds on deflation, re-inflate and leave in cavity for 24 hours with appropriate antibiotic coverage
○ Consider repeat hysteroscopic examination with directed coagulation if bleeding persists
Hemorrhage
Foley catheter Intrauterine vasopressin soaked in gauze Laparoscopic/Laparotomic evaluation with
repair of perforation Uterine artery ligation Embolization Hysterectomy
Complications of Hysteroscopy - Early
Cervical trauma
Uterine perforation
Hemorrhage
Distension media complication
Air or gas embolism
41
Distension Media Complications - Intravasation
Factors Intrauterine pressure
Mean arterial pressure
Depth of myometrial invasion
Partial perforation
Length of surgery
Distension Media Complications - Intravasation
Intrauterine pressure Distension – 60-75 mmHg
Venous sinuses Submucous myomata
Deep myometrial resection
Minimal protective effects of MAP
Goal to maximize vision & minimize intravasation
Distension Media Complications - Intravasation
Vasopressin
RCT – double blinded
Decreased blood loss
Decreased intravasation (448 vs 819 mL)
Decreased OR time
Avoiding cervical trauma may decrease intravasation
Phillips, D R, Nathanson, H G, Milim, S J, et al. (1996). The effect of dilute vasopressin solution on blood loss
during operative hysteroscopy: a randomized controlled trial. Obstetrics and gynecology, 88(5), 761-6.
Uterine Distension MediaNonviscous solutions
Electrolyte-containing media Saline, LR - Isotonic
Electrolyte-free media 1.5% glycine - Hypotonic
3% sorbitol - Hypotonic
Mannitol - Isotonic
Distension Media Complications
Electrolyte-containing media Pulmonary edema and CHF
Electrolyte-free media, non-conductive Free water intoxication
Hyponatremia
Cerebral edema
Death
Fluid Deficit Monitoring
Automated fluid management highly desirable Removes the human factor
Allows for early warning of excess deficit
Provides the relative rate of intravasation
If mechanical monitoring is unavailable, a dedicated person should tally deficit
Both anesthesiologist and surgeon should be aware of deficit on a frequent basis
42
Distension Media Complications - Prevention
Electrolyte-free media parameters 750 mL deficit (1000 mL with NS)
○ Signals impending need to complete the procedure
1000 mL deficit
○ check lytes in PACU, consider 10mg Lasix
1500 mL deficit (2500 mL with NS)
○ stop surgery
Communicate deficit regularly
Distension Media Complications - Prevention
Control of Intrauterine pressure
Avoid excessive operating time
Anesthesia to closely monitor / limit IVFs
Chill distension media
GnRH agonist?
Distension Media Complications - Prevention
2010, RCT – non-blinded
Directly to surgery or 2 mo pretx with GnRHa
Shorter OR time (15 vs 21 min)
Reduced fluid absorption (378 vs 566 mL)
Surgeon satisfaction was significantly better in pretreated cases (non-blinded)
Muzii, L, Boni, T, Bellati, F, et al. (2010). GnRH analogue treatment before hysteroscopic resection of submucous myomas: a prospective, randomized, multicenter study. Fertility and sterility, 94(4), 1496-9.
Complications of Hysteroscopy - Early
Cervical trauma
Uterine perforation
Hemorrgae
Distension media complication
Air or gas embolism
Air / Gas embolism - Pathophysiology
Enter venous circulation and either equilibrate with pulmonary clearance or exceed pulmonary clearance
Gas diffuses in the alveoli and is exhaled
A large bolus of air can cause an airlock in the right heart, outflow obstruction, and decreased pulmonary venous return with decreased left ventricular preload and cardiac output
43
Air/Gas Embolism -Predisposing Factors
Unpurged fluid in-flow line
Use of rigid bottle for distention medium
Inadequate uterine flushing of bubbles
Piston-like action of repetitive insertions
Excessive intrauterine pressure
Air/Gas Embolism -Predisposing Factors
Size of instruments
Trendelenburg position
Presence of large intramural venous channels (e.g., vascular myoma)
Penetration into the myometrium
Disruption and exposure of vasculature
Excessive operating times
Gas Embolism with Electrosurgery
No clinically significant difference in gas produced by monopolar or bipolar
Composition – soluble: H+, CO, CO2, & O2
Gas diffuses in the alveoli and is exhaled
Munro, M G, Weisberg, M, & Rubinstein, E. (2001). Gas and air embolization during hysteroscopic electrosurgical vaporization: comparison of gas generation using bipolar and monopolar electrodes in an experimental model. The
Journal of the American Association of Gynecologic Laparoscopists, 8(4), 488-94.
Gas Embolism with Electrosurgery
Prospective observational study
Intraop echo performed to detect bubble formation in IVC, hepatic veins, & right heart
All with gas bubble entrainment
One patient had transient drop in CO2
Bloomstone, J, Chow, C, Isselbacher, E, et al. (2002). A pilot study examining the frequency and quantity of gas embolization during operative hysteroscopy using a monopolar resectoscope. The Journal of the American Association
of Gynecologic Laparoscopists, 9(1), 9-14.
Air / Gas Embolism -Prevention
Purge and prevent entry of air
Minimize intrauterine pressure
Keep outflow port continuously open
Avoid Trendelenburg position
Avoid deep myometrial resection
Minimize reinsertion of instruments
Ensure awareness by anesthesiologist
Avoid nitrous oxide anesthesia
Air / Gas Embolism -Detection
Awareness – early detection and intervention are crucial
End title CO2
O2 saturation
Hypotension or dysrhythmia
Heart murmur
Groenman, F A, Peters, L W, Rademaker, B M, et al. (2008). Embolism of air and gas in hysteroscopic procedures: pathophysiology and implication for daily practice. Journal of Minimally Invasive Gynecology, 15(2), 241-7.
44
Air / Gas Embolism -Treatment
Stop case – cessation of further air entry
Cessation of nitrous oxide - prevent bubble expansion
Left lateral decubitus – prevents air lock in the right heart
Evacuate embolized air in through CVP or PA line
Maintenance of cardiac output – raise BP and push air out
Closed chest cardiac message / respiratory care
Complications of Hysteroscopy - Late
Adhesion formation
Infection
Hematometra
Nerve injuries
Postoperative Adhesions
Do not resect two opposing fibroids
Consider postop est/progsupplementation
Consider stent/IUD
Tonguc, E A, Var, T, Yilmaz, N, et al. (2010). Intrauterine device or estrogen treatment after hysteroscopic uterine septum resection. International journal of gynecology and obstetrics, 109(3), 226-9.
Infection
Postoperative endometritis (0.01-1.42%)
Pain, discharge, fever, tenderness, WBCs
ACOG does not recommend routine use of prophylactic antibiotics for hysteroscopicprocedures
Munro, M G. (2010). Complications of hysteroscopic and uterine resectoscopic surgery. Obstetrics and gynecology clinics of North America, 37(3), 399-425.
Hematometra
Due to intrauterine synechiae or cervical stenosis
Cyclic pelvic pain TVUS or MRI diagnosis Treat with cervical dilation or
hysteroscopically, consider ultrasound guidance
Munro, M G. (2010). Complications of hysteroscopic and uterine resectoscopic surgery. Obstetrics and gynecology clinics of North America, 37(3), 399-425.
Nerve injuries
Risk to any patient in lithotomy position
Femoral nerve compression from overflexion of the hip, abduction, and external rotation
Sciatic and peroneal nerves stretch injury as a result of flexion at the hip with the knee straight or extreme external rotation
Peroneal nerve compression at the head of the fibula
Munro, M G. (2010). Complications of hysteroscopic and uterine resectoscopic surgery. Obstetrics and gynecology clinics of North America, 37(3), 399-425.
45
Thanks! References Groenman, F A, Peters, L W, Rademaker, B M, et al. (2008). Embolism of air and gas in
hysteroscopic procedures: pathophysiology and implication for daily practice. Journal of Minimally Invasive Gynecology, 15(2), 241-7. (not available)
Shveiky, D, Rojansky, N, Revel, A, et al. (2007). Complications of hysteroscopic surgery: "Beyond the learning curve". Journal of Minimally Invasive Gynecology, 14(2), 218-22.
Crane, J M, & Healey, S. (2006). Use of misoprostol before hysteroscopy: a systematic review. Journal of obstetrics and gynaecology Canada, 28(5), 373-9.
Phillips, D R, Nathanson, H G, Milim, S J, et al. (1997). The effect of dilute vasopressin solution on the force needed for cervical dilatation: a randomized controlled trial. Obstetrics and gynecology, 89(4), 507-11.
Phillips, D R, Nathanson, H G, Milim, S J, et al. (1996). The effect of dilute vasopressin solution on blood loss during operative hysteroscopy: a randomized controlled trial. Obstetrics and gynecology, 88(5), 761-6.
Pluchino, N, Ninni, F, Angioni, S, et al. (2010). Office vaginoscopic hysteroscopy in infertile women: effects of gynecologist experience, instrument size, and distention medium on patient discomfort. Journal of Minimally Invasive Gynecology, 17(3), 344-50.
Siristatidis, C, & Chrelias, C. (2010). Feasibility of office hysteroscopy through the "see and treat technique" in private practice: a prospective observational study. Archives of gynecology and obstetrics,
Van Kruchten, P M, Vermelis, J M, Herold, I, et al. (2010). Hypotonic and isotonic fluid overload as a complication of hysteroscopic procedures: two case reports. Minerva anestesiologica, 76(5), 373-7.
Leibowitz, D, Benshalom, N, Kaganov, Y, et al. (2010). The incidence and haemodynamic significance of gas emboli during operative hysteroscopy: a prospective echocardiographic study. European journal of echocardiography, 11(5), 429-31.
References Bloomstone, J, Chow, C, Isselbacher, E, et al. (2002). A pilot study examining the
frequency and quantity of gas embolization during operative hysteroscopy using a monopolar resectoscope. The Journal of the American Association of Gynecologic Laparoscopists, 9(1), 9-14.
Groenman, F A, Peters, L W, Rademaker, B M, et al. (2008). Embolism of air and gas in hysteroscopic procedures: pathophysiology and implication for daily practice. Journal of Minimally Invasive Gynecology, 15(2), 241-7.
Munro, M G. (2010). Complications of hysteroscopic and uterine resectoscopic surgery. Obstetrics and gynecology clinics of North America, 37(3), 399-425.
Campo, S, Campo, V, & Gambadauro, P. (2005). Short-term and long-term results of resectoscopic myomectomy with and without pretreatment with GnRH analogs in premenopausal women. Acta obstetricia et gynecologica Scandinavica, 84(8), 756-60.
Parazzini, F, Vercellini, P, De Giorgi, O, et al. (1998). Efficacy of preoperative medical treatment in facilitating hysteroscopic endometrial resection, myomectomy and metroplasty: literature review. Human Reproduction, 13(9), 2592-7.
Muzii, L, Boni, T, Bellati, F, et al. (2010). GnRH analogue treatment before hysteroscopic resection of submucous myomas: a prospective, randomized, multicenter study. Fertility and sterility, 94(4), 1496-9
Munro, M G, Weisberg, M, & Rubinstein, E. (2001). Gas and air embolization during hysteroscopic electrosurgical vaporization: comparison of gas generation using bipolar and monopolar electrodes in an experimental model. The Journal of the American Association of Gynecologic Laparoscopists, 8(4), 488-94.
Tonguc, E A, Var, T, Yilmaz, N, et al. (2010). Intrauterine device or estrogen treatment after hysteroscopic uterine septum resection. International journal of gynecology and obstetrics, 109(3), 226-9.
Question
Which statements are correct? Select all that apply.
1. With a fundal perforation without RF energy, discontinue case and observe
2. With a lateral perforation, discontinue case and observe
3. With a fundal perforation with RF energy, perform laparoscopy to inspect for visceral injury
4. With an anterior perforation, perform cystoscopy
Answers: 1, 3, and 4
46
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%
47