Deep Endometriosis – Diagnosis, Impact of Surgical ...Faculty: Mauricio S. Abrao, Charles Chapron,...

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Deep Endometriosis – Diagnosis, Impact

of Surgical Treatment, Future Perspectives

on Therapies (Didactic)

PROGRAM CHAIR

Charles E. Miller, MD

Mauricio S. Abrao, MD Charles Chapron, MD Jim Tsaltas, MD

Professional Education Information Target Audience Educational activities are developed to meet the needs of surgical gynecologists in practice and in training, as well as, other allied healthcare professionals 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 ...................................................................................................................................................... 3 Current and Future Strategies to Plan the Treatment of Endometriosis M.S. Abrao .................................................................................................................................................... 5 Treatment of the Ovarian Endometrioma J. Tsaltas ..................................................................................................................................................... 15 Strategies in the Dissection of the Frozen Pelvis C.E. Miller ................................................................................................................................................... 19 Current Surgical Techniques to Treat Bowel Endometriosis M.S. Abrao .................................................................................................................................................. 23 Urinary Tract Endometriosis – Therapeutic Strategies C. Chapron .................................................................................................................................................. 27 The AAGL Classification for Endometriosis M.S. Abrao .................................................................................................................................................. 38 Cultural and Linguistics Competency ......................................................................................................... 48

PG 210 Deep Endometriosis – Diagnosis, Impact of Surgical Treatment,

Future Perspectives on Therapies (Didactic)

Charles E. Miller, Chair Faculty: Mauricio S. Abrao, Charles Chapron, Jim Tsaltas

Course Description

Due to the inexperience in appreciating the diagnosis prior to surgery, the complexity of the surgery itself, and the potential need for a multidisciplinary approach, many women with deep endometriosis are not satisfactorily treated at the time of the initial laparoscopic surgery. This course demystifies the surgical approach to deep endometriosis, including proper pre-surgical assessment and the current surgical therapies recommended. This will include strategies for the treatment of the ovarian endometrioma, bowel and urinary tract endometriosis, as well as the frozen pelvis. The new AAGL Classification for Endometriosis will be introduced. Teaching will be enhanced with interactive video session, featuring all faculty members.

Learning Objectives At the conclusion of this course, the participant will be able to: 1) Discuss pre-operative strategies to diagnose deep endometriosis; 2) explain surgical tenants in treating the frozen pelvis; 3) discuss how to treat deep endometriosis of the bowel and urinary tract; 4) explain how the new AAGL Classification of Endometriosis was derived; and 5) demonstrate the proper surgical technique in the treatment of the ovarian endometrioma.

Course Outline 8:00 Welcome, Introductions and Course Overview C.E. Miller C. Miller 8:05 Current and Future Strategies to Plan the Treatment of Endometriosis M.S. Abrao 8:30 Treatment of the Ovarian Endometrioma J. Tsaltas 8:55 Strategies in the Dissection of the Frozen Pelvis C.E. Miller 9:20 Video/Interactive Session, Q&A All Faculty 9:55 Break 10:10 Current Surgical Techniques to Treat Bowel Endometriosis M.S. Abrao 10:35 Urinary Tract Endometriosis – Therapeutic Strategies C. Chapron 11:00 The AAGL Classification for Endometriosis M.S. Abrao

1

11:25 Video/Interactive Session, Q&A All Faculty 12:00 Course Evaluation

2

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 Consultant: Conceptus Incorporated Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Jonathan Solnik Other: Lecturer - Olympus, Lecturer - Karl Storz Endoscopy-America SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical Other: Royalties - CooperSurgical Linda Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm Keith Isaacson Consultant: Karl Storz Endoscopy Rosanne M. Kho Other: Honorarium - Ethicon Endo-Surgery C.Y. Liu* Javier Magrina* Ceana H. Nezhat Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy-America Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology William H. Parker Grants/Research Support: Ethicon Women's Health & Urology Consultant: Ethicon Women's Health & Urology Craig J. Sobolewski Consultant: Covidien, CareFusion, TransEnterix Stock Shareholder: TransEnterix Speaker's Bureau: Covidien, Abbott Laboratories Other: Proctor - Intuitve 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). Charles E. Miller Grants/Research Support: Covidien, Femasys, Olympus, Novartis, Abbott Laboratories Consultant: Covidien, Femasys, Abbott Laboratories, Ferring Pharm Mauricio S. Abrao Other: Visanne Board Member -Bayer Healthcare Corp. Charles Chapron*

3

Jim Tsaltas Grants/Research Support: Covidien, Merck Serono Scott G. Chudnoff* Asterisk (*) denotes no financial relationships to disclose.

4

ENDOMETRIOSIS

Current and Future Strategies to Plan the Treatment

2012

Mauricio S Abrao, MD

Endometriosis Division, Sao Paulo University, Braz

www.endometriosis.com.br

Disclosure

Other: Visanne Board Member - Bayer HealthcareOther: Visanne Board Member Bayer Healthcare Corp.

• Deeply infiltrating endometriosis

•

DEEP ENDOMETRIOSIS

INTRODUCTION

• Depth of lesion >5mm

• Deeply infiltrating endometriosis is related to more intense clinical complaints (pelvic pain)

Cornillie et al. Fertil Steril. 1990; 53(6):978-83Fauconnier & Chapron, Hum Reprod Update. 2005; 11(6):595-606

39 %

Endometriosis: 756 cases

Endometriosis Division, Sao Paulo University, 200

%

%

%

%

%

ENDOMETRIOSIS DIAGNOSIS

LAPAROSCOPYMARKERS

CLINICAL

DIAGNOSIS

IMAGING



CLINICAL

DIAGNOSIS


5

Endometriosis: questions that must be answered before the surgery:

Clinical Data: Main Symptom, 1077 cases

30%

35%

40%

45%

%

5%

10%

15%

20%

25%

30%

Dism

enorrh

ea

Aciclic

Pain

Infe

rtilit

y

Bowel

Sym

pt

Urinar

y Sym

pt

Dyspare

unia

Asym

ptom

atic

Endometriosis Division - Sao Paulo University 1990-2008

Time elapsed from onset of symptoms to diagnosis of endometriosis

= 40

30

20

12,1 years

4.5 years

Mean: 7 years from the onset of symptoms to the diagnosis of endometriosis

Arruda M, Petta C, Abrao MS et al. Hum Reprod 18:756, 2003

Years

Age at the Onset of the Symptoms

< 20 yo 20 - 29yo > 30 yo> 30 a n o s 20 a 29 <20 anos

10

0

-10

3.3 years

Mean time (+/-SD) elapsed between the onset of symptoms

and the diagnosis of

Time elapsed between onset of symptoms and diagnosis of deep endometriosis

RESULTS

and the diagnosis of endometriosis (years)*

Deep endometriosis affecting rectum-sigmoid, bladder

and/or ureter (n=53)

7.71 +/- 5.6

Without deep endometriosis (n=178)

6.12 +/- 5.26

*p<0.05ABRÃO, MS et al., 2008

ENDOMETRIOSIS: pain x most severe disease site

819 casesSymptom Peritoneal Ovarian Deep p

SevereDysmenorrhea 22(51.8%) 126(48.5%) 229(62.9%) 0.005

Chronic pain 96(50.3%) 143(54.8%) 233(63.5%) 0.006

Bellelis, P; Abrao, MS et al. - RAMB 2010

Infertility 56(28.7%) 66(25.2%) 124(34.1%) 0.03

Cyclic Dyschezia 21(11.4%) 33(13%) 120(33.5%) <0.001

Cyclic Dysuria 27(14.1%) 34(13%) 56(15.3%) 0.71

Dyspareunia 97(51.6%) 138(52.9%) 227(63.4%) 0.007

Clinical Exam

Adnexial massesCul de sac painUSL thickness

Cul the sac Pain

ENDOMETRIOSISCurrent and Future Strategies to Plan the Treatment

STRATEGY 1

Helpful for additional diagnostic methodsGood Clinical Exam

Helpful for additional diagnostic methods

6


MARKERS

DIAGNOSIS


200

250

ENDOMETRIOSIS

Laboratorial Diagnosis - CA 125

• Main Serum MarkerCA125UI/ml

0

50

100

150

Control I II III IV

1º, 2º ou 3º dia do ciclo 8º, 9º ou 10º dia do ciclo

• To be measured on the 1st, 2nd or 3rd days of the menstrual cycle

• Low accuracy in early stages

Abrao MS et al. Human Reprod 12:2523, 1997

1st, 2nd or 3rd days

8th, 9th or 10th days

Endometriosis & InflammationIL-1, IL-6, SAA

• Serum IL-6 and peritoneal fluid SAA: diagnosis of endometriosis

• Best acuracy: serum IL-6y

• Cut-off of3.45pg/ml• sensibility: 52.6%• specificity: 61.5%

Ejzenberg , Abrão et al., 2012

Endometriosis & InflammationTreg Cells – Foxp3

•• Foxp3 presence in peritoneal cells: RT-PCR

• CD4+CD25+ peritoneal fluid cells of endometriosis patients:

Arbitrary units

cells of endometriosis patients: high levels of Foxp3

• Treg cells

Podgaec , Abrão et al., in press. 2011

n (%) Endometriosis n=45

Lupus n=15

Controls n=21

p p* p**

ANA + 8 (18) 14 (93) 0 0.001 0.0005 0.014

Pattern

ENDOMETRIOSISAntinuclear Antibodies (ANA)

- Homogêneo

- Pontilhado

- Misto

1 (12,5)

5 (62,5)

2 (25)

2 (14)

9 (64)

3 (22)

_

_

_

_

_

_

1.0

1.0

1.0

_

_

_

Levels

- 1:40 a 1:160

- >1:160

3 (37,5)5 (62,5)

4 (29)

10 (71)

_

_

_

_

_

1.0

_

_

Pasoto SG, Abrao MS et al. Am J Reprod Immunol 53: 85, 2005

n (%)ANA +

n=8ANA -n=37 p

ENDOMETRIOSISAntinuclear Antibodies (ANA)

78 kDa Ab

- positive

- negative

3 (38)

5 (52)0

37 (100)

0.004

Ab ANTI-78 KDa NEGATIVELupus Patients and Controls

Pasoto SG, Abrao MS et al. Am J Reprod Immunol 53: 85, 2005

7


STRATEGY 2

Markers

?

CA 125

Measurement during the period

(1st, 2nd or 3rd days)

ENDOMETRIOSIS DIAGNOSISDIAGNOSIS

IMAGING


US FindingsUS Findings nn %%

NormalNormal 66 16.7 16.7

Deep Endometriosis:Rectal Endoscopic Ultrasound

Deeply Infiltrating Deeply Infiltrating Endometriosis without rectal Endometriosis without rectal

involvementinvolvement2424 66.6 66.6

Deeply Infiltrating Deeply Infiltrating Endometriosis with rectal Endometriosis with rectal

involvementinvolvement66 16.7 16.7

Abrao MS et al. J Am Assoc Gynecol Laparosc 11:50, 2004

Deep Endometriosis:Rectal Endoscopic Ultrasound

Deep Endometriosis:Rectal Endoscopic Ultrasound: Disadvantadges

Cost

Under sedationUnder sedation

Public health purposes

other sites of disease

Deep Endometriosis

Transvaginal Ultrasound with bowel preparation

QuickTime™ and aDV/DVCPRO - NTSC decompressor

are needed to see this picture.

8

Deeply Endometriosis

Transvaginal Ultrasound normal Rectal Layers

SerosaOuter musculisna

Inner musculisnaSubmucosea

MucosaeMU

SM

Muscularis

t

SMALL LESION (<1cm) SMALL LESION (<1cm) -- Serosa of the Rectum Serosa of the Rectum

LESIONMP

SM

TVUS - Diagnosis of Deep Endometriosis

Lus D

septoSM

M

hypoechoic irregular nodule compromising the hypoechoic irregular nodule compromising the serosa of the rectum serosa of the rectum

•Non invasive and well tolerate for the patients

•High accuracy to demonstrate ovarian and

MRI - Diagnosis of Endometriosis

MRI - beneficts

High accuracy to demonstrate ovarian and deep endometriosisProviding a pelvic cavity map

•Associate pathologies (Fibroids and adenomyosis)

Kinkel et al., 2006

Radiologist ( blind about symptoms / USG)Radiologist ( blind about symptoms / USG)


PATIENTS AND METHODS

Yes / NoYes / No

BladderBladder OvaryOvary RetrocervicalRetrocervicalRectum / SygmoidRectum / Sygmoid UreterUreter

Laparoscopic / histopathological findingsLaparoscopic / histopathological findings

Sensitivity

Specificity

PPV NPV Accuracy

% 100% 71,4% 80.6% 100% 87%

RESULTS - OVARY


n 50 / 50 30 / 42 50 / 62 30 / 30 80 / 92

T1 FS

Sensitivity Specificity PPV NPV Accuracy

% 91,5% 69,7% 84,4% 82,1%

RESULTS - RETROCERVICAL


n 54 / 59 23 / 33 54 / 64 23 / 28

9

Sensitivity Specificity PPV NPV Accuracy

% 85,1% 86,7% 87% 84,8%

n 40 / 47 39 / 45 40 / 46 39 / 46

RESULTS - RECTUM / SYGMOID


n 40 / 47 39 / 45 40 / 46 39 / 46

Transvaginal US x MRI for Deep Endometriosis

Abrao MS et al. Human Reproduction, 2007


Local Method Sensitivity Specificity

TVUS 98.1% 100%


Rectum Endo MRI 83.3% 97.8%

CLinical Exam 72.3% 54%

TVUS 95.1% 98.4%

Retrocervical Endo

MRI 76% 68%

Clinical Exam 68.3% 46%

Hum Reprod. 2009 Mar;24(3):602-7. Epub 2008 Dec 17.

Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination.

Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, Borghese B, Chapron C.Source

Department of Gynecology, Obstetrics II and Reproductive Medicine, Université Paris Descartes, Paris, France.

AbstractBACKGROUND:Transvaginal ultrasonography (TVUS) has important advantages compared with transrectal ultrasonography (TRUS):

it is less invasive, is cost-effective, is a familiar and well-accepted approach, and anesthesia is not required. We compared the accuracy of TVUS and TRUS for diagnosing rectal wall involvement in patients presenting with histologically proved deeply infiltrating endometriosis (DIE).

METHODS:Prospective study of 134 patients with histologically proved DIE underwent preoperative investigations using both

TVUS and TRUS. The radiologist (TVUS) and sonographer (TRUS) were unaware of the clinical findings but knew that DIE was suspected.

RESULTS:DIE was confirmed histologically for all the patients. A rectal wall involvement was histologically proved for 75

patients (56%). For the diagnosis of infiltration of the intestinal wall, TVUS and TRUS, respectively, had a sensitivity of 90.7% and 96.0%, a specificity of 96.5% and 100.0%, a positive predictive value of 97.1% and 100.0% and a negative predictive value of 88.9% and 95.2%.

CONCLUSIONS:TVUS and TRUS have similar degrees of accuracy for predicting intestinal involvement. TVUS must be the first-line

imaging process to perform for patients presenting with clinically suspected DIE. The question for the coming years is to define if it is necessary for TRUS to be carried out systematically in cases of clinically suspected DIE.

•Mauricio S Abrao M D a ; Manoel OC Goncalves M D b ;

Comparison between transvaginal ultrasound and rectal endoscopic ultrasound

for the diagnosis of deep endometriosis

Abrao MS et al. 2011 in press

Mauricio S Abrao, M.D., ; Manoel OC Goncalves, M.D ;

• Lucio Rossini, M.D.c ; Joao A Dias Jr, M.D.a ; Luis FC Fernandes, M.D. a , Sergio Podgaec, M.D.a

a Department of Obstetrics and Gynecology, University of São Paulo Medical School, São Paulo, Brazil

b Digimagem Medicina Diagnóstica, São Paulo, Brazilc Santa Casa Medical School, São Paulo, Brazil

Sensitivity Specificity PPV NPV

Bl dd 95% 100% 100% 88%

RESULTS

TVUS & REU - Diagnosis of Deep Endometriosis

Bladder 95% 100% 100% 88%

TVUS Retrocervical 92% 87% 94% 81%

Rectum/sigmoid 98% 100% 100% 83%

Bladder - - - -

REU Retrocervical 68% 80% 89% 50%

Rectum/sigmoid 94% 80% 98% 57%

10


STRATEGY 3

B t I i th dTRANSVAGINAL US

with

Simple enema before the exam

Best Imaging method

for deep endometriosis

If the bowel is compromised:If the bowel is compromised:

is the disease multifocal?is the disease multifocal?

which is de deepest layer of the bowel with endo?which is de deepest layer of the bowel with endo?

Bowel Endometriosis: Questions that must be answered before the surgery

p yp y

what is the distance between the lesion and the what is the distance between the lesion and the

anal verge?anal verge?

is the ileum/cecum and appendix compromised?is the ileum/cecum and appendix compromised?

TVUS-BP x number of lesions and rectosigmoid layers in Bowel

Endometriosis

TVUS-BP x number of lesions and rectosigmoid layers in Bowel

Endometriosis

Sensitivity

Specificity

PPV NPV Accuracy

Rectosigmoid lesion detection 97% 100% 100% 98% 99%

Goncalves, MO; Abrao MS et al Human Reproduction 2009 in press

Presence of at least two

rectosigmoid lesions

81% 99% 93% 96% 96%

Lesions affecting the

submucosal/mucosal layer submucoc

83% 94% 77% 96% 92%

Sensitivity

Specificity

PPV NPV Accuracy

TVUS without Bowel Prep x rectosigmoid layers in Bowel Endometriosis

Hudelist, G; Keckstein J. et al. Can TVUS predict infiltration depth in patient with DIE of the rectum? Human Reprod. 2009; 24(5):1012-17

Serosa/Muscularis 98% 99% 99% 99% 99%

Submucosa/mucosa 62% 53% 97% 97% 94%

Deep Endometriosis

The distance between the lesion and the anal verge

8cm

Gonçalves, Abrão et al - Human Reprod 2010

8cm

11


STRATEGY 4Transvaginal US with bowel prep to

di tRectosigmoid

Endometriosis

predict:

Number of lesions

Size of lesions

Distance from the anal verge

Without Pain

Bowel EndometriosisDecision concerning the symptom

Clinical Exam + TVUS

DIE compromisinng the Bowel

With PainVAS>7

Sugery ? Clinical treatment

TrimestralControl

VAS>7

Involv. of inner layer Muscularis

or deeper

Segmental ressection

Involv. of serosa or outer layer Muscularis

Nodule ressection






STRATEGY 5

Superficial unifocal Lesions Deep and or multifocal Lesions

(< Inner muscularis)

Disc resection

(> inner Muscularis)

Segmental resection

Bowel Endometriosis: Small Bowel/appendix


STRATEGY 6Ultrasound: Abdominal

ProbeEndometriosis

compromising the

Ileum/Cecum/appendix

Probe

special care with:

Bowel obstruction

Carcinoid of appendix

12

•posterior bladder wall, distal ureters

• S

Endometriosis of Urinary Tract

•US and MRI: Bladder and Hydronephrosis

•Other exams: cistoscopy, urography or uro MRI

BEXIGA

Bladder endometriosis


STRATEGY 7

Endometriosis

compromising the

Special care with

Ureterscompromising the

vagina > 3cm

Ureters

Endometriosis

Pre Surgical Work up

Normal ConclusivDoubts

Clinical Exam + Ca125

TVUS(Bowel Preparation)

No disease orEarly stages

e

Treatment

Doubts

RV Septum/ USLRECTOSIGMOID

TRANSRECTAL US

Ovary

MRI UrographyURO -MRI

Urinary Tract

Clinical EvaluationClinical Evaluation

Transvaginal US: Simple, Best Exam , Transvaginal US: Simple, Best Exam , Simple trainingSimple training

Endometriosis: how to plan tre treatment

•• Multidisciplinary team; bowel prepMultidisciplinary team; bowel prep

•• One shot surgeryOne shot surgery

13

New Markers

New imaging methodsNew imaging methods

Future Strategies

Combined techniquesCombined techniques


Sérgio PodgaecCarlos Alberto PettaMauricio S. Abrao

Paula ZulianLuiz Fernando Pina de CarvalhoLuiz Fernando HenriquePatrick BellelisLuciano GibranAlessandra PellogiaDaniel CaraçaFlavia Fairbanks de SouzaLuiz Flávio FernandesNicolau DAmicoJoão Antônio Dias Jr

Marta Bellodi PrivatoMaria Lucia MarinAna Carolina PoppeAntonio ColdibelliGiuliano BorrelliPaula Gabriela FiguiraRoberta DraxlerFrederico CorreaAna Lucia BeltrameLidia Myiung

Ginecology Manoel Orlando GonçalvesLeandro A. MattosAna Paula K. Leite

Marcelo AverbachMarco Antonio Bassi

Colorectal Surg

Imaging

Jorge KalilLuiz Vicente RizzoEsper Kallas

Immunology

Silvia RogattoClaudia Rainho

Genetics

Pathology

Annacarolina SilvaFilomena Carvalho

University of Sao Paulo, Medical School, Brazil

14

Treatment of the Treatment of the Ovarian Ovarian EndometriomaEndometriomaO a iaO a ia E o e io aE o e io a

Dr Jim TsaltasPresident AGES

Head of Gynaecological Endoscopy Southern Health and Monash Medical Centre

Melbourne IVF

DisclosuresDisclosures• Grants/Research Support: Covidien, Merck Serono

Scope of talkScope of talk• Pathophysiology• Histology• Diagnosis • Impact on Fertility• Surgical Management• Ovarian Reserve

PathogenesisPathogenesis• Three (3) main theories of endometrioma formation:

o Invagination secondary to bleeding of a superficial implanto Invagination secondary to metaplasia of coelomic epihelium in cortical

inclusion cysts o Endometriotic transformation of functional cysts

• Postulated by different groups but there is no reason to believe that they are mutually exclusive

• (Brosens I A et al – 1994, Nisolle M & Donnez J -1997, Nehzat et al – 1992)

HistopatholgyHistopatholgy• Classically – endometriomas are described as

ovarian cysts• Sometimes loculated and at least partially lined by

an endometrium – like epithelium, stroma and haemosiderin-laden macrophages haemosiderin laden macrophages

• It is important to note that the follicular densities in the ovarian cortex surrounding endometriomasappear to be much lower than in other benign cysts such as dermoid cysts ( Schubert B et al 2005)

o May imply lower baseline ovarian reserve

Lumen

Lining epithelium

Haemorrhage, fibrosis and haemosiderinladen macrophages in cyst wall

15

Lumen

Lining endometrial type epithelium and stroma with haemorrhage

Classical Symptoms Classical Symptoms • Severity of symptoms does not correlate well with

the degree of disease • Endometriomas – may have the following

symptoms:o Cyclical paino Cyclical paino Ovulation paino Pain with intercourseo Acute pelvic pain associated with possible endometrioma rupture

• Diagnosis o Examination – Ovarian masso Ultrasound – extremely accurate method of diagnosis (classic ground

glass cyst, reduced ovarian mobiltiy)- sensitivity 84-100% and specificity 90-100% (Moore et al – 2002)

• Ground glass appearance

• Thick walled

• Uni- or multilocular

• Multiple lesions

• Kissing ovaries

• Hyperechogenic wall foci

Abnormal anatomy: Ovary

• Hyperechogenic wall foci

• Wall nodularities

• Acoustic enhancement

• Absence of internal vascularity

• ‘shifting’ content

• (No acoustic streaming)

• Do not regress

Tip of the icebergTip of the iceberg• Endometriomas are often seen as marker of more

severe disease(Banerjee SK et al – 2008) • Important to be aware that there may be more

severe disease once you start operating (ChapronC et al – 2009)C et al 2009)

• Surgery – anatomical assessment and normalization of anatomy

• Mobilization of ovaries, identification of other lesions, decision to treat

o Endometriomas, other areas of DIE, single or two step procedureo Have a formal approach

Planning SurgeryPlanning Surgery• Careful pre op assessment• Indication for surgery

o Confirm diagnosiso Paino Infertility

i io Facilitate access to oocytes at IVF OPU

• Assessment of ovarian reserve – will become more critical

o Ultrasound to include – AFCo AMH (Anti-Mullerian hormone)

• AMH is produced by the follicles, it corresponds well with AFC and ovarian response to hyperstimulation in IVF, it is the only marker that is menstrual cycle independent and easily measurable (Chang HJ et al – 2010)

Infertility and Infertility and endometriomasendometriomas

• Time to treat – 6 – 12 months depending on age, symptoms, pain, male factor

• Need to individualize treatement• Treatment of endometrioma dependent on a

number of factors:number of factors:o Ovarian reserveo Size of the endometrioma(4cm or greater – ESHRE Guidelines – 2005)o If IVF can we access oocytes at OPUo Reduce chance of infection at OPUo Associated pain and QOL issues o Appropriate access to trained surgeons and IVF specialists o Must no look at surgery and IVF as competing interests but rather as

complementary therapeutic strategies

16

Excision of Excision of endometriomasendometriomas

• Laparoscopic cystectomy by excisional surgery for endometriomata 4cm or greater improves fertility(spontaneous pregnancy rates) compared to drainage and coagulation (Beretta 1998, Alborzi2004). Many other observational studies show an increased pregnancy rate after surgery for increased pregnancy rate after surgery for endometriomas with a weighted mean of 50% -summarized in Vercellini 2009 (see next slide)

• As well as improved fertility rates excision has lower recurrence of endometriomas and symptoms (Hart 2008 and updated 2011 – cochrane review) as compared to drainage and coagulation

• Early studies suggested minimal if any damage to the ovarian reserve after surgical treatment for endometriomas – (Loh 1999, Donnez 2001, Canis 2001)

• Recent studies however have demonstrated

Issues related to treatmentIssues related to treatment

Recent studies however have demonstrated damage to the ovarian reserve

o Methodology to assess this includes D2 FSH, AFC, Ovarian reserve, response to gonadotrophins in IVF and AMH

o (Somigliani 2003, Somigliani 2006, Chang 2010, Benaglia 2010, )o Damage may also relate to size of endometrioma being excised (Roman

2010)

• Care with surgical techniqueo Excision is preferred methodo Care with identification of planes (Canis Principle)o Minimize diathermy and conserve all ovarian tissue possible

• Recent small randomized clinical trial – shows potential less reduction in ovarian reserve when suturing is used for haemostasis – AFC outcome measure (Coric 2011)

• Minimize the amount of coagulation used – be very precise in its application• Combined technique – excisional surgery and also ablative surgery for 10 – 20% of endometrioma wall next to

hilus (Donnez 2010)• Small study looked at reduction of post operative adhesions by suture to close the

ovary for haemostasis compared to traditional diathermy(endometriomas) RCT –f d t i P lli 2008

Reducing RisksReducing Risks

favored suturing – Pellicano 2008o This is now our practice

• Haemostatic Aids in the ovary – ie Floseal with or without suturing (Angioli R eta l –2009)

• AMH excellent marker• should consider recommendation of routine AMH testing pre and 3 mths post endometrioma surgery

• should consider egg freezing prior to recurrent endometrioma surgery in young patient with low AMH not trying to conceive

• Should consider IVF if ovarian reserve is compromized but will depend on ability to access follicles – LDR protocol with 3 M GnRH analogue pre stimulation(Garcia-Velasco J, Somigliana E – 2009)

If ovarian reserve If ovarian reserve compromisedcompromised

• Consider egg freezing in women under age of 39 if ovarian reserve is compromized pre or post surgery

• Consider particularly prior to recurrent endometrioma surgery

• We will see more of this • We will see more of this • Appropriate consent and understanding of chance

of success – move from slow freeze to vitrification(what are the long term results ???)

• Sclerotherapy with ethanol may be a promising alternative to repeat surgery for recurrent endometriomas – risk infection (Hsieh et al 2009)

Reducing recurrenceReducing recurrence• Recurrence rates post surgery have been quoted at

12 – 30% after 2-5 year follow up (Seracchioli et al 2010)

• The length of use of the COCP post surgery is one of the critical factors related to recurrence the critical factors related to recurrence

• Method of use is also critical • Seracchioli’s study – divided patients into three

groups; o 1: Continuous COCP, 2: Cyclical COCP, 3: No COCP

• Recurrence rate at 24 months: o 1: 8.2%, 2: 14.7%, 3: 29%

17

ConclusionConclusion• Symptoms• Diagnosis• Indications for surgery• Markers of ovarian reserve• Preservation of ovarian tissue• Consider surgical technique• Post operative reduction in recurrence• Egg Freezing prior to recurrent surgery or even after

primary surgery in young women – we will see more of this

18

Strategies in the Dissection of the Frozen Pelvis

Charles E. Miller, MD, FACOG

• President, International Society for Gynecologic Endoscopy (ISGE)

• President, AAGL (2007-2008)

• Clinical Associate Professor, Department OB/GYN, University of Illinois at Chicago, Chicago, IL USA

• Director of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge, IL USA

• Director, AAGL/SRS Fellowship in Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge, IL USA

Charles E. Miller, MD, FACOG

Disclosures:

• Grants/Research Support: Covidien, Femasys, Olympus, Novartis, Abbott Laboratories

• Consultant: Covidien, Femasys, Abbott Laboratories, Ferring Pharm

2


Objectives

1. Discuss a generalized approach to the frozen pelvis.

2. Outline the repair of a small bowel laceration at the time of surgery.

3

3. Identify the appropriate use of energy in the frozen pelvis.


THE MOST DIFFICULT MINIMALLY INVASIVE

SURGERY IN THE GYNECOLOGIST’SARMAMENTARIUM…

4


• No roadmap to success

• Greatest risk to vital structures

• Increased risk of bleedingIncreased risk of bleeding

• Concern for post operative adhesions

5


Keys to Success – Meticulous Adhesiolysis

• Proper preoperative evaluation

• Consider LUQ incision

• Visualize the endpoint

• Know the anatomyy

• Minimize energy

• Maintain hemostasis

• Generally work lateral to midline

• Resect vs. transect adhesions when possible

• Utilize barriers unless contraindicated

6

19


Minimize Energy

• Use “cold” scissors when possible

• If energy necessary, use monopolar scissors with “cutting current” or ultrasonic energy at “max

• Consider use of 5mm clipsConsider use of 5mm clips

• Minimize bipolar energy especially around vital structures

• Use rectal probe, and “back fill” bladder as necessary

7


Adhesiolysis

• Step 1 – mobilize bowel off anterior abdomen and pelvis

• Step 2 – mobilize bowel off adnexa

• Step 3 – mobilize adnexa off pelvic side wall, medial broad ligament, uterus and cul-de-sacStep 4 – excise pelvic sidewall endometriosis – margin must be clean

• Step 5 – consider liberal use of ureterolysis to accomplish steps 3 & 4

• Step 6 – consider suspending adnexa while addressing remaining adhesions

• Step 7 - mobilize rectosigmoid off of medial posterior broad ligament

8


Adhesiolysis

• Step 8 – resect endometriosis as necessary– Ureterolysis

– Watch uterine vessels

• Step 9 – mobilize rectosigmoid off of anterior portion of posterior cul-de-sac– Develops pararectal spaces

• Dissect into rectovaginal space

• Use rectal probe

• Step 10 – resect endometriosis of uterosacral ligaments, posterior cervix, and cul-de-sac

• Step 11 – treat deep infiltrative endometriosis of rectum and vagina

• Step 12 – use adhesion barrier when not contraindicated

9


Special Considerations – Bowel InjuryRepair should be perpendicular to the long access of the bowel to prevent narrowing of the bowel lumen

• Small bowel– “Freshen up edges”

– Serosa• No repair

• Single layer closure– Continuous vs. interrupted

– 3-0 vs. synthetic absorbable sutures

– Muscularis or mucosa• Single layer closure

– Continuous vs. interrupted

– 3-0 silk vs. synthetic absorbable sutures

Note: large defects may require resection with reanastomosis

10Mann W., et al., UpToDate, complications of gynecologic surgery, 2012

Strategies in the Dissection of the Frozen PelvisSpecial Considerations – Bowel InjuryRepair should be perpendicular to the long access of the bowel to prevent narrowing of the bowel lumen

• Large bowel– “Freshen up edges”

– Serosa• Single layer closure

– Continuous vs. interrupted

– 3-0 vs. synthetic absorbable sutures

– Muscularis• Two layer closure

– Layer one – through and through interrupted with 3-0 silk

– Layer two – imbricating stitch with 3-0 silk or synthetic absorbable sutures

– Mucosa• Two layer closure

– Layer one – through and through interrupted with 3-0 silk

– Layer two – imbricating stitch with 3-0 silk or synthetic absorbable sutures

Note: large defects may require resection and reanastomosis; rarely colostomy11Mann W., et al., UpToDate, complications of gynecologic surgery, 2012


Adhesions Before and After Ovariopexy in Patients with Deep Infiltrative Endometriosis Undergoing Radical Surgery

• N = 65

• Second look laparoscopy 6-12 weeks post surgery

Before After

Stage 1 75 50

Stage 2 93 10

12Keckstein J, et al., Ceska Gynekol 2004; 69(5): 408-11

20


Posterior Cul-De-Sac Obliteration Associated with Endometriosis: MR Imaging Evaluation

• Retrospective study– 30 patients scored by 4 radiologists

• Scores based on retroflexed uterus, vaginal fornix, intestinal gtethering or tethered appearance of the rectum in direction of uterus, faint strands between uterus and intestine, fibrotic plaque or nodule covering serosal surface of the uterus

13Kataoka ML, et al., Radiology 2005; 234(3): 815-23. Epub 2005
















21



Performance of MR Imaging Criteria for Diagnosing Posterior Cul-De-Sac Obliteration


References• Mann, W, et al., UpToDate, complications of gynecologic surgery, 2012

• Keckstein J, et al., Ceska Gynekol 2004; 69(5): 408-11

• Kataoka ML, et al., Radiology 2005; 234(3): 815-23. Epub 2055

20

22

Current Surgical Techniques to Treat Bowel

Endometriosis2012

Mauricio S Abrao, MD

Endometriosis Division, Sao Paulo University, Brazil


Disclosure

• Other: Visanne Board Member - Bayer Healthcare CorpHealthcare Corp.

Morphologic aspects

Fibrosis x Endometriosis

ENDOMETRIOSIS COMPROMISING THE RECTUM:

Depth x Circumpherence

Is it possible to define the criteria before surgery ?

Rectosigmoid endometriosis:

Shaving, Nodulectomy or Segmental resection ?

Morphologic aspects





Deep endometriosis : non rectal



Rectum/Sigmoid Endometriosis:Morphologic aspects - 345 cases

Morphologic aspectMorphologic aspect nn %%

MultifocalMultifocal 145145 4242

Mean Longitudinal Mean Longitudinal DiameterDiameter

3.4 3.4 cmcm

--

Undiferentiated or Undiferentiated or Mixed diseaseMixed disease 324324 94%94%

Abrao MS et al. in press 2012

Morphologic aspects








23

Müllerian Differentiation, normal or abnormal

EndosalpingiosisEndocervicosisEpithelial endometrioid Metaplasia Stromal endometrioid Metaplasia Fibrosis

Stem Cells

?genetics factors

Mullerianosis

hyperplasia

“borderline”

CarcinomaEndometriosis

?genetics factors

ER and PR - Immunohistochemistry smc deep endo

uterosacral endometriosis n = 14;

bladder endometriosis n = 10;

l i d t i i 16

Estrogen and progesterone receptors in smooth muscle component of deep infiltrating endometriosis

colonic endometriosis n = 16;

rectovaginal endometriosis n = 20

ER and PR did not differ significantly with cycle's

phases.

ns difference between ER and PR in SMC around

endometriotic foci than at a distance Noel J et al. Fertil Steril 2010

Morphologic aspects








Nodulectomy or Segmental resection ?

% of the circumference of the rectum compromised: 45 cases

Circumference affected

≤ 40% > 40% p

Length of the lesion (cm)

Lesion Lenght X Circumference (n = 68)

Abrão MS, Podgaec S, Dias JA Jr, Averbach M, Silva LF, de Carvalho FM.Endometriosis lesions that compromise the rectum deeper than the inner

muscularis layer have more than 40% of the circumference of the rectum affected by the disease. J Minim Invasive Gynecol. 2008;15(3):280-5

Mean 2.1 2.7 0.02

Standard deviation 1.2 1.0

Range 0.0 – 4.5 1.0 – 6.0

Endometriosis lesions that compromise the rectum deeper than the inner muscularis layer h h 40% f h i f f

% of the circumference of the rectum compromised: 45 cases

have more than 40% of the circumference of the rectum-sigmoid affected by the disease

Abrão MS, Podgaec S, Dias JA Jr, Averbach M, Silva LF, de Carvalho FM.Endometriosis lesions that compromise the rectum deeper than the inner

muscularis layer have more than 40% of the circumference of the rectum affected by the disease. J Minim Invasive Gynecol. 2008;15(3):280-5

Deeply Endometriosis

Transvaginal Ultrasound normal Rectal Layers

Abrao MS et al. Eur J Obstet Gynecol 123 (suppl 1): 04, 2005

SerosaOuter musculisna

Inner musculisnaSubmucosea

MucosaeMU

SM

Muscularis

24

Pain < VAS 7

Bowel EndometriosisDecision concerning the symptom

Clinical Exam + Ca125

DIE compromisinng the Bowel

Pain > VAS 7

Sugery ? Clinical treatment

TrimestralControl

7

Multifocal or Involv. of inner layer

Muscularis or deeper

Segmental ressection

Unifocal or Involv. of

or outer layer Muscularis

Nodule ressection

Morphologic aspects









Morphologic aspects







Discoid Resection - Circular Stapler

• One Lesion



• < 3cm

• < submucosa

Bowel Resection

• Step one: Overview of the abdominal cavity



25

Rectum mobilization / identification of the left ureter.

Bowel Resection

QuickTime™ and aApple ProRes 422 decompressorare needed to see this picture.

Bowel Resection


Bowel Resection


Bowel Resection


Clinical DataClinical Data

Transvaginal US, enema one hour before for Transvaginal US, enema one hour before for d dd d

Endometriosis: how to plan tre treatment

deep endodeep endo

•• Multidisciplinary team; bowel prepMultidisciplinary team; bowel prep


26

Urinary Tract Endometriosis:

Therapeutic strategies

Professor Charles Chapron, MDHead of Department,

Université Paris Descartes,

Sorbonne Paris Cité

Faculté de Médecine, AP-HP,

GHU Ouest, CHU Cochin, Paris, France

Disclosure Slide

N fi i l l ti hiNo financial relationships to disclose

Learning Objectives Slide

At the conclusion of this activity,th ti i t ill b bl t dithe participant will be able to discuss

the diagnostic and therapeutic strategies for patients with

urinary tract endometriosis

Gynecology Surgical unit:

C Chapron, B Borghese, P Santulli, H Foulot, MC Lafay-Pillet, A Bourret, G Pierre, A Bititi, C Souza

Medical unit:A Gompel, G Plu-Bureau

Laboratory: GeneticD Vaiman, F Mondon, S Barbaux

Laboratory: ImunulogyB Weill, F Batteux, C Nicco, C Chéreau

Reproductive endocrinology unit:D de Ziegler V Gayet,I Streuli, FX Aubriot

Intestinal surgeryB Dousset, M Leconte.

C cco, C C é eau

Laboratory: Reproducive biologyJP Wolf, V Lange, K Pocate,JM Kuntzman, C Chalas

Statistical unitF Goffinet, de Mouzon J

D de Ziegler, Professor and Head, Reproductive Endocrinology and Infertility unit,A Gompel, Professor and Head, Medical Gynecological unit,

C Chapron, Professor and Chair, Dpt Gynecology Obstetrics II and Reproductive Medicine

Endometriosis: DéfinitionsENDOMETRIOSIS IS DEFINED BY THE

PRESENCE OUTSIDE OF THE UTERUS

OF ENDOMETRIAL TISSUE:

- Endometrial glands

- Stroma

DIE IS ARBITRARLY DEFINED AS LESIONS EXTENDING

MORE THAN 5MMUNDERNEATH THE

PERITONEUM

Koninckx et al., Fertil Steril (1991)

Deep endometriosis: Définitions

JC Noel (2010)

Hum Reprod (2010)

JC Noel (2010)

Invasion ofthe muscularis propria

27

Severe ureteral endometriosis:Definition- Only DIE lesions causing

significanty obstruction to urinary flow with ureteral stenosis (Uro-MRI) : 11 mm

- Severe ureterolysis for complete resection of DIE lesions but not causing ureteral stenosis were not considered as SUE.

Chapron et al., Fertil Steril (2010)

Ureteral endometriosisDefinition: Two histological types

- Intrinsic: presence of endometriotic glands and stroma in the ureteral wall, «resulting in a thickened ureteric wall with fibrosis and

Intrinsic endometriosis

proliferation of the ureteric muscularis» (Clement PB, 1989).

Intrinsic endometriosis

-Extrinsic:Compression of the ureteric wall by endometriotic lesions.

Urinary Tract Deep EndometriosisN = 920 patients with histologically proved DIE lesions

DIE Lesions N

Bladder without ureter 107Bladder with ureter 10Ureter without bladder 48

Chapron, non published data (2012)

117 / 920 = 12.7%

58 / 920 = 6.3%

Bladder DIE : pathogenesis

Regurgitationand

implantation

Chapron et al.,Hum Reprod (2006)

Metaplasia ofMüllerian remnants

Nisolle and Donnez, Fertil Steril (1997)

Bladder DIEpathogenesis

implantation

Adenomyosis Iatrogenic

Fedele et al.,Fertil Steril (1998)

Vercellini et al.,

J Urol (1996)

Deep bladder endometriosis:pathogenesis

J Urol (1996)

Spontaneous Iatrogenic

2 Types

Materials and methodsMarch 2003 March 2011

41068

Bladder

Prospective observationnal studyProspective observationnal study

16 1%410DIE Patients

Bladder DIE Patients

57 not scared uterus (84%)57 not scared uterus (84%)

11 scared uterus (16%)11 scared

uterus (16%)

16.1%

28

Deep bladder endometriosis: Results

Preop VAS Scared Not scared pscores (n= 11) (n = 57)

DM 7.5 ± 2.6 7.5 ± 2.1 NSDP 4.3 ± 3.6 3.7 ± 3.2 NSNCCPP 3.4 ± 3.4 2.5 ± 3.2 NSGI symptoms 3.6 ± 4.3 3.8 ± 3.3 NSLUT symptoms 5.0 ± 3.4 4.9 ± 3.6 NS


rAFS Scared Not scared pClassification (n= 11) (n = 57)Classification (n= 11) (n = 57)

III 2 18.2 4 7.0 NS

IV 4 36.4 27 47.4 NS


rAFS scores Scared Not scared p(n= 11) (n = 57)

Implants 9.2 ± 8.1 13.1 ± 12.3 NSAdhesions 24.0 ± 25.0 28.6 ± 29.6 NS

Total 33.1 ± 29.7 41.7 ± 37.6 NS


Scared Not scared p(n= 11) (n = 57)(n 11) (n 57)

Mean Nbof associated 3.4 ± 2.4 3.2 ± 2.2 NSDIE lesions


Total Nb of Scared Not scared pDIE lesions (n= 11) (n = 57)

1 4 36.4 22 38.6 NS2 2 18.2 6 10.5 NS≥ 3 5 45.5 29 50.9 NS

Deep endometriosis:Association between bladder and ureter lesions

Fertil Steril (2009)

29

Deep endometriosis:Association between bladder and ureter lesions

Authors Bladder AssociatedDIE t l DIEDIE ureteral DIE

Abrao (2009) 26 0 0.0%

Chapron (2012) 117 10 8.5%

Severe ureteral endometriosisAnatomic distribution ( n = 58 patients; 65 ureteral DIE lesions)

Location Patients Ureteral DIE lesionsn % n %

Right 11 19 18 28

Bilateral 7 12

Left 40 69 47 72


Deeply infiltrating endometriosis :Anatomic distribution

n = 426 patients; n = 730 n = 426 patients; n = 730 PELVICPELVIC DIE lesionsDIE lesions

Compartment n %

ANTERIOR 48 6.6

POSTERIOR 682 93.4

Chapron et al., Hum Reprod (2006)p < 0.0001

Deeply infiltrating endometriosis :Anatomic distribution n = 426 patients; n = 759 n = 426 patients; n = 759 TOTALTOTAL DIE lesions (Uni + Bil)DIE lesions (Uni + Bil)

Main lesions n Left Median Right

USL 400 227 - 173VAGINA 123 - 123 -BLADDER 48 - 48 -INTESTINE 172 30 123 19URETER 16 11 - 5

Total 759 268(35.3%) 294(38.7%) 197(26.0%)57.6% 42.4%

p < 0.0001 p = 0.02

Chapron et al., Hum Reprod (2006)

• Pelvic lesions > Abdominal lesions

P l i P t i l i > A t i l i

Deeply infiltrating endometriosis : Anatomic distribution

n = 759 DIE lesions (Uni + Bil)

• Pelvis: Posterior lesions > Anterior lesions

• Pelvis: Left lesions > Right lesions

• Abdomen: Right lesions > Left lesions

Chapron et al, Hum Reprod (2006)

FOUR predominant sites for preferentiel, repeated or arrested flow of PF:

- Pouch of the Douglas at the rectosigmoid level

Diagram of the pathways of flow of intraperitoneal fluid .

[Adaptated from Meyers (1973)]

rectosigmoid level- Right lower quadrant at the termination of the small bowel mesentery- Left lower quadran along the superior border of the sigmoid mesocolon and colon- Right paracolic gutter lateral to the cecum and ascending colon

30

Deeply infiltrating endometriosis: Anatomical distribution of intestinal DIE lesions

Chapron et al.,Hum Reprod (2006)

L: 83.47%R: 11.02%

Endometriosis: PathogenesisMenstrual blood

Retrograde menstruation

Transplantation theory

Guidice and Kao,Lancet (2004)

Endometriosis

IntraperitonealFluid flows

GravidityAsymetric pelvic

anatomy

Anatomic distribution for all Osis types

Urinary Tract Deep Endometriosis:Therapeutic strategies

Therapeutict t istrategies

SurgeryDiagnosis



Diagnosis

Endometriosis: Clinical symptoms

Endometriosis

Pelvic pain InfertilityPelvic pain Infertility

Surgery for bladder endometriosis


31

Bladder DIE endometriosis

Baseline characteristics(n = 117 patients)

Patients characteristics N %

Hematuria 12 16.0ATCD transurethral resection 14 18.7Speculum: red/bluish lesions 0 0.0Pelvic examination: anterior nodule palpated 42 56.0Positive cyystoscopy 22 29.3


Bladder deep endometriosis:Transvaginal ultrasonography

Bladder DIE nodule

Parietal bladder

endometriosis nodule

Severe Ureteral endometriosis

Clinical signs(n = 29 patients)

PatientsN %

No urologic symptoms 17 58.6Severe posterior painful symptoms 26 89.6Haematuria 2 6.9Rectorraghia 5 17.2


Severe Ureteral endometriosisSilent loss of kidney

(n = 58 patients)

PatientsPatients

N %

Nephrectomy 13 22.4 !!!!!!!


Severe Ureteral endometriosisMRI

Severe ureteraldilatation

DIE nodule

Severe Ureteral endometriosisMRI

32

Severe Ureteral endometriosisMRI: Bilateral lesions

Unilateralureteral

dilatation

Bilateralureteral

dilatation

Severe Ureteral endometriosisKidney scintigraphy: symetric curves

Severe Ureteral endometriosisKidney scintigraphy: asymetric curves



Surgery

Bladder DIE endometriosis Previous surgical history (n = 117 patients)

Patients characteristics N %

ATCD transurethral resection 14 18.7


Bladder endometriosis:Laparoscopic partial cystectomy

33


Bladder

Left

ureter

Vagina

Uterine isthmus



Leftureter

Vagina

Uterine isthmus

Partial cystectomy suture

Surgery for bladder endometriosis


Endometriosis: Relationshipbetween osis and chronic pelvic pain

Endometriosis

Pelvic pain

Symptomaticendometriosis

Asymptomaticendometriosis

Adaptated from Hurd Obstet Gynecol (1998)

Deep endometriosis: Painful heterogeneity

Prospective observational study

88 patients with untreated asymptomatic DIE

Median follow-up time: 5.7 years (1 – 9)

No DIE treatment during laparoscopy

Peritoneal and ovarian lesions fully treated

DIE lesions biopsied

Progression of disease and/or appaerance of pain

symptoms attributable to DIE:

6 patients; 6.8% 95% CI: 1.9% - 11.7%

Estimated cumulative proportion of patients with

progression of disease and/or appearanceof pain

symptoms attributable to DIE after 6 years: 9.7%

Fedele et al, AJOG (2004)

34

Deep endometriosisPainful heterogeneity

Bladder Endometriosis Reoperation for

N = 75 Follow-up: 59.9 ± 44.6 months (range 3 – 182) recurrence

N %

Deep bladder Osis

N % n

Isolated 27 36.0 0

Associated posterior DIE 48 64.0

Symptomatic (Surgical exeresis) 33 44.0 0

No symptoms (NO Surgical exeresis) 15 20.0 1


Deep endometriosisPainful heterogeneity

Deep bladder OsisChapron et al., Hum Reprod (2010)

Bladder DIE endometriosis

Associated DIE lesions(n = 117 patients)

Patients DIE lesionsN % N

USL 44 38 104VAGINA 35 30 35BLADDER 117 100 117INTESTINE 41 35 86URETER 10 8 12

Total 117 354

Chapron, unpublished data (2012)

2.7 ± 2.1 (range 1 to 10)



Patients DIE lesionsN % N

USL 38 65 104VAGINA 35 60 35BLADDER 10 17 10INTESTINE 48 83 96URETER 58 100 65

Total 58 310

Chapron, unpublished data (2012)

4.6 ± 2.6 (range 1 to 17)



Ureteral DIE

N %

Isolated 2 3.5

Associated Intestinal DIE 48 82.8


Severe Ureteral endometriosis:Extrinsic versus intrinsic

(n = 29 patients ; n = 34 ureteral lesions)

Patients Ureteral lesions

I t i i 11 37 9% 13 38 2%Intrinsic 11 37.9% 13 38.2%

Extrinsic 18 62.1% 21 61.8%

Total 29 34


35




I t i i 11 37 9% 13 38 2%Intrinsic 11 37.9% 13 38.2%

Extrinsic 18 62.1% 21 61.8%

Total 29 34





I t i i 11 37 9% 13 38 2%Intrinsic 11 37.9% 13 38.2%

Extrinsic 18 62.1% 21 61.8%

Total 29 34


Severe ureteral endometriosis


Urinary Tract Deep EndometriosisN = 920 patients with histologically proved DIE lesions

DIEParameters Bladder Ureteral

(n = 117 patients) (n = 58 patients)(n 117 patients) (n 58 patients)

n % n %

Associated OMAs 28 23.9 26 44.8Associated intestinal DIE 41 35.0 48 82.7Mean Nb DIE lesions 2.68 ± 2.1 4.59 ± 2.6


Take home messages

Strategies Bladder deep endometriosis

Diagnosis Painful urinary symptoms during menstruationTransvaginal ultrasonography

Surgery No place for transureteral resectionGold standard: Partial cystectomyOnly exeresis of painful nodules

Take home messages

Strategies Ureteral deep endometriosis

Diagnosis Rarely urinary symptomsMRI and kidney scintigraphyMajor risk: silent kidney loss

Surgery Multifocal disease: Multidisciplinary approach Referal center

Two types Histology: extrinsic versus intrinsicSurgery:

Minimal ureteral endometriosis Extensive ureterolysisor

Severe ureteral endometriosis Radical surgery

36

PresidentsFelice Petraglia

(Siena, Italy)Charles Chapron (Paris, France)

Hans Rudolf Tinnemberg (Giessen, Germany)

References list (1)

Koninckx PR, Meuleman C, Demeyere S, Lessafre E, Cornillie FJ: Suggestive evidence that pelvic endometriosis is a progresive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 1991, 55: 759-765.

Chapron C, Bourret A, Chopin N, Dousset B, Leconte M, Amsellem-Ouazana D, de Ziegler D, Borghese B: Surgery for bladder endometriosis: Long term results and concomitant management of associated posterior deep lesions. Hum Reprod 2010; 25 (4): 884-889.

Chapron C Chiodo I Leconte M Amsellem-Ouazana D Chopin N Borghese B Dousset B:Chapron C, Chiodo I, Leconte M, Amsellem Ouazana D, Chopin N, Borghese B, Dousset B: Severe ureteral endometriosis: the intrinsic type is not so rare after complete surgical exeresis of deep endometriotic lesions. Fertil Steril 2010, 93: 2115-2120.

Clement PB, Dieases of the peritoneum. New York: Spinger-Verlag, 1994.

Chapron C, Chopin N, Borghese B, Foulot H, Dousset B, Vacher-Lavenu MC, Vieira M, Hasan W, Bricou A:Deeply infiltrating endometriosis: Pathogenetic implications of the anatomic distribution. Hum Reprod 2006; 21(7): 1839-1845.

Nisolle M, Donnez J: Peritoneal endometriosis, ovarian endometriosis and adenomyotic nodule of the rectovaginal septum are three different entities. Fertil Steril 1997; 68: 585-596.

References list (2)Fedele L, Bladder endometriosis: deep infiltrating endometriosis or adenomyosis.

Fertil Steril 1998; 69: 972-975.

Vercellini P, Meschia M, de Giorgi O, Panazza S, Cortesi I, Crosignani PG: Bladder detrusor endometriosis: clinical and pathogenesis implications. J Urol 1996; 155: 84-86.

Abrao MS, Dias JA Jr, Bellelis P, Podagec S, Bautzer CR, Gromatsky C: Endometriosis of the ureter and bladder are not associated diseases. Fertil Steril 2009; 91: 1662-1667.

Meyers MA: Distribution of intra-abdominal malignat seeding: dependency on dynamics of flow of ascitic fluid. Am J Roentgenol Radium Ther Nucl Med 1973; 119: 198-206.

Hurd WW: Criteria that indicate endometriosis is the cause of chronic pelvic pain. Onstet Gynecol 1998; 92: 1029-1032

Fedele L, Bianchi S, Zanconato G, Raffaelli R, Berlanda N: Is rectovaginal endometriosis a progressive disease? Am J Obstet Gynecol 2004; 191: 1539-1542.

37

NEW ENDOMETRIOSIS CLASSIFICATION

2012

REPRODUCTIVE SURGERY & ENDOMETRIOSIS AAGL SIG

Disclosure

• Other: Visanne Board Member - Bayer Healthcare Corp.

Acosta et al, 1973

Kistner et al, 1977Kistner et al, 1977

Schweppe et al, 1984Schweppe et al, 1984

AFS, 1985AFS, 1985

ASRMr, 1986ASRMr, 1986

Why do we need a new endometriosis classification?

Koninckx and Martin, 1992Koninckx and Martin, 1992

Adamyan, 1993Adamyan, 1993

Enzian ScoreEnzian Score

Abrao et al, 2000Abrao et al, 2000

Adamson, 2010Adamson, 2010DEEP ENDOMETRIOSIS, 1990DEEP ENDOMETRIOSIS, 1990

Good correlation with the symptomsGood correlation with the symptoms

Easy to performEasy to perform

Good correlation with the therapeutic Good correlation with the therapeutic responseresponse

Criteria for a good classification system

responseresponse

Association with all types of the Association with all types of the diseasedisease

Helpful to predict the prognosis of the Helpful to predict the prognosis of the diseasedisease

ENDOMETRIOSE < 1 cm 1-3 cm > 3 cm

Superficial

Profunda

D superficial

Profunda

E superficial

Profunda

OBLITERAÇÃO DO FUNDO

DE SACO POSTERIOR

1

2

1

4

1

4

2

4

2

16

2

16

4

6

4

20

4

20

Parcial Completa

4 40

OVÁRIO

PERITÔNIO

ADERÊNCIAS < 1/3 Envolvido 1/3 - 2/3 Envolvidos > 2/3 Envolvidos

D Velamentosa

Densa

1

4

2

8

4

16OVÁRIO

ASRM classification: associated with all types of endometriosis?

Densa

E Velamentosa

Densa

4

1

4

1

4*

8

2

8

2

8*

16

4

16

4

16TROMPA

D Velamentosa

Densa

E Velamentosa

Densa

1

4*

2

8*

4

16

2



32 yo

Severe dysmenorrhea (VAS 10)

Deep DispareuniaDeep Dispareunia

Aciclic pelvic pain

Infertility

38

ENDOMETRIOSEClassificação

AFS - 1985 / ASRM - 1996

4 1

QuickTime™ and aQuickTime and aDV/DVCPRO - NTSC decompressor




Does it have correlation with the symptoms?Does it have correlation with the symptoms?

Does it have correlation with the therapeutic Does it have correlation with the therapeutic response?response?

Doubts about the ASRM classification for this case:

Does it predict the amount of disease?Does it predict the amount of disease?

•• Is it helpful to predict the prognosis of the disease?Is it helpful to predict the prognosis of the disease?

Does the ASRM stage correlate with the symptoms?Does the ASRM stage correlate with the symptoms?

Does the ASRM stage correlate with the therapeutic Does the ASRM stage correlate with the therapeutic response?response?

Does the ASRM stage predict the actual amount ofDoes the ASRM stage predict the actual amount of

Limitations of the ASRM classification

Does the ASRM stage predict the actual amount of Does the ASRM stage predict the actual amount of disease?disease?

•• Is the ASRM stage helpful in predicting the prognosis Is the ASRM stage helpful in predicting the prognosis of the disease?of the disease?

Does the ASRM stage correlate with the symptoms?Does the ASRM stage correlate with the symptoms?

Does the ASRM stage correlate with the therapeutic Does the ASRM stage correlate with the therapeutic response?response?

Limitations of the ASRM classification

No !Does the ASRM stage predict the actual amount of Does the ASRM stage predict the actual amount of disease?disease?

•• Is the ASRM stage helpful in predicting the prognosis Is the ASRM stage helpful in predicting the prognosis of the disease?of the disease?

No !Tipe 1: SUPERFICIAL

INFILTRATIVE ENDOMETRIOSIS

Koninckx PR, Martin D. Fertil Steril 58:942, 1992

39

Tipe II: RETRACTION





Tipe III:“ADENOMIOSIS

EXTERNA”





ENDOMETRIOSIS

Three Diferent Diseases

Peritoneal

Nisolle, M; Donnez, J; Fertil Steril, 1997

Ovarian Rectovaginal Septum

Endometriosis Fenotypes

Endometriosis

• More comom• Implantation• Superficial

F i t

Adenomiosis

• Less comom• Metaplasia• Deeper

M i t

Brosens I, Brosens JJ. Human Reprod 15:1, 2000

• Fewer sintomas• Progressive ?• Better response to Hormonal treatment

• More sintomas• Progressive• Fewer response to Hormonal treatment

DEEPLY INFILTRATING ENDOMETRIOSIS:Retrocervical ou Retovaginal septum?

Retrocervical

Martin DC J Am Assoc Gynecol Laparosc 8:12, 2002

Retovaginal Septum

Retrocervical

Endometriosis: Morphologic Criteria

Classical: Endometrial Stroma Fibrosis and hemorrhagia

Actual Criteria: Stroma

CD10 positive (Groisman CD10 positive (Groisman GM, Meir A. 2003)

Citoplasmatic Expression of COX-2 (Terada et al. 2006)

Müllerian Epithelium With stroma With hemorrhagia and

fibrosis Citoplasmatic Expression of

COX-2 (Terada et al. 2006)

40

Endometrial Stroma and endometriosis

Induces the mullerian epithelial differentiation in the mesothelium (Mai et al 97)

Possible origin of the Possible origin of the epithelial component of the lesion (Zámecník 98)

High proliferative activity and higher level of ER and PR (Nisolle et al 97, Porto 98)

Epithelial morphology in Endometriosis

Different phenotips of the endometrial epithelial glands

Different patterns of mullerian differentiation

ENDOMETRIOSIS

Histological Appearence

Schweppe KW, Wynn RM Europ J Obstet Gynecol Reprod Biol 1984; 17:193-208

Highly Differentiated / Stromal Disease

Poor differentiated / Mixed Disease

Histologic Classification of endometriosis: an alternative for the prediction of the response to the treatment

Stromal Disease presence of stromaof stroma morphologically similar to that of topical endometrium

Abrao MS et al. Int J Gynaecol Obstet 82:31, 2003

Well Differentiated glandular pattern:


pattern:

morphology of the epithelial cells is indistinguishable from that of topical endometrium


Undifferentiated glandular pattern:


epithelium is flattened or low cuboidal, with no correspondence with topical epithelium, resembling the mesothelium lining the peritoneum


41

Glandular pattern of mixed differentiation:


differentiation:

epithelium with a well-differentiated or undifferentiated pattern in the same biopsy


412 biopsies obtained from 241 patients Division of Endometriosis of the Gynecology Clinic of

the University Hospital, Faculty of Medicine, University of São Paulo

Correlation between Histologic Classification and:


Correlation between Histologic Classification and: Stage of the disease (ASRM, 1996) Site of the disease: Peritoneal, ovarian or Deep

endometriosis Level of Pain before the treatment (Low, Moderate

and Severe) Clinical outcome: pain and infertility


Two Groups: With and Without Undifferentiated Endometriosis


Undifferentiated39 biopsies (9,5%)

Well Differentiated165 biopsies (40%)

Mixed95 biopsies (23,1%)


Stromal113 biopsies

(27,4%)

60%

70%

80%

Histologic Classification of endometriosis: Distribution according ASRMr (1996) Classification

15%

5%

28%19%

35%40%

22%

36%

%

10%

20%

30%

40%

50%

60%

I II III IV

Differentiated Undifferentiated

Abrao MS et al. Int J Gynaecol Obstet 82:31, 2003I+II x III+IV p < 0.05

74%

61%60%

70%

80%

p < 0,002

Histologic Classification of endometriosis: Site of the Disease

26%

39%48% 52%

%

10%

20%

30%

40%

50%

60%

Peritoneal Ovarian Deep

Differentiated Undifferentiated

Abrao MS et al. Int J Gynaecol Obstet 82:31, 2003p < 0.05

Histologic Classification of endometriosis: LEvel of Pain Before the treatment

35(78%)

106(56%)


( )

10(22%)

82(44%)

p < 0.05

42

Histologic Classification of endometriosis: Outcome according level of Pain two years after Surgical treatment

Level of Pain before

treatment

Histological Pattern Poor/none

OUTCOMEPartial Complete

TOTAL

Low or moderate

Well dif / StromalUndi/Mixed

0 (0%)

0 (0%)

11 (33%)

7 (88%)

22 (67%)

1 (12%)33 (100%)8 (100%)


moderate Undi/Mixed 0 (0%) 7 (88%) 1 (12%) 8 (100%)

HighWell dif / Stromal

Undi/Mixed2 (2%)

14 (18%)

34 (35%)

44 (56%)

60 (63%)

21 (26%)96 (100%)79 (100%)

TOTAL 16 (7%) 96 (45%) 104 (48%)216

(100%)

p < 0.05

Histologic Classification of endometriosis: Outcome according Infertility two years after Surgical treatment

Histological Pattern

Became pregnant

Didn’t Become Pregnant

TOTAL

Well differentiated / Stromal 27 (60%) 18 (40%) 45 (100%)


/ Stromal 27 (60%) 18 (40%) 45 (100%)

Undifferentiated/Mixed

27 (79%) 7 (21%) 34 (100%)

54 (68%) 25 (32) 79 (100%)

p < 0.05

Understanding Endometriosis

Different ways in its genesis and

developing

Undifferentiated Endometriosis: worse

prognosis

Mullerian disease: may be associated

?

with the capacity of differentiation from

the stem cells

Fundamental: Interaction between

Gynecologist and Pathologist

AAGL 2011 ENDOMETRIOSIS CLASSIFICATION

ENDOMETRIOSIS AND REPRODUCTIVE SURGERY AAGL SIG

MAURICIO S. ABRAO, CHAIRMAN

G 30Alan Lam

Arnie AdvinculaBob Albee

Carlos PettaCharles Chapron

Charles KohCharles Miller

Dan MartinDavid AdamsonDavid RedwineEdgardo RolloEduardo Schor

Errico ZupiCHARLES MILLER - VICE CHAIR

WILLIAM HURD - IMMEDIATE PAST CHAIR

CHARLES CHAPRON

ROY MASCHIACH

Harry ReichJacques DonnezJavier Magrina

Jim TsaltasJoerg KecksteinKeith IsaacsonLudovico Muzii

Luis AugeMario Malzoni

Maurício AbrãoMauro BusaccaMichelle NisollePatrick Yeung

Paulo Ayrosa RibeiroPaya PasicPeter Maher

Sérgio PodgaecTommaso Falcone

Step 1 Tabulation System: G30: METHODS

• 30 endometriosis experts were asked to provide a score (0-10)

regarding the importance of each involvement site on the outcomes of

pain, infertility and surgical difficulty.

Step 1 Tabulation System: G30

A - Peritoneal (superficial) endometriosis : <3cm ____ >=3cm _____ (sum of total lesion diameter)

B- Ovarian endometriosis*: Superficial: _______ endometrioma < 3cm ______ endometrioma >= 3cm ______

C- Deep endometriosis: Retrocervical Endometriosis**: < 3cm _____ > = 3cm _____Vaginal endometriosis (muscularis) **: < 3cm _____ > = 3cm _____

Bladder Endometriosis(muscularis) ** : < 3cm ______ >= 3cm ______Rectovaginal Septum disease # _______Rectum/Sigmoid endometriosis (muscularis) ** (if more than one lesion: ****) <3cm _____ >=3cm _____Ureter: Extrinsec _____ Intrinsec______ hydroureter ______Appendix endometriosis:Appendix endometriosis: _______Small bowel/Cecum endomtriosis: < 3cm ____ >= 3cm ______

D- Cul the sac Obliteration: Partial _____ Complete: _________

E- Tubal Condition: Slight Serosal Injury: ___ Moderate serosal injury/moderate immobility ____Severe immobility ____ Complete obstruction ____

F- Other sites/associated condictions (only to be cited, not participating of the score system): Adenomyosis / Diaphragm Endometriosis / Lung Endometriosis / etc

* the size correspond on the sum of the major diameters of the cysts in the same ovary; if the patient has an unilateral

** Retrocervical = USL and/or torus uterinos and/or paracervical . Bladder / Rectum/Sigmoid/small bowel: If muscularis affected.

**** if more than one bowel lesion: sum the major longitudinal diameters of the lesions

# bellow the peritoneal reflexion (if the patient has an anterior low rectal lesion, compromising the RVS, score here and in the rectum/sigmoid endometriosis)

43

Step 1 Tabulation System: G30 Step 1 Tabulation System: G30

AAGL ENDOMETRIOSIS CLASSIFICATION, 2011

Endometriosis Superficial <3cm >=3cm

Peritoneal 1.8 3.8

Ovarian 1.3 3.1 4.6

D Retrocervical 5.3 7.4

E Vaginal 5.4 7.8

E Bladdeer 5.1 7.1

P Rectum/Sigmoid 6.9 9

Small Bowell 5.6 7.6

Rectovaginal septum 7.7 Appendix 4.5

Cul de Sac Obliteration partial Complete

5.6 8.9

Extrinsec Intrinsec Hydroureter

Ureter 4.0 5.6 6.1

Tubes Slight Serosal injury Moderate Injury Severe Immobility Complete obstruction

1.6 2.9 4.1 $4.

90

STAGE Scores

I 0-4II 5-17III 17-28IV 29 +

Step 2 Validation of the score system

• Pain Scores (for dysmenorrhea, deep dyspareunia, acyclic pelvic pain,

dyschezia and or dysuria) were obtained from patients before surgery

(VAS, 0-10)

•Infertility before surgery was documented

• Surgical Difficulty were categorized into 4 levels:

Level 1 - Excision or desiccation of superficial implants, and simple thin avascular adhesions

Step 2 Validation of the score system

Level 2 - Stripping of ovarian endometriomas, appendectomy, deep endometriosis non involving the bowel, vagina, ureter or bladder (not requiring suture), dense adhesions not involving the bowel or the ureter

Level 3 - Dense adhesions involving the bowel or the ureter; bladder surgery requiring suture, ureterolysis, bowel surgery without resection

Level 4 - Bowel resection or ureteral reimplantation or anastomosis

Step 2 VALIDATION RESULTS: 521 patients

ASRM Stage

AAGL Stage I II III IV Grand Total

I 79 18 30 3 130

Agreement between ASRM and AAGL Staging

I 79 18 30 3 130

II 22 29 37 12 100

III 4 18 27 18 67

IV 2 40 33 149 224

Grand Total 107 105 127 182 521

44

Step 2 STATISTICAL EVALUATION

ASRM Stage

AAGL Stage I II III IV Grand Total

I 18 30 3 130


I 79 18 30 3 130

II 22 29 37 12 100

III 4 18 27 18 67

IV 2 40 33 149 224

Grand Total 107 105 127 182 521

In only 284 (54.1%) there was an agreement between both stages


% of patients with INFERTILITY for ASRM and AAGL Stagings

475260

3841

47

41

48

34

53

0

10

20

30

40

50

I II III IV

AAGL ASRM

%AAGL Classification

correlated with infertility in a linear fashion, better than ASRM system


TOTAL PAIN AVERAGE for ASRM and AAGL Stagings

21.299999225

13.8999996

18.5 18.7999992

14

19.2999992

17

19.2000008

0

5

10

15

20

I II III IV

AAGL ASRM

Total

Pain

Average AAGL Classification correlated with patients levels of Pain in a linear fashion, better than ASRM system


SURGICAL DIFFICULTY between ASRM and AAGL Stagings

3.7

3 73 5

4

1.6

2.3

3

1.8

2.90000012.7

3.7

0

0.5

1

1.5

2

2.5

3

3.5

A B C D

AAGL ASRM

%AAGL Classification

correlated with surgical difficulty in a linear fashion, better than ASRM system

In conclusion:

• First validated classification for Endometriosis correlated with patients level of pain, infertility and surgical difficulty

AAGL Endometriosis Classification, 2011

• User-friendly

• Preliminary data shows that it is better than the existing classification system in associating the stage to the levels of pain, to the infertility and to the level of surgical difficulty

In conclusion:



• User-friendly


45

In conclusion:



• User-friendly


Step 3 Daily use: mobile app

Step 3 Daily use: mobile app Step 2 STATISTICAL EVALUATION


Peritoneal (superficial) endometriosis

< 3 cm

≥ 3 cm



Peritoneal (superficial) endometriosis

< 3 cm

≥ 3 cm


Agreement between ASRM and AAGL StagingEndometriosis

Superficial

<3cm >=3cm

Peritoneal 1.8 3.8

Ovarian 1.3 3.1 4.6

D Retrocervical

5.3 7.4

E Vaginal 5.4 7.8

E Bladdeer 5.1 7.1

P Rectum/Sigmoid

6.9 9

Small Bowell

5.6 7.6

Rectovaginal septum

7.7 Appendix

4.5al septum dix

Cul de Sac Obliteration

partial Complete

5.6 8.9

Extrinsec

Intrinsec

Hydroureter

Ureter 4.0 5.6 6.1

Tubes Slight Serosal injury

Moderate Injury

Severe Immobility

Complete obstruction

1.6 2.9 4.1 $

4.90

46



STAGE Scores

I 0-7

II 8-15

III 16-23

IV 24-95

ENDOMETRIOSIS AND REPRODUCTIVE SURGERY AAGL SIG

MAURICIO S. ABRAO, CHAIRMAN

CHARLES MILLER - VICE CHAIR

WILLIAM HURD - IMMEDIATE PAST CHAIR

CHARLES CHAPRON

ROY MASCHIACH

47

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

OtherAsianIndo-Euro

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

48

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

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