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Be a Surgical “Multiplier” in MIGS Inspire Brilliance Through Teamwork
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Scientific Program ChairJubilee Brown, MD
Honorary ChairBarbara S. Levy, MD
PresidentMarie Fidela R. Paraiso, MD
SYLLABUSSURGICAL TUTORIAL 1:
Before, During and After- Comprehensive Team Approach to
Laparoscopic Management of Severe Endometriosis
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 1.0 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. Anti-Harassment Statement AAGL encourages its members to interact with each other for the purposes of professional development and scholarly interchange so that all members may learn, network, and enjoy the company of colleagues in a professional atmosphere. Consequently, it is the policy of the AAGL to provide an environment free from all forms of discrimination, harassment, and retaliation to its members and guests at all regional educational meetings or courses, the annual global congress (i.e. annual meeting), and AAGL-hosted social events (AAGL sponsored activities). Every individual associated with the AAGL has a duty to maintain this environment free of harassment and intimidation. AAGL encourages reporting all perceived incidents of harassment, discrimination, or retaliation. Any individual covered by this policy who believes that he or she has been subjected to such an inappropriate incident has two (2) options for reporting:
1. By toll free phone to AAGL’s confidential 3rd party hotline: (833) 995-AAGL (2245) during the AAGL Annual or Regional Meetings.
2. By email or phone to: The Executive Director, Linda Michels, at [email protected] or (714) 503-6200.
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Table of Contents Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 Pre-op Workup and Inform Consent for Severe Endometriosis with Visceral Involvement T.T.M. Lee ...................................................................................................................................................... 3 Multi-Disciplinary Team Approach Should Be the Way Forward for Complex Endometriosis A.M. Lam ....................................................................................................................................................... 8 Rectosigmoid Endometriosis: Anterior Discoid Resection R.S. Furr ....................................................................................................................................................... 11 Stepwise Strategies to Deal with Deep Infiltrative Endometriosis and Frozen Pelvis A.M. Lam .................................................................................................................................................... 24 Urinary Endometriosis: A Surgical Tutorial T.T.M. Lee ................................................................................................................................................... 27 Persistent Pain despite Aggressive Excision: Now What? S. As-Sanie ................................................................................................................................................ UNA Cultural and Linguistics Competency .......................................................................................................... 31
Surgical Tutorial 1: Before, During and After- Comprehensive Team Approach to Laparoscopic Management of Severe Endometriosis
Chair: Ted T.M. Lee
Faculty: Robert S. Furr, Alan M. Lam, Sawsan As-Sanie
Course Description This high-profile session will use a case study to illustrate many facets of care when managing patients with severe endometriosis with visceral involvement. Each expert will highlight various aspects of patient care before, during and after surgery which will include proper work-up, inform consent process, orchestrating a multidisciplinary team and understanding the potential etiologies of suboptimal symptom relief despite expert execution of surgical plan.
Course Objectives At the conclusion of this activity, the participant will be able to: 1) Articulate surgical planning for severe endometriosis with visceral involvement from work up, inform consent, fielding a multidisciplinary team, intraoperative decision making and management of persistent symptoms.
Course Outline
3:05 Welcome, Introductions, and Course Overview T.T.M. Lee 3:10 Pre-op Workup and Inform Consent for Severe Endometriosis with
Visceral Involvement T.T.M. Lee
3:20 Multi-Disciplinary Team Approach Should Be the Way Forward for Complex Endometriosis
A.M. Lam
3:35 Rectosigmoid Endometriosis: Anterior Discoid Resection R.S. Furr 3:50 Stepwise Strategies to Deal with Deep Infiltrative Endometriosis and
Frozen Pelvis A.M. Lam
4:05 Urinary Endometriosis: A Surgical Tutorial T.T.M. Lee 4:20 Persistent Pain despite Aggressive Excision: Now What? S. As-Sanie 4:35 Question and Answer All Faculty 4:45 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 Director, AAGL* Linda D. Bradley, Medical Director, AAGL* Erin T. Carey Consultant: MedIQ Mark W. Dassel Contracted Research: Myovant Sciences Erica Dun* Adi Katz* Linda Michels, Executive Director, AAGL* Erinn M. Myers Speakers Bureau: Laborie Medical Technologies, Teleflex Medical Other: Unrestricted educational grant to support NC FPMRS Fellow Cadaver Lab: Boston Scientific Corp. Inc. Amy Park* Grace Phan, Professional Education Specialist, AAGL* Harold Y. Wu* Linda C. Yang Other: Ownership Interest: KLAAS LLC Ted T.M. Lee* SCIENTIFIC PROGRAM COMMITTEE Linda D. Bradley, Medical Director, AAGL* Jubilee Brown* Nichole Mahnert* Shanti Indira Mohling* Fariba Mohtashami Consultant: Hologic Marie Fidela R. Paraiso* Shailesh P. Puntambekar* Matthew T. Siedhoff Consultant: Applied Medical, Caldera Medical, CooperSurgical, Olympus Amanda C. Yunker Consultant: Olympus Linda Michels, Executive Director, AAGL*
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). Sawsan As-Sanie Consultant: AbbVie, Myovant Robert S. Furr* Alan M. Lam* Ted T.M. Lee* Content Reviewer has nothing to disclose. Asterisk (*) denotes no financial relationships to disclose.
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Pre‐op Workup and Inform Consent for Severe
Endometriosis with Visceral Involvement
Ted Lee, M.D.
Director, Minimally Invasive Gynecologic Surgery
Magee Womens Hospital
University of Pittsburgh Medical Center
Disclosure
I have no financial relationships to disclose.
Objectives
• Use the learning process to understand the nuances in history and physical exam to triage patients for proper diagnostic modalities and to assess the need for multidisciplinary treatment approachfor endometriosis surgery
• Apply the results of the imaging studies and other diagnostic modalities for optimal surgical planning and proper inform and consent.
History
• Age• G and P: previous c‐sec, unexplained nullaparity• Desire for Future Fertility• Pain or Infertility or Both• Onset• 3 D’s –Dysmenorrhea , Dyspareunia (location, severity), Dyschezia (quality, location, temporality. )
• Location: RLQ, LLQ, Midline, lower back , etc Lateralized pain worsen with menses
• Temporality: intermittent, constant, relationship to menses and ovulation
History
• Quality: Sharp, stabbing, crampy, dull , achy, etc. ( Not so important except for the degree of dramatic descriptors)
• Exacerbating factors:• Associated menstrual symptoms: menorrhagia,metrorrhagia, menometrorrhagia, amenorrhea,oligomenorhea
• Associated GI or GU symptoms‐dysuria, pain with full bladder, hematuria, hematochezia
• Severity: mild, annoying, debilitating, absenteeism , effect on relationship.
Symptoms Suggestive of Bowel Endometriosis
• Dyschezia with or without cyclic exacerbation.
• Cyclic hematochezia or episodic hematochezia
• Constipation and diarrhea with or without cyclic exacerbation
• Asymptomatic
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Triggers for Further Workup for Deeply Invasive Endometriosis
• Nodularity on exam.
• Suspected endometrioma on ultrasound
• Cyclic hematochezia without palpable nodularity
• Cyclic hematuria
• Unexplained hydronephrosis.
Workup for Rectosigmoid Endometriosis
• Palpable nodule or unexplained cyclic hematochezia
• Transvaginal Ultrasound
• Endorectal ultrasound
• MRI
MRI Images of Rectal
Endometriosis
MRI Images of Rectal
Endometriosis
MRI Images of Rectal
Endometriosis
MRI Images of Rectal and Bladder
Endometriosis
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Endorectal Ultrasound
•Done in conjunction with sigmoidoscopy or colonoscopy.
•Better for higher rectosigmoid lesions which are frequently missed by MRI.
Symptoms Suggestive of Urinary Endometriosis
• Dysuria with or without cyclic exacerbation.
• Pain with full bladder with or without cyclic exacerbation.
• Cyclic hematuria
• Flank pain
• Asymptomatic
Symptoms of Ureteral Endometriosis
• Some present with symptoms of acute obstruction. Flank pain in 25%
• Hematuria in 15%
• Asymptomatic in 50%
• Most with symptoms typical for endometriosis in general.
• Secondary hydronephrosis resulted from extrinsic as well as intrinsic obstruction.
Workup for Bladder Endometriosis
• High index of clinical suspicion.
• Ultrasound orMRI.
• Cystourethroscopy.
• Be vigilant of endometriosis elsewhere in the pelvis.
MRI Images of Bladder Endometriosis MRI Images of Bladder Endometriosis
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MRI Images of Bladder
Endometriosis
Ultrasound Images of bladder endometriosis
Role of Cystoscopy
• Provide histopathologic diagnosis. Rule out other intravesical pathology.
• Assess the proximity of endometriotic nodule to the ureteral orifice.
Cystoscopy for Bladder Endometriosis
Diagnosis of Ureteral Endometriosis
• Screening renal ultrasound for patients withsuspected endometriosis.
• IVP
• Ureteroscopy
• Endoluminal ultrasound
• Laparoscopy
29 year old female G0P0 who present with pelvic pain. Pain began since 2 years ago. It is located in the umbilical regions as well lower pelvic pain. Pt reports long history of severe dysmenorrhea since high school. Pain can be severe at times that she cannot walk. She describes it as sharp and crampy . She describes the pain as being only during her menses, but she reports irregular frequent bleeding. Her pain is worsened by intercourse and bowel movement ( mostly during menses) and improved by heat pad and pain meds. She denies constipation, hematuria and hematochezia.
Pt previously on OCP from age 19‐26. Pt still had some dysmenorrhea but not severe. Pt got married 3 years ago and stop OCP and her pain got progressive worse. Pt first noticed umbilical pain before and during menses in 10/2013. Pt first noticed bleeding first time last month. Pt had ultrasound which show persistent bilateral 5 cm debris filled ovarian cysts. Pt had laparoscopy 3 months ago. Pelvic endometriosis was diagnosed and pt was started on Lupron the same month. Pt was given Norethindrone add back. Pt's pelvic pain improved while Lupron but her umbilical pain continue to get worse.
Pictures from her previous laparoscopy shows: two small endometriotic nodule over the bladder, Partial obliteration of cul de sac with both adnexa adherent to pelvic sidewall and posterior to the uterus, rectosigmoid colon adherent to the posterior uterus, Distension of left fallopian tubes consistent with hydrosalpinx.
Case Presentation
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Abdomen: Benign, soft, non‐tender, no hernia, masses, or lymphadenopathy, maroon color cystic area on the right side of of umbilicus Picture of her umbilicus when she was severely symptomatic show the cystic area to be approximately 2‐3 cm out of umbilus and bulging toward the leftPelvic examination:Vagina: Normal appearance, est effect, no discharge, lesions, cystocele or rectocele,endometriosis noted on posterior fornix
Cervix: Normal appearance, no lesions, discharge or tendernessUterus: Normal size, contour, position, mobile, no tenderness and descensusAdnexae:No masses, tenderness or nodularityNo anterior vaginal wall tenderness, no levator obturator tenderness, large 3‐5 cm
RV endometriotic nodule in the RV septum with ? Invasion into the rectum
Case Presentation
Severe endometriosis with multi visceral involvement as well as umbilical endometriosis. Optimal debulking of endometriosis may require surgery on the bowel, bladder or ureter. In terms of bowel surgery for endometriosis, discoid resection with two‐layer primary closure would be done typically and occasionally segmental resection and anastomosis maybe necessary in some cases if the nodule is bigger or if the disease is multifocal. There is about 1‐5 % risk of bowel leak with primary anastomosis and simple primary closure. In the event of bowel leak, diverting colostomy or ileostomy may become necessary. Other risk of bowel surgery include stricture and fistula were also explained to the patient. In terms of bladder endometriosis, usually simple two‐layer repair of bladder would be done to repair the cystotomy created after excision of bladder endometriosis. If bladder endometriosis is located near where the ureter join the bladder, ureter may need to be implanted. Risk of bladder surgery include leak of from the repair, decreased bladder capacity and reflux from reimplantation. In terms of ureteral endometriosis, segmental resection of the diseased segment of ureter and anastomosis or ureteral reimplantation of ureter may be necessary.Risk of ureteral surgery also include leak from repair, fistula, ureteral stricture and reflux.
Case Presentation
Pt understand the risks and would like to have most of her endometriosis removedlaparoscopically in the same setting if technically feasible.
Pt will also need partial resection of umbilicus for umbilical endometriosis.
Check MRI of pelvis and abdomen to assess for the degree and location of bowel, bladder and umbilical involvement . Pt will have consultation with colorectal surgery.. Do not recommend pt to undergo IVF before surgery as egg retrieval would be impossible due the presence of large rectovaginal nodule.
Case Presentation
Pt is here with her husband to go over the result of her MRI and go over the extent of surgery. On MRI endometriosis was noted on the posterior fornix with extension to the rectum. Because of the sheer size of her endometriosis, anterior resection and anastomosis will likely be necessary. Pt was also noted to have endometriosis involving the bladder, the right side of umbilicus.
Pt is consented for laparoscopic excision of rectovaginal endometriosis with partial vaginectomy, anterior resection and anastomosis, excision of bladder endometriosis with cystotomy repair as well as excision of umbilical endometriosis with revision of umbilicus. The specific risk of bowel surgery has been reviewed by the MIS colorectal surgeon. Risk and benefit of the procedure fully discussed with the patient and her husband. Pt fully informed and consented the aforementionedprocedures.
Case Presentation
Inform and Consent
• Opportunity to set the expectation of the surgeries.
• Readdress the objectives , priorities of the surgery.
• Be upfront about the risk . Get patient fully invested in their own health.
Conclusion
• Proper work up for severe endometriosis with visceral involvement start with good history and physical exam. Well chosen imaging will refine the pathologies to be addressed. Meticulous preoperative work up will facilitate surgical planning and optimize the inform and consent process.
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Multi‐Disciplinary Team (MDT) Approach Should Be the Way
Forward for Complex Endometriosis
Alan LamAssociate Professor, Sydney Medical School, Royal North Shore Hospital
Director, Centre for Advanced Reproductive Endosurgery (CARE)
Past President, Australian Gynaecological Endoscopy& Surgery Society (AGES)
Past Board member, American Association of Gynecologic Laparoscopists (AAGL),
World Endometriosis Society (WES) & International Society Gynecologic Endoscopy (ISGE)
Disclosure
I have no financial relationships to disclose.
Objective
Discuss the benefits and barriers to multi‐disciplinary team in treating complex endometriosis.
General background regarding MDT
• Multidisciplinary team working has been implemented in cancer care systems throughout much of Europe, the United States, and Australia.
• In the UK, multidisciplinary teams have also recently been recommended for the management of other conditions including diabetes, stroke and neurological rehabilitation, chronic obstructive pulmonary disease, and coronary heart disease.
Multidisciplinary team working in cancer: what is the evidence? Taylor C et al. BMJ 2010;340:743‐745.
What is the ‘best’ model of endometriosis care?
• Globally, the best model of endometriosis care has received increasing attention.
• Leading organisations such as National Institute for Health and Care Excellence (NICE), World Endometriosis Society (WES) … have promoted the concept that:
‘the care of women with complex endometriosis would benefit from a multidisciplinary network of experts sufficiently skilled in providing advice on and treatment of endometriosis and its associated symptoms, based on the best available evidence, their extensive experience and their transparent record of success rates’.
NICE guideline Endometriosis: diagnosis and Management. September 2017. nice.org.uk/guidance/ng73Consensus on current management of endometriosis. Johnson N, Hummelshoj L. Human Reproduction 2013; 28: 1552–1568.
Should Multi‐Disciplinary Team (MDT) approach be the way forward for Complex Endometriosis?
• There is a need for significant improvements in outcomes for individuals with this condition, with earlier diagnosis and intervention, broader multi‐disciplinary treatment options and clear care management pathways possible.
• Model of care (MOC) must be multidisciplinary and adaptable for various contexts and settings in the Australian healthcare landscape, including regional and rural service providers, must be implementation‐focused, and should aid quality assurance and the nationalisation of standards across all services.
National Action Plan for Endometriosis July 2018 /Australian Government Department of Health
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Multifunctional purposes of MDT
• To ensure that all patients receive timely treatment and continuity of care from appropriately skilled professionals
• To ensure that patients get adequate information and support.
• To facilitate communication between primary, secondary, and tertiary care
• To collect reliable data for the benefit of individual patients and for audit and research.
• To monitor adherence to clinical guidelines and promote the effective use of resources.
• To improve participants’ working lives, not least by providing opportunities for learning and development.
Multidisciplinary team working in cancer: what is the evidence? Taylor C et al. BMJ 2010;340:743‐745.
Specialist endometriosis services (endometriosis centres)
• gynaecologists with expertise in diagnosing and managing endometriosis, including
• advanced laparoscopic surgical skills
• a colorectal surgeon with an interest in endometriosis
• a urologist with an interest in endometriosis
• an endometriosis specialist nurse
• a multidisciplinary pain management service with expertise in pelvic pain
• a healthcare professional with specialist expertise in gynaecological imaging of
• endometriosis
• advanced diagnostic facilities (for example, radiology and histopathology)
• fertility services.
NICE guideline Endometriosis: diagnosis and Management. September 2017. nice.org.uk/guidance/ng73
‘Complex’ endometriosis?
• Infertile patient with ovarian endometrioma
• Urinary tract involvement • Bowel involvement • Vascular involvement• Nerve involvement• Chronic pain
Discussion and consideration:• the benefits and risks of laparoscopic surgery as a treatment option
• whether laparoscopic surgery may alter the chance of future pregnancy
• the possible impact on ovarian reserve
• the possible impact on fertility if complications arise
• alternatives to surgery
NICE guideline Endometriosis: diagnosis and Management. September 2017. nice.org.uk/guidance/ng73
Infertile woman with ‘complex’ endometrioma
• Asymptomatic vs symptomatic
• Endometrioma size > 5 cm
• Unilateral vs bilateral
• Normal vs low ovarian reserve (AMH)
• Typical vs atypicalultrasound features and raised CA‐125
Endometrioma with clot.Classic endometrioma Papillary serous carcinoma arising in an endometriotic cyst in a postmenopausal woman.
Variations in Appearance of Endometriomas. Asch E. J Ultrasound Med 2007; 26:993–1002
Urinary tract and Bowel involvement
• Asymptomatic vs symptomatic
• Symptoms – types, severity, consistency
• Fertility considerations
• Extent of deep infiltration
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Bowel and ureteric endometriosis surgical management Bowel and ureteric endometriosis surgical management
• 24 yo single woman
• Severe dysmenorrhoea, dyschezia, low back pain
• Not responded to hormonal therapies
• Rectovaginal endometriosis and left ureteric obstruction
• Fertility desire but no partner
Multi‐disciplinary approach to complex urinary tract, bowel, pelvic sidewall endometriosis
Multi‐disciplinary approach to complex urinary tract, bowel, pelvic sidewall endometriosis
Should Multi‐Disciplinary Team (MDT) approach be the way forward for Complex Endometriosis?
• MDT working has been widely introduced around the UK for the provision of cancer care, but there is little evidence for its direct effect on the quality of patient care or that MDT meetings resulted in improvements in clinical outcomes Multidisciplinary teams in cancer care: are they effective in the UK? Fleissig A et al. Lancet Oncol
2006; 7: 935–43.
• Future research should assess the impact of MDT meetings on patient satisfaction and quality of life, as well as, rates of cross‐referral between disciplines.The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A systematic review of the literature. Pillay B et al . Cancer Treatment Reviews
2016; 42: 56–72.
MDT – Benefits and Barriers
Benefits • Evidence is growing that effective multidisciplinary teams are associated with improved:
• Evidence‐based clinical decision making• Clinical outcomes• Patient experience• Working lives of team members• Medico‐legal protection
Barriers • Requires time
• Requires resources (organisation, administration, documentation)
• Requires collaboration• Requires high‐quality evidence
Multidisciplinary teams in cancer care: are they effective in the UK? Fleissig A et al. Lancet Oncol 2006; 7: 935–43
References
1. Multidisciplinary team working in cancer: what is the evidence? Taylor C et al. BMJ 2010;340:743‐745.
2. Multidisciplinary teams in cancer care: are they effective in the UK? Fleissig A et al. Lancet Oncol 2006; 7: 935–43.
3. NICE guideline Endometriosis: diagnosis and Management. September 2017. nice.org.uk/guidance/ng73
4. Consensus on current management of endometriosis. Johnson Neil P, Hummelshoj Lone. Hum Reprod. 2013;28(6):1552–68. Doi: 10.1093/humrep/det050.
5. The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A systematic review of the literature. Pillay B et al . Cancer Treatment Reviews 2016; 42: 56–72).
6. National Action Plan for Endometriosis July 2018 / Australian Government Department of Health
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Rectosigmoid Endometriosis: Anterior Discoid Resection
Robert S. Furr, MD
Disclosure
I have no financial relationships to disclose.
Objectives
• Outline the pathophysiologic pathway of endometriosis as it relates to pain
• Classify endometriosis based on anatomic location and histology
• Differentiate symptoms affecting patients with endometriosis and correlate them with surgical expectations
• Describe the evidence that supports specific surgical approaches when managing endometriosis
• Review surgical techniques for excision of endometriosis / peritoneal stripping
Falcone T, Flyckt R. Clinical Management of Endometriosis. Obstet Gynecol. 2018;131(3):557‐571.
PAINAn unpleasant sensory and emotional experience associated
with actual or potential tissue damageDoes endometriosis cause pain?
1
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Slide 6
1 Steve Radtke, 2/14/2018
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• Between 2‐43% asymptomatic women are found to have lesions
• Majority of studies average around 10‐11%
• Most common study modality is identification at time of tubal ligation
• In asymptomatic women with endometriosis, there is VERY low chance that it will become symptomatic over a 10 year period
Moen MH, Stokstad T. A long‐term followup study of women with asymptomatic endometriosis diagnosed incidentally at sterilization. Fertil Steril. 2002;78:773–776.
• In contrast, 70‐90% of women with chronic pelvic pain will have endometriosis
• Is this enough to establish causation?
• Rules of causation• Consistency
• Temporality
• Biological Gradient
• Plausibility
• Multiple attempts to classify or grade endometriosis based on involvement, appearance, etc and find a correlation with symptoms have been made
• Most widely known classification system is the rAFS staging diagram, but its association with severity of pain is weak at best
• 469 women enrolled completed pelvic pain surveys
• Subsequently underwent laparoscopy by blinded physicians
Stage rAFS VAS menstrual vs non‐menstrualpain score
I 7.7 v 6.5
II 7.5 v 6.2
III 7.4 v 6.2
IV 7.6 v 6.3
Relationship between stage, site and morphological characteristics of pelvic endometriosis and pain. Hum Reprod. 2001;16(12):2668‐71.
Is there any evidence that would lead to the conclusion that endometriosis causes pain?
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• 63 patients with pain (pelvic pain, dysmenorrhea, dyspareunia) randomized to laser ablation of endometriosis lesions/uterine nerve ablation vs expectant management
• Follow‐up at 3‐6 months after surgery
• When only patients with mild‐moderate disease were analyzed, 73.7% achieved pain relief vs 22.6% in expectant management group
Sutton CJ, Ewen SP, Whitelaw N, Haines P. Prospective, randomized, double‐blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril. 1994;62(4):696‐700.
Not all endometriosis is equal
Endometriosis
SuperficialDeeply
InfiltratingOvarian
Endometrioma
• Menstrual debris encapsulated in ovarian tissue. “pseudocyst”
• Present in approximately 17‐44% of patients with endometrisois
• 83% sensitivity 89% specificity on ultrasound
• Decision to operate based on size: cysts larger than 5 cm have a higher risk of ovarian torsion
• Removal/Excision as opposed to drainage is recommended• Marana et al showed a recurrence rate of 4% with excision/cystectomy and 84% with drainage/cystotomy
Zanelotti A, Decherney AH. Surgery and Endometriosis. Clin Obstet Gynecol. 2017;60(3):477‐484.
Deep infiltrating endometriosis
• Deep infiltrating lesions (DIE) occur approximately in 1‐2% of reproductive aged women and in 20% of patients with endometriosis
• Defined as an invasion greater than 5 mm into the peritoneal surface
• Most severe form of disease
• DIE is associated with severe pain in more than 95% of women
Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J. Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril 2012;98:564–71.
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When looking at DIE only, does location of disease matter?
• 225 women with pelvic pain and DIE
• Retrospective study where pain symptoms (dysmenorrhea, non‐cyclic pain, dyspareunia, dyschezia, urinary symptoms) were collected from medical records
• Anatomic locations of DIE were coded from operative report
Fauconnier A, Chapron C, Dubuisson JB, Vieira M, Dousset B, Bréart G. Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis. Fertil Steril. 2002;78(4):719‐26. Fauconnier A, Chapron C, Dubuisson JB, Vieira M, Dousset B, Bréart G. Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis. Fertil Steril. 2002;78(4):719‐26.
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• Study concluded that different types of pelvic pain are associated with specific locations of DIE
• Deep dyspareunia – involvement of USL
• Dyschezia – Involvement of vagina
• Non‐cyclical pain – involvement of bowel
• Lower urinary tract symptoms – involvement of bladder
• Severe dysmenorrhea was correlated with adhesions in the Dogulas pouch
Fauconnier A, Chapron C, Dubuisson JB, Vieira M, Dousset B, Bréart G. Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis. Fertil Steril. 2002;78(4):719‐26.
Endometriosis
SuperficialDeeply
Infiltrating
USL
Vagina
Bladder/ureter
Intestines
Ovarian
Does appearance of lesions correlate with symptoms?
Appearance
• PPV of visually identified endometriosis has been reported to be as low as 45%
• There is a body of literature reporting morphologic differences in lesions and their ability to elicit pain or produce inflammatory mediators
• To this date there is no clear evidence of an association between endometriosis appearance matters
What is the physiologic explanation of endometriosis pain?
• Pelvic pain is most common symptom in symptomatic patients• Increase in inflammatory mediators (IL‐6, TNF)
• Neurological dysfunction
• Estrogen‐mediated neuromodulation of the peripheral sensory neurons
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Physiology of endometriosis related pain
Secondary to increased concentration of prostaglandins (E2 and F2a)
COX catalyzes conversion of arachidonic acid to PGH2 which is converted to PGE2 and F2a by PG synthetase
COX‐2 is expressed in higher concentration in endometrial implants compared to endometrial cells.
Increased concentration of PGE2 also provides stimulus for estrogen production.
Attia GR, Zeitoun K, Edwards D, et al. Progesterone receptor isoform A but not B is expressed in endometriosis. J Clin Endocrinol Metab. 2000;85:2897–2902.
Bulun SE, Cheng YH, Yin P, et al. Progesterone resistance in endometriosis: link to failure to metabolize estradiol. Mol Cell Endocrinol. 2006; 248:94–103.
• Infertility is proposed to be due to multiple mechanisms• Underlying adhesions
• Ovarian cysts
• Change in tubal anatomy
• Inflammatory mediators that result in suboptimal oocyte and sperm
• Decreased endometrial receptivity
• Decreased ovarian reserve
Endometriosis is hormonal‐dependent(to some extent)
• Estrogen can come from multiple sources• Intrinsic aromatase activity (cholesterol‐estradiol)
• Estradiol from ovary
• Estrone from adipose tissue
Zhao H, Zhou L, Shangguan AJ, et al. Aromatase expression and regulation in breast and endometrial cancer. J Mol Endocrinol. 2016;57:R19–R33.
Summary of medical therapies
Rafique S, Decherney AH. Medical Management of Endometriosis. Clin Obstet Gynecol. 2017;60(3):485‐496.
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Rafique S, Decherney AH. Medical Management of Endometriosis. Clin Obstet Gynecol. 2017;60(3):485‐496.
Does surgery improve symptoms?
• 132 patients with pelvic pain and histologically confirmed DIE• Retrospective analysis• Patients had completed a preop and postop survey (median followup time 3.3 years)
Chopin N, Vieira M, Borghese B, et al. Operative management of deeply infiltrating endometriosis: results on pelvic pain symptoms according to a surgical classification. J Minim Invasive Gynecol. 2005;12(2):106‐12.
Chopin N, Vieira M, Borghese B, et al. Operative management of deeply infiltrating endometriosis: results on pelvic pain symptoms according to a surgical classification. J Minim Invasive Gynecol. 2005;12(2):106‐12.
Chopin N, Vieira M, Borghese B, et al. Operative management of deeply infiltrating endometriosis: results on pelvic pain symptoms according to a surgical classification. J Minim Invasive Gynecol. 2005;12(2):106‐12.
• Prospective observational study• 254 women referred with pelvic pain out of which 216
underwent surgery, and of these 176 had histologically confirmed endometriosis
• Followed between 2 and 5 years
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Long term pain
Improved 67%
Worsened 25%
Unchanged 8% 36%
• Laparoscopic excision significantly reduces pain and improves quality of life and sexual function in women with all stages of endometriosis for up to 5 years
Abbott JA, Hawe J, Clayton RD, Garry R. The effects and effectiveness of laparoscopic excision of endometriosis: a prospective study with 2‐5 year follow‐up. Hum Reprod. 2003;18(9):1922‐7.
Excision or ablation?
Pundir J, Omanwa K, Kovoor E, Pundir V, Lancaster G, Barton‐smith P. Laparoscopic Excision Versus Ablation for Endometriosis‐associated Pain: An Updated Systematic Review and Meta‐analysis. J Minim Invasive Gynecol. 2017;24(5):747‐756.
Dyspareunia
Dyschezia
Chronic pelvic pain
Pundir J, Omanwa K, Kovoor E, Pundir V, Lancaster G, Barton‐smith P. Laparoscopic Excision Versus Ablation for Endometriosis‐associated Pain: An Updated Systematic Review and Meta‐analysis. J Minim Invasive Gynecol. 2017;24(5):747‐756.
Does COMPLETE excision make a difference?
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Complete wComplete w/o Incomplete w/o Incomplete w
Cumulative pain score
• Recurrence rate in women with DIE varies between 2‐43.5%
• 3 risk factors for recurrence identified• Age
• Weight
• Type of surgery
Ianieri MM, Mautone D, Ceccaroni M. Recurrence in Deep Infiltrating Endometriosis: a Systematic Review of the Literature. J Minim Invasive Gynecol. 2018;
Does performing a hysterectomy make a difference?
55.4%46.6%
23%13.4%
8.3%8.3% Excision + Hyst + BSO
Excision + Hyst
Excision
Shakiba K, Bena JF, Mcgill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7‐year follow‐up on the requirement for further surgery. Obstet Gynecol. 2008;111(6):1285‐92.
Who to operate on?
• Patients who decline, do not respond, do not tolerate or have contraindications to medical therapy
• Acute surgical or pain event
• Deep endometriosis
• Concomitant management of disease
• Pelvic pain and desire to conceive
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Is there a role for pre‐operative imaging?
• Basic transvaginal ultrasound important in CPP patient in order to evaluate other sources of discomfort
• Adenomyosis• Adnexal masses • Fibroids
• Focused imaging has the goal of identifying DIE in specific locations in order to counsel patient and plan surgery
• Obliterated cul‐de‐sac (sliding sign)• Nodules in USL (Sensitivity 75%)• Colorectal nodules (Sensitivity 95%)• Bladder nodules
Falcone T, Flyckt R. Clinical Management of Endometriosis. Obstet Gynecol. 2018;131(3):557‐571.
Bowel endometriosis
• Transrectal sonography can diagnose low rectal nodules (below the level of the USLs)
• Can asses infiltration to the muscularis layer but not so good detecting infiltration to submucosal and mucosal layer
• Techniques for removal involve• Shaving of the nodule
• Discoid resection
• Segmental resection
• Women with bowel occlusion of >50% or longer than 2‐3 cm should be scheduled for elective bowel resection
Bowel endometriosis
De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx P. Bowel resection for deep endometriosis: a systematic review. BJOG 2011;118:285–91.
Bladder/ureter endometriosis
• Accuracy of transvaginal ultrasound to detect bladder lesions has been reported as high as 97%
• When an endometriotic nodule of the bladder is suspected, a cystoscopy is performed to rule out a transitional epithelium carcinoma, and measure the distance to ureteral meatus
• Removal of nodules being closer than 2 cm is associated with higher rate of complications, and may require ureteroneocystostomy
• When ureteral involvement is suspected, hydronephrosis must be ruled out
Bladder/ureter endometriosis
• Ureterolysis is adequate for treating ureteral endometriosis
• Ureteral resection is necessary in case of hydroureteronephrosis with intrinsic localization of disease
• Segmental bladder resection represtents standard treatment for vesical endometriosis
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Berlanda N, Vercellini P, Carmignani L, Aimi G, Amicarelli F, Fedele L. Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis. ObstetGynecol Surv 2009;64:830–42.
Incidental appendectomy
Incidental appendectomy
• Majority of recent studies agree that prophylactic/incidental appendectomy during pelvic pain/endometriosis surgery may be worthwhile
• Some form of pathology found in appendix in 10‐30% of cases
Does adjuvant therapy improve outcomes?
• 16 trials included in latest version of meta‐analysis
• There was no evidence of benefit for post‐surgical hormonal suppression of endometriosis compared to surgery alone for the outcomes of pain, disease recurrence or pregnancy rates (RR 0.84, 95% 0.59‐1.18)
Yap C, Furness S, Farquhar C. Pre and post operative medical therapy for endometriosis surgery. Cochrane Database Syst Rev. 2004;(3):CD003678.
HRT after surgery for endometriosis
• Low dose estrogen (0.625 premarin) has minimal impact on disease recurrence
• Studies in patients taking GnRH agonists have demonstrated that pain does not begin until an E2 level of 40pg/mL, which will not be reached with low dose preparations
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Videos
Conclusions
• DIE causes pelvic pain
• Symptoms can orient towards location
• Imaging (ultrasound, etc) can predict more extensive surgery
• Hysterectomy/BSO alone is NOT adequate treatment
• Surgery for endometriosis (complete excision) appears to yield beneficial results
• Excision performs better than ablation
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Step‐wise Strategies to deal with Frozen Pelvis and Deep Infiltrative Endometriosis
Alan LamAssociate Professor, Sydney Medical School, Royal North Shore Hospital
Director, Centre for Advanced Reproductive Endosurgery (CARE)
Past President, Australian Gynaecological Endoscopy& Surgery Society (AGES)
Past Board member, American Association of Gynecologic Laparoscopists (AAGL),
World Endometriosis Society (WES) & International Society Gynecologic Endoscopy (ISGE)
Disclosure
I have no financial relationships to disclose.
Objective
Discuss step by step strategies in dealing with froze pelvis and deep endometriosis.
Deep infiltrative endometriosis, often hidden below thick adhesions of a frozen pelvis, is one of the most difficult surgical procedures which consistently challenge the mind and skills of the most experienced open or endoscopic gynaecologic surgeons.
To deal with this disease entity
Navigate the way into the pelvis through the often grossly distorted anatomy caused by extensive fibrosis
Recognise the variable disease phenotypes
Excise the deeply infiltrative disease to the extent the surgeon feels ‘comfortable’
Prevent and appropriately manage inherent risk of damage to blood vessels, bowels, ureter, bladder and nerves
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Ten step‐wise strategiesTen strategies and pearls
1. Adequate assessment and counselling to define treatment goal(s), benefits and risks before surgery
2. Thorough communication and critical information exchange to colleagues (anaesthetist, colorectal, urological...) to plan procedure beforehand
3. Appropriate selection of energy sources for dissection and haemostasis
4. Routine mobilisation of rectosigmoid adhesions
5. Systematic identification and exposure of the ureters
6. Minimise use of energy when dissecting close to bowels and ureter
7. Limit the extent of bowel and /or urinary tract endometriosis excision to symptomatic, informed patient
8. Competent laparoscopic suturing skills to deal with tissue trauma
9. Multi‐disciplinary team approach to complex cases
10. Thorough post‐op. surveillance, communication and documentation
1. Adequate assessment, counselling and discussion to define treatment goal(s), benefits and risks
1. Adequate assessment, counselling and discussion to define treatment goal(s), benefits and risks
• The ‘Google’ know‐all
• The ‘reluctant’
• The ‘indecisive’
• The ‘chronic pain’
• The ‘infertile’
• The ‘atypical’ cyst
• The ‘repeated’ surgical patient
2. Thorough communication and exchange of information with colleagues before surgery2. Thorough communication and exchange of information with colleagues before surgery
3. Appropriate selection of energy sources for dissection and control of haemostasis
4. Routine mobilisation of rectosigmoid adhesions
5. Systematic exposure and identification of the ureters using knowledge of the pelvic surgical layers
6. Minimise use of energy when dissecting close to bowels and ureter
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7. Limit the extent of bowel and /or urinary tract endometriosis excision to symptomatic, informed patient8. Competent laparoscopic suturing skills to deal with tissue trauma
9. Multi‐disciplinary team (Gyn‐Uro‐Colorectal‐Vascular) Management of a very complex endometriosis
9. Multi‐disciplinary team (Gyn‐Uro‐Colorectal‐Vascular) Management of a very complex endometriosis
10. Thorough postop. surveillance, communication and documentation
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Urinary Endometriosis-
A Surgical Tutorial
Ted Lee, M.D.Director, Minimally Invasive Gynecologic Surgery Magee Womens HospitalUnversity of Pittsburgh Medical Center
I have no financial relationships to disclose.
Disclosure
Discuss anatomy-based principles on surgical management of bladder and ureteralendometriosis.
Objectives
Definition: endometriosis infiltrating detrusor muscle
Bladder Endometriosis
• Similar to other deep infiltrating endometriosis.
• It can be iatrogenic from previous c-sec.
Pathogenesis
• Simple partial cystectomy with two layer closure for bladder dome nodule.
• Ureteral stents are recommended especially for lower nodules.
• Need to develop vesicovaginal space for nodule closer to the vesicouterine junction. Partial resection of myometrium maybe necessary for vesicouterine nodule
• For large defect, retropubic space should be developed for tension free closure.
Surgical Treatment
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• If nodule is close to ureteral orifice, intravesical portion of ureter may be involved. Ureteroneocystostomy may be necessary especially in patients with known hydronephrosis.
• Bladder is backfilled to ensure watertight closure.
• Foley catheter is left in place for 7-10 days. Followed by VCUG.
Surgical Treatment Laparoscopic Treatment of Bladder Endometriosis
Prognosis after Partial Cystectomy for Deep Bladder Endometriosis
• Dome lesions: symptom recurrence 7%, objective recurrence 0% in 3 years.
• Bladder base lesions: symptom recurrence 37%, objective recurrence 26%.
Fedele et al., Fertil Steril June 2005;83: 1729-1733
Symptoms of Ureteral Endometriosis
• Some present with symptoms of acute obstruction. Flank pain in 25%
• Hematuria in 15%
• Asymptomatic in 50%
• Most with symptoms typical for endometriosis in general.
• Secondary hydronephrosis resulted from extrinsic as well as intrinsic obstruction.
• Secondary hydronephrosis resulted from extrinsic as well as intrinsic obstruction.
• Extrinsic lesion 70-80%
• Intrinsic lesion 20-30%.
• Bilateral involvement 12%
• Unilateral involvement 88%.
• Left 83% . Right 5%
Distribution of Ureteral Endometriosis Diagnosis of Ureteral Endometriosis
• Screening renal ultrasound for patients withsuspected endometriosis.
• IVP
• Ureteroscopy
• Endoluminal ultrasound
• Laparoscopy
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• Largely ineffective as fibrosis does not respond to hormonal suppression.
Medical Treatment of Ureteral Endometriosis Surgical Treatment of Ureteral Endometriosis
• Uretolysis followed by double J stent
• Segmental ureteral resection with end to endanastomosis or ureteroneocystotomy with orwithout psoas hitch.
Outcome of Laparoscopic Uretolysis
• 33 patients underwent uretolysis for mod to severe hydronephrosis with median 16 month follow-up.
• Bilateral involvement 12%
• Unilateral involvement 88% with the left ureter involvement in 83%
• Ureteral obstruction recurrence rate 12 %.
Ghezzi et al, Fertil Steril 2006 ;86:418-422
Laparoscopic Treatment for Ureteral Endometriosis.
Laparoscopic Ureteral Reimplantation
• Regardless of types of surgical treatments ( uretolysis, segmental resection anastomosis, ureteroneocystomy), endometriosis should be excised in addition to the treatment of hydronephrosis to ensure pain/symptom relief as well as to minimize the risk of recurrent hydronephrosis.
Surgical Treatment of Ureteral Endometriosis
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• Urinary endometriosis is relatively rare.
• Non specific urinary symptoms maybe present. Most patients have endometriosis elsewhere in the pelvis and presents with typical symptoms of endometriosis.
• High index of suspicion is often required to ensure proper preoperative workup, which is useful for proper inform and consent.
• Initial medical treatment for bladder endometriosis is reasonable after confirmation of diagnosis.
• Most patients responds well to partial cystectomy especially if the nodule is located at the bladder dome.
Summary and Recommendations
• Endometriosis nodule near triagone may requireureteroneocystotomy.
• Screening renal ultrasound in patients with suspected endometriosis is useful to prevent silent loss of renal function.
• Medical treatment of ureteral endometriosis associated with persistent hydronephrosis is largely ineffective.
• The majority of ureteral endometriosis is extrinsic in nature. Uretolysis can be attempted in most patients with hydronephrosis but reparative ureteral surgeries may be required in some.
Summary and Recommendations
1. Fedele L, Bianchi S, Zanconato G, Bergamini V, Berlanda N, Carmignani L. Longterm follow-up after conservative surgery for bladder endometriosis. Fertil Steril 2005;83:1729-1733.
2. Ghezzi F, Cromi A, Bergamini V, Serati M, Sacco A, Mueller MD. Outcome of laparoscopic ureterolysis for ureteral endometriosis. Fertil Steril 2006;86:418-422.
3. Berlanda N, Vercellini P, Fedele L, Endometriosis of theurinary tract, Up to Date, 2015
4. Chamsy D, Lee T, The Use of Barbed Suture for Bladder and Bowel Repair. J Minim Invasive Gynecol 2015; 22:648–652
References
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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%
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