Charles E. Miller, MD

Recently, two studies were published addressing the potential association of childhood cancer and assisted reproductive technology. For more than a decade and a half, it has been acknowledged that ART is associated with increased concern both with structural birth defects, as well as imprinting disorders. As both of these issues have been linked to greater cancer risk in children, it is important to decipher the impact of ART on childhood cancer risk.

Published online April 1 in JAMA Pediatrics, the study, “Association of in vitro fertilization [IVF] with childhood cancer in the United States,”¹ by LG Spector et al. looked retrospectively at birth and cancer registries in 14 states with 8 years of data on 275,686 children were conceived via ART through 2013, who were compared with 2,266,847 children selected randomly.

The overall cancer rate per 1,000,000 person-years was low in both groups: 252 for the IVF group and 193 for the control group, for an overall hazard risk of 1.17. Of note, the rate of hepatic tumors was higher among the IVF group than the non-IVF group (18 vs. 5.7; hazard ratio, 2.46). There appeared to be no association with specific IVF treatments, whether children were conceived by donor egg vs. autologous egg; frozen embryos vs. fresh embryos; use of intracytoplasmic sperm injection (ICSI) vs. none; assisted hatching vs. none; and day-3 vs. day-5 transfer. The researchers concluded that the “increased rate of embryonal cancers, particularly hepatic tumors, that could not be attributed to IVF rather than to underlying infertility.”

This first and largest cohort study of association between IVF and the risk of childhood cancer ever published showed little evidence of excess risk of most cancers, including more common cancers such as leukemia.

The authors did note limitations in their study. Mothers who conceived via IVF were more likely to be white, non-Hispanic, more educated, and older. Could this patient population undergoing ART be at greater risk of producing offspring with cancer concerns? If that were the case – and not great risk of childhood cancer in ART, per se – one therefore would extrapolate that couples undergoing ART vs. alternative infertility treatment should not show a treatment-biased risk (i.e., ART vs. non-ART).

This was demonstrated recently in the study, “Risk of cancer in children and young adults conceived by assisted reproductive technology.”² This Dutch historical cohort study with prospective follow-up of a median 21 years evaluated 47,690 live-born children, of which 24,269 were ART conceived, 13,761 naturally conceived, and 9,660 conceived naturally or with fertility drugs but not by ART.

Overall, cancer risk was not increased in ART-conceived children, compared with naturally conceived subfertile women or even the general population. A nonsignificant increased risk was observed in children conceived by ICSI or cryopreservation.

On the basis of these two studies, there appears to be no significant increased risk of cancer in children conceived through fertility treatment, including ART.

Although these studies do not support the conclusion reached by a 2013 meta-analysis of 9 studies that specifically looked at ART and 16 other studies that looked at other types of medically assisted reproduction (such medically assisted reproduction as reproduction achieved through ovulation induction; controlled ovarian stimulation; ovulation triggering; intrauterine, intracervical, or intravaginal insemination) which reported a significant increased risk of overall cancers (1.33), including leukemia, CNS cancer, and neuroblastoma,³ they do agree more closely with two prospective studies conducted in the United Kingdom and Nordic countries.

In the U.K. study,⁴ there was no overall increased risk of cancer associated with ART, but two types of cancer were noted to be higher in the ART-conceived group – hepatoblastoma (3.27 risk) and rhabdomyosarcoma (2.62 risk) – but the absolute risk of these two types of cancer was small in this 17-year study of 106,013 children. This, of course, would be consistent with the JAMA Pediatrics study. In the Nordic study,⁵ similar to the Dutch Study, IVF was not associated with a significant increased risk of cancer (1.08). The Nordic study included 91,796 children born of ART-assisted pregnancies, compared with 358,419 children born after spontaneous conceptions.

The evidence so far shows that there appears to be no significant increased risk of cancer overall associated with fertility treatments, including IVF.
 

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He also is a member of Ob.Gyn. News editorial advisory board. Dr. Miller disclosed that he is president of the Advanced IVF Institute in Park Ridge and Naperville, Ill.

References

1. JAMA Pediatr. 2019 Apr 1. doi: 10.1001/jamapediatrics.2019.0392.

2. Hum Reprod. 2019 Apr 1;34(4):740-50.

3. Fertil Steril. 2013 Jul. doi: 10.1016/j.fertnstert.2013.03.017.

4. N Engl J Med. 2013 Nov 7;369(19):1819-27.

5. Hum Reprod. 2014 Sep;29(9):2050-7.

Recently, two studies were published addressing the potential association of childhood cancer and assisted reproductive technology. For more than a decade and a half, it has been acknowledged that ART is associated with increased concern both with structural birth defects, as well as imprinting disorders. As both of these issues have been linked to greater cancer risk in children, it is important to decipher the impact of ART on childhood cancer risk.

Published online April 1 in JAMA Pediatrics, the study, “Association of in vitro fertilization [IVF] with childhood cancer in the United States,”¹ by LG Spector et al. looked retrospectively at birth and cancer registries in 14 states with 8 years of data on 275,686 children were conceived via ART through 2013, who were compared with 2,266,847 children selected randomly.

The overall cancer rate per 1,000,000 person-years was low in both groups: 252 for the IVF group and 193 for the control group, for an overall hazard risk of 1.17. Of note, the rate of hepatic tumors was higher among the IVF group than the non-IVF group (18 vs. 5.7; hazard ratio, 2.46). There appeared to be no association with specific IVF treatments, whether children were conceived by donor egg vs. autologous egg; frozen embryos vs. fresh embryos; use of intracytoplasmic sperm injection (ICSI) vs. none; assisted hatching vs. none; and day-3 vs. day-5 transfer. The researchers concluded that the “increased rate of embryonal cancers, particularly hepatic tumors, that could not be attributed to IVF rather than to underlying infertility.”

This first and largest cohort study of association between IVF and the risk of childhood cancer ever published showed little evidence of excess risk of most cancers, including more common cancers such as leukemia.

The authors did note limitations in their study. Mothers who conceived via IVF were more likely to be white, non-Hispanic, more educated, and older. Could this patient population undergoing ART be at greater risk of producing offspring with cancer concerns? If that were the case – and not great risk of childhood cancer in ART, per se – one therefore would extrapolate that couples undergoing ART vs. alternative infertility treatment should not show a treatment-biased risk (i.e., ART vs. non-ART).

This was demonstrated recently in the study, “Risk of cancer in children and young adults conceived by assisted reproductive technology.”² This Dutch historical cohort study with prospective follow-up of a median 21 years evaluated 47,690 live-born children, of which 24,269 were ART conceived, 13,761 naturally conceived, and 9,660 conceived naturally or with fertility drugs but not by ART.

Overall, cancer risk was not increased in ART-conceived children, compared with naturally conceived subfertile women or even the general population. A nonsignificant increased risk was observed in children conceived by ICSI or cryopreservation.

On the basis of these two studies, there appears to be no significant increased risk of cancer in children conceived through fertility treatment, including ART.

Although these studies do not support the conclusion reached by a 2013 meta-analysis of 9 studies that specifically looked at ART and 16 other studies that looked at other types of medically assisted reproduction (such medically assisted reproduction as reproduction achieved through ovulation induction; controlled ovarian stimulation; ovulation triggering; intrauterine, intracervical, or intravaginal insemination) which reported a significant increased risk of overall cancers (1.33), including leukemia, CNS cancer, and neuroblastoma,³ they do agree more closely with two prospective studies conducted in the United Kingdom and Nordic countries.

In the U.K. study,⁴ there was no overall increased risk of cancer associated with ART, but two types of cancer were noted to be higher in the ART-conceived group – hepatoblastoma (3.27 risk) and rhabdomyosarcoma (2.62 risk) – but the absolute risk of these two types of cancer was small in this 17-year study of 106,013 children. This, of course, would be consistent with the JAMA Pediatrics study. In the Nordic study,⁵ similar to the Dutch Study, IVF was not associated with a significant increased risk of cancer (1.08). The Nordic study included 91,796 children born of ART-assisted pregnancies, compared with 358,419 children born after spontaneous conceptions.

The evidence so far shows that there appears to be no significant increased risk of cancer overall associated with fertility treatments, including IVF.
 

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He also is a member of Ob.Gyn. News editorial advisory board. Dr. Miller disclosed that he is president of the Advanced IVF Institute in Park Ridge and Naperville, Ill.

References

1. JAMA Pediatr. 2019 Apr 1. doi: 10.1001/jamapediatrics.2019.0392.

2. Hum Reprod. 2019 Apr 1;34(4):740-50.

3. Fertil Steril. 2013 Jul. doi: 10.1016/j.fertnstert.2013.03.017.

4. N Engl J Med. 2013 Nov 7;369(19):1819-27.

5. Hum Reprod. 2014 Sep;29(9):2050-7.

Recently, two studies were published addressing the potential association of childhood cancer and assisted reproductive technology. For more than a decade and a half, it has been acknowledged that ART is associated with increased concern both with structural birth defects, as well as imprinting disorders. As both of these issues have been linked to greater cancer risk in children, it is important to decipher the impact of ART on childhood cancer risk.

Published online April 1 in JAMA Pediatrics, the study, “Association of in vitro fertilization [IVF] with childhood cancer in the United States,”¹ by LG Spector et al. looked retrospectively at birth and cancer registries in 14 states with 8 years of data on 275,686 children were conceived via ART through 2013, who were compared with 2,266,847 children selected randomly.

The overall cancer rate per 1,000,000 person-years was low in both groups: 252 for the IVF group and 193 for the control group, for an overall hazard risk of 1.17. Of note, the rate of hepatic tumors was higher among the IVF group than the non-IVF group (18 vs. 5.7; hazard ratio, 2.46). There appeared to be no association with specific IVF treatments, whether children were conceived by donor egg vs. autologous egg; frozen embryos vs. fresh embryos; use of intracytoplasmic sperm injection (ICSI) vs. none; assisted hatching vs. none; and day-3 vs. day-5 transfer. The researchers concluded that the “increased rate of embryonal cancers, particularly hepatic tumors, that could not be attributed to IVF rather than to underlying infertility.”

This first and largest cohort study of association between IVF and the risk of childhood cancer ever published showed little evidence of excess risk of most cancers, including more common cancers such as leukemia.

The authors did note limitations in their study. Mothers who conceived via IVF were more likely to be white, non-Hispanic, more educated, and older. Could this patient population undergoing ART be at greater risk of producing offspring with cancer concerns? If that were the case – and not great risk of childhood cancer in ART, per se – one therefore would extrapolate that couples undergoing ART vs. alternative infertility treatment should not show a treatment-biased risk (i.e., ART vs. non-ART).

This was demonstrated recently in the study, “Risk of cancer in children and young adults conceived by assisted reproductive technology.”² This Dutch historical cohort study with prospective follow-up of a median 21 years evaluated 47,690 live-born children, of which 24,269 were ART conceived, 13,761 naturally conceived, and 9,660 conceived naturally or with fertility drugs but not by ART.

Overall, cancer risk was not increased in ART-conceived children, compared with naturally conceived subfertile women or even the general population. A nonsignificant increased risk was observed in children conceived by ICSI or cryopreservation.

On the basis of these two studies, there appears to be no significant increased risk of cancer in children conceived through fertility treatment, including ART.

Although these studies do not support the conclusion reached by a 2013 meta-analysis of 9 studies that specifically looked at ART and 16 other studies that looked at other types of medically assisted reproduction (such medically assisted reproduction as reproduction achieved through ovulation induction; controlled ovarian stimulation; ovulation triggering; intrauterine, intracervical, or intravaginal insemination) which reported a significant increased risk of overall cancers (1.33), including leukemia, CNS cancer, and neuroblastoma,³ they do agree more closely with two prospective studies conducted in the United Kingdom and Nordic countries.

In the U.K. study,⁴ there was no overall increased risk of cancer associated with ART, but two types of cancer were noted to be higher in the ART-conceived group – hepatoblastoma (3.27 risk) and rhabdomyosarcoma (2.62 risk) – but the absolute risk of these two types of cancer was small in this 17-year study of 106,013 children. This, of course, would be consistent with the JAMA Pediatrics study. In the Nordic study,⁵ similar to the Dutch Study, IVF was not associated with a significant increased risk of cancer (1.08). The Nordic study included 91,796 children born of ART-assisted pregnancies, compared with 358,419 children born after spontaneous conceptions.

The evidence so far shows that there appears to be no significant increased risk of cancer overall associated with fertility treatments, including IVF.
 

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He also is a member of Ob.Gyn. News editorial advisory board. Dr. Miller disclosed that he is president of the Advanced IVF Institute in Park Ridge and Naperville, Ill.

References

1. JAMA Pediatr. 2019 Apr 1. doi: 10.1001/jamapediatrics.2019.0392.

2. Hum Reprod. 2019 Apr 1;34(4):740-50.

3. Fertil Steril. 2013 Jul. doi: 10.1016/j.fertnstert.2013.03.017.

4. N Engl J Med. 2013 Nov 7;369(19):1819-27.

5. Hum Reprod. 2014 Sep;29(9):2050-7.

Women at high risk of ovarian cancer secondary to genetic predisposition (BRCA gene mutation, Lynch syndrome) still are recommended to undergo bilateral salpingo-oophorectomy after completion of child bearing or by age 40-45 years depending on the specific mutation and family history. For a woman not at risk of hereditary-related ovarian cancer, opportunistic salpingectomy would appear to reduce the risk of ovarian cancer.

Unlike bilateral tubal ligation, which has a greater protective risk of endometrioid and clear-cell carcinoma of the ovary, bilateral salpingectomy appears to further reduce risk of serous carcinoma of the ovaries as well. A Swedish population-based cohort study involving over a quarter of a million women undergoing benign surgery noted a statistically significant decrease in ovarian cancer risk with salpingectomy. The degree of risk reduction was greater when bilateral salpingectomy was performed.¹ Moreover, a Danish case-control study of over 13,000 women with ovarian cancer demonstrated a 42% decrease in epithelial carcinoma risk following bilateral salpingectomy.²

Bilateral salpingectomy does not appear to decrease ovarian function. A study by Venturella et al. that compared 91 women undergoing bilateral salpingectomy with 95 women with mesosalpinx removal within the tubes during salpingectomy observed no significant difference in change of ovarian reserve.³ Moreover, Kotlyar et al. performed a literature review and noted similar findings.⁴ Finally, in another study by Venturella et al. no effects were noted 3-5 years following prophylactic bilateral salpingectomy on ovarian reserve in women undergoing total laparoscopic hysterectomy in their late reproductive years, compared with healthy women with intact uterus and adnexa.⁵

Introduction of opportunistic salpingectomy secondary to potential ovarian cancer reduction has seen increased adoption over the years. A U.S. study of 400,000 hysterectomies performed for benign indications from 1998 to 2011 showed an increased annual rate of bilateral salpingectomy of 8% (1998-2008) and a 24% annual increase (2008-2011).⁶ A retrospective study of 12,143 hysterectomies performed within a large U.S. health care system reported an increased rate of salpingectomy from 15% in 2011 to 45% in 2012 to 73% in 2014.⁷

Given the fact that the American College of Obstetricians and Gynecologists and the AAGL recommend vaginal hysterectomy as the approach of choice when feasible, tips and tricks on opportunistic salpingectomy form an important topic.

For this edition of the Master Class in Gynecologic Surgery, I have enlisted the assistance of Rosanne M. Kho, MD. Dr. Kho’s academic and clinical work focuses on advancing vaginal and minimally invasive surgery. Dr. Kho is a strong advocate of the vaginal approach for benign hysterectomy and is recognized for her passion for bringing vaginal surgery back into the armamentarium of the gynecologic surgeon. Dr. Kho is published in the field of gynecologic surgery, having authored many peer-reviewed manuscripts and book chapters. She is currently an associate editor for the Journal of Minimally Invasive Gynecology (JMIG).

It is truly a pleasure to welcome Dr. Kho to this edition of the Master Class in Gynecologic Surgery.

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He has no disclosures relevant to this Master Class.

References

1. J Natl Cancer Inst. 2015 Jan 27. doi: 10.1093/jnci/dju410.

2. Acta Obstet Gynecol Scand. 2015 Jan;94(1):86-94.

3. Fertil Steril. 2015 Nov;104(5):1332-9.

4. J Minim Invasive Gynecol. 2017 May-Jun;24(4):563-78.

5. J Minim Invasive Gynecol. 2017 Jan 1;24(1):145-50.

6. Am J Obstet Gynecol. 2015 Nov;213(5):713.e1-13.

7. Obstet Gynecol. 2016 Aug;128(2):277-83.

Women at high risk of ovarian cancer secondary to genetic predisposition (BRCA gene mutation, Lynch syndrome) still are recommended to undergo bilateral salpingo-oophorectomy after completion of child bearing or by age 40-45 years depending on the specific mutation and family history. For a woman not at risk of hereditary-related ovarian cancer, opportunistic salpingectomy would appear to reduce the risk of ovarian cancer.

Unlike bilateral tubal ligation, which has a greater protective risk of endometrioid and clear-cell carcinoma of the ovary, bilateral salpingectomy appears to further reduce risk of serous carcinoma of the ovaries as well. A Swedish population-based cohort study involving over a quarter of a million women undergoing benign surgery noted a statistically significant decrease in ovarian cancer risk with salpingectomy. The degree of risk reduction was greater when bilateral salpingectomy was performed.¹ Moreover, a Danish case-control study of over 13,000 women with ovarian cancer demonstrated a 42% decrease in epithelial carcinoma risk following bilateral salpingectomy.²

Bilateral salpingectomy does not appear to decrease ovarian function. A study by Venturella et al. that compared 91 women undergoing bilateral salpingectomy with 95 women with mesosalpinx removal within the tubes during salpingectomy observed no significant difference in change of ovarian reserve.³ Moreover, Kotlyar et al. performed a literature review and noted similar findings.⁴ Finally, in another study by Venturella et al. no effects were noted 3-5 years following prophylactic bilateral salpingectomy on ovarian reserve in women undergoing total laparoscopic hysterectomy in their late reproductive years, compared with healthy women with intact uterus and adnexa.⁵

Introduction of opportunistic salpingectomy secondary to potential ovarian cancer reduction has seen increased adoption over the years. A U.S. study of 400,000 hysterectomies performed for benign indications from 1998 to 2011 showed an increased annual rate of bilateral salpingectomy of 8% (1998-2008) and a 24% annual increase (2008-2011).⁶ A retrospective study of 12,143 hysterectomies performed within a large U.S. health care system reported an increased rate of salpingectomy from 15% in 2011 to 45% in 2012 to 73% in 2014.⁷

Given the fact that the American College of Obstetricians and Gynecologists and the AAGL recommend vaginal hysterectomy as the approach of choice when feasible, tips and tricks on opportunistic salpingectomy form an important topic.

For this edition of the Master Class in Gynecologic Surgery, I have enlisted the assistance of Rosanne M. Kho, MD. Dr. Kho’s academic and clinical work focuses on advancing vaginal and minimally invasive surgery. Dr. Kho is a strong advocate of the vaginal approach for benign hysterectomy and is recognized for her passion for bringing vaginal surgery back into the armamentarium of the gynecologic surgeon. Dr. Kho is published in the field of gynecologic surgery, having authored many peer-reviewed manuscripts and book chapters. She is currently an associate editor for the Journal of Minimally Invasive Gynecology (JMIG).

It is truly a pleasure to welcome Dr. Kho to this edition of the Master Class in Gynecologic Surgery.

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He has no disclosures relevant to this Master Class.

References

1. J Natl Cancer Inst. 2015 Jan 27. doi: 10.1093/jnci/dju410.

2. Acta Obstet Gynecol Scand. 2015 Jan;94(1):86-94.

3. Fertil Steril. 2015 Nov;104(5):1332-9.

4. J Minim Invasive Gynecol. 2017 May-Jun;24(4):563-78.

5. J Minim Invasive Gynecol. 2017 Jan 1;24(1):145-50.

6. Am J Obstet Gynecol. 2015 Nov;213(5):713.e1-13.

7. Obstet Gynecol. 2016 Aug;128(2):277-83.

Women at high risk of ovarian cancer secondary to genetic predisposition (BRCA gene mutation, Lynch syndrome) still are recommended to undergo bilateral salpingo-oophorectomy after completion of child bearing or by age 40-45 years depending on the specific mutation and family history. For a woman not at risk of hereditary-related ovarian cancer, opportunistic salpingectomy would appear to reduce the risk of ovarian cancer.

Unlike bilateral tubal ligation, which has a greater protective risk of endometrioid and clear-cell carcinoma of the ovary, bilateral salpingectomy appears to further reduce risk of serous carcinoma of the ovaries as well. A Swedish population-based cohort study involving over a quarter of a million women undergoing benign surgery noted a statistically significant decrease in ovarian cancer risk with salpingectomy. The degree of risk reduction was greater when bilateral salpingectomy was performed.¹ Moreover, a Danish case-control study of over 13,000 women with ovarian cancer demonstrated a 42% decrease in epithelial carcinoma risk following bilateral salpingectomy.²

Bilateral salpingectomy does not appear to decrease ovarian function. A study by Venturella et al. that compared 91 women undergoing bilateral salpingectomy with 95 women with mesosalpinx removal within the tubes during salpingectomy observed no significant difference in change of ovarian reserve.³ Moreover, Kotlyar et al. performed a literature review and noted similar findings.⁴ Finally, in another study by Venturella et al. no effects were noted 3-5 years following prophylactic bilateral salpingectomy on ovarian reserve in women undergoing total laparoscopic hysterectomy in their late reproductive years, compared with healthy women with intact uterus and adnexa.⁵

Introduction of opportunistic salpingectomy secondary to potential ovarian cancer reduction has seen increased adoption over the years. A U.S. study of 400,000 hysterectomies performed for benign indications from 1998 to 2011 showed an increased annual rate of bilateral salpingectomy of 8% (1998-2008) and a 24% annual increase (2008-2011).⁶ A retrospective study of 12,143 hysterectomies performed within a large U.S. health care system reported an increased rate of salpingectomy from 15% in 2011 to 45% in 2012 to 73% in 2014.⁷

Given the fact that the American College of Obstetricians and Gynecologists and the AAGL recommend vaginal hysterectomy as the approach of choice when feasible, tips and tricks on opportunistic salpingectomy form an important topic.

For this edition of the Master Class in Gynecologic Surgery, I have enlisted the assistance of Rosanne M. Kho, MD. Dr. Kho’s academic and clinical work focuses on advancing vaginal and minimally invasive surgery. Dr. Kho is a strong advocate of the vaginal approach for benign hysterectomy and is recognized for her passion for bringing vaginal surgery back into the armamentarium of the gynecologic surgeon. Dr. Kho is published in the field of gynecologic surgery, having authored many peer-reviewed manuscripts and book chapters. She is currently an associate editor for the Journal of Minimally Invasive Gynecology (JMIG).

It is truly a pleasure to welcome Dr. Kho to this edition of the Master Class in Gynecologic Surgery.

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He has no disclosures relevant to this Master Class.

References

1. J Natl Cancer Inst. 2015 Jan 27. doi: 10.1093/jnci/dju410.

2. Acta Obstet Gynecol Scand. 2015 Jan;94(1):86-94.

3. Fertil Steril. 2015 Nov;104(5):1332-9.

4. J Minim Invasive Gynecol. 2017 May-Jun;24(4):563-78.

5. J Minim Invasive Gynecol. 2017 Jan 1;24(1):145-50.

6. Am J Obstet Gynecol. 2015 Nov;213(5):713.e1-13.

7. Obstet Gynecol. 2016 Aug;128(2):277-83.

With the wax and wane in the popularity of single-port surgery and with the advent of improved instrumentation, minilaparoscopy would appear to be the next long-lasting surgical technique to enhance postsurgical cosmetic appearance. For this reason, it is surprising that the use of minilaparoscopy has not been acknowledged and evaluated as a viable option more often in general surgery and urology. This, despite the fact that the use of this technique in hysterectomy was described nearly 20 years ago.¹

Our minimally invasive gynecologic surgery (MIGS) team has utilized minilaparoscopy for diagnostic laparoscopy, lysis of adhesions, treatment of stage I, II, and occasionally stage III endometriosis, ovarian cystectomy, ureterolysis, presacral neurectomy, and total laparoscopic hysterectomy – as has our guest author Steven McCarus, MD. When performing hysterectomy via minilaparoscopy, our team closes the vaginal cuff laparoscopically, placing the suture transvaginally.

By removing the fibroid via a colpotomy incision, the Italian MIGS surgeon Fabio Ghezzi, MD, is able to perform myomectomy and hysterectomy routinely via minilaparoscopy.² Articles have been published regarding the feasibility of performing minilaparoscopic surgery for both the treatment of benign adnexal mases³ and endometriosis.⁴

Dr. McCarus presents compelling evidence regarding the cosmetic advantage of minilaparoscopy, but the reported impact on pain has been variable: As Alyssa Small Layne et al. states, “Some studies associate minilaparoscopy with decreased pain, whereas others did not find a difference.”⁵ In part, this is attributable to the fact that no matter what technique is performed, the pathology must be excised. However, it is my belief that with improvements in instrumentation – as noted by Dr. McCarus and our collected added experience – the postoperative pain profile for the patient undergoing minilaparoscopy will change dramatically.

For this edition of the Master Class in Gynecologic Surgery, I have enlisted the assistance of Dr. McCarus, who is the chief of gynecological surgery at Florida Hospital Celebration Health, Celebration. With over 25 years of experience, Dr. McCarus is nationally known as a leader in the practice of minimally invasive gynecologic surgery.

It is a pleasure to welcome Dr. McCarus to this edition of the Master Class in Gynecologic Surgery.
 

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He has no disclosures relevant to this Master Class.

References

1. J Am Assoc Gynecol Laparosc. 1999 Feb;6(1):97-100.

2. J Minim Invasive Gynecol. 2011 Jul-Aug;18(4):455-61.

3. J Clin Med Res. 2017 Jul;9(7):613-7.

4. Gynecol Minim Invasive Ther. 2013 Aug;2(3):85-8.

5. Curr Opin Obstet Gynecol. 2016 Aug;28(4):255-60.

With the wax and wane in the popularity of single-port surgery and with the advent of improved instrumentation, minilaparoscopy would appear to be the next long-lasting surgical technique to enhance postsurgical cosmetic appearance. For this reason, it is surprising that the use of minilaparoscopy has not been acknowledged and evaluated as a viable option more often in general surgery and urology. This, despite the fact that the use of this technique in hysterectomy was described nearly 20 years ago.¹

Our minimally invasive gynecologic surgery (MIGS) team has utilized minilaparoscopy for diagnostic laparoscopy, lysis of adhesions, treatment of stage I, II, and occasionally stage III endometriosis, ovarian cystectomy, ureterolysis, presacral neurectomy, and total laparoscopic hysterectomy – as has our guest author Steven McCarus, MD. When performing hysterectomy via minilaparoscopy, our team closes the vaginal cuff laparoscopically, placing the suture transvaginally.

By removing the fibroid via a colpotomy incision, the Italian MIGS surgeon Fabio Ghezzi, MD, is able to perform myomectomy and hysterectomy routinely via minilaparoscopy.² Articles have been published regarding the feasibility of performing minilaparoscopic surgery for both the treatment of benign adnexal mases³ and endometriosis.⁴

Dr. McCarus presents compelling evidence regarding the cosmetic advantage of minilaparoscopy, but the reported impact on pain has been variable: As Alyssa Small Layne et al. states, “Some studies associate minilaparoscopy with decreased pain, whereas others did not find a difference.”⁵ In part, this is attributable to the fact that no matter what technique is performed, the pathology must be excised. However, it is my belief that with improvements in instrumentation – as noted by Dr. McCarus and our collected added experience – the postoperative pain profile for the patient undergoing minilaparoscopy will change dramatically.

For this edition of the Master Class in Gynecologic Surgery, I have enlisted the assistance of Dr. McCarus, who is the chief of gynecological surgery at Florida Hospital Celebration Health, Celebration. With over 25 years of experience, Dr. McCarus is nationally known as a leader in the practice of minimally invasive gynecologic surgery.

It is a pleasure to welcome Dr. McCarus to this edition of the Master Class in Gynecologic Surgery.
 

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He has no disclosures relevant to this Master Class.

References

1. J Am Assoc Gynecol Laparosc. 1999 Feb;6(1):97-100.

2. J Minim Invasive Gynecol. 2011 Jul-Aug;18(4):455-61.

3. J Clin Med Res. 2017 Jul;9(7):613-7.

4. Gynecol Minim Invasive Ther. 2013 Aug;2(3):85-8.

5. Curr Opin Obstet Gynecol. 2016 Aug;28(4):255-60.

With the wax and wane in the popularity of single-port surgery and with the advent of improved instrumentation, minilaparoscopy would appear to be the next long-lasting surgical technique to enhance postsurgical cosmetic appearance. For this reason, it is surprising that the use of minilaparoscopy has not been acknowledged and evaluated as a viable option more often in general surgery and urology. This, despite the fact that the use of this technique in hysterectomy was described nearly 20 years ago.¹

Our minimally invasive gynecologic surgery (MIGS) team has utilized minilaparoscopy for diagnostic laparoscopy, lysis of adhesions, treatment of stage I, II, and occasionally stage III endometriosis, ovarian cystectomy, ureterolysis, presacral neurectomy, and total laparoscopic hysterectomy – as has our guest author Steven McCarus, MD. When performing hysterectomy via minilaparoscopy, our team closes the vaginal cuff laparoscopically, placing the suture transvaginally.

By removing the fibroid via a colpotomy incision, the Italian MIGS surgeon Fabio Ghezzi, MD, is able to perform myomectomy and hysterectomy routinely via minilaparoscopy.² Articles have been published regarding the feasibility of performing minilaparoscopic surgery for both the treatment of benign adnexal mases³ and endometriosis.⁴

Dr. McCarus presents compelling evidence regarding the cosmetic advantage of minilaparoscopy, but the reported impact on pain has been variable: As Alyssa Small Layne et al. states, “Some studies associate minilaparoscopy with decreased pain, whereas others did not find a difference.”⁵ In part, this is attributable to the fact that no matter what technique is performed, the pathology must be excised. However, it is my belief that with improvements in instrumentation – as noted by Dr. McCarus and our collected added experience – the postoperative pain profile for the patient undergoing minilaparoscopy will change dramatically.

For this edition of the Master Class in Gynecologic Surgery, I have enlisted the assistance of Dr. McCarus, who is the chief of gynecological surgery at Florida Hospital Celebration Health, Celebration. With over 25 years of experience, Dr. McCarus is nationally known as a leader in the practice of minimally invasive gynecologic surgery.

It is a pleasure to welcome Dr. McCarus to this edition of the Master Class in Gynecologic Surgery.
 

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He has no disclosures relevant to this Master Class.

References

1. J Am Assoc Gynecol Laparosc. 1999 Feb;6(1):97-100.

2. J Minim Invasive Gynecol. 2011 Jul-Aug;18(4):455-61.

3. J Clin Med Res. 2017 Jul;9(7):613-7.

4. Gynecol Minim Invasive Ther. 2013 Aug;2(3):85-8.

5. Curr Opin Obstet Gynecol. 2016 Aug;28(4):255-60.

Vesicovaginal fistula continues to be the most common form of genitourinary fistula, with resultant diminishment in quality of life secondary to physical and psychosocial distress. While it has been reported that 1 million women in Sub-Saharan Africa have untreated vesicovaginal fistula secondary to obstetric trauma, vesicovaginal fistulas are relatively rare in the United States. Per the United States National Hospital Discharge Survey, in 2007, fewer than 5,000 vesicovaginal fistula repairs were performed out of over 2.3 million procedures involving the female urinary and genital system.

The rarity of the diagnosis is also reflected in data collected from the English National Health Service, where vesicovaginal fistula occurred in 1 in 788 hysterectomies (although more common in radical hysterectomy, at 1 in 87).

In a recent systematic review and meta-analysis on the management of vesicovaginal fistulas in women following benign gynecologic surgery, Bodner-Adler et al. evaluated 282 full-text articles to identify 124 studies for inclusion (PLoS One. 2017 Feb 22;12[2]:e0171554). Only ten studies involved solely conservative management with prolonged bladder drainage. Dismal success was noted: 8%. Surgery was performed in 96.4% of cases (1379/1430); transvaginal in 39%, transabdominal/transvesical in 36%, laparoscopic/robotic approach in 15%, and transabdominal/transvaginal in 3%. Overall success rate in these surgical cases was 97.98% (95% confidence interval, 96.13%-99.29%); with similar procedural success: transvaginal, 89.96%-97.49%; transabdominal/transvesical, 94.55%-99.18%; and laparoscopic/robotic, 96.85%-99.99%. Studies are very limited comparing the various surgical techniques, with only one study comparing transvaginal, transabdominal, and laparoscopic approaches. Interestingly, in this study, the laparoscopic approach was noted to have the least morbidity (Ou CS et al. J Lapraoendosc Adv Surg Tech A. 2004 Feb;14(1):17-21).

For this edition of the Master Class in Gynecologic Surgery, I have enlisted the assistance of Alan D. Garely, MD, FACOG, FACS, of the Icahn School of Medicine at Mount Sinai, New York. Dr. Garely has served on the board of directors for the American Urogynecologic Society, serves as chair of the gynecology and obstetrics advisory board for the American College of Surgeons, and has published numerous papers and book chapters.

It is a pleasure to welcome Dr. Garely to this edition of the Master Class in Gynecologic Surgery.

Dr. Miller is a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL. He has no disclosures related to this column.

Vesicovaginal fistula continues to be the most common form of genitourinary fistula, with resultant diminishment in quality of life secondary to physical and psychosocial distress. While it has been reported that 1 million women in Sub-Saharan Africa have untreated vesicovaginal fistula secondary to obstetric trauma, vesicovaginal fistulas are relatively rare in the United States. Per the United States National Hospital Discharge Survey, in 2007, fewer than 5,000 vesicovaginal fistula repairs were performed out of over 2.3 million procedures involving the female urinary and genital system.

The rarity of the diagnosis is also reflected in data collected from the English National Health Service, where vesicovaginal fistula occurred in 1 in 788 hysterectomies (although more common in radical hysterectomy, at 1 in 87).

In a recent systematic review and meta-analysis on the management of vesicovaginal fistulas in women following benign gynecologic surgery, Bodner-Adler et al. evaluated 282 full-text articles to identify 124 studies for inclusion (PLoS One. 2017 Feb 22;12[2]:e0171554). Only ten studies involved solely conservative management with prolonged bladder drainage. Dismal success was noted: 8%. Surgery was performed in 96.4% of cases (1379/1430); transvaginal in 39%, transabdominal/transvesical in 36%, laparoscopic/robotic approach in 15%, and transabdominal/transvaginal in 3%. Overall success rate in these surgical cases was 97.98% (95% confidence interval, 96.13%-99.29%); with similar procedural success: transvaginal, 89.96%-97.49%; transabdominal/transvesical, 94.55%-99.18%; and laparoscopic/robotic, 96.85%-99.99%. Studies are very limited comparing the various surgical techniques, with only one study comparing transvaginal, transabdominal, and laparoscopic approaches. Interestingly, in this study, the laparoscopic approach was noted to have the least morbidity (Ou CS et al. J Lapraoendosc Adv Surg Tech A. 2004 Feb;14(1):17-21).

For this edition of the Master Class in Gynecologic Surgery, I have enlisted the assistance of Alan D. Garely, MD, FACOG, FACS, of the Icahn School of Medicine at Mount Sinai, New York. Dr. Garely has served on the board of directors for the American Urogynecologic Society, serves as chair of the gynecology and obstetrics advisory board for the American College of Surgeons, and has published numerous papers and book chapters.

It is a pleasure to welcome Dr. Garely to this edition of the Master Class in Gynecologic Surgery.

Dr. Miller is a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL. He has no disclosures related to this column.

Vesicovaginal fistula continues to be the most common form of genitourinary fistula, with resultant diminishment in quality of life secondary to physical and psychosocial distress. While it has been reported that 1 million women in Sub-Saharan Africa have untreated vesicovaginal fistula secondary to obstetric trauma, vesicovaginal fistulas are relatively rare in the United States. Per the United States National Hospital Discharge Survey, in 2007, fewer than 5,000 vesicovaginal fistula repairs were performed out of over 2.3 million procedures involving the female urinary and genital system.

The rarity of the diagnosis is also reflected in data collected from the English National Health Service, where vesicovaginal fistula occurred in 1 in 788 hysterectomies (although more common in radical hysterectomy, at 1 in 87).

In a recent systematic review and meta-analysis on the management of vesicovaginal fistulas in women following benign gynecologic surgery, Bodner-Adler et al. evaluated 282 full-text articles to identify 124 studies for inclusion (PLoS One. 2017 Feb 22;12[2]:e0171554). Only ten studies involved solely conservative management with prolonged bladder drainage. Dismal success was noted: 8%. Surgery was performed in 96.4% of cases (1379/1430); transvaginal in 39%, transabdominal/transvesical in 36%, laparoscopic/robotic approach in 15%, and transabdominal/transvaginal in 3%. Overall success rate in these surgical cases was 97.98% (95% confidence interval, 96.13%-99.29%); with similar procedural success: transvaginal, 89.96%-97.49%; transabdominal/transvesical, 94.55%-99.18%; and laparoscopic/robotic, 96.85%-99.99%. Studies are very limited comparing the various surgical techniques, with only one study comparing transvaginal, transabdominal, and laparoscopic approaches. Interestingly, in this study, the laparoscopic approach was noted to have the least morbidity (Ou CS et al. J Lapraoendosc Adv Surg Tech A. 2004 Feb;14(1):17-21).

For this edition of the Master Class in Gynecologic Surgery, I have enlisted the assistance of Alan D. Garely, MD, FACOG, FACS, of the Icahn School of Medicine at Mount Sinai, New York. Dr. Garely has served on the board of directors for the American Urogynecologic Society, serves as chair of the gynecology and obstetrics advisory board for the American College of Surgeons, and has published numerous papers and book chapters.

It is a pleasure to welcome Dr. Garely to this edition of the Master Class in Gynecologic Surgery.

Dr. Miller is a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL. He has no disclosures related to this column.

The treatment of the rectovaginal endometriotic nodule continues to be controversial. While proponents of “shaving” the nodule are quick to point out that compared with segmental bowel resection, pelvic pain, dyspareunia, dysmenorrhea, and postoperative pregnancy rates are similarly reduced, most comparative studies are retrospective and are not randomized. That is, patients with larger nodules or multifocal disease with deep infiltration into the muscularis layer of the bowel, or involving more than half of the bowel wall circumference, with surrounding severe fibrosis, invariably are more likely to undergo segmental bowel resection. Even with performance of segmental bowel resection to treat more extensive disease, there is a trend toward greater improvement of pain-related symptoms when compared with the “shaving” technique. Furthermore, the risk of rectal recurrence is acknowledged to be greater in patients undergoing endometriotic rectal nodule shaving.

Concern must be raised with segmental bowel resection. Not only is the risk of temporary ileostomy increased, but subsequent anastomotic leakage and rectovaginal fistula is noted in up to 10% of women. Although reduced with nerve sparing techniques, bladder denervation secondary to damage of the parasympathetic plexus causes urinary retention. In a study of 436 cases of laparoscopic colorectal resection, 9.5% presented after 30 days with persistent urinary retention and 4.2% with constipation (Surg Endosc. 2010 Jan;24:63-7).

A highly-regarded lecturer and surgeon, Dr. Lee has taught and performed live surgeries around the world.

Dr. Lee’s practice is entirely dedicated to minimally invasive surgical options for women. He is a firm believer that virtually all benign gynecologic surgical conditions should be treated using a minimally invasive approach. Dr. Lee’s clinical expertise includes minimally invasive surgery for treatments of endometriosis (including severe endometriosis involving bowel, bladder, and ureter); fibroids; abnormal uterine bleeding; urinary incontinence; and pelvic organ prolapse.

It is a great honor for the Master Class in Gynecologic Surgery to have Dr. Lee as guest author for this important area of our surgical arena.

Dr. Miller is a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL.

The treatment of the rectovaginal endometriotic nodule continues to be controversial. While proponents of “shaving” the nodule are quick to point out that compared with segmental bowel resection, pelvic pain, dyspareunia, dysmenorrhea, and postoperative pregnancy rates are similarly reduced, most comparative studies are retrospective and are not randomized. That is, patients with larger nodules or multifocal disease with deep infiltration into the muscularis layer of the bowel, or involving more than half of the bowel wall circumference, with surrounding severe fibrosis, invariably are more likely to undergo segmental bowel resection. Even with performance of segmental bowel resection to treat more extensive disease, there is a trend toward greater improvement of pain-related symptoms when compared with the “shaving” technique. Furthermore, the risk of rectal recurrence is acknowledged to be greater in patients undergoing endometriotic rectal nodule shaving.

Concern must be raised with segmental bowel resection. Not only is the risk of temporary ileostomy increased, but subsequent anastomotic leakage and rectovaginal fistula is noted in up to 10% of women. Although reduced with nerve sparing techniques, bladder denervation secondary to damage of the parasympathetic plexus causes urinary retention. In a study of 436 cases of laparoscopic colorectal resection, 9.5% presented after 30 days with persistent urinary retention and 4.2% with constipation (Surg Endosc. 2010 Jan;24:63-7).

A highly-regarded lecturer and surgeon, Dr. Lee has taught and performed live surgeries around the world.

Dr. Lee’s practice is entirely dedicated to minimally invasive surgical options for women. He is a firm believer that virtually all benign gynecologic surgical conditions should be treated using a minimally invasive approach. Dr. Lee’s clinical expertise includes minimally invasive surgery for treatments of endometriosis (including severe endometriosis involving bowel, bladder, and ureter); fibroids; abnormal uterine bleeding; urinary incontinence; and pelvic organ prolapse.

It is a great honor for the Master Class in Gynecologic Surgery to have Dr. Lee as guest author for this important area of our surgical arena.

Dr. Miller is a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL.

The treatment of the rectovaginal endometriotic nodule continues to be controversial. While proponents of “shaving” the nodule are quick to point out that compared with segmental bowel resection, pelvic pain, dyspareunia, dysmenorrhea, and postoperative pregnancy rates are similarly reduced, most comparative studies are retrospective and are not randomized. That is, patients with larger nodules or multifocal disease with deep infiltration into the muscularis layer of the bowel, or involving more than half of the bowel wall circumference, with surrounding severe fibrosis, invariably are more likely to undergo segmental bowel resection. Even with performance of segmental bowel resection to treat more extensive disease, there is a trend toward greater improvement of pain-related symptoms when compared with the “shaving” technique. Furthermore, the risk of rectal recurrence is acknowledged to be greater in patients undergoing endometriotic rectal nodule shaving.

Concern must be raised with segmental bowel resection. Not only is the risk of temporary ileostomy increased, but subsequent anastomotic leakage and rectovaginal fistula is noted in up to 10% of women. Although reduced with nerve sparing techniques, bladder denervation secondary to damage of the parasympathetic plexus causes urinary retention. In a study of 436 cases of laparoscopic colorectal resection, 9.5% presented after 30 days with persistent urinary retention and 4.2% with constipation (Surg Endosc. 2010 Jan;24:63-7).

A highly-regarded lecturer and surgeon, Dr. Lee has taught and performed live surgeries around the world.

Dr. Lee’s practice is entirely dedicated to minimally invasive surgical options for women. He is a firm believer that virtually all benign gynecologic surgical conditions should be treated using a minimally invasive approach. Dr. Lee’s clinical expertise includes minimally invasive surgery for treatments of endometriosis (including severe endometriosis involving bowel, bladder, and ureter); fibroids; abnormal uterine bleeding; urinary incontinence; and pelvic organ prolapse.

It is a great honor for the Master Class in Gynecologic Surgery to have Dr. Lee as guest author for this important area of our surgical arena.

Dr. Miller is a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL.

While originally pioneered by European anesthesiologists and surgeons in Europe in the 1990s, enhanced recovery after surgery (ERAS) programs, also known as enhanced recovery protocols or fast-track surgery, have now gained popularity across the surgical spectrum within the United States. The goal of these programs is to utilize multidisciplinary and multimodal interventions to minimize the physiologic changes associated with surgery and thereby enhance the perioperative experience – reduced morbidity and mortality, shorter length of stay, less postoperative opioid use, and faster resumption to normal activity, at a decreased cost of care.

1. Enhanced patient education, including managing expectations.

2. Decreased perioperative fasting periods.

3. Blood volume and temperature maintenance intraoperatively.

4. Postoperative mobilization early and often.

5. Multimodal pain relief and nausea/vomiting prophylaxis.

6. Use of postoperative drains and catheters only as long as required.

Today, I have asked Kirsten Sasaki, MD, to discuss some of these ERAS concepts. I have asked Dr. Sasaki to especially focus on decreasing opioid utilization. For a thorough discussion on ERAS recommendations using an evidence-based approach, one can review two excellent papers by Nelson et al. (Gynecol Oncol. 2016 Feb;140[2]:313-22; Gynecol Oncol. 2016 Feb;140[2]:323-32).

Dr. Sasaki completed her internship and residency at Tufts Medical Center, Boston. Dr. Sasaki then went on to become our second fellow at the Fellowship in Minimally Invasive Gynecologic Surgery in affiliation with AAGL and Society of Reproductive Surgeons at Advocate Lutheran General Hospital, Park Ridge, Ill. As a Fellow, Dr. Sasaki was recognized for her excellent teaching and research capabilities. Ultimately, however, it was her tremendous surgical skills and surgical sense that led me to invite her to join my practice in 2014.

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He has no disclosures relevant to this Master Class.

While originally pioneered by European anesthesiologists and surgeons in Europe in the 1990s, enhanced recovery after surgery (ERAS) programs, also known as enhanced recovery protocols or fast-track surgery, have now gained popularity across the surgical spectrum within the United States. The goal of these programs is to utilize multidisciplinary and multimodal interventions to minimize the physiologic changes associated with surgery and thereby enhance the perioperative experience – reduced morbidity and mortality, shorter length of stay, less postoperative opioid use, and faster resumption to normal activity, at a decreased cost of care.

1. Enhanced patient education, including managing expectations.

2. Decreased perioperative fasting periods.

3. Blood volume and temperature maintenance intraoperatively.

4. Postoperative mobilization early and often.

5. Multimodal pain relief and nausea/vomiting prophylaxis.

6. Use of postoperative drains and catheters only as long as required.

Today, I have asked Kirsten Sasaki, MD, to discuss some of these ERAS concepts. I have asked Dr. Sasaki to especially focus on decreasing opioid utilization. For a thorough discussion on ERAS recommendations using an evidence-based approach, one can review two excellent papers by Nelson et al. (Gynecol Oncol. 2016 Feb;140[2]:313-22; Gynecol Oncol. 2016 Feb;140[2]:323-32).

Dr. Sasaki completed her internship and residency at Tufts Medical Center, Boston. Dr. Sasaki then went on to become our second fellow at the Fellowship in Minimally Invasive Gynecologic Surgery in affiliation with AAGL and Society of Reproductive Surgeons at Advocate Lutheran General Hospital, Park Ridge, Ill. As a Fellow, Dr. Sasaki was recognized for her excellent teaching and research capabilities. Ultimately, however, it was her tremendous surgical skills and surgical sense that led me to invite her to join my practice in 2014.

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He has no disclosures relevant to this Master Class.

While originally pioneered by European anesthesiologists and surgeons in Europe in the 1990s, enhanced recovery after surgery (ERAS) programs, also known as enhanced recovery protocols or fast-track surgery, have now gained popularity across the surgical spectrum within the United States. The goal of these programs is to utilize multidisciplinary and multimodal interventions to minimize the physiologic changes associated with surgery and thereby enhance the perioperative experience – reduced morbidity and mortality, shorter length of stay, less postoperative opioid use, and faster resumption to normal activity, at a decreased cost of care.

1. Enhanced patient education, including managing expectations.

2. Decreased perioperative fasting periods.

3. Blood volume and temperature maintenance intraoperatively.

4. Postoperative mobilization early and often.

5. Multimodal pain relief and nausea/vomiting prophylaxis.

6. Use of postoperative drains and catheters only as long as required.

Today, I have asked Kirsten Sasaki, MD, to discuss some of these ERAS concepts. I have asked Dr. Sasaki to especially focus on decreasing opioid utilization. For a thorough discussion on ERAS recommendations using an evidence-based approach, one can review two excellent papers by Nelson et al. (Gynecol Oncol. 2016 Feb;140[2]:313-22; Gynecol Oncol. 2016 Feb;140[2]:323-32).

Dr. Sasaki completed her internship and residency at Tufts Medical Center, Boston. Dr. Sasaki then went on to become our second fellow at the Fellowship in Minimally Invasive Gynecologic Surgery in affiliation with AAGL and Society of Reproductive Surgeons at Advocate Lutheran General Hospital, Park Ridge, Ill. As a Fellow, Dr. Sasaki was recognized for her excellent teaching and research capabilities. Ultimately, however, it was her tremendous surgical skills and surgical sense that led me to invite her to join my practice in 2014.

Dr. Miller is a clinical associate professor at the University of Illinois in Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago and the director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. He has no disclosures relevant to this Master Class.

As a practicing reproductive endocrinologist and minimally invasive gynecologic surgeon, falling reimbursement has become routine. Furthermore, it was disadvantageous to perform in-office procedures while physician reimbursement was similar whether cases were performed in office, the hospital, or a surgery center. Higher procedural costs in the office, including reusable and disposable instrumentation and staffing, actually discouraged the physician who wanted to perform cases in the office, as it led to an overall reduction in reimbursement. Of course, certain outlying procedures have been reimbursed at a far greater rate in office and, as a result, global endometrial ablation and the Essure procedure now are generally performed in office.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He is a consultant for Medtronic.

As a practicing reproductive endocrinologist and minimally invasive gynecologic surgeon, falling reimbursement has become routine. Furthermore, it was disadvantageous to perform in-office procedures while physician reimbursement was similar whether cases were performed in office, the hospital, or a surgery center. Higher procedural costs in the office, including reusable and disposable instrumentation and staffing, actually discouraged the physician who wanted to perform cases in the office, as it led to an overall reduction in reimbursement. Of course, certain outlying procedures have been reimbursed at a far greater rate in office and, as a result, global endometrial ablation and the Essure procedure now are generally performed in office.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He is a consultant for Medtronic.

As a practicing reproductive endocrinologist and minimally invasive gynecologic surgeon, falling reimbursement has become routine. Furthermore, it was disadvantageous to perform in-office procedures while physician reimbursement was similar whether cases were performed in office, the hospital, or a surgery center. Higher procedural costs in the office, including reusable and disposable instrumentation and staffing, actually discouraged the physician who wanted to perform cases in the office, as it led to an overall reduction in reimbursement. Of course, certain outlying procedures have been reimbursed at a far greater rate in office and, as a result, global endometrial ablation and the Essure procedure now are generally performed in office.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He is a consultant for Medtronic.

The first case of diaphragmatic endometriosis was reported by Alan Brews in 1954¹. Unfortunately, no guidelines exist to enhance the recognition and treatment.

Diaphragmatic and thoracic endometriosis often is overlooked by the gynecologist, not only because of lack of appreciation of the symptoms but also because of the failure to properly work-up the patient and evaluate the diaphragm at time of surgery. In a retrospective review of 3,008 patients with pelvic endometriosis published in Surgical Endoscopy in 2013, Marcello Ceccaroni, MD, PhD, and his colleagues found 46 cases (1.53%) with the intraoperative diagnosis of diaphragmatic endometriosis, six with liver involvement. Multiple diaphragmatic endometriosis lesions were seen in 70% of patients and, the vast majority being right-sided lesions (87%), with 11% of cases having bilateral lesions.² While in the study, superficial lesions were generally vaporized using the argon beam coagulator, deep lesions were removed by sharp dissection, highlighting the need to have adequately trained minimally invasive surgeons treating diaphragmatic lesions via incision. If a pneumothorax occurred, and reabsorbable suture was placed after adequate expansion of the lung via positive pressure ventilation and progressive air suctioning with complete evacuation of the pneumothorax prior to the final closure (i.e., a purse string around the suction device), then the integrity of the closure could be proven using a bubble test with 500cc of saline placed at the diaphragm.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He reported having no financial disclosures related to this column.

References

1. Proc R Soc Med. 1954 Jun; 47(6):461-8.

2. Surg Endosc. 2013 Feb;27(2):625-32.

The first case of diaphragmatic endometriosis was reported by Alan Brews in 1954¹. Unfortunately, no guidelines exist to enhance the recognition and treatment.

Diaphragmatic and thoracic endometriosis often is overlooked by the gynecologist, not only because of lack of appreciation of the symptoms but also because of the failure to properly work-up the patient and evaluate the diaphragm at time of surgery. In a retrospective review of 3,008 patients with pelvic endometriosis published in Surgical Endoscopy in 2013, Marcello Ceccaroni, MD, PhD, and his colleagues found 46 cases (1.53%) with the intraoperative diagnosis of diaphragmatic endometriosis, six with liver involvement. Multiple diaphragmatic endometriosis lesions were seen in 70% of patients and, the vast majority being right-sided lesions (87%), with 11% of cases having bilateral lesions.² While in the study, superficial lesions were generally vaporized using the argon beam coagulator, deep lesions were removed by sharp dissection, highlighting the need to have adequately trained minimally invasive surgeons treating diaphragmatic lesions via incision. If a pneumothorax occurred, and reabsorbable suture was placed after adequate expansion of the lung via positive pressure ventilation and progressive air suctioning with complete evacuation of the pneumothorax prior to the final closure (i.e., a purse string around the suction device), then the integrity of the closure could be proven using a bubble test with 500cc of saline placed at the diaphragm.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He reported having no financial disclosures related to this column.

References

1. Proc R Soc Med. 1954 Jun; 47(6):461-8.

2. Surg Endosc. 2013 Feb;27(2):625-32.

The first case of diaphragmatic endometriosis was reported by Alan Brews in 1954¹. Unfortunately, no guidelines exist to enhance the recognition and treatment.

Diaphragmatic and thoracic endometriosis often is overlooked by the gynecologist, not only because of lack of appreciation of the symptoms but also because of the failure to properly work-up the patient and evaluate the diaphragm at time of surgery. In a retrospective review of 3,008 patients with pelvic endometriosis published in Surgical Endoscopy in 2013, Marcello Ceccaroni, MD, PhD, and his colleagues found 46 cases (1.53%) with the intraoperative diagnosis of diaphragmatic endometriosis, six with liver involvement. Multiple diaphragmatic endometriosis lesions were seen in 70% of patients and, the vast majority being right-sided lesions (87%), with 11% of cases having bilateral lesions.² While in the study, superficial lesions were generally vaporized using the argon beam coagulator, deep lesions were removed by sharp dissection, highlighting the need to have adequately trained minimally invasive surgeons treating diaphragmatic lesions via incision. If a pneumothorax occurred, and reabsorbable suture was placed after adequate expansion of the lung via positive pressure ventilation and progressive air suctioning with complete evacuation of the pneumothorax prior to the final closure (i.e., a purse string around the suction device), then the integrity of the closure could be proven using a bubble test with 500cc of saline placed at the diaphragm.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He reported having no financial disclosures related to this column.

References

1. Proc R Soc Med. 1954 Jun; 47(6):461-8.

2. Surg Endosc. 2013 Feb;27(2):625-32.

Despite recent negative lay press and a boxed safety warning from the Food and Drug Administration, Essure tubal microinserts continue to be a popular method of permanent contraception. It is imperative for patients to understand that this method of contraception cannot be reversed, and thereafter, the only method to achieve pregnancy would be via in vitro fertilization. Furthermore, preoperatively, patients must be counseled that placement of the Essure tubal microinserts may be associated with pelvic pain, abnormal bleeding, and even allergic reaction.

Even with our best effort to properly inform our patients as to the risks and benefits of permanent sterilization via Essure tubal microinserts, secondary to undesired side effects, patients desire their removal. This can be a challenging endeavor for the practitioner, especially if the women is not interested in hysterectomy.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He reported having no financial disclosures related to this column.

Despite recent negative lay press and a boxed safety warning from the Food and Drug Administration, Essure tubal microinserts continue to be a popular method of permanent contraception. It is imperative for patients to understand that this method of contraception cannot be reversed, and thereafter, the only method to achieve pregnancy would be via in vitro fertilization. Furthermore, preoperatively, patients must be counseled that placement of the Essure tubal microinserts may be associated with pelvic pain, abnormal bleeding, and even allergic reaction.

Even with our best effort to properly inform our patients as to the risks and benefits of permanent sterilization via Essure tubal microinserts, secondary to undesired side effects, patients desire their removal. This can be a challenging endeavor for the practitioner, especially if the women is not interested in hysterectomy.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He reported having no financial disclosures related to this column.

Despite recent negative lay press and a boxed safety warning from the Food and Drug Administration, Essure tubal microinserts continue to be a popular method of permanent contraception. It is imperative for patients to understand that this method of contraception cannot be reversed, and thereafter, the only method to achieve pregnancy would be via in vitro fertilization. Furthermore, preoperatively, patients must be counseled that placement of the Essure tubal microinserts may be associated with pelvic pain, abnormal bleeding, and even allergic reaction.

Even with our best effort to properly inform our patients as to the risks and benefits of permanent sterilization via Essure tubal microinserts, secondary to undesired side effects, patients desire their removal. This can be a challenging endeavor for the practitioner, especially if the women is not interested in hysterectomy.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He reported having no financial disclosures related to this column.

Chronic pelvic pain continues not only to burden the individual, but society as well.

One in seven women between the ages of 18 and 50 endure chronic pelvic pain; with a lifetime incidence of as high as 33%, according to one Gallup poll. Interstitial cystitis/bladder pain syndrome (IC/BPS) has been estimated to have a prevalence of 850 in 100,000 women and 60 in 100,000 men in self-report studies. The RAND Interstitial Cystitis Epidemiology (RICE) study, a symptoms survey, showed that between 2.7% and 6.5% of women (3.3 to 7.9 million women) in the United States have symptoms consistent with a diagnosis of IC/BPS.

Unfortunately, there is little known about the etiology and pathogenesis of IC/PBS. Moreover, oftentimes, the diagnosis is one of exclusion.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He is an investigator on an interstitial cystitis study sponsored by Allergan.

Chronic pelvic pain continues not only to burden the individual, but society as well.

One in seven women between the ages of 18 and 50 endure chronic pelvic pain; with a lifetime incidence of as high as 33%, according to one Gallup poll. Interstitial cystitis/bladder pain syndrome (IC/BPS) has been estimated to have a prevalence of 850 in 100,000 women and 60 in 100,000 men in self-report studies. The RAND Interstitial Cystitis Epidemiology (RICE) study, a symptoms survey, showed that between 2.7% and 6.5% of women (3.3 to 7.9 million women) in the United States have symptoms consistent with a diagnosis of IC/BPS.

Unfortunately, there is little known about the etiology and pathogenesis of IC/PBS. Moreover, oftentimes, the diagnosis is one of exclusion.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He is an investigator on an interstitial cystitis study sponsored by Allergan.

Chronic pelvic pain continues not only to burden the individual, but society as well.

One in seven women between the ages of 18 and 50 endure chronic pelvic pain; with a lifetime incidence of as high as 33%, according to one Gallup poll. Interstitial cystitis/bladder pain syndrome (IC/BPS) has been estimated to have a prevalence of 850 in 100,000 women and 60 in 100,000 men in self-report studies. The RAND Interstitial Cystitis Epidemiology (RICE) study, a symptoms survey, showed that between 2.7% and 6.5% of women (3.3 to 7.9 million women) in the United States have symptoms consistent with a diagnosis of IC/BPS.

Unfortunately, there is little known about the etiology and pathogenesis of IC/PBS. Moreover, oftentimes, the diagnosis is one of exclusion.

Dr. Miller is clinical associate professor at the University of Illinois at Chicago, and past president of the AAGL. He is a reproductive endocrinologist and minimally invasive gynecologic surgeon in metropolitan Chicago; director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill.; and the medical editor of this column. He is an investigator on an interstitial cystitis study sponsored by Allergan.