AAGL Global Congress of Minimally Invasive Gynecology 2015

LAS VEGAS – Robot-assisted laparoscopic hysterectomy is just as quick and safe as standard laparoscopic hysterectomy – at least in the hands of an experienced surgeon, according to a surgical trial of 144 women.

The first prospective, randomized trial comparing the two techniques found no differences in operative time, intraoperative complications, postoperative pain, length of stay, or 12-week complications, Dr. Timothy Deimling reported at a meeting sponsored by the AAGL.

Michele Sullivan/Frontline Medical News

He did caution, however, that the single surgeon who performed all of the procedures was highly experienced with robotic surgery, having performed more than 600 cases in his career.

The trial included 144 women who underwent hysterectomy for benign conditions. There were 72 women in each surgical group. They were consented at the time of consult, but not randomized until the morning of surgery, said Dr. Deimling of the Penn State Milton S. Hershey Medical Center, in Hershey, Pa.

There were no significant between-group differences in any of the baseline characteristics, nor in any of the indications for surgery, with one exception: More women in the laparoscopic group had undergone prior cesarean sections (44% vs. 23%).

The primary outcome was mean operative time, which was considered initial incision to closure. This was similar in the robot-assisted and laparoscopic groups (74 vs. 75 minutes).

Secondary outcomes were also similar, including pain, which was scored on a 1-10 scale. The mean score was 3.9 in the laparoscopic group and 3.8 in the robotic group. Likewise length of stay was similar (mean 19.6 vs. 22 hours).

There was one serious intraoperative complication. A patient in the laparoscopic group experienced a ureteral injury after the insertion of the first trocar, which resulted in termination of the surgery. She later had a successful laparoscopic hysterectomy. Postoperative complications were also similar in the two groups.

But it’s unclear if the results are generalizable. Dr. Deimling noted that the single surgeon who performed all the cases was highly experienced in robotic surgery. Additionally, all cases were assisted by a surgical team of nurses and technicians who were highly trained in both laparoscopic and robotic gynecologic surgery.

Dr. Deimling reported having no relevant financial disclosures.

[email protected]

LAS VEGAS – Robot-assisted laparoscopic hysterectomy is just as quick and safe as standard laparoscopic hysterectomy – at least in the hands of an experienced surgeon, according to a surgical trial of 144 women.

The first prospective, randomized trial comparing the two techniques found no differences in operative time, intraoperative complications, postoperative pain, length of stay, or 12-week complications, Dr. Timothy Deimling reported at a meeting sponsored by the AAGL.

Michele Sullivan/Frontline Medical News

He did caution, however, that the single surgeon who performed all of the procedures was highly experienced with robotic surgery, having performed more than 600 cases in his career.

The trial included 144 women who underwent hysterectomy for benign conditions. There were 72 women in each surgical group. They were consented at the time of consult, but not randomized until the morning of surgery, said Dr. Deimling of the Penn State Milton S. Hershey Medical Center, in Hershey, Pa.

There were no significant between-group differences in any of the baseline characteristics, nor in any of the indications for surgery, with one exception: More women in the laparoscopic group had undergone prior cesarean sections (44% vs. 23%).

The primary outcome was mean operative time, which was considered initial incision to closure. This was similar in the robot-assisted and laparoscopic groups (74 vs. 75 minutes).

Secondary outcomes were also similar, including pain, which was scored on a 1-10 scale. The mean score was 3.9 in the laparoscopic group and 3.8 in the robotic group. Likewise length of stay was similar (mean 19.6 vs. 22 hours).

There was one serious intraoperative complication. A patient in the laparoscopic group experienced a ureteral injury after the insertion of the first trocar, which resulted in termination of the surgery. She later had a successful laparoscopic hysterectomy. Postoperative complications were also similar in the two groups.

But it’s unclear if the results are generalizable. Dr. Deimling noted that the single surgeon who performed all the cases was highly experienced in robotic surgery. Additionally, all cases were assisted by a surgical team of nurses and technicians who were highly trained in both laparoscopic and robotic gynecologic surgery.

Dr. Deimling reported having no relevant financial disclosures.

[email protected]

LAS VEGAS – Robot-assisted laparoscopic hysterectomy is just as quick and safe as standard laparoscopic hysterectomy – at least in the hands of an experienced surgeon, according to a surgical trial of 144 women.

The first prospective, randomized trial comparing the two techniques found no differences in operative time, intraoperative complications, postoperative pain, length of stay, or 12-week complications, Dr. Timothy Deimling reported at a meeting sponsored by the AAGL.

Michele Sullivan/Frontline Medical News

He did caution, however, that the single surgeon who performed all of the procedures was highly experienced with robotic surgery, having performed more than 600 cases in his career.

The trial included 144 women who underwent hysterectomy for benign conditions. There were 72 women in each surgical group. They were consented at the time of consult, but not randomized until the morning of surgery, said Dr. Deimling of the Penn State Milton S. Hershey Medical Center, in Hershey, Pa.

There were no significant between-group differences in any of the baseline characteristics, nor in any of the indications for surgery, with one exception: More women in the laparoscopic group had undergone prior cesarean sections (44% vs. 23%).

The primary outcome was mean operative time, which was considered initial incision to closure. This was similar in the robot-assisted and laparoscopic groups (74 vs. 75 minutes).

Secondary outcomes were also similar, including pain, which was scored on a 1-10 scale. The mean score was 3.9 in the laparoscopic group and 3.8 in the robotic group. Likewise length of stay was similar (mean 19.6 vs. 22 hours).

There was one serious intraoperative complication. A patient in the laparoscopic group experienced a ureteral injury after the insertion of the first trocar, which resulted in termination of the surgery. She later had a successful laparoscopic hysterectomy. Postoperative complications were also similar in the two groups.

But it’s unclear if the results are generalizable. Dr. Deimling noted that the single surgeon who performed all the cases was highly experienced in robotic surgery. Additionally, all cases were assisted by a surgical team of nurses and technicians who were highly trained in both laparoscopic and robotic gynecologic surgery.

Dr. Deimling reported having no relevant financial disclosures.

[email protected]

LAS VEGAS – A laparoscopic transversus abdominis plane (TAP) block is easy to learn, quick to perform, and provides effective postoperative analgesia for women undergoing minimally invasive gynecologic surgeries.

TAP blocks are usually done by an anesthesiologist under ultrasound guidance, Dr. Shanti Mohling said at a meeting sponsored by AAGL. But they can also be performed quite efficiently during a laparoscopic procedure using anatomic landmarks.

“All you need to perform this is a knowledge of the anatomy, a beveled needle with tubing, and two syringes with 20-30 cc of analgesic,” said Dr. Mohling of the University of Tennessee, Chattanooga. “It takes about 3 minutes and it’s very time saving, compared to having an anesthesiologist do this with ultrasound guidance.”

She presented a video of her technique, which relies on identification of the lumbar triangle of Petit to deliver a large volume of anesthetic into the transversus abdominis plane – the neurovascular space between the internal oblique and transversus abdominis muscles. The area is of critical importance to pain sensation, she said. “This plane carries the afferent nociceptor nerves for T7-L1, including the ilioinguinal and iliohypogastric nerves.”

The efficacy of a laparoscopically administered TAP block during laparoscopic gynecologic surgery has been demonstrated in several studies, she noted. One – a review of 61 cases of total laparoscopic hysterectomy - found associations between the use of the TAP black and reduced length of stay and lower opioid consumption (Aust N Z J Obstet Gynaecol. 2011 Dec;51[6]:544-7.).

The video described her technique, beginning with identifying the triangle of Petit. “The triangle of Petit is the area formed between the iliac crest inferiorly, the latissimus dorsi posteriorly, and the external oblique anteriorly. Within this triangle, we find perfect access to the transversus abdominis plane.”

Once the triangle is identified, a beveled needle is advanced slowly, “as to appreciate the ‘double pop sensation’ of the needle as it passes the fascia of the external and internal oblique muscles. Laparoscopically, this can be observed,” Dr. Mohling said. “If the needle can be seen just beneath the peritoneum, then it has penetrated too far.”

Once into the space, which can easily accommodate a large volume of fluid, she delivers the anesthetic into the neurovascular plane. “Importantly, the injectate must be of sufficient volume to effectively spread throughout the neurovascular plane. Typically this requires 20-30 cc on each side,” she said.

Long-acting agents like bupivacaine or ropivacaine are preferable. Dr. Mohling uses a solution of 10 cc liposomal bupivacaine; 10 cc 0.25% bupivacaine; and 10 cc normal saline.

As the anesthetic is injected, it’s important to track it visually to assure correct placement, she noted. “The delivery can be noted laparoscopically by watching a bulge spreading beneath the transversus abdominis fascia.”

The potential for complications is low, but these include intraperitoneal injection; abdominal wall or bowel hematoma; transient femoral nerve palsy; and local anesthetic toxicity.

Dr. Mohling is in the process of conducting a randomized controlled trial of 100 women undergoing planned laparoscopic or robotic hysterectomy. They will be assigned to either TAP block with the liposomal bupivacaine solution or to traditional preincisional local anesthetic with bupivacaine alone.

“I believe we should all add this technique to our practice,” she said. “It’s easy and there is an increasing body of evidence supporting these blocks.”

Dr. Mohling reported having no financial disclosures.

[email protected]

LAS VEGAS – A laparoscopic transversus abdominis plane (TAP) block is easy to learn, quick to perform, and provides effective postoperative analgesia for women undergoing minimally invasive gynecologic surgeries.

TAP blocks are usually done by an anesthesiologist under ultrasound guidance, Dr. Shanti Mohling said at a meeting sponsored by AAGL. But they can also be performed quite efficiently during a laparoscopic procedure using anatomic landmarks.

“All you need to perform this is a knowledge of the anatomy, a beveled needle with tubing, and two syringes with 20-30 cc of analgesic,” said Dr. Mohling of the University of Tennessee, Chattanooga. “It takes about 3 minutes and it’s very time saving, compared to having an anesthesiologist do this with ultrasound guidance.”

She presented a video of her technique, which relies on identification of the lumbar triangle of Petit to deliver a large volume of anesthetic into the transversus abdominis plane – the neurovascular space between the internal oblique and transversus abdominis muscles. The area is of critical importance to pain sensation, she said. “This plane carries the afferent nociceptor nerves for T7-L1, including the ilioinguinal and iliohypogastric nerves.”

The efficacy of a laparoscopically administered TAP block during laparoscopic gynecologic surgery has been demonstrated in several studies, she noted. One – a review of 61 cases of total laparoscopic hysterectomy - found associations between the use of the TAP black and reduced length of stay and lower opioid consumption (Aust N Z J Obstet Gynaecol. 2011 Dec;51[6]:544-7.).

The video described her technique, beginning with identifying the triangle of Petit. “The triangle of Petit is the area formed between the iliac crest inferiorly, the latissimus dorsi posteriorly, and the external oblique anteriorly. Within this triangle, we find perfect access to the transversus abdominis plane.”

Once the triangle is identified, a beveled needle is advanced slowly, “as to appreciate the ‘double pop sensation’ of the needle as it passes the fascia of the external and internal oblique muscles. Laparoscopically, this can be observed,” Dr. Mohling said. “If the needle can be seen just beneath the peritoneum, then it has penetrated too far.”

Once into the space, which can easily accommodate a large volume of fluid, she delivers the anesthetic into the neurovascular plane. “Importantly, the injectate must be of sufficient volume to effectively spread throughout the neurovascular plane. Typically this requires 20-30 cc on each side,” she said.

Long-acting agents like bupivacaine or ropivacaine are preferable. Dr. Mohling uses a solution of 10 cc liposomal bupivacaine; 10 cc 0.25% bupivacaine; and 10 cc normal saline.

As the anesthetic is injected, it’s important to track it visually to assure correct placement, she noted. “The delivery can be noted laparoscopically by watching a bulge spreading beneath the transversus abdominis fascia.”

The potential for complications is low, but these include intraperitoneal injection; abdominal wall or bowel hematoma; transient femoral nerve palsy; and local anesthetic toxicity.

Dr. Mohling is in the process of conducting a randomized controlled trial of 100 women undergoing planned laparoscopic or robotic hysterectomy. They will be assigned to either TAP block with the liposomal bupivacaine solution or to traditional preincisional local anesthetic with bupivacaine alone.

“I believe we should all add this technique to our practice,” she said. “It’s easy and there is an increasing body of evidence supporting these blocks.”

Dr. Mohling reported having no financial disclosures.

[email protected]

LAS VEGAS – A laparoscopic transversus abdominis plane (TAP) block is easy to learn, quick to perform, and provides effective postoperative analgesia for women undergoing minimally invasive gynecologic surgeries.

TAP blocks are usually done by an anesthesiologist under ultrasound guidance, Dr. Shanti Mohling said at a meeting sponsored by AAGL. But they can also be performed quite efficiently during a laparoscopic procedure using anatomic landmarks.

“All you need to perform this is a knowledge of the anatomy, a beveled needle with tubing, and two syringes with 20-30 cc of analgesic,” said Dr. Mohling of the University of Tennessee, Chattanooga. “It takes about 3 minutes and it’s very time saving, compared to having an anesthesiologist do this with ultrasound guidance.”

She presented a video of her technique, which relies on identification of the lumbar triangle of Petit to deliver a large volume of anesthetic into the transversus abdominis plane – the neurovascular space between the internal oblique and transversus abdominis muscles. The area is of critical importance to pain sensation, she said. “This plane carries the afferent nociceptor nerves for T7-L1, including the ilioinguinal and iliohypogastric nerves.”

The efficacy of a laparoscopically administered TAP block during laparoscopic gynecologic surgery has been demonstrated in several studies, she noted. One – a review of 61 cases of total laparoscopic hysterectomy - found associations between the use of the TAP black and reduced length of stay and lower opioid consumption (Aust N Z J Obstet Gynaecol. 2011 Dec;51[6]:544-7.).

The video described her technique, beginning with identifying the triangle of Petit. “The triangle of Petit is the area formed between the iliac crest inferiorly, the latissimus dorsi posteriorly, and the external oblique anteriorly. Within this triangle, we find perfect access to the transversus abdominis plane.”

Once the triangle is identified, a beveled needle is advanced slowly, “as to appreciate the ‘double pop sensation’ of the needle as it passes the fascia of the external and internal oblique muscles. Laparoscopically, this can be observed,” Dr. Mohling said. “If the needle can be seen just beneath the peritoneum, then it has penetrated too far.”

Once into the space, which can easily accommodate a large volume of fluid, she delivers the anesthetic into the neurovascular plane. “Importantly, the injectate must be of sufficient volume to effectively spread throughout the neurovascular plane. Typically this requires 20-30 cc on each side,” she said.

Long-acting agents like bupivacaine or ropivacaine are preferable. Dr. Mohling uses a solution of 10 cc liposomal bupivacaine; 10 cc 0.25% bupivacaine; and 10 cc normal saline.

As the anesthetic is injected, it’s important to track it visually to assure correct placement, she noted. “The delivery can be noted laparoscopically by watching a bulge spreading beneath the transversus abdominis fascia.”

The potential for complications is low, but these include intraperitoneal injection; abdominal wall or bowel hematoma; transient femoral nerve palsy; and local anesthetic toxicity.

Dr. Mohling is in the process of conducting a randomized controlled trial of 100 women undergoing planned laparoscopic or robotic hysterectomy. They will be assigned to either TAP block with the liposomal bupivacaine solution or to traditional preincisional local anesthetic with bupivacaine alone.

“I believe we should all add this technique to our practice,” she said. “It’s easy and there is an increasing body of evidence supporting these blocks.”

Dr. Mohling reported having no financial disclosures.

[email protected]

LAS VEGAS – The combination of three-dimensional ultrasound and a graduated intrauterine palpator significantly increased the rate of complete metroplasties in a group of women with unexplained infertility or repeat miscarriage.

The instrument, which is marked in millimeters, allows the surgeon to more accurately gauge how much of a uterine septum is removed during the procedure, as well as approximate the shape of what is left. Combined with transvaginal ultrasound visualization, the technique makes a complete, but not overly aggressive, resection more likely, Dr. Attilio Di Spiezio Sardo said at the meeting sponsored by the AAGL.

“One of man’s dilemmas in everyday life is knowing when to stop,” said Dr. Sardo of the University of Naples “Federico II,” Italy. “The same applies to hysteroscopic metroplasties. We still don’t know where to end the incision in order to avoid complications, significant bleeding, or perforation, and in order to avoid abnormal anatomical results.”

The new data he presented builds on his 2009 work, which used 3-D transvaginal ultrasound as the basis for a new subclassification system for uterine anomalies to be used during in-office hysteroscopy.

The aim of the current study was to assess whether the addition of a 5 French graduated intrauterine palpator could improve the accuracy of hysteroscopic metroplasty, compared with that obtained without the instrument. Anatomic results were assessed by 3-D transvaginal ultrasound and second-look hysteroscopy and classified as complete (residual septum less than 5 mm), suboptimal (residual septum 5 mm-10 mm), or incomplete (residual septum greater than 10 mm).

All procedures were performed with the same initial technique under conscious sedation with a 5 mm hysteroscope and miniaturized 5 French instruments. First, the surgeon used a bipolar electrode to remove three-quarters of the septum. Blunt scissors were then used to refine the septal base.

In the intervention group, however, the intrauterine palpator was used to measure the portion of the remaining septum. The metroplasty was stopped when the intrauterine palpator showed that the resected septum corresponded to the presurgical ultrasonographic measures, and had a fundal notch of 1 cm. In the control group, the procedure was stopped when the tubal ostia were clearly visible on the same line and/or hemorrhage from small myometrial vessels of the fundus occurred.

The mean procedural time was similar in the palpator and control groups (12.6 minutes vs. 11.7 minutes). There was one postsurgical intrauterine adhesion in each group.

There were significantly more complete resections in the palpator group than the control group (71% vs. 41%), although the number of suboptimal resections was similar (28% vs. 20%). There were 12 incomplete resections, all of which were in the control group. There was no correlation between septal length and the completeness of resection, Dr. Sardo added.

The combination of 3-D transvaginal ultrasound and a graduated palpator to physically explore the intrauterine space should help improve outcomes in what can be a frustrating procedure, he said.

“I used to think my metroplasties were perfect, and then I reviewed the videos and ultrasounds and sometimes saw that part of the septum was still there,” Dr. Sardo said. “After endometrial ablation, I think hysteroscopic metroplasty is one of the most frustrating problems” for a gynecologic surgeon.

Dr. Sardo reported having no financial disclosures.

[email protected]

LAS VEGAS – The combination of three-dimensional ultrasound and a graduated intrauterine palpator significantly increased the rate of complete metroplasties in a group of women with unexplained infertility or repeat miscarriage.

The instrument, which is marked in millimeters, allows the surgeon to more accurately gauge how much of a uterine septum is removed during the procedure, as well as approximate the shape of what is left. Combined with transvaginal ultrasound visualization, the technique makes a complete, but not overly aggressive, resection more likely, Dr. Attilio Di Spiezio Sardo said at the meeting sponsored by the AAGL.

“One of man’s dilemmas in everyday life is knowing when to stop,” said Dr. Sardo of the University of Naples “Federico II,” Italy. “The same applies to hysteroscopic metroplasties. We still don’t know where to end the incision in order to avoid complications, significant bleeding, or perforation, and in order to avoid abnormal anatomical results.”

The new data he presented builds on his 2009 work, which used 3-D transvaginal ultrasound as the basis for a new subclassification system for uterine anomalies to be used during in-office hysteroscopy.

The aim of the current study was to assess whether the addition of a 5 French graduated intrauterine palpator could improve the accuracy of hysteroscopic metroplasty, compared with that obtained without the instrument. Anatomic results were assessed by 3-D transvaginal ultrasound and second-look hysteroscopy and classified as complete (residual septum less than 5 mm), suboptimal (residual septum 5 mm-10 mm), or incomplete (residual septum greater than 10 mm).

All procedures were performed with the same initial technique under conscious sedation with a 5 mm hysteroscope and miniaturized 5 French instruments. First, the surgeon used a bipolar electrode to remove three-quarters of the septum. Blunt scissors were then used to refine the septal base.

In the intervention group, however, the intrauterine palpator was used to measure the portion of the remaining septum. The metroplasty was stopped when the intrauterine palpator showed that the resected septum corresponded to the presurgical ultrasonographic measures, and had a fundal notch of 1 cm. In the control group, the procedure was stopped when the tubal ostia were clearly visible on the same line and/or hemorrhage from small myometrial vessels of the fundus occurred.

The mean procedural time was similar in the palpator and control groups (12.6 minutes vs. 11.7 minutes). There was one postsurgical intrauterine adhesion in each group.

There were significantly more complete resections in the palpator group than the control group (71% vs. 41%), although the number of suboptimal resections was similar (28% vs. 20%). There were 12 incomplete resections, all of which were in the control group. There was no correlation between septal length and the completeness of resection, Dr. Sardo added.

The combination of 3-D transvaginal ultrasound and a graduated palpator to physically explore the intrauterine space should help improve outcomes in what can be a frustrating procedure, he said.

“I used to think my metroplasties were perfect, and then I reviewed the videos and ultrasounds and sometimes saw that part of the septum was still there,” Dr. Sardo said. “After endometrial ablation, I think hysteroscopic metroplasty is one of the most frustrating problems” for a gynecologic surgeon.

Dr. Sardo reported having no financial disclosures.

[email protected]

LAS VEGAS – The combination of three-dimensional ultrasound and a graduated intrauterine palpator significantly increased the rate of complete metroplasties in a group of women with unexplained infertility or repeat miscarriage.

The instrument, which is marked in millimeters, allows the surgeon to more accurately gauge how much of a uterine septum is removed during the procedure, as well as approximate the shape of what is left. Combined with transvaginal ultrasound visualization, the technique makes a complete, but not overly aggressive, resection more likely, Dr. Attilio Di Spiezio Sardo said at the meeting sponsored by the AAGL.

“One of man’s dilemmas in everyday life is knowing when to stop,” said Dr. Sardo of the University of Naples “Federico II,” Italy. “The same applies to hysteroscopic metroplasties. We still don’t know where to end the incision in order to avoid complications, significant bleeding, or perforation, and in order to avoid abnormal anatomical results.”

The new data he presented builds on his 2009 work, which used 3-D transvaginal ultrasound as the basis for a new subclassification system for uterine anomalies to be used during in-office hysteroscopy.

The aim of the current study was to assess whether the addition of a 5 French graduated intrauterine palpator could improve the accuracy of hysteroscopic metroplasty, compared with that obtained without the instrument. Anatomic results were assessed by 3-D transvaginal ultrasound and second-look hysteroscopy and classified as complete (residual septum less than 5 mm), suboptimal (residual septum 5 mm-10 mm), or incomplete (residual septum greater than 10 mm).

All procedures were performed with the same initial technique under conscious sedation with a 5 mm hysteroscope and miniaturized 5 French instruments. First, the surgeon used a bipolar electrode to remove three-quarters of the septum. Blunt scissors were then used to refine the septal base.

In the intervention group, however, the intrauterine palpator was used to measure the portion of the remaining septum. The metroplasty was stopped when the intrauterine palpator showed that the resected septum corresponded to the presurgical ultrasonographic measures, and had a fundal notch of 1 cm. In the control group, the procedure was stopped when the tubal ostia were clearly visible on the same line and/or hemorrhage from small myometrial vessels of the fundus occurred.

The mean procedural time was similar in the palpator and control groups (12.6 minutes vs. 11.7 minutes). There was one postsurgical intrauterine adhesion in each group.

There were significantly more complete resections in the palpator group than the control group (71% vs. 41%), although the number of suboptimal resections was similar (28% vs. 20%). There were 12 incomplete resections, all of which were in the control group. There was no correlation between septal length and the completeness of resection, Dr. Sardo added.

The combination of 3-D transvaginal ultrasound and a graduated palpator to physically explore the intrauterine space should help improve outcomes in what can be a frustrating procedure, he said.

“I used to think my metroplasties were perfect, and then I reviewed the videos and ultrasounds and sometimes saw that part of the septum was still there,” Dr. Sardo said. “After endometrial ablation, I think hysteroscopic metroplasty is one of the most frustrating problems” for a gynecologic surgeon.

Dr. Sardo reported having no financial disclosures.

[email protected]

LAS VEGAS – Levonorgestrel and hysterectomy are probably the best treatments for adenomyosis – or at least the most well-supported medical and surgical options.

There are other therapies, Dr. Jason Abbott said at a meeting sponsored by AAGL, but almost every treatment has limited high-quality data.

Hysterectomy cures the problem of pain and uterine bleeding completely with no serious adverse effects. But it’s invasive and irreversible, said Dr. Abbott of the Royal Hospital for Women, Australia. And many women, no matter how bad their symptoms or where they are in their reproductive life, simply don’t want to give up their uterus.

“Hysterectomy, as a therapy for adenomyosis, is beautiful,” Dr. Abbott said. “We love it because it cures the condition – but it’s an end game, for sure.”

Intrauterine levonorgestrel systems are probably the best-supported medical therapy, he said.

“The levonorgestrel intrauterine system does work and there are a number of randomized controlled trials comparing this to hysterectomy,” Dr. Abbott said. “It controls adenomyosis very well, and if you look at iron and anemia outcomes a year after treatment initiation, there is no difference – so that is a very good outcome.”

Levonorgestrel is also fully reversible – a must for women who want to conceive in the future. And it’s cheap, especially compared to surgery.

“Even if you allow for the 18%-20% who won’t like it and have it removed, then there’s a pretty good chance you’ll still come up on the positive side compared to hysterectomy, even if you have to repeat the 5-year course two, three, or four times,” he said.

While there are no economic data comparing it directly to hysterectomy, conclusions can be extrapolated from studies that compared endometrial ablation and the surgery.

“You need a 40% failure of ablation for the levonorgestrel to be less economically effective, because then you are getting into having two procedures,” he said. “With levonorgestrel, we have a much lower 20% failure rate and you’re already starting with a much lower cost. So I would say this is entirely reasonable, and a very good place to start. We should continue to offer this to our patients.”

Dr. Abbott noted other treatment options as well:

• Danazol

“This has been around since the 1970s and it works. But women absolutely hate it. They don’t want to look or sound like a man,” Dr. Abbott said. “It’s fallen pretty much by the wayside and [is] only used when we are absolutely desperate.”

There are, however, data suggesting that contraceptive devices loaded with danazol have much less systemic absorption and can be effective without the androgenic effects. A 2010 case series of 35 infertile women found that both a cervical ring and intrauterine device effected endometrial atrophy but did not inhibit ovulation; 13% of those using the IUD and 66% of those using the ring were able to conceive.

• Gonadotropin-releasing hormone agonists

“These are used for a lot of issues with endometriosis, but there’s only one randomized controlled trial on adenomyosis, which compared it with aromatase inhibitors,” Dr. Abbott said. “Both were effective in reducing the symptoms. Once you induce amenorrhea, you don’t have pain with periods.”

There are also studies comparing GnRH agonists with oral contraceptives in adenomyosis. “They do work equally well, but the problem is these are only short-term studies [6-24 months]. Once you stop, your symptoms do come back, and women could have 10-15 years before menopause stops the problem. So this is a short-term solution to a long-term problem,” he said.

The GnRH agonist side effect profile can be problematic, he added.

• Oral contraceptives

“The pill is fantastic and we all use it to control abnormal bleeding. It’s cheap, and it’s been around forever. However, a lot of women now don’t want to use any hormones in any way, shape, or form. There are also no randomized data for its use in adenomyosis,” Dr. Abbott said. “I think pragmatically, yes, it can give very good symptom control and if there’s no direct evidence against it, what’s the worst that can happen? They don’t like it and then you take them off. I think it’s a perfectly reasonable option.”

• Ablation

There are no randomized data supporting endometrial ablation in adenomyosis. “What we’ve got are the randomized data in studies of abnormal uterine bleeding, which suggest a 25% failure rate,” he said. “I think it’s a reasonable procedure for adenomyosis.”

• Resection

Surgery for adenomyosis is very difficult to perform and carries some not inconsiderable risks. “You’re removing a big chunk of myometrium and you’re never sure if you’re getting it all anyway, so there’s a big chance of persistence and recurrence,” Dr. Abbott said. There’s also the chance that the surgery will introduce abnormal tissue into unaffected myometrium, he added.

And while there aren’t a lot of data out there on obstetric outcomes, the current literature suggests a 2% rate of uterine rupture even before labor and delivery. “But it doesn’t remove the uterus, so that’s something to consider,” he said. “It is an option that’s out there.”

Dr. Abbott reported that he has consulted with Bayer on the Mirena levonorgestrel intrauterine system.

[email protected]

LAS VEGAS – Levonorgestrel and hysterectomy are probably the best treatments for adenomyosis – or at least the most well-supported medical and surgical options.

There are other therapies, Dr. Jason Abbott said at a meeting sponsored by AAGL, but almost every treatment has limited high-quality data.

Hysterectomy cures the problem of pain and uterine bleeding completely with no serious adverse effects. But it’s invasive and irreversible, said Dr. Abbott of the Royal Hospital for Women, Australia. And many women, no matter how bad their symptoms or where they are in their reproductive life, simply don’t want to give up their uterus.

“Hysterectomy, as a therapy for adenomyosis, is beautiful,” Dr. Abbott said. “We love it because it cures the condition – but it’s an end game, for sure.”

Intrauterine levonorgestrel systems are probably the best-supported medical therapy, he said.

“The levonorgestrel intrauterine system does work and there are a number of randomized controlled trials comparing this to hysterectomy,” Dr. Abbott said. “It controls adenomyosis very well, and if you look at iron and anemia outcomes a year after treatment initiation, there is no difference – so that is a very good outcome.”

Levonorgestrel is also fully reversible – a must for women who want to conceive in the future. And it’s cheap, especially compared to surgery.

“Even if you allow for the 18%-20% who won’t like it and have it removed, then there’s a pretty good chance you’ll still come up on the positive side compared to hysterectomy, even if you have to repeat the 5-year course two, three, or four times,” he said.

While there are no economic data comparing it directly to hysterectomy, conclusions can be extrapolated from studies that compared endometrial ablation and the surgery.

“You need a 40% failure of ablation for the levonorgestrel to be less economically effective, because then you are getting into having two procedures,” he said. “With levonorgestrel, we have a much lower 20% failure rate and you’re already starting with a much lower cost. So I would say this is entirely reasonable, and a very good place to start. We should continue to offer this to our patients.”

Dr. Abbott noted other treatment options as well:

• Danazol

“This has been around since the 1970s and it works. But women absolutely hate it. They don’t want to look or sound like a man,” Dr. Abbott said. “It’s fallen pretty much by the wayside and [is] only used when we are absolutely desperate.”

There are, however, data suggesting that contraceptive devices loaded with danazol have much less systemic absorption and can be effective without the androgenic effects. A 2010 case series of 35 infertile women found that both a cervical ring and intrauterine device effected endometrial atrophy but did not inhibit ovulation; 13% of those using the IUD and 66% of those using the ring were able to conceive.

• Gonadotropin-releasing hormone agonists

“These are used for a lot of issues with endometriosis, but there’s only one randomized controlled trial on adenomyosis, which compared it with aromatase inhibitors,” Dr. Abbott said. “Both were effective in reducing the symptoms. Once you induce amenorrhea, you don’t have pain with periods.”

There are also studies comparing GnRH agonists with oral contraceptives in adenomyosis. “They do work equally well, but the problem is these are only short-term studies [6-24 months]. Once you stop, your symptoms do come back, and women could have 10-15 years before menopause stops the problem. So this is a short-term solution to a long-term problem,” he said.

The GnRH agonist side effect profile can be problematic, he added.

• Oral contraceptives

“The pill is fantastic and we all use it to control abnormal bleeding. It’s cheap, and it’s been around forever. However, a lot of women now don’t want to use any hormones in any way, shape, or form. There are also no randomized data for its use in adenomyosis,” Dr. Abbott said. “I think pragmatically, yes, it can give very good symptom control and if there’s no direct evidence against it, what’s the worst that can happen? They don’t like it and then you take them off. I think it’s a perfectly reasonable option.”

• Ablation

There are no randomized data supporting endometrial ablation in adenomyosis. “What we’ve got are the randomized data in studies of abnormal uterine bleeding, which suggest a 25% failure rate,” he said. “I think it’s a reasonable procedure for adenomyosis.”

• Resection

Surgery for adenomyosis is very difficult to perform and carries some not inconsiderable risks. “You’re removing a big chunk of myometrium and you’re never sure if you’re getting it all anyway, so there’s a big chance of persistence and recurrence,” Dr. Abbott said. There’s also the chance that the surgery will introduce abnormal tissue into unaffected myometrium, he added.

And while there aren’t a lot of data out there on obstetric outcomes, the current literature suggests a 2% rate of uterine rupture even before labor and delivery. “But it doesn’t remove the uterus, so that’s something to consider,” he said. “It is an option that’s out there.”

Dr. Abbott reported that he has consulted with Bayer on the Mirena levonorgestrel intrauterine system.

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LAS VEGAS – Levonorgestrel and hysterectomy are probably the best treatments for adenomyosis – or at least the most well-supported medical and surgical options.

There are other therapies, Dr. Jason Abbott said at a meeting sponsored by AAGL, but almost every treatment has limited high-quality data.

Hysterectomy cures the problem of pain and uterine bleeding completely with no serious adverse effects. But it’s invasive and irreversible, said Dr. Abbott of the Royal Hospital for Women, Australia. And many women, no matter how bad their symptoms or where they are in their reproductive life, simply don’t want to give up their uterus.

“Hysterectomy, as a therapy for adenomyosis, is beautiful,” Dr. Abbott said. “We love it because it cures the condition – but it’s an end game, for sure.”

Intrauterine levonorgestrel systems are probably the best-supported medical therapy, he said.

“The levonorgestrel intrauterine system does work and there are a number of randomized controlled trials comparing this to hysterectomy,” Dr. Abbott said. “It controls adenomyosis very well, and if you look at iron and anemia outcomes a year after treatment initiation, there is no difference – so that is a very good outcome.”

Levonorgestrel is also fully reversible – a must for women who want to conceive in the future. And it’s cheap, especially compared to surgery.

“Even if you allow for the 18%-20% who won’t like it and have it removed, then there’s a pretty good chance you’ll still come up on the positive side compared to hysterectomy, even if you have to repeat the 5-year course two, three, or four times,” he said.

While there are no economic data comparing it directly to hysterectomy, conclusions can be extrapolated from studies that compared endometrial ablation and the surgery.

“You need a 40% failure of ablation for the levonorgestrel to be less economically effective, because then you are getting into having two procedures,” he said. “With levonorgestrel, we have a much lower 20% failure rate and you’re already starting with a much lower cost. So I would say this is entirely reasonable, and a very good place to start. We should continue to offer this to our patients.”

Dr. Abbott noted other treatment options as well:

• Danazol

“This has been around since the 1970s and it works. But women absolutely hate it. They don’t want to look or sound like a man,” Dr. Abbott said. “It’s fallen pretty much by the wayside and [is] only used when we are absolutely desperate.”

There are, however, data suggesting that contraceptive devices loaded with danazol have much less systemic absorption and can be effective without the androgenic effects. A 2010 case series of 35 infertile women found that both a cervical ring and intrauterine device effected endometrial atrophy but did not inhibit ovulation; 13% of those using the IUD and 66% of those using the ring were able to conceive.

• Gonadotropin-releasing hormone agonists

“These are used for a lot of issues with endometriosis, but there’s only one randomized controlled trial on adenomyosis, which compared it with aromatase inhibitors,” Dr. Abbott said. “Both were effective in reducing the symptoms. Once you induce amenorrhea, you don’t have pain with periods.”

There are also studies comparing GnRH agonists with oral contraceptives in adenomyosis. “They do work equally well, but the problem is these are only short-term studies [6-24 months]. Once you stop, your symptoms do come back, and women could have 10-15 years before menopause stops the problem. So this is a short-term solution to a long-term problem,” he said.

The GnRH agonist side effect profile can be problematic, he added.

• Oral contraceptives

“The pill is fantastic and we all use it to control abnormal bleeding. It’s cheap, and it’s been around forever. However, a lot of women now don’t want to use any hormones in any way, shape, or form. There are also no randomized data for its use in adenomyosis,” Dr. Abbott said. “I think pragmatically, yes, it can give very good symptom control and if there’s no direct evidence against it, what’s the worst that can happen? They don’t like it and then you take them off. I think it’s a perfectly reasonable option.”

• Ablation

There are no randomized data supporting endometrial ablation in adenomyosis. “What we’ve got are the randomized data in studies of abnormal uterine bleeding, which suggest a 25% failure rate,” he said. “I think it’s a reasonable procedure for adenomyosis.”

• Resection

Surgery for adenomyosis is very difficult to perform and carries some not inconsiderable risks. “You’re removing a big chunk of myometrium and you’re never sure if you’re getting it all anyway, so there’s a big chance of persistence and recurrence,” Dr. Abbott said. There’s also the chance that the surgery will introduce abnormal tissue into unaffected myometrium, he added.

And while there aren’t a lot of data out there on obstetric outcomes, the current literature suggests a 2% rate of uterine rupture even before labor and delivery. “But it doesn’t remove the uterus, so that’s something to consider,” he said. “It is an option that’s out there.”

Dr. Abbott reported that he has consulted with Bayer on the Mirena levonorgestrel intrauterine system.

[email protected]

LAS VEGAS – Adhesion barriers may cause more problems than they prevent when employed in myomectomy and hysterectomy.

Ileus, fever, hematomas, and even small bowel obstruction occurred significantly more often when the barriers were used in conjunction with those procedures – especially when performed as open surgeries, Dr. François Closon reported at the AAGL Global Congress. And although their use remains relatively small among these patients, it’s been steadily rising since 2003, he said.

“Adhesion barriers are also being used about eight times more often in myomectomies than in hysterectomies, and this seems to be going up every year,” Dr. Closon of McGill University, Montreal, said at the meeting sponsored by AAGL.

His retrospective study drew on the U.S. Healthcare Cost and Utilization Project Nationwide Inpatient Sample, and examined the perioperative outcomes of adhesion barriers among nearly 475,000 women who underwent myomectomy or hysterectomy during 2003-2011. Of these, 9,000 (about 2%) had an adhesion barrier applied during the surgery. There were no significant baseline differences between the groups, except for age. Women in the myomectomy group were younger than those in the hysterectomy group (mean 36 years vs. 46 years). Age, however, was not associated with the use of an adhesion barrier.

Dr. Closon found a significant linear increase in the use of barriers in both procedures over the study period. In hysterectomy, barrier use rose slightly, but significantly, from 0.37% in 2003 to 2% in 2011. The increase was much greater for use in myomectomy, which rose from 3% to 7% during the same period.

Ileus was significantly more common among myomectomies that used the barrier (4% vs. 3%; OR, 1.49). The difference was more pronounced with hysterectomies (5% vs. 2.5%; OR, 1.97).

Small bowel obstruction was rare, but significantly more common in hysterectomies that employed adhesion barriers (0.2% vs. 0.4%; OR, 1.89).

Fever was also significantly more common in both procedures when the barrier was used (myomectomy 4.4% vs. 3%; OR, 1.43; hysterectomy 2.5% vs. 1.6%; OR, 1.65).

“The odds of intra-abdominal hematoma, postoperative pain, and a length of stay of 3 or more days were also significantly higher when an adhesion barrier was applied,” Dr. Closon said.

He reported having no financial disclosures.

[email protected]

LAS VEGAS – Adhesion barriers may cause more problems than they prevent when employed in myomectomy and hysterectomy.

Ileus, fever, hematomas, and even small bowel obstruction occurred significantly more often when the barriers were used in conjunction with those procedures – especially when performed as open surgeries, Dr. François Closon reported at the AAGL Global Congress. And although their use remains relatively small among these patients, it’s been steadily rising since 2003, he said.

“Adhesion barriers are also being used about eight times more often in myomectomies than in hysterectomies, and this seems to be going up every year,” Dr. Closon of McGill University, Montreal, said at the meeting sponsored by AAGL.

His retrospective study drew on the U.S. Healthcare Cost and Utilization Project Nationwide Inpatient Sample, and examined the perioperative outcomes of adhesion barriers among nearly 475,000 women who underwent myomectomy or hysterectomy during 2003-2011. Of these, 9,000 (about 2%) had an adhesion barrier applied during the surgery. There were no significant baseline differences between the groups, except for age. Women in the myomectomy group were younger than those in the hysterectomy group (mean 36 years vs. 46 years). Age, however, was not associated with the use of an adhesion barrier.

Dr. Closon found a significant linear increase in the use of barriers in both procedures over the study period. In hysterectomy, barrier use rose slightly, but significantly, from 0.37% in 2003 to 2% in 2011. The increase was much greater for use in myomectomy, which rose from 3% to 7% during the same period.

Ileus was significantly more common among myomectomies that used the barrier (4% vs. 3%; OR, 1.49). The difference was more pronounced with hysterectomies (5% vs. 2.5%; OR, 1.97).

Small bowel obstruction was rare, but significantly more common in hysterectomies that employed adhesion barriers (0.2% vs. 0.4%; OR, 1.89).

Fever was also significantly more common in both procedures when the barrier was used (myomectomy 4.4% vs. 3%; OR, 1.43; hysterectomy 2.5% vs. 1.6%; OR, 1.65).

“The odds of intra-abdominal hematoma, postoperative pain, and a length of stay of 3 or more days were also significantly higher when an adhesion barrier was applied,” Dr. Closon said.

He reported having no financial disclosures.

[email protected]

LAS VEGAS – Adhesion barriers may cause more problems than they prevent when employed in myomectomy and hysterectomy.

Ileus, fever, hematomas, and even small bowel obstruction occurred significantly more often when the barriers were used in conjunction with those procedures – especially when performed as open surgeries, Dr. François Closon reported at the AAGL Global Congress. And although their use remains relatively small among these patients, it’s been steadily rising since 2003, he said.

“Adhesion barriers are also being used about eight times more often in myomectomies than in hysterectomies, and this seems to be going up every year,” Dr. Closon of McGill University, Montreal, said at the meeting sponsored by AAGL.

His retrospective study drew on the U.S. Healthcare Cost and Utilization Project Nationwide Inpatient Sample, and examined the perioperative outcomes of adhesion barriers among nearly 475,000 women who underwent myomectomy or hysterectomy during 2003-2011. Of these, 9,000 (about 2%) had an adhesion barrier applied during the surgery. There were no significant baseline differences between the groups, except for age. Women in the myomectomy group were younger than those in the hysterectomy group (mean 36 years vs. 46 years). Age, however, was not associated with the use of an adhesion barrier.

Dr. Closon found a significant linear increase in the use of barriers in both procedures over the study period. In hysterectomy, barrier use rose slightly, but significantly, from 0.37% in 2003 to 2% in 2011. The increase was much greater for use in myomectomy, which rose from 3% to 7% during the same period.

Ileus was significantly more common among myomectomies that used the barrier (4% vs. 3%; OR, 1.49). The difference was more pronounced with hysterectomies (5% vs. 2.5%; OR, 1.97).

Small bowel obstruction was rare, but significantly more common in hysterectomies that employed adhesion barriers (0.2% vs. 0.4%; OR, 1.89).

Fever was also significantly more common in both procedures when the barrier was used (myomectomy 4.4% vs. 3%; OR, 1.43; hysterectomy 2.5% vs. 1.6%; OR, 1.65).

“The odds of intra-abdominal hematoma, postoperative pain, and a length of stay of 3 or more days were also significantly higher when an adhesion barrier was applied,” Dr. Closon said.

He reported having no financial disclosures.

[email protected]