OBG Management

Another year brings changes to Current Procedural Terminology (CPT) codes (which are developed and copyrighted by the American Medical Association) in the form of additions and revisions, and payments related to resource-based relative value scale (RBRVS) revisions for selected services. As of January 1, 2018, 2 new Category I codes pertain to laparoscopic treatments for gynecologic cancer, and the 4 existing codes for colporrhaphy have been revised to include cystourethroscopy. New Category III codes include 4 for fetal magnetocardiography and 1 for transvaginal tactile imaging. Medicare also has reevaluated certain relative value units (RVUs) in outpatient and facility settings.

New and revised Category I codes

Laparoscopic treatments for gynecologic cancer. Technologic advances in performing laparoscopic procedures have allowed for more extensive laparoscopic surgery for various gynecologic cancers and, to this end, 2 new codes have been added.

First, a new code was added to capture comprehensive laparoscopic surgical staging for gynecologic cancer. This new code, 38573, Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed, may not be reported with any other code that includes lymphadenectomy, omentectomy, or hysterectomy. It is intended primarily for a stand-alone staging procedure after an initial biopsy shows a gynecologic malignancy such as ovarian cancer. This new code has been valued at 33.59 RVUs.

Second, a new code was added to capture laparoscopic debulking in conjunction with hysterectomy. The new code, 58575, Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed, has been valued at 53.62 RVUs. The open equivalent to this new code is 58953, Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking.

Cystourethroscopy. The revisions involve no longer permitting separate reporting of 52000, Cystourethroscopy (separate procedure), with the colporrhaphy codes 57240−57265. The rationale behind this change was that surgeons were routinely performing cystoscopy at the time of these procedures and therefore it should become part of the surgical procedure. Currently the Medicare National Correct Coding Initiative (NCCI) bundles 52000 with these 4 codes, but only code 57250 allows for the use of a modifier -59 to bypass the edit if the purpose of the cystoscopy was evaluation of a distinct complaint or problem (such as evaluating patient-expressed urinary symptoms prior to the surgery that were investigated at the time of the prolapse surgery). When codes 57240, 57260, or 57265 are billed along with 52000, the cystoscopy will be denied and a modifier -59 cannot be reported to bypass this edit.

New Category III codes

The new Category III codes represent emerging technology, and it is important to report them, rather than an unlisted code, if the procedures described are performed so that data can be collected for later consideration to make these Category I CPT codes. Since these codes are not assigned relative values, the provider will need to let the payer know which existing CPT Category I code most closely represents the work involved.

Fetal magnetocardiography. The new Category III codes for fetal magnetocardiography describe essentially a fetal electrocardiogram (ECG) that would be performed to assess fetal arrhythmias by placing up to 3 leads on the mother’s abdomen. Possible comparison codes for physician work might include 59050, fetal monitoring by consultant during labor; 93000−93010, 12-lead ECG, or 93040−93042, rhythm strip up to 3 leads. However, because the equipment is very expensive, these codes would not capture practice expense and the physician would have to negotiate a reasonable reimbursement level with the payer, if the magnetocardiography was a covered service. The new codes are as follows:

• 0475T, Recording of fetal magnetic cardiac signal using at least 3 channels; patient recording and storage, data scanning with signal extraction, technical analysis and result, as well as supervision, review, and interpretation of report by a physician or other qualified health care professional
• 0476T, Recording of fetal magnetic cardiac signal using at least 3 channels; patient recording, data scanning, with raw electronic signal transfer of data and storage
• 0477T, Recording of fetal magnetic cardiac signal using at least 3 channels; signal extraction, technical analysis, and result.

Transvaginal tactile imaging. The new Category III code, 0487T, Biomechanical mapping, transvaginal, with report, describes the use of a pressure sensor probe inserted into the vaginal canal to measure and collect data on pelvic muscle strength, elasticity, tissue integrity, and tone. These data produce images in real time that are mapped to produce a report for physician review, interpretation, and report. The data allow quantification of pelvic floor dysfunction and may be useful in determining the most appropriate treatment (whether surgical or medical) for this gynecologic condition. The procedure uses a transvaginal probe like an ultrasound, so using 76830, transvaginal ultrasound, would not be unreasonable as a comparison code as a start.

Medicare relative value changes

Every year, Medicare reevaluates potentially misvalued CPT codes and this year was no exception. The TABLE represents the winners and losers for codes in the outpatient and facility settings that have increased or decreased RVUs by more than 10%.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Another year brings changes to Current Procedural Terminology (CPT) codes (which are developed and copyrighted by the American Medical Association) in the form of additions and revisions, and payments related to resource-based relative value scale (RBRVS) revisions for selected services. As of January 1, 2018, 2 new Category I codes pertain to laparoscopic treatments for gynecologic cancer, and the 4 existing codes for colporrhaphy have been revised to include cystourethroscopy. New Category III codes include 4 for fetal magnetocardiography and 1 for transvaginal tactile imaging. Medicare also has reevaluated certain relative value units (RVUs) in outpatient and facility settings.

New and revised Category I codes

Laparoscopic treatments for gynecologic cancer. Technologic advances in performing laparoscopic procedures have allowed for more extensive laparoscopic surgery for various gynecologic cancers and, to this end, 2 new codes have been added.

First, a new code was added to capture comprehensive laparoscopic surgical staging for gynecologic cancer. This new code, 38573, Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed, may not be reported with any other code that includes lymphadenectomy, omentectomy, or hysterectomy. It is intended primarily for a stand-alone staging procedure after an initial biopsy shows a gynecologic malignancy such as ovarian cancer. This new code has been valued at 33.59 RVUs.

Second, a new code was added to capture laparoscopic debulking in conjunction with hysterectomy. The new code, 58575, Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed, has been valued at 53.62 RVUs. The open equivalent to this new code is 58953, Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking.

Cystourethroscopy. The revisions involve no longer permitting separate reporting of 52000, Cystourethroscopy (separate procedure), with the colporrhaphy codes 57240−57265. The rationale behind this change was that surgeons were routinely performing cystoscopy at the time of these procedures and therefore it should become part of the surgical procedure. Currently the Medicare National Correct Coding Initiative (NCCI) bundles 52000 with these 4 codes, but only code 57250 allows for the use of a modifier -59 to bypass the edit if the purpose of the cystoscopy was evaluation of a distinct complaint or problem (such as evaluating patient-expressed urinary symptoms prior to the surgery that were investigated at the time of the prolapse surgery). When codes 57240, 57260, or 57265 are billed along with 52000, the cystoscopy will be denied and a modifier -59 cannot be reported to bypass this edit.

New Category III codes

The new Category III codes represent emerging technology, and it is important to report them, rather than an unlisted code, if the procedures described are performed so that data can be collected for later consideration to make these Category I CPT codes. Since these codes are not assigned relative values, the provider will need to let the payer know which existing CPT Category I code most closely represents the work involved.

Fetal magnetocardiography. The new Category III codes for fetal magnetocardiography describe essentially a fetal electrocardiogram (ECG) that would be performed to assess fetal arrhythmias by placing up to 3 leads on the mother’s abdomen. Possible comparison codes for physician work might include 59050, fetal monitoring by consultant during labor; 93000−93010, 12-lead ECG, or 93040−93042, rhythm strip up to 3 leads. However, because the equipment is very expensive, these codes would not capture practice expense and the physician would have to negotiate a reasonable reimbursement level with the payer, if the magnetocardiography was a covered service. The new codes are as follows:

• 0475T, Recording of fetal magnetic cardiac signal using at least 3 channels; patient recording and storage, data scanning with signal extraction, technical analysis and result, as well as supervision, review, and interpretation of report by a physician or other qualified health care professional
• 0476T, Recording of fetal magnetic cardiac signal using at least 3 channels; patient recording, data scanning, with raw electronic signal transfer of data and storage
• 0477T, Recording of fetal magnetic cardiac signal using at least 3 channels; signal extraction, technical analysis, and result.

Transvaginal tactile imaging. The new Category III code, 0487T, Biomechanical mapping, transvaginal, with report, describes the use of a pressure sensor probe inserted into the vaginal canal to measure and collect data on pelvic muscle strength, elasticity, tissue integrity, and tone. These data produce images in real time that are mapped to produce a report for physician review, interpretation, and report. The data allow quantification of pelvic floor dysfunction and may be useful in determining the most appropriate treatment (whether surgical or medical) for this gynecologic condition. The procedure uses a transvaginal probe like an ultrasound, so using 76830, transvaginal ultrasound, would not be unreasonable as a comparison code as a start.

Medicare relative value changes

Every year, Medicare reevaluates potentially misvalued CPT codes and this year was no exception. The TABLE represents the winners and losers for codes in the outpatient and facility settings that have increased or decreased RVUs by more than 10%.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Another year brings changes to Current Procedural Terminology (CPT) codes (which are developed and copyrighted by the American Medical Association) in the form of additions and revisions, and payments related to resource-based relative value scale (RBRVS) revisions for selected services. As of January 1, 2018, 2 new Category I codes pertain to laparoscopic treatments for gynecologic cancer, and the 4 existing codes for colporrhaphy have been revised to include cystourethroscopy. New Category III codes include 4 for fetal magnetocardiography and 1 for transvaginal tactile imaging. Medicare also has reevaluated certain relative value units (RVUs) in outpatient and facility settings.

New and revised Category I codes

Laparoscopic treatments for gynecologic cancer. Technologic advances in performing laparoscopic procedures have allowed for more extensive laparoscopic surgery for various gynecologic cancers and, to this end, 2 new codes have been added.

First, a new code was added to capture comprehensive laparoscopic surgical staging for gynecologic cancer. This new code, 38573, Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed, may not be reported with any other code that includes lymphadenectomy, omentectomy, or hysterectomy. It is intended primarily for a stand-alone staging procedure after an initial biopsy shows a gynecologic malignancy such as ovarian cancer. This new code has been valued at 33.59 RVUs.

Second, a new code was added to capture laparoscopic debulking in conjunction with hysterectomy. The new code, 58575, Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed, has been valued at 53.62 RVUs. The open equivalent to this new code is 58953, Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking.

Cystourethroscopy. The revisions involve no longer permitting separate reporting of 52000, Cystourethroscopy (separate procedure), with the colporrhaphy codes 57240−57265. The rationale behind this change was that surgeons were routinely performing cystoscopy at the time of these procedures and therefore it should become part of the surgical procedure. Currently the Medicare National Correct Coding Initiative (NCCI) bundles 52000 with these 4 codes, but only code 57250 allows for the use of a modifier -59 to bypass the edit if the purpose of the cystoscopy was evaluation of a distinct complaint or problem (such as evaluating patient-expressed urinary symptoms prior to the surgery that were investigated at the time of the prolapse surgery). When codes 57240, 57260, or 57265 are billed along with 52000, the cystoscopy will be denied and a modifier -59 cannot be reported to bypass this edit.

New Category III codes

The new Category III codes represent emerging technology, and it is important to report them, rather than an unlisted code, if the procedures described are performed so that data can be collected for later consideration to make these Category I CPT codes. Since these codes are not assigned relative values, the provider will need to let the payer know which existing CPT Category I code most closely represents the work involved.

Fetal magnetocardiography. The new Category III codes for fetal magnetocardiography describe essentially a fetal electrocardiogram (ECG) that would be performed to assess fetal arrhythmias by placing up to 3 leads on the mother’s abdomen. Possible comparison codes for physician work might include 59050, fetal monitoring by consultant during labor; 93000−93010, 12-lead ECG, or 93040−93042, rhythm strip up to 3 leads. However, because the equipment is very expensive, these codes would not capture practice expense and the physician would have to negotiate a reasonable reimbursement level with the payer, if the magnetocardiography was a covered service. The new codes are as follows:

• 0475T, Recording of fetal magnetic cardiac signal using at least 3 channels; patient recording and storage, data scanning with signal extraction, technical analysis and result, as well as supervision, review, and interpretation of report by a physician or other qualified health care professional
• 0476T, Recording of fetal magnetic cardiac signal using at least 3 channels; patient recording, data scanning, with raw electronic signal transfer of data and storage
• 0477T, Recording of fetal magnetic cardiac signal using at least 3 channels; signal extraction, technical analysis, and result.

Transvaginal tactile imaging. The new Category III code, 0487T, Biomechanical mapping, transvaginal, with report, describes the use of a pressure sensor probe inserted into the vaginal canal to measure and collect data on pelvic muscle strength, elasticity, tissue integrity, and tone. These data produce images in real time that are mapped to produce a report for physician review, interpretation, and report. The data allow quantification of pelvic floor dysfunction and may be useful in determining the most appropriate treatment (whether surgical or medical) for this gynecologic condition. The procedure uses a transvaginal probe like an ultrasound, so using 76830, transvaginal ultrasound, would not be unreasonable as a comparison code as a start.

Medicare relative value changes

Every year, Medicare reevaluates potentially misvalued CPT codes and this year was no exception. The TABLE represents the winners and losers for codes in the outpatient and facility settings that have increased or decreased RVUs by more than 10%.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

3/13/18. DAY 3 AT SGS

A busy day gets underway

During a busy morning scientific session, Dr. Amit Sood (@amitsoodMD) delivered the TeLinde lecture, titled "Building resilience," which he defined as doing well when you should not be doing well. He walked meeting attendees through a few exercises, including practicing morning gratitude and finding curious moments. He received a well-deserved standing ovation.

After a quick lunch, the group reconvened for a riveting panel discussion regarding the future of ObGyn in the session, "What is the future of gynecologic surgery and the subspecialties?" Dr. Eric Sokol moderated the discussion, and the panelists included Dr. Carl Zimmerman representing general gynecology, Dr. Dee Fenner from urogynecology, Dr. Arnold Advincula from minimally invasive gynecologic surgery (MIGS), Dr. Javier Magrina from gynecologic oncology, and Dr. Wilma Larsen representing the American Board of Obstetrics and Gynecology (ABOG). Many opinions were shared, including the possibility of allowing residents to choose a track in obstetrics or gynecology. Clearly there is a lot to explore in the future of our field. As a MIGS fellow, it was great to hear Dr. Advincula define our specialty as "non-malignant, advanced pelvic surgery."

The FMIGS Young Alumni Network then met to hear Dr. Samar Nahas give a talk on "Life as you see it, from all the struggles to all the success." She gave an inspiring overview of her life and encouraged those in attendance to keep searching for their next goal in life, whether it be academic, career-related, family, or personal.

Taking in Orlando sun and fun

The afternoon was free for leisure, and many meeting attendees took advantage of the activities offered, including a golf tournament as well as ziplining at nearby Gatorland. Others, like myself, simply took the opportunity to enjoy the sun and warm weather in Orlando, especially while there was a nor'easter occurring back home.

SGS' Got Talent was the festive evening activity on the agenda, during which a competitive talent show occurred. Attendees were able to vote for their favorites while giving donations to the organization Surgeons Helping Advance Research & Education (SHARE). Highlights included a Disney sing-along and a rousing medley of Michael Jackson songs sung on the kazoo.

See you next year!

Tomorrow is the last day of #SGS2018. I look forward to returning to my MIGS fellowship at Bridgeport Hospital in Bridgeport, Connecticut, and sharing all that I have learned. Thank you to Dr. Nancy Frankel, SGS, and OBG Management and all the sponsors supporting the Fellow Scholar program for allowing us trainees to take part in this excellent conference! I am looking forward to #SGS2019 in Tucson, Arizona.

3/12/18. DAY 2 AT SGS

Something for everyone at Day 2 SGS sessions

This morning’s Scientific Sessions began with the Keynote address by Dr. James Merlino, President and Chief Medical Officer, Strategic Consulting, at Press Ganey, who spoke on “Patient Experience: It Is Not About Making People Happy.” Dr. Merlino opened with a personal anecdote about an experience he had with a poor hospital outcome. He reminded us that showing empathy can make a huge difference in patients’ perspectives on their experience and that “an engaged culture is essential to high performance.” He also emphasized that all physicians are leaders and that our involvement in patient safety and decreasing errors is essential.

Surgeons debate best approach for POP

Another highlight of the Scientific Sessions was the debate moderated by Dr. Peter Rosenblatt on “Optimal Surgical Management of Stage 3 and 4 Pelvic Organ Prolapse.” Drs. Rebecca Rogers, Patrick Culligan, and Vincent Lucente participated. The consensus was that Dr. Rogers won over the crowd, convincing us that native tissue repair is the answer. Excellent job by all the panelists for an informative—and entertaining—debate!

Focus on fellows

Immediately following the third Scientific Session, the fellows convened at the Fellows’ Pelvic Research Network (FPRN)^® meeting. After a quick joint session during which Dr. Donna Mazloomdoost gave an informative talk on the grant process at the National Institute of Child Health and Human Development (NICHD), the MIGS fellows broke out to review projects that are currently recruiting new sites and to hear a new proposal for a collaborative multicenter study.

President’s events

Evening activities included the President’s Awards Ceremony and the President’s Reception. Awards Ceremony notable moments included the “Honor your Mentor” session, during which the honored individuals were each recognized. Dr. Ralph Chesson then received the inaugural “Mentor of the Year” award, to much applause. Fellow/Resident awards were up next. Dr. Christina Jones received the President’s Award–Prize Paper for her oral presentation, “Liposomal bupivacaine efficacy for postoperative pain following posterior vaginal surgery: a randomized, double-blind, placebo-controlled trial.” Congratulations! The day concluded with the President’s Reception, where the food, drink, and conversation were plentiful.

Get appy

Finally, conference attendees were able to plan their meeting on their smartphones using the Event Pilot App, which also had a running Twitter thread under the hashtag #SGS2018. A Twitter scavenger hunt was also underway, with #speculumsunday, #maskmembermonday, and #trocartuesday. During this event attendees are encouraged to find the “object of the day,” Tweet a response to a prompt, and then bring the object to the social media booth to receive a prize.

Stay tuned to @ChrisTierneyMD for more live updates from #SGS2018.

Photo credit: Dr. Mohammad Islam @MoMIGSMD

3/11/18. DAY 1 AT SGS

Good morning from sunny Orlando!

It was a very early morning, due to the conveniently timed daylight savings to start the Annual Scientific Meeting of the Society of Gynecologic Surgeons (SGS). First on the agenda was the postgraduate (PG) course, “Endometriosis: Contemporary Approaches to Diagnosis and Treatment” led by Dr. Rosanne Kho. Excellent talks were given and reminded us that, as a specialty, we have made great strides in advancing the diagnosis and treatment of endometriosis. Nevertheless, there is much work to be done in developing a better classification system, including identifying markers that can help stratify the extent of disease.

A highlight was a question from the audience regarding the important facets of a physical exam in diagnosing deep endometriosis. Dr. Mauricio Abrao reviewed his strategy, which included palpating for adnexal masses, pain, or nodules in the cul-de-sac and evaluating trigger points along the psoas muscle. Dr. Scott Young, a radiologist, then provided some key signs to look for in pelvic magnetic resonance imaging and endovaginal ultrasound in diagnosing deep endometriosis. He reminded all of us that a partnership with an excellent radiology department is key in diagnosing and treating deep endometriosis effectively. Dr. Tommaso Falcone then gave an excellent overview of anatomy in relation to deep endometriosis, teaching us all about the different layers of the retroperitoneum.

An afternoon of simulation

After a quick break, it was on to the next course: “Train the Trainer: Comprehensive Hysterectomy Simulation Course for Educators.” Dr. Christine Vaccaro headed this interactive session, and started us off with a reminder that “simulation is the future, and we need to jump on board!” Unfortunately for trainees, the overall number of hysterectomies performed during residency are decreasing secondary to medical management available for abnormal uterine bleeding and the fact that the 4 years of ObGyn residency have a heavy focus on obstetrics. Therefore, it was great to hear Dr. Vaccaro say that the American Board of Obstetrics and Gynecology (ABOG) is requiring Fundamentals of Laparoscopic Surgery (FLSTM) training for those seeking board certification. Attendees of this session included a combination of trainers and trainees, so to speak, and we took turns rotating around models for abdominal, vaginal, laparoscopic, and robotic hysterectomies. I took the opportunity to learn some tips and tricks from experts like Dr. Ernie Lockrow during a simulated laparoscopic myomectomy, in which the struggle felt very real.

Mix and mingle

Other PG courses offered and attended throughout the day included: “Surgical Coding: Working through the Entire Procedure,” “Variations in the Management of the Vaginal Apex during Reconstructive Pelvic Surgery,” Gynecologic Care of Girls and Young Women Born with Urogenital Anomalies,” and “Social Media, Medicine and your Digital Footprint.” SGS Fellow Scholars were then invited to the “Senior Members Engaging Young Learners” event, designed to connect senior SGS members with residents and fellows. Here, residents and fellows mingled with distinguished faculty, many of them with red badges on their nametags, indicating 20 years of membership with SGS. I learned firsthand that connections are very easy to make in this friendly group, where everyone is willing to introduce you to someone who will help advance your career. After this, we moved straight onto the Welcome Reception, where conversations and connections continued.

I look forward to a full day tomorrow! Stay tuned to @ChrisTierneyMD for live updates from #SGS2018.

3/13/18. DAY 3 AT SGS

A busy day gets underway

During a busy morning scientific session, Dr. Amit Sood (@amitsoodMD) delivered the TeLinde lecture, titled "Building resilience," which he defined as doing well when you should not be doing well. He walked meeting attendees through a few exercises, including practicing morning gratitude and finding curious moments. He received a well-deserved standing ovation.

After a quick lunch, the group reconvened for a riveting panel discussion regarding the future of ObGyn in the session, "What is the future of gynecologic surgery and the subspecialties?" Dr. Eric Sokol moderated the discussion, and the panelists included Dr. Carl Zimmerman representing general gynecology, Dr. Dee Fenner from urogynecology, Dr. Arnold Advincula from minimally invasive gynecologic surgery (MIGS), Dr. Javier Magrina from gynecologic oncology, and Dr. Wilma Larsen representing the American Board of Obstetrics and Gynecology (ABOG). Many opinions were shared, including the possibility of allowing residents to choose a track in obstetrics or gynecology. Clearly there is a lot to explore in the future of our field. As a MIGS fellow, it was great to hear Dr. Advincula define our specialty as "non-malignant, advanced pelvic surgery."

The FMIGS Young Alumni Network then met to hear Dr. Samar Nahas give a talk on "Life as you see it, from all the struggles to all the success." She gave an inspiring overview of her life and encouraged those in attendance to keep searching for their next goal in life, whether it be academic, career-related, family, or personal.

Taking in Orlando sun and fun

The afternoon was free for leisure, and many meeting attendees took advantage of the activities offered, including a golf tournament as well as ziplining at nearby Gatorland. Others, like myself, simply took the opportunity to enjoy the sun and warm weather in Orlando, especially while there was a nor'easter occurring back home.

SGS' Got Talent was the festive evening activity on the agenda, during which a competitive talent show occurred. Attendees were able to vote for their favorites while giving donations to the organization Surgeons Helping Advance Research & Education (SHARE). Highlights included a Disney sing-along and a rousing medley of Michael Jackson songs sung on the kazoo.

See you next year!

Tomorrow is the last day of #SGS2018. I look forward to returning to my MIGS fellowship at Bridgeport Hospital in Bridgeport, Connecticut, and sharing all that I have learned. Thank you to Dr. Nancy Frankel, SGS, and OBG Management and all the sponsors supporting the Fellow Scholar program for allowing us trainees to take part in this excellent conference! I am looking forward to #SGS2019 in Tucson, Arizona.

3/12/18. DAY 2 AT SGS

Something for everyone at Day 2 SGS sessions

This morning’s Scientific Sessions began with the Keynote address by Dr. James Merlino, President and Chief Medical Officer, Strategic Consulting, at Press Ganey, who spoke on “Patient Experience: It Is Not About Making People Happy.” Dr. Merlino opened with a personal anecdote about an experience he had with a poor hospital outcome. He reminded us that showing empathy can make a huge difference in patients’ perspectives on their experience and that “an engaged culture is essential to high performance.” He also emphasized that all physicians are leaders and that our involvement in patient safety and decreasing errors is essential.

Surgeons debate best approach for POP

Another highlight of the Scientific Sessions was the debate moderated by Dr. Peter Rosenblatt on “Optimal Surgical Management of Stage 3 and 4 Pelvic Organ Prolapse.” Drs. Rebecca Rogers, Patrick Culligan, and Vincent Lucente participated. The consensus was that Dr. Rogers won over the crowd, convincing us that native tissue repair is the answer. Excellent job by all the panelists for an informative—and entertaining—debate!

Focus on fellows

Immediately following the third Scientific Session, the fellows convened at the Fellows’ Pelvic Research Network (FPRN)^® meeting. After a quick joint session during which Dr. Donna Mazloomdoost gave an informative talk on the grant process at the National Institute of Child Health and Human Development (NICHD), the MIGS fellows broke out to review projects that are currently recruiting new sites and to hear a new proposal for a collaborative multicenter study.

President’s events

Evening activities included the President’s Awards Ceremony and the President’s Reception. Awards Ceremony notable moments included the “Honor your Mentor” session, during which the honored individuals were each recognized. Dr. Ralph Chesson then received the inaugural “Mentor of the Year” award, to much applause. Fellow/Resident awards were up next. Dr. Christina Jones received the President’s Award–Prize Paper for her oral presentation, “Liposomal bupivacaine efficacy for postoperative pain following posterior vaginal surgery: a randomized, double-blind, placebo-controlled trial.” Congratulations! The day concluded with the President’s Reception, where the food, drink, and conversation were plentiful.

Get appy

Finally, conference attendees were able to plan their meeting on their smartphones using the Event Pilot App, which also had a running Twitter thread under the hashtag #SGS2018. A Twitter scavenger hunt was also underway, with #speculumsunday, #maskmembermonday, and #trocartuesday. During this event attendees are encouraged to find the “object of the day,” Tweet a response to a prompt, and then bring the object to the social media booth to receive a prize.

Stay tuned to @ChrisTierneyMD for more live updates from #SGS2018.

Photo credit: Dr. Mohammad Islam @MoMIGSMD

3/11/18. DAY 1 AT SGS

Good morning from sunny Orlando!

It was a very early morning, due to the conveniently timed daylight savings to start the Annual Scientific Meeting of the Society of Gynecologic Surgeons (SGS). First on the agenda was the postgraduate (PG) course, “Endometriosis: Contemporary Approaches to Diagnosis and Treatment” led by Dr. Rosanne Kho. Excellent talks were given and reminded us that, as a specialty, we have made great strides in advancing the diagnosis and treatment of endometriosis. Nevertheless, there is much work to be done in developing a better classification system, including identifying markers that can help stratify the extent of disease.

A highlight was a question from the audience regarding the important facets of a physical exam in diagnosing deep endometriosis. Dr. Mauricio Abrao reviewed his strategy, which included palpating for adnexal masses, pain, or nodules in the cul-de-sac and evaluating trigger points along the psoas muscle. Dr. Scott Young, a radiologist, then provided some key signs to look for in pelvic magnetic resonance imaging and endovaginal ultrasound in diagnosing deep endometriosis. He reminded all of us that a partnership with an excellent radiology department is key in diagnosing and treating deep endometriosis effectively. Dr. Tommaso Falcone then gave an excellent overview of anatomy in relation to deep endometriosis, teaching us all about the different layers of the retroperitoneum.

An afternoon of simulation

After a quick break, it was on to the next course: “Train the Trainer: Comprehensive Hysterectomy Simulation Course for Educators.” Dr. Christine Vaccaro headed this interactive session, and started us off with a reminder that “simulation is the future, and we need to jump on board!” Unfortunately for trainees, the overall number of hysterectomies performed during residency are decreasing secondary to medical management available for abnormal uterine bleeding and the fact that the 4 years of ObGyn residency have a heavy focus on obstetrics. Therefore, it was great to hear Dr. Vaccaro say that the American Board of Obstetrics and Gynecology (ABOG) is requiring Fundamentals of Laparoscopic Surgery (FLSTM) training for those seeking board certification. Attendees of this session included a combination of trainers and trainees, so to speak, and we took turns rotating around models for abdominal, vaginal, laparoscopic, and robotic hysterectomies. I took the opportunity to learn some tips and tricks from experts like Dr. Ernie Lockrow during a simulated laparoscopic myomectomy, in which the struggle felt very real.

Mix and mingle

Other PG courses offered and attended throughout the day included: “Surgical Coding: Working through the Entire Procedure,” “Variations in the Management of the Vaginal Apex during Reconstructive Pelvic Surgery,” Gynecologic Care of Girls and Young Women Born with Urogenital Anomalies,” and “Social Media, Medicine and your Digital Footprint.” SGS Fellow Scholars were then invited to the “Senior Members Engaging Young Learners” event, designed to connect senior SGS members with residents and fellows. Here, residents and fellows mingled with distinguished faculty, many of them with red badges on their nametags, indicating 20 years of membership with SGS. I learned firsthand that connections are very easy to make in this friendly group, where everyone is willing to introduce you to someone who will help advance your career. After this, we moved straight onto the Welcome Reception, where conversations and connections continued.

I look forward to a full day tomorrow! Stay tuned to @ChrisTierneyMD for live updates from #SGS2018.

3/13/18. DAY 3 AT SGS

A busy day gets underway

During a busy morning scientific session, Dr. Amit Sood (@amitsoodMD) delivered the TeLinde lecture, titled "Building resilience," which he defined as doing well when you should not be doing well. He walked meeting attendees through a few exercises, including practicing morning gratitude and finding curious moments. He received a well-deserved standing ovation.

After a quick lunch, the group reconvened for a riveting panel discussion regarding the future of ObGyn in the session, "What is the future of gynecologic surgery and the subspecialties?" Dr. Eric Sokol moderated the discussion, and the panelists included Dr. Carl Zimmerman representing general gynecology, Dr. Dee Fenner from urogynecology, Dr. Arnold Advincula from minimally invasive gynecologic surgery (MIGS), Dr. Javier Magrina from gynecologic oncology, and Dr. Wilma Larsen representing the American Board of Obstetrics and Gynecology (ABOG). Many opinions were shared, including the possibility of allowing residents to choose a track in obstetrics or gynecology. Clearly there is a lot to explore in the future of our field. As a MIGS fellow, it was great to hear Dr. Advincula define our specialty as "non-malignant, advanced pelvic surgery."

The FMIGS Young Alumni Network then met to hear Dr. Samar Nahas give a talk on "Life as you see it, from all the struggles to all the success." She gave an inspiring overview of her life and encouraged those in attendance to keep searching for their next goal in life, whether it be academic, career-related, family, or personal.

Taking in Orlando sun and fun

The afternoon was free for leisure, and many meeting attendees took advantage of the activities offered, including a golf tournament as well as ziplining at nearby Gatorland. Others, like myself, simply took the opportunity to enjoy the sun and warm weather in Orlando, especially while there was a nor'easter occurring back home.

SGS' Got Talent was the festive evening activity on the agenda, during which a competitive talent show occurred. Attendees were able to vote for their favorites while giving donations to the organization Surgeons Helping Advance Research & Education (SHARE). Highlights included a Disney sing-along and a rousing medley of Michael Jackson songs sung on the kazoo.

See you next year!

Tomorrow is the last day of #SGS2018. I look forward to returning to my MIGS fellowship at Bridgeport Hospital in Bridgeport, Connecticut, and sharing all that I have learned. Thank you to Dr. Nancy Frankel, SGS, and OBG Management and all the sponsors supporting the Fellow Scholar program for allowing us trainees to take part in this excellent conference! I am looking forward to #SGS2019 in Tucson, Arizona.

3/12/18. DAY 2 AT SGS

Something for everyone at Day 2 SGS sessions

This morning’s Scientific Sessions began with the Keynote address by Dr. James Merlino, President and Chief Medical Officer, Strategic Consulting, at Press Ganey, who spoke on “Patient Experience: It Is Not About Making People Happy.” Dr. Merlino opened with a personal anecdote about an experience he had with a poor hospital outcome. He reminded us that showing empathy can make a huge difference in patients’ perspectives on their experience and that “an engaged culture is essential to high performance.” He also emphasized that all physicians are leaders and that our involvement in patient safety and decreasing errors is essential.

Surgeons debate best approach for POP

Another highlight of the Scientific Sessions was the debate moderated by Dr. Peter Rosenblatt on “Optimal Surgical Management of Stage 3 and 4 Pelvic Organ Prolapse.” Drs. Rebecca Rogers, Patrick Culligan, and Vincent Lucente participated. The consensus was that Dr. Rogers won over the crowd, convincing us that native tissue repair is the answer. Excellent job by all the panelists for an informative—and entertaining—debate!

Focus on fellows

Immediately following the third Scientific Session, the fellows convened at the Fellows’ Pelvic Research Network (FPRN)^® meeting. After a quick joint session during which Dr. Donna Mazloomdoost gave an informative talk on the grant process at the National Institute of Child Health and Human Development (NICHD), the MIGS fellows broke out to review projects that are currently recruiting new sites and to hear a new proposal for a collaborative multicenter study.

President’s events

Evening activities included the President’s Awards Ceremony and the President’s Reception. Awards Ceremony notable moments included the “Honor your Mentor” session, during which the honored individuals were each recognized. Dr. Ralph Chesson then received the inaugural “Mentor of the Year” award, to much applause. Fellow/Resident awards were up next. Dr. Christina Jones received the President’s Award–Prize Paper for her oral presentation, “Liposomal bupivacaine efficacy for postoperative pain following posterior vaginal surgery: a randomized, double-blind, placebo-controlled trial.” Congratulations! The day concluded with the President’s Reception, where the food, drink, and conversation were plentiful.

Get appy

Finally, conference attendees were able to plan their meeting on their smartphones using the Event Pilot App, which also had a running Twitter thread under the hashtag #SGS2018. A Twitter scavenger hunt was also underway, with #speculumsunday, #maskmembermonday, and #trocartuesday. During this event attendees are encouraged to find the “object of the day,” Tweet a response to a prompt, and then bring the object to the social media booth to receive a prize.

Stay tuned to @ChrisTierneyMD for more live updates from #SGS2018.

Photo credit: Dr. Mohammad Islam @MoMIGSMD

3/11/18. DAY 1 AT SGS

Good morning from sunny Orlando!

It was a very early morning, due to the conveniently timed daylight savings to start the Annual Scientific Meeting of the Society of Gynecologic Surgeons (SGS). First on the agenda was the postgraduate (PG) course, “Endometriosis: Contemporary Approaches to Diagnosis and Treatment” led by Dr. Rosanne Kho. Excellent talks were given and reminded us that, as a specialty, we have made great strides in advancing the diagnosis and treatment of endometriosis. Nevertheless, there is much work to be done in developing a better classification system, including identifying markers that can help stratify the extent of disease.

A highlight was a question from the audience regarding the important facets of a physical exam in diagnosing deep endometriosis. Dr. Mauricio Abrao reviewed his strategy, which included palpating for adnexal masses, pain, or nodules in the cul-de-sac and evaluating trigger points along the psoas muscle. Dr. Scott Young, a radiologist, then provided some key signs to look for in pelvic magnetic resonance imaging and endovaginal ultrasound in diagnosing deep endometriosis. He reminded all of us that a partnership with an excellent radiology department is key in diagnosing and treating deep endometriosis effectively. Dr. Tommaso Falcone then gave an excellent overview of anatomy in relation to deep endometriosis, teaching us all about the different layers of the retroperitoneum.

An afternoon of simulation

After a quick break, it was on to the next course: “Train the Trainer: Comprehensive Hysterectomy Simulation Course for Educators.” Dr. Christine Vaccaro headed this interactive session, and started us off with a reminder that “simulation is the future, and we need to jump on board!” Unfortunately for trainees, the overall number of hysterectomies performed during residency are decreasing secondary to medical management available for abnormal uterine bleeding and the fact that the 4 years of ObGyn residency have a heavy focus on obstetrics. Therefore, it was great to hear Dr. Vaccaro say that the American Board of Obstetrics and Gynecology (ABOG) is requiring Fundamentals of Laparoscopic Surgery (FLSTM) training for those seeking board certification. Attendees of this session included a combination of trainers and trainees, so to speak, and we took turns rotating around models for abdominal, vaginal, laparoscopic, and robotic hysterectomies. I took the opportunity to learn some tips and tricks from experts like Dr. Ernie Lockrow during a simulated laparoscopic myomectomy, in which the struggle felt very real.

Mix and mingle

Other PG courses offered and attended throughout the day included: “Surgical Coding: Working through the Entire Procedure,” “Variations in the Management of the Vaginal Apex during Reconstructive Pelvic Surgery,” Gynecologic Care of Girls and Young Women Born with Urogenital Anomalies,” and “Social Media, Medicine and your Digital Footprint.” SGS Fellow Scholars were then invited to the “Senior Members Engaging Young Learners” event, designed to connect senior SGS members with residents and fellows. Here, residents and fellows mingled with distinguished faculty, many of them with red badges on their nametags, indicating 20 years of membership with SGS. I learned firsthand that connections are very easy to make in this friendly group, where everyone is willing to introduce you to someone who will help advance your career. After this, we moved straight onto the Welcome Reception, where conversations and connections continued.

I look forward to a full day tomorrow! Stay tuned to @ChrisTierneyMD for live updates from #SGS2018.

CASE Chronic pelvic pain from endometriosis

A 40-year-old woman (G0) has a 20-year history of chronic pelvic pain. Stage III endometriosis is diagnosed on laparoscopic excision of endometriotic tissue. Postoperative pain symptoms include dysmenorrhea and deep dyspareunia, and the patient is feeling anxious. Physical examination reveals a retroverted uterus, right adnexal fullness and tenderness, and tenderness on palpation of the right levator ani and right obturator internus; rectovaginal examination findings are unremarkable. The patient, though now engaged in a pelvic floor physical therapy program, has yet to achieve the pain control she desires. After reviewing the treatment strategies for endometriosis with the patient, she elects definitive surgical management with minimally invasive hysterectomy and salpingo-oophorectomy. What pre-, intra-, and postoperative pain management plan do you devise for this patient?

Chronic pelvic pain presents a unique clinical challenge, as pain typically is multifactorial, and several peripheral pain generators may be involved. Although surgery can be performed to manage anatomically based disease processes, it does not address pain from musculoskeletal or neuropathic sources. A complete medical history and a physical examination are of utmost importance in developing a comprehensive multimodal management plan that may include surgery as treatment for the pain.

The standard of care for surgery is a minimally invasive approach (vaginal, laparoscopic, or robot-assisted laparoscopic), as it causes the least amount of trauma. Benefits of minimally invasive surgery include shorter hospitalization and faster recovery, likely owing to improved perioperative pain control, decreased blood loss, and fewer infections. Although this approach minimizes surgical trauma and thereby helps decrease the surgical stress response, the patient experience can be optimized with use of enhanced recovery pathways (ERPs), a multimodal approach to perioperative care.

ERPs were initially proposed as a means of reducing the degree of surgical injury and the subsequent physiologic stress response.¹ This multimodal approach begins in the outpatient setting, includes preoperative and intraoperative modalities, and continues postoperatively. In patients with chronic pain, ERPs are even more important. Assigning “prehabilitation” and setting expectations for surgery goals are the first step in improving the patient experience. Intraoperative use of opioid-sparing anesthetics or regional anesthesia can improve recovery. After surgery, patients with chronic pain and/or opioid dependence receive medications on a schedule, along with short-interval follow-up. Ultimately, reducing acute postoperative pain may lower the risk of developing chronic pain.

In this article on patients with chronic pelvic pain, we highlight elements of ERPs within the framework of enhanced recovery after surgery. Many of the interventions proposed here also can be used to improve the surgical experience of patients without chronic pain.

Preadmission education, expectations, and optimization

Preoperative counseling for elective procedures generally occurs in the outpatient setting. Although discussion traditionally has covered the type of procedure and its associated risks, benefits, and alternatives, new guidelines suggest a more mindful and comprehensive approach is warranted. Individualized patient-centered education programs have a positive impact on the perioperative course, effecting reductions in preoperative anxiety, opioid requirements, and hospital length of stay.² From a pain management perspective, the clinician can take some time during preoperative counseling to inform the patient about the pain to be expected from surgery, the ways the pain will be managed intraoperatively and postoperatively, and the multimodal strategies that will be used throughout the patient’s stay² and that may allow for early discharge. Although preadmission counseling still should address expectations for the surgery, it also presents an opportunity both to assess the patient’s ability to cope with the physical and psychological stress of surgery and to offer the patient appropriate need-based interventions, such as prehabilitation and cognitive-behavioral therapy (CBT).

Prehabilitation is the process of increasing functional capacity before surgery in order to mitigate the stress of the surgery. Prehabilitation may involve aerobic exercise, strength training, or functional task training. The gynecologic surgery literature lacks prehabilitation data, but data in the colorectal literature support use of a prehabilitation program for patients having a scheduled colectomy, with improved postoperative recovery.³ Although the colectomy cohort predominantly included older men, the principle that guides program implementation is the same: improve recovery after the stress of abdominal surgery. Indeed, a patient who opts for an elective surgery may have to wait several weeks before undergoing the procedure, and during this period behavioral interventions can take effect. With postoperative complications occurring more often in patients with reduced functional capacity, the data support using prehabilitation to decrease the incidence of postoperative complications, particularly among the most vulnerable patients.⁴ However, a definitive recommendation on use of pelvic floor exercises as an adjunct to prehabilitation cannot be made.⁴ Successful prehabilitation takes at least 4 weeks and should be part of a multimodal program that addresses other behavioral risk factors that may negatively affect recovery.⁵ For example, current tobacco users have compromised pulmonary status and wound healing immediately after surgery, and use more opioids.⁶ Conversely, smoking cessation for as little as 4 weeks before surgery is associated with fewer complications.⁷ In addition, given that alcohol abuse may compromise the surgical stress response and increase the risk of opioid misuse, addressing alcohol abuse preoperatively may improve postoperative recovery.⁸

Treating mood disorders that coexist with chronic pain disorders is an important part of outpatient multimodal management—psychological intervention is a useful adjunct to prehabilitation in reducing perioperative anxiety and improving postoperative functional capacity.⁹ For patients who have chronic pain and are undergoing surgery, it is important to address any anxiety, depression, or poor coping skills (eg, pain catastrophizing) to try to reduce the postoperative pain experience and decrease the risk of chronic postsurgical pain (CPSP).^10,11

Before surgery, patients with chronic pain syndromes should be evaluated for emotional distress and pain coping ability. When possible, they should be referred to a pain psychologist, who can initiate CBT and other interventions. In addition, pain coping skills can be developed or reinforced to address preoperative anxiety and pain catastrophizing. These interventions, which may include use of visual imagery, breathing exercises, and other relaxation techniques, are applicable to the management of postoperative anxiety as well.

Read about preoperative multimodal analgesia and intra- and postoperative management.

Preoperative multimodal analgesia

Multimodal analgesia has several benefits. Simultaneous effects can be generated on multiple pain-related neurotransmitters, and a synergistic effect (eg, of acetaminophen and a nonsteroidal anti-inflammatory drug [NSAID]) can improve pain management. In addition, small doses of multiple medications can be given, instead of a large dose of a single medication. Of course, this strategy must be modified in elderly and patients with impaired renal function, who are at high risk for polypharmacy.

Preoperative administration of 3 medications—a selective cyclooxygenase 2 (COX-2) inhibitor, acetaminophen, and a gabapentinoid—is increasingly accepted as part of multimodal analgesia. The selective COX-2 inhibitor targets inflammatory prostaglandins and has anti-inflammatory and analgesic effects; acetaminophen, an effective analgesic with an unclear mechanism of action, can reduce postoperative opioid consumption¹² and works synergistically with NSAIDs¹³; and the gabapentinoid gabapentin has an analgesic effect likely contributing to decreased movement-related pain and subsequent improved functional recovery (data are mixed on whether continuing gabapentin after surgery prevents CPSP).¹⁴⁻¹⁶

Although serotonin and norepinephrine reuptake inhibitors (SNRIs) are commonly used in outpatient management of chronic pelvic pain, data suggest that their role in perioperative pain management is evolving. As SNRIs may reduce central nervous system (CNS) sensitization,¹⁷ their analgesic effect is thought to result from increased descending inhibitory tone in the CNS, which makes this class of medication ideal for patients with chronic neuropathic pain.¹⁵

Limited data also suggest a role for SNRIs in decreasing immediate postoperative pain and CPSP in high-risk patients. Studies of duloxetine use in the immediate perioperative period have found reduced postoperative acute pain and opioid use.^18,19 In addition, a short course of low-dose (37.5 mg) venlafaxine both before and after surgery has demonstrated a reduction in postoperative opioid use and a reduction in movement-related pain 6 months after surgery.²⁰

Intraoperative management

The surgical and anesthesia teams share the goal of optimizing both pain control and postoperative recovery. Surgical team members, who want longer-acting anesthetics for infiltration of incision sites, discuss with the anesthesiologist the appropriateness of using peripheral nerve blocks or neuraxial anesthesia, given the patient’s history and planned procedure. Anesthesia team members can improve anesthesia and minimize intraoperative opioid use through several methods, including total intravenous anesthesia,²¹ dexamethasone,²² ketorolac,²³ and intravenous ketamine. Ketamine, in particular, has a wide range of surgical applications and has been found to reduce postoperative pain, postoperative pain medication use, and the risk of CPSP.²

Incision sites should be infiltrated before and after surgery. Lidocaine traditionally is used for its rapid onset of action in reducing surgical site pain, but its short half-life may limit its applicability to postoperative pain. Recently, bupivacaine (half-life, 3.5 hours) and liposomal bupivacaine (24–34 hours) have gained more attention. Both of these medications appear to be as effective as lidocaine in reducing surgical site pain.²⁴

Transversus abdominis plane (TAP) blocks have been used as an adjunct in pain management during abdominopelvic surgery. Although initial data on postoperative pain and opioid use reductions with TAP blocks were inconclusive,²⁵ more recent data showed a role for TAP blocks in a multimodal approach for reducing opioid use during laparoscopic and open surgery.^26,27 Given the small number of studies on using liposomal bupivacaine for peripheral nerve blocks (eg, TAP blocks) in postoperative pain management, current data are inconclusive.²⁸

Postoperative management

The ERP approach calls for continuing multimodal analgesia after surgery—in most cases, scheduling early use of oral acetaminophen and ibuprofen, and providing short-acting, low-dose opioid analgesia as needed. All patients should be given a bowel regimen. Similar to undergoing prehabilitation for surgery, patients should prepare themselves for recovery. They should be encouraged to engage in early ambulation and oral intake and, when clinically appropriate, be given same-day discharge for minimally invasive surgical procedures.

Patients with chronic pain before surgery are at increased risk for suboptimal postoperative pain management, and those who are dependent on opioids require additional perioperative measures for adequate postoperative pain control. In these complicated cases, it is appropriate to enlist a pain specialist, potentially before surgery, to help plan perioperative and postoperative pain management.² Postoperative pain management for opioid-dependent patients should include pharmacologic and nonpharmacologic interventions, such as use of nonopioid medications (eg, gabapentin) and continuation of CBT. Patients with chronic pain should be closely followed up for assessment of postoperative pain control and recovery.

CASE Resolved

Surgical management is one aspect of the longer term multimodal pain management strategy for this patient. After preoperative pelvic floor physical therapy, she is receptive to starting a trial of an SNRI for her pain and mood symptoms. Both interventions allow for optimization of her preoperative physical and psychological status. Expectations are set that she will be discharged the day of surgery and that the surgery is but one component of her multimodal treatment plan. In addition, before surgery, she takes oral acetaminophen, gabapentin, and celecoxib—previously having had no contraindications to these medications. During surgery, bupivacaine is used for infiltration of all incision sites, and the anesthesia team administers ketamine and a TAP block. After surgery, the patient is prepared for same-day discharge and given the NSAIDs and acetaminophen she is scheduled to take over the next 72 hours. She is also given a limited prescription for oxycodone for breakthrough pain. An office visit 1 to 2 weeks after surgery is scheduled.

ERP strategies for surgical management of endometriosis have not only improved this patient’s postoperative recovery but also reduced her surgical stress response and subsequent transition to chronic postoperative pain. Many of the strategies used in this case are applicable to patients without chronic pain.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

CASE Chronic pelvic pain from endometriosis

A 40-year-old woman (G0) has a 20-year history of chronic pelvic pain. Stage III endometriosis is diagnosed on laparoscopic excision of endometriotic tissue. Postoperative pain symptoms include dysmenorrhea and deep dyspareunia, and the patient is feeling anxious. Physical examination reveals a retroverted uterus, right adnexal fullness and tenderness, and tenderness on palpation of the right levator ani and right obturator internus; rectovaginal examination findings are unremarkable. The patient, though now engaged in a pelvic floor physical therapy program, has yet to achieve the pain control she desires. After reviewing the treatment strategies for endometriosis with the patient, she elects definitive surgical management with minimally invasive hysterectomy and salpingo-oophorectomy. What pre-, intra-, and postoperative pain management plan do you devise for this patient?

Chronic pelvic pain presents a unique clinical challenge, as pain typically is multifactorial, and several peripheral pain generators may be involved. Although surgery can be performed to manage anatomically based disease processes, it does not address pain from musculoskeletal or neuropathic sources. A complete medical history and a physical examination are of utmost importance in developing a comprehensive multimodal management plan that may include surgery as treatment for the pain.

The standard of care for surgery is a minimally invasive approach (vaginal, laparoscopic, or robot-assisted laparoscopic), as it causes the least amount of trauma. Benefits of minimally invasive surgery include shorter hospitalization and faster recovery, likely owing to improved perioperative pain control, decreased blood loss, and fewer infections. Although this approach minimizes surgical trauma and thereby helps decrease the surgical stress response, the patient experience can be optimized with use of enhanced recovery pathways (ERPs), a multimodal approach to perioperative care.

ERPs were initially proposed as a means of reducing the degree of surgical injury and the subsequent physiologic stress response.¹ This multimodal approach begins in the outpatient setting, includes preoperative and intraoperative modalities, and continues postoperatively. In patients with chronic pain, ERPs are even more important. Assigning “prehabilitation” and setting expectations for surgery goals are the first step in improving the patient experience. Intraoperative use of opioid-sparing anesthetics or regional anesthesia can improve recovery. After surgery, patients with chronic pain and/or opioid dependence receive medications on a schedule, along with short-interval follow-up. Ultimately, reducing acute postoperative pain may lower the risk of developing chronic pain.

In this article on patients with chronic pelvic pain, we highlight elements of ERPs within the framework of enhanced recovery after surgery. Many of the interventions proposed here also can be used to improve the surgical experience of patients without chronic pain.

Preadmission education, expectations, and optimization

Preoperative counseling for elective procedures generally occurs in the outpatient setting. Although discussion traditionally has covered the type of procedure and its associated risks, benefits, and alternatives, new guidelines suggest a more mindful and comprehensive approach is warranted. Individualized patient-centered education programs have a positive impact on the perioperative course, effecting reductions in preoperative anxiety, opioid requirements, and hospital length of stay.² From a pain management perspective, the clinician can take some time during preoperative counseling to inform the patient about the pain to be expected from surgery, the ways the pain will be managed intraoperatively and postoperatively, and the multimodal strategies that will be used throughout the patient’s stay² and that may allow for early discharge. Although preadmission counseling still should address expectations for the surgery, it also presents an opportunity both to assess the patient’s ability to cope with the physical and psychological stress of surgery and to offer the patient appropriate need-based interventions, such as prehabilitation and cognitive-behavioral therapy (CBT).

Prehabilitation is the process of increasing functional capacity before surgery in order to mitigate the stress of the surgery. Prehabilitation may involve aerobic exercise, strength training, or functional task training. The gynecologic surgery literature lacks prehabilitation data, but data in the colorectal literature support use of a prehabilitation program for patients having a scheduled colectomy, with improved postoperative recovery.³ Although the colectomy cohort predominantly included older men, the principle that guides program implementation is the same: improve recovery after the stress of abdominal surgery. Indeed, a patient who opts for an elective surgery may have to wait several weeks before undergoing the procedure, and during this period behavioral interventions can take effect. With postoperative complications occurring more often in patients with reduced functional capacity, the data support using prehabilitation to decrease the incidence of postoperative complications, particularly among the most vulnerable patients.⁴ However, a definitive recommendation on use of pelvic floor exercises as an adjunct to prehabilitation cannot be made.⁴ Successful prehabilitation takes at least 4 weeks and should be part of a multimodal program that addresses other behavioral risk factors that may negatively affect recovery.⁵ For example, current tobacco users have compromised pulmonary status and wound healing immediately after surgery, and use more opioids.⁶ Conversely, smoking cessation for as little as 4 weeks before surgery is associated with fewer complications.⁷ In addition, given that alcohol abuse may compromise the surgical stress response and increase the risk of opioid misuse, addressing alcohol abuse preoperatively may improve postoperative recovery.⁸

Treating mood disorders that coexist with chronic pain disorders is an important part of outpatient multimodal management—psychological intervention is a useful adjunct to prehabilitation in reducing perioperative anxiety and improving postoperative functional capacity.⁹ For patients who have chronic pain and are undergoing surgery, it is important to address any anxiety, depression, or poor coping skills (eg, pain catastrophizing) to try to reduce the postoperative pain experience and decrease the risk of chronic postsurgical pain (CPSP).^10,11

Before surgery, patients with chronic pain syndromes should be evaluated for emotional distress and pain coping ability. When possible, they should be referred to a pain psychologist, who can initiate CBT and other interventions. In addition, pain coping skills can be developed or reinforced to address preoperative anxiety and pain catastrophizing. These interventions, which may include use of visual imagery, breathing exercises, and other relaxation techniques, are applicable to the management of postoperative anxiety as well.

Read about preoperative multimodal analgesia and intra- and postoperative management.

Preoperative multimodal analgesia

Multimodal analgesia has several benefits. Simultaneous effects can be generated on multiple pain-related neurotransmitters, and a synergistic effect (eg, of acetaminophen and a nonsteroidal anti-inflammatory drug [NSAID]) can improve pain management. In addition, small doses of multiple medications can be given, instead of a large dose of a single medication. Of course, this strategy must be modified in elderly and patients with impaired renal function, who are at high risk for polypharmacy.

Preoperative administration of 3 medications—a selective cyclooxygenase 2 (COX-2) inhibitor, acetaminophen, and a gabapentinoid—is increasingly accepted as part of multimodal analgesia. The selective COX-2 inhibitor targets inflammatory prostaglandins and has anti-inflammatory and analgesic effects; acetaminophen, an effective analgesic with an unclear mechanism of action, can reduce postoperative opioid consumption¹² and works synergistically with NSAIDs¹³; and the gabapentinoid gabapentin has an analgesic effect likely contributing to decreased movement-related pain and subsequent improved functional recovery (data are mixed on whether continuing gabapentin after surgery prevents CPSP).¹⁴⁻¹⁶

Although serotonin and norepinephrine reuptake inhibitors (SNRIs) are commonly used in outpatient management of chronic pelvic pain, data suggest that their role in perioperative pain management is evolving. As SNRIs may reduce central nervous system (CNS) sensitization,¹⁷ their analgesic effect is thought to result from increased descending inhibitory tone in the CNS, which makes this class of medication ideal for patients with chronic neuropathic pain.¹⁵

Limited data also suggest a role for SNRIs in decreasing immediate postoperative pain and CPSP in high-risk patients. Studies of duloxetine use in the immediate perioperative period have found reduced postoperative acute pain and opioid use.^18,19 In addition, a short course of low-dose (37.5 mg) venlafaxine both before and after surgery has demonstrated a reduction in postoperative opioid use and a reduction in movement-related pain 6 months after surgery.²⁰

Intraoperative management

The surgical and anesthesia teams share the goal of optimizing both pain control and postoperative recovery. Surgical team members, who want longer-acting anesthetics for infiltration of incision sites, discuss with the anesthesiologist the appropriateness of using peripheral nerve blocks or neuraxial anesthesia, given the patient’s history and planned procedure. Anesthesia team members can improve anesthesia and minimize intraoperative opioid use through several methods, including total intravenous anesthesia,²¹ dexamethasone,²² ketorolac,²³ and intravenous ketamine. Ketamine, in particular, has a wide range of surgical applications and has been found to reduce postoperative pain, postoperative pain medication use, and the risk of CPSP.²

Incision sites should be infiltrated before and after surgery. Lidocaine traditionally is used for its rapid onset of action in reducing surgical site pain, but its short half-life may limit its applicability to postoperative pain. Recently, bupivacaine (half-life, 3.5 hours) and liposomal bupivacaine (24–34 hours) have gained more attention. Both of these medications appear to be as effective as lidocaine in reducing surgical site pain.²⁴

Transversus abdominis plane (TAP) blocks have been used as an adjunct in pain management during abdominopelvic surgery. Although initial data on postoperative pain and opioid use reductions with TAP blocks were inconclusive,²⁵ more recent data showed a role for TAP blocks in a multimodal approach for reducing opioid use during laparoscopic and open surgery.^26,27 Given the small number of studies on using liposomal bupivacaine for peripheral nerve blocks (eg, TAP blocks) in postoperative pain management, current data are inconclusive.²⁸

Postoperative management

The ERP approach calls for continuing multimodal analgesia after surgery—in most cases, scheduling early use of oral acetaminophen and ibuprofen, and providing short-acting, low-dose opioid analgesia as needed. All patients should be given a bowel regimen. Similar to undergoing prehabilitation for surgery, patients should prepare themselves for recovery. They should be encouraged to engage in early ambulation and oral intake and, when clinically appropriate, be given same-day discharge for minimally invasive surgical procedures.

Patients with chronic pain before surgery are at increased risk for suboptimal postoperative pain management, and those who are dependent on opioids require additional perioperative measures for adequate postoperative pain control. In these complicated cases, it is appropriate to enlist a pain specialist, potentially before surgery, to help plan perioperative and postoperative pain management.² Postoperative pain management for opioid-dependent patients should include pharmacologic and nonpharmacologic interventions, such as use of nonopioid medications (eg, gabapentin) and continuation of CBT. Patients with chronic pain should be closely followed up for assessment of postoperative pain control and recovery.

CASE Resolved

Surgical management is one aspect of the longer term multimodal pain management strategy for this patient. After preoperative pelvic floor physical therapy, she is receptive to starting a trial of an SNRI for her pain and mood symptoms. Both interventions allow for optimization of her preoperative physical and psychological status. Expectations are set that she will be discharged the day of surgery and that the surgery is but one component of her multimodal treatment plan. In addition, before surgery, she takes oral acetaminophen, gabapentin, and celecoxib—previously having had no contraindications to these medications. During surgery, bupivacaine is used for infiltration of all incision sites, and the anesthesia team administers ketamine and a TAP block. After surgery, the patient is prepared for same-day discharge and given the NSAIDs and acetaminophen she is scheduled to take over the next 72 hours. She is also given a limited prescription for oxycodone for breakthrough pain. An office visit 1 to 2 weeks after surgery is scheduled.

ERP strategies for surgical management of endometriosis have not only improved this patient’s postoperative recovery but also reduced her surgical stress response and subsequent transition to chronic postoperative pain. Many of the strategies used in this case are applicable to patients without chronic pain.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

CASE Chronic pelvic pain from endometriosis

A 40-year-old woman (G0) has a 20-year history of chronic pelvic pain. Stage III endometriosis is diagnosed on laparoscopic excision of endometriotic tissue. Postoperative pain symptoms include dysmenorrhea and deep dyspareunia, and the patient is feeling anxious. Physical examination reveals a retroverted uterus, right adnexal fullness and tenderness, and tenderness on palpation of the right levator ani and right obturator internus; rectovaginal examination findings are unremarkable. The patient, though now engaged in a pelvic floor physical therapy program, has yet to achieve the pain control she desires. After reviewing the treatment strategies for endometriosis with the patient, she elects definitive surgical management with minimally invasive hysterectomy and salpingo-oophorectomy. What pre-, intra-, and postoperative pain management plan do you devise for this patient?

Chronic pelvic pain presents a unique clinical challenge, as pain typically is multifactorial, and several peripheral pain generators may be involved. Although surgery can be performed to manage anatomically based disease processes, it does not address pain from musculoskeletal or neuropathic sources. A complete medical history and a physical examination are of utmost importance in developing a comprehensive multimodal management plan that may include surgery as treatment for the pain.

The standard of care for surgery is a minimally invasive approach (vaginal, laparoscopic, or robot-assisted laparoscopic), as it causes the least amount of trauma. Benefits of minimally invasive surgery include shorter hospitalization and faster recovery, likely owing to improved perioperative pain control, decreased blood loss, and fewer infections. Although this approach minimizes surgical trauma and thereby helps decrease the surgical stress response, the patient experience can be optimized with use of enhanced recovery pathways (ERPs), a multimodal approach to perioperative care.

ERPs were initially proposed as a means of reducing the degree of surgical injury and the subsequent physiologic stress response.¹ This multimodal approach begins in the outpatient setting, includes preoperative and intraoperative modalities, and continues postoperatively. In patients with chronic pain, ERPs are even more important. Assigning “prehabilitation” and setting expectations for surgery goals are the first step in improving the patient experience. Intraoperative use of opioid-sparing anesthetics or regional anesthesia can improve recovery. After surgery, patients with chronic pain and/or opioid dependence receive medications on a schedule, along with short-interval follow-up. Ultimately, reducing acute postoperative pain may lower the risk of developing chronic pain.

In this article on patients with chronic pelvic pain, we highlight elements of ERPs within the framework of enhanced recovery after surgery. Many of the interventions proposed here also can be used to improve the surgical experience of patients without chronic pain.

Preadmission education, expectations, and optimization

Preoperative counseling for elective procedures generally occurs in the outpatient setting. Although discussion traditionally has covered the type of procedure and its associated risks, benefits, and alternatives, new guidelines suggest a more mindful and comprehensive approach is warranted. Individualized patient-centered education programs have a positive impact on the perioperative course, effecting reductions in preoperative anxiety, opioid requirements, and hospital length of stay.² From a pain management perspective, the clinician can take some time during preoperative counseling to inform the patient about the pain to be expected from surgery, the ways the pain will be managed intraoperatively and postoperatively, and the multimodal strategies that will be used throughout the patient’s stay² and that may allow for early discharge. Although preadmission counseling still should address expectations for the surgery, it also presents an opportunity both to assess the patient’s ability to cope with the physical and psychological stress of surgery and to offer the patient appropriate need-based interventions, such as prehabilitation and cognitive-behavioral therapy (CBT).

Prehabilitation is the process of increasing functional capacity before surgery in order to mitigate the stress of the surgery. Prehabilitation may involve aerobic exercise, strength training, or functional task training. The gynecologic surgery literature lacks prehabilitation data, but data in the colorectal literature support use of a prehabilitation program for patients having a scheduled colectomy, with improved postoperative recovery.³ Although the colectomy cohort predominantly included older men, the principle that guides program implementation is the same: improve recovery after the stress of abdominal surgery. Indeed, a patient who opts for an elective surgery may have to wait several weeks before undergoing the procedure, and during this period behavioral interventions can take effect. With postoperative complications occurring more often in patients with reduced functional capacity, the data support using prehabilitation to decrease the incidence of postoperative complications, particularly among the most vulnerable patients.⁴ However, a definitive recommendation on use of pelvic floor exercises as an adjunct to prehabilitation cannot be made.⁴ Successful prehabilitation takes at least 4 weeks and should be part of a multimodal program that addresses other behavioral risk factors that may negatively affect recovery.⁵ For example, current tobacco users have compromised pulmonary status and wound healing immediately after surgery, and use more opioids.⁶ Conversely, smoking cessation for as little as 4 weeks before surgery is associated with fewer complications.⁷ In addition, given that alcohol abuse may compromise the surgical stress response and increase the risk of opioid misuse, addressing alcohol abuse preoperatively may improve postoperative recovery.⁸

Treating mood disorders that coexist with chronic pain disorders is an important part of outpatient multimodal management—psychological intervention is a useful adjunct to prehabilitation in reducing perioperative anxiety and improving postoperative functional capacity.⁹ For patients who have chronic pain and are undergoing surgery, it is important to address any anxiety, depression, or poor coping skills (eg, pain catastrophizing) to try to reduce the postoperative pain experience and decrease the risk of chronic postsurgical pain (CPSP).^10,11

Before surgery, patients with chronic pain syndromes should be evaluated for emotional distress and pain coping ability. When possible, they should be referred to a pain psychologist, who can initiate CBT and other interventions. In addition, pain coping skills can be developed or reinforced to address preoperative anxiety and pain catastrophizing. These interventions, which may include use of visual imagery, breathing exercises, and other relaxation techniques, are applicable to the management of postoperative anxiety as well.

Read about preoperative multimodal analgesia and intra- and postoperative management.

Preoperative multimodal analgesia

Multimodal analgesia has several benefits. Simultaneous effects can be generated on multiple pain-related neurotransmitters, and a synergistic effect (eg, of acetaminophen and a nonsteroidal anti-inflammatory drug [NSAID]) can improve pain management. In addition, small doses of multiple medications can be given, instead of a large dose of a single medication. Of course, this strategy must be modified in elderly and patients with impaired renal function, who are at high risk for polypharmacy.

Preoperative administration of 3 medications—a selective cyclooxygenase 2 (COX-2) inhibitor, acetaminophen, and a gabapentinoid—is increasingly accepted as part of multimodal analgesia. The selective COX-2 inhibitor targets inflammatory prostaglandins and has anti-inflammatory and analgesic effects; acetaminophen, an effective analgesic with an unclear mechanism of action, can reduce postoperative opioid consumption¹² and works synergistically with NSAIDs¹³; and the gabapentinoid gabapentin has an analgesic effect likely contributing to decreased movement-related pain and subsequent improved functional recovery (data are mixed on whether continuing gabapentin after surgery prevents CPSP).¹⁴⁻¹⁶

Although serotonin and norepinephrine reuptake inhibitors (SNRIs) are commonly used in outpatient management of chronic pelvic pain, data suggest that their role in perioperative pain management is evolving. As SNRIs may reduce central nervous system (CNS) sensitization,¹⁷ their analgesic effect is thought to result from increased descending inhibitory tone in the CNS, which makes this class of medication ideal for patients with chronic neuropathic pain.¹⁵

Limited data also suggest a role for SNRIs in decreasing immediate postoperative pain and CPSP in high-risk patients. Studies of duloxetine use in the immediate perioperative period have found reduced postoperative acute pain and opioid use.^18,19 In addition, a short course of low-dose (37.5 mg) venlafaxine both before and after surgery has demonstrated a reduction in postoperative opioid use and a reduction in movement-related pain 6 months after surgery.²⁰

Intraoperative management

The surgical and anesthesia teams share the goal of optimizing both pain control and postoperative recovery. Surgical team members, who want longer-acting anesthetics for infiltration of incision sites, discuss with the anesthesiologist the appropriateness of using peripheral nerve blocks or neuraxial anesthesia, given the patient’s history and planned procedure. Anesthesia team members can improve anesthesia and minimize intraoperative opioid use through several methods, including total intravenous anesthesia,²¹ dexamethasone,²² ketorolac,²³ and intravenous ketamine. Ketamine, in particular, has a wide range of surgical applications and has been found to reduce postoperative pain, postoperative pain medication use, and the risk of CPSP.²

Incision sites should be infiltrated before and after surgery. Lidocaine traditionally is used for its rapid onset of action in reducing surgical site pain, but its short half-life may limit its applicability to postoperative pain. Recently, bupivacaine (half-life, 3.5 hours) and liposomal bupivacaine (24–34 hours) have gained more attention. Both of these medications appear to be as effective as lidocaine in reducing surgical site pain.²⁴

Transversus abdominis plane (TAP) blocks have been used as an adjunct in pain management during abdominopelvic surgery. Although initial data on postoperative pain and opioid use reductions with TAP blocks were inconclusive,²⁵ more recent data showed a role for TAP blocks in a multimodal approach for reducing opioid use during laparoscopic and open surgery.^26,27 Given the small number of studies on using liposomal bupivacaine for peripheral nerve blocks (eg, TAP blocks) in postoperative pain management, current data are inconclusive.²⁸

Postoperative management

The ERP approach calls for continuing multimodal analgesia after surgery—in most cases, scheduling early use of oral acetaminophen and ibuprofen, and providing short-acting, low-dose opioid analgesia as needed. All patients should be given a bowel regimen. Similar to undergoing prehabilitation for surgery, patients should prepare themselves for recovery. They should be encouraged to engage in early ambulation and oral intake and, when clinically appropriate, be given same-day discharge for minimally invasive surgical procedures.

Patients with chronic pain before surgery are at increased risk for suboptimal postoperative pain management, and those who are dependent on opioids require additional perioperative measures for adequate postoperative pain control. In these complicated cases, it is appropriate to enlist a pain specialist, potentially before surgery, to help plan perioperative and postoperative pain management.² Postoperative pain management for opioid-dependent patients should include pharmacologic and nonpharmacologic interventions, such as use of nonopioid medications (eg, gabapentin) and continuation of CBT. Patients with chronic pain should be closely followed up for assessment of postoperative pain control and recovery.

CASE Resolved

Surgical management is one aspect of the longer term multimodal pain management strategy for this patient. After preoperative pelvic floor physical therapy, she is receptive to starting a trial of an SNRI for her pain and mood symptoms. Both interventions allow for optimization of her preoperative physical and psychological status. Expectations are set that she will be discharged the day of surgery and that the surgery is but one component of her multimodal treatment plan. In addition, before surgery, she takes oral acetaminophen, gabapentin, and celecoxib—previously having had no contraindications to these medications. During surgery, bupivacaine is used for infiltration of all incision sites, and the anesthesia team administers ketamine and a TAP block. After surgery, the patient is prepared for same-day discharge and given the NSAIDs and acetaminophen she is scheduled to take over the next 72 hours. She is also given a limited prescription for oxycodone for breakthrough pain. An office visit 1 to 2 weeks after surgery is scheduled.

ERP strategies for surgical management of endometriosis have not only improved this patient’s postoperative recovery but also reduced her surgical stress response and subsequent transition to chronic postoperative pain. Many of the strategies used in this case are applicable to patients without chronic pain.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Endometriosis is one of the more daunting diagnoses that gynecologists treat. In this roundtable discussion, moderated by OBG Management Board Member Arnold P. Advincula, MD, 2 leading surgeons discuss endometriosis diagnosis as well as medical and surgical management.

First-time evaluation

Arnold P. Advincula, MD: When a patient presents to your practice for the first time and you suspect endometriosis, what considerations tailor your evaluation, and what does that evaluation involve?

Hye-Chun Hur, MD, MPH: The diagnosis is contingent on a patient’s presenting profile. How symptomatic is she? How old is she? What are her reproductive goals? The gold standard for diagnosis is a histologic diagnosis, which is surgical. Depending on the age profile, however, and how close she is to menopause, the patient may be managed medically. Even women in the young reproductive age group may be managed medically if symptoms are responsive to medical treatment.

Douglas N. Brown, MD: I agree. When a patient presents without a laparoscopy, or a tissue diagnosis, but the symptoms are consistent with likely endometriosis (depending on where she is in her reproductive cycle and what her goals are), I think treating with a first-line therapy—hormonal treatments such as progestin-only oral contraceptive pills—is acceptable. I usually conduct a treatment trial period of 3 to 6 months to see if she obtains any symptom relief.

If that first-line treatment fails, generally you can move to a second-line treatment.

I have a discussion in which I either offer a second-line treatment, such as medroxyprogesterone (Depo-Provera) or leuprolide acetate (Lupron Depot), or get a tissue diagnosis, if possible, by performing laparoscopy. If first-line or even second-line therapy fails, you need to consider doing a diagnostic laparoscopy to confirm or deny the diagnosis.

Dr. Advincula: Are there any points in the evaluation of a patient who visits your practice for the first time where you would immediately offer a surgical approach, as opposed to starting with medical management?

Dr. Hur: A large percentage of my patients undergo surgical evaluation, as surgical diagnosis is the gold standard. If you look at the literature, even among surgeons, the accuracy of visual diagnosis is not great.^1,2 I target individuals who are either not responsive to medical treatment or who have never tried medical treatment but are trying to conceive, so they are not medical candidates, or individuals who genuinely want a diagnosis for surgical management—sometimes even before first-line medical treatment.

Dr. Brown: Your examination sometimes also dictates your approach. A patient may never have had a laparoscopy or hormone therapy, but if you find uterosacral ligament nodularity, extreme pain on examination, and suspicious findings on ultrasound or otherwise, a diagnostic laparoscopy may be warranted to confirm the diagnosis.

Endometrioma management

Dr. Advincula: Let’s jump ahead. You have decided to proceed with laparoscopy and you encounter an endometrioma. What is your management strategy, particularly in a fertility-desiring patient?

Dr. Hur: Even if a woman has not undergone first-line medical treatment, if she is trying to conceive or presents with infertility, it’s a different balancing act for approaching the patient. When a woman presents, either with an ultrasound finding or an intraoperative finding of an endometrioma, I am a strong advocate of treating symptomatic disease, which means complete cyst excision. Good clinical data suggest that reproductive outcomes are improved for spontaneous pregnancy rates when you excise an endometrioma.^3-6

Dr. Advincula: What are the risks of excision of an endometrioma cyst that patients need to know about?

Dr. Brown: Current standard of care is cystectomy, stripping the cyst wall away from the ovarian cortex. There is some concern that the stripping process, depending on how long the endometrioma has been present within the ovary, can cause some destruction to the underlying oocytes and perhaps impact that ovary’s ability to produce viable eggs.

Some studies, from France in particular, have investigated different energy sources, such as plasma energy, that make it possible to remove part of the cyst and then use the plasma energy to vaporize the rest of the cyst wall that may be lying on the cortex. Researchers looked at anti-Müllerian hormone levels, and there does seem to be a difference in terms of how you remove the cyst.^7-9 This energy source is not available to everyone; it’s similar to laser but does not have as much penetration. Standard of care is still ovarian stripping.

The conversation with the patient—if she is already infertile and this cyst is a problem—would be that it likely needs to be removed. There is a chance that she may need assisted reproduction; she might not be able to get pregnant on her own due either to the presence of the endometrioma or to the surgical process of removing it and stripping.

Dr. Advincula: How soon after surgery can a patient start to pursue trying to get pregnant?

Dr. Hur: I think there is no time restraint outside of recovery. As long as the patient has a routine postoperative course, she can try to conceive, spontaneously or with assisted reproduction. Some data suggest, however, that ovarian reserve is diminished immediately after surgery.^10–12 If you look at the spontaneous clinical pregnancy outcomes, they are comparable 3 to 6 months postsurgery.^4,12–14

Dr. Brown: I agree. Time is of the essence with a lot of patients, many of whom present after age 35.

Dr. Hur: It’s also important to highlight that there are 2 presentations with endometrioma: the symptomatic patient and the asymptomatic patient. In the asymptomatic patient, her age, reproductive goals, and the bilaterality (whether it is present on both sides or on one side) of the endometrioma are important in deciding on a patient-centered surgical plan. For someone with a smaller cyst, unilateral presentation, and maybe older age at presentation, it may or may not impact assisted reproductive outcomes.

If the patient is not symptomatic and she is older with bilateral endometriomas less than 4 cm, some data suggest that patient might be better served in a conservative fashion.^6,15–17 Then, once she is done with assisted reproduction, we might be more aggressive surgically by treating the finding that would not resolve spontaneously without surgical management. It is important to highlight that endometriomas do not resolve on their own; they require surgical management.

Read about managing endometriosis for the patient not seeking fertility

Endometriosis management for the patient not seeking fertility

Dr. Advincula: Let’s now consider a patient on whom you have performed laparoscopy not only to diagnose and confirm the evidence of endometriosis but also to treat endometriosis, an endometrioma, and potentially deeply infiltrative disease. But this person is not trying to get pregnant. Postoperatively, what is your approach?

Dr. Brown: Suppressive therapy for this patient could be first-line or second-line therapy, such as a Lupron Depot or Depo-Provera. We keep the patient on suppressive therapy (whatever treatments work for her), until she’s ready to get pregnant; then we take her off. Hopefully she gets pregnant. After she delivers, we reinitiate suppressive therapy. I will follow these women throughout their reproductive cycle, and I think having a team of physicians who are all on the same page can help this patient manage her disease through her reproductive years.

Dr. Hur: If a patient presented warranting surgical management once, and she is not menopausal, the likelihood that disease will recur is quite high. Understanding the nature and the pathology of the disease, hormonal suppression would be warranted. Suppression is not just for between pregnancies, it’s until the patient reaches natural menopause. It’s also in the hopes of suppressing the disease so she does not need recurrent surgeries.

We typically do not operate unless patients have recurrence of symptoms that no longer respond to medical therapy. Our hope is to buy them more time closer to the age of natural menopause so that medical repercussions do not result in hysterectomy and ovary removal, which have other nongynecologic manifestations, including negative impact on bone and cardiac health.

The role of the LNG-IUD

Dr. Advincula: Something that often comes up is the role of a levonorgestrel-releasing intrauterine device (LNG-IUD) as one therapy option, either preoperatively or postoperatively. What is your perspective?

Dr. Hur: I reserve the LNG-IUD as a second-line therapy for patients, predominantly because it allows direct delivery of the medication to the womb (rather than systemic exposure of the medication). For patients who experience adverse effects due to systemic exposure to first-line treatments, it might be a great option. However, I do not believe that it consistently suppresses the ovaries, which we understand feeds the pathology of the hormonal stimulation, and so typically I will reserve it as a second-line treatment.

Dr. Brown: I utilize the LNG-IUD in a similar fashion. I may have patients who have had a diagnostic laparoscopy somewhere else and were referred to me because they now have known stage 3 or 4 endometriosis without endometriomas. Those patients, if they are going to need suppressive therapy after surgery and are not ready to get pregnant, do very well with the LNG-IUD, and I will place it during surgery under anesthesia. If a patient has endometriomas seen at the time of surgery, we could still place an LNG-IUD at the time of surgery. We may need to add on an additional medication, however, like another oral progesterone. I do have patients that use both an IUD and either combined oral contraceptive pills and/or oral progestins. Those patients usually have complicated cases with very deep infiltrative disease.

Read about managing endometriosis involving the bowel

Managing endometriosis involving the bowel

Dr. Advincula: Patients often are quite concerned when the words “endometriosis” and “bowel” come together. How do you manage disease that involves the bowel?

Illustration: Kimberly Martens for OBG Management

Dr. Hur: A lot of patients with endometriosis have what I call neighboring disease—it’s not limited just to the pelvis, but it involves the neighboring organs including the bowel and bladder. Patients can present with symptoms related to those adjacent organs. However, not all disease involving the bowel or bladder manifests with symptoms, and patients with symptoms may not have visible disease.

Typically, when a patient presents with symptoms of bowel involvement, where the bowel lumen is narrowed to more than 50% and/or she has functional manifestations (signs of obstruction that result in abnormal bowel function), we have serious conversations about a bowel resection. If she has full-thickness disease without significant bowel dysfunction—other than blood in her stool—sometimes we talk about more conservative treatment because of the long-term manifestations that a bowel resection could have.

Dr. Brown: I agree completely. It is important to have a good relationship with our colorectal surgeons. If I suspect that the patient has narrowing of the lumen of the large bowel or she actually has symptoms such as bloody diarrhea during menstruation—which is suggestive of deep, infiltrative and penetrative disease—I will often order a colonoscopy ahead of time to get confirmed biopsies. Then the patient discussion occurs with our colorectal surgeon, who operates with me jointly if we decide to proceed with a bowel resection. It’s important to have subspecialty colleagues involved in this care, because a low anterior resection is a very big surgery and there can be down-the-stream complications.

The importance of multidisciplinary care

Dr. Advincula: What are your perspectives on a multidisciplinary or interdisciplinary approach to the patient with endometriosis?

Dr. Brown: As I previously mentioned, it is important to develop a good relationship with colorectal surgery/urology. In addition, behavioral therapists may be involved in the care of patients with endometriosis, for a number of reasons. The disease process is fluid. It will change during the patient’s reproductive years, and you need to manage it accordingly based on her symptoms. Sometimes the diagnosis is not made for 5 to 10 years, and that can lead to other issues: depression, fibromyalgia, or irritable bowel syndrome.

The patient may have multiple issues plus endometriosis. I think having specialists such as gastroenterologists and behavioral therapists on board, as well as colorectal and urological surgeons who can perform these complex surgeries, is very beneficial to the patient. That way, she benefits from the team’s focus and is cared for from start to finish.

Dr. Hur: I like to call the abdomen a studio. It does not have separate compartments for each organ system. It’s one big room, and often the neighboring organs are involved, including the bowel and bladder. I think Dr. Brown’s observation—the multidisciplinary approach to a patient’s comprehensive care—is critical. Like any surgery, preoperative planning and preoperative assessment are essential, and these steps should include the patient. The discussion should cover not only the surgical outcomes that the surgeons expect, but also what the patient expects to be improved. For example, for patients with extensive disease and bowel involvement, a bowel resection is not always the right approach because it can have potential long-term sequelae. Balancing the risks associated with surgery with the long-term benefits is an important part of the discussion.

Dr. Advincula: Those are both excellent perspectives. Endometriosis is a very complicated disease state, does require a multidisciplinary approach to management, and there are implications and strategies that involve both the medical approach to management and the surgical approach.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Endometriosis is one of the more daunting diagnoses that gynecologists treat. In this roundtable discussion, moderated by OBG Management Board Member Arnold P. Advincula, MD, 2 leading surgeons discuss endometriosis diagnosis as well as medical and surgical management.

First-time evaluation

Arnold P. Advincula, MD: When a patient presents to your practice for the first time and you suspect endometriosis, what considerations tailor your evaluation, and what does that evaluation involve?

Hye-Chun Hur, MD, MPH: The diagnosis is contingent on a patient’s presenting profile. How symptomatic is she? How old is she? What are her reproductive goals? The gold standard for diagnosis is a histologic diagnosis, which is surgical. Depending on the age profile, however, and how close she is to menopause, the patient may be managed medically. Even women in the young reproductive age group may be managed medically if symptoms are responsive to medical treatment.

Douglas N. Brown, MD: I agree. When a patient presents without a laparoscopy, or a tissue diagnosis, but the symptoms are consistent with likely endometriosis (depending on where she is in her reproductive cycle and what her goals are), I think treating with a first-line therapy—hormonal treatments such as progestin-only oral contraceptive pills—is acceptable. I usually conduct a treatment trial period of 3 to 6 months to see if she obtains any symptom relief.

If that first-line treatment fails, generally you can move to a second-line treatment.

I have a discussion in which I either offer a second-line treatment, such as medroxyprogesterone (Depo-Provera) or leuprolide acetate (Lupron Depot), or get a tissue diagnosis, if possible, by performing laparoscopy. If first-line or even second-line therapy fails, you need to consider doing a diagnostic laparoscopy to confirm or deny the diagnosis.

Dr. Advincula: Are there any points in the evaluation of a patient who visits your practice for the first time where you would immediately offer a surgical approach, as opposed to starting with medical management?

Dr. Hur: A large percentage of my patients undergo surgical evaluation, as surgical diagnosis is the gold standard. If you look at the literature, even among surgeons, the accuracy of visual diagnosis is not great.^1,2 I target individuals who are either not responsive to medical treatment or who have never tried medical treatment but are trying to conceive, so they are not medical candidates, or individuals who genuinely want a diagnosis for surgical management—sometimes even before first-line medical treatment.

Dr. Brown: Your examination sometimes also dictates your approach. A patient may never have had a laparoscopy or hormone therapy, but if you find uterosacral ligament nodularity, extreme pain on examination, and suspicious findings on ultrasound or otherwise, a diagnostic laparoscopy may be warranted to confirm the diagnosis.

Endometrioma management

Dr. Advincula: Let’s jump ahead. You have decided to proceed with laparoscopy and you encounter an endometrioma. What is your management strategy, particularly in a fertility-desiring patient?

Dr. Hur: Even if a woman has not undergone first-line medical treatment, if she is trying to conceive or presents with infertility, it’s a different balancing act for approaching the patient. When a woman presents, either with an ultrasound finding or an intraoperative finding of an endometrioma, I am a strong advocate of treating symptomatic disease, which means complete cyst excision. Good clinical data suggest that reproductive outcomes are improved for spontaneous pregnancy rates when you excise an endometrioma.^3-6

Dr. Advincula: What are the risks of excision of an endometrioma cyst that patients need to know about?

Dr. Brown: Current standard of care is cystectomy, stripping the cyst wall away from the ovarian cortex. There is some concern that the stripping process, depending on how long the endometrioma has been present within the ovary, can cause some destruction to the underlying oocytes and perhaps impact that ovary’s ability to produce viable eggs.

Some studies, from France in particular, have investigated different energy sources, such as plasma energy, that make it possible to remove part of the cyst and then use the plasma energy to vaporize the rest of the cyst wall that may be lying on the cortex. Researchers looked at anti-Müllerian hormone levels, and there does seem to be a difference in terms of how you remove the cyst.^7-9 This energy source is not available to everyone; it’s similar to laser but does not have as much penetration. Standard of care is still ovarian stripping.

The conversation with the patient—if she is already infertile and this cyst is a problem—would be that it likely needs to be removed. There is a chance that she may need assisted reproduction; she might not be able to get pregnant on her own due either to the presence of the endometrioma or to the surgical process of removing it and stripping.

Dr. Advincula: How soon after surgery can a patient start to pursue trying to get pregnant?

Dr. Hur: I think there is no time restraint outside of recovery. As long as the patient has a routine postoperative course, she can try to conceive, spontaneously or with assisted reproduction. Some data suggest, however, that ovarian reserve is diminished immediately after surgery.^10–12 If you look at the spontaneous clinical pregnancy outcomes, they are comparable 3 to 6 months postsurgery.^4,12–14

Dr. Brown: I agree. Time is of the essence with a lot of patients, many of whom present after age 35.

Dr. Hur: It’s also important to highlight that there are 2 presentations with endometrioma: the symptomatic patient and the asymptomatic patient. In the asymptomatic patient, her age, reproductive goals, and the bilaterality (whether it is present on both sides or on one side) of the endometrioma are important in deciding on a patient-centered surgical plan. For someone with a smaller cyst, unilateral presentation, and maybe older age at presentation, it may or may not impact assisted reproductive outcomes.

If the patient is not symptomatic and she is older with bilateral endometriomas less than 4 cm, some data suggest that patient might be better served in a conservative fashion.^6,15–17 Then, once she is done with assisted reproduction, we might be more aggressive surgically by treating the finding that would not resolve spontaneously without surgical management. It is important to highlight that endometriomas do not resolve on their own; they require surgical management.

Read about managing endometriosis for the patient not seeking fertility

Endometriosis management for the patient not seeking fertility

Dr. Advincula: Let’s now consider a patient on whom you have performed laparoscopy not only to diagnose and confirm the evidence of endometriosis but also to treat endometriosis, an endometrioma, and potentially deeply infiltrative disease. But this person is not trying to get pregnant. Postoperatively, what is your approach?

Dr. Brown: Suppressive therapy for this patient could be first-line or second-line therapy, such as a Lupron Depot or Depo-Provera. We keep the patient on suppressive therapy (whatever treatments work for her), until she’s ready to get pregnant; then we take her off. Hopefully she gets pregnant. After she delivers, we reinitiate suppressive therapy. I will follow these women throughout their reproductive cycle, and I think having a team of physicians who are all on the same page can help this patient manage her disease through her reproductive years.

Dr. Hur: If a patient presented warranting surgical management once, and she is not menopausal, the likelihood that disease will recur is quite high. Understanding the nature and the pathology of the disease, hormonal suppression would be warranted. Suppression is not just for between pregnancies, it’s until the patient reaches natural menopause. It’s also in the hopes of suppressing the disease so she does not need recurrent surgeries.

We typically do not operate unless patients have recurrence of symptoms that no longer respond to medical therapy. Our hope is to buy them more time closer to the age of natural menopause so that medical repercussions do not result in hysterectomy and ovary removal, which have other nongynecologic manifestations, including negative impact on bone and cardiac health.

The role of the LNG-IUD

Dr. Advincula: Something that often comes up is the role of a levonorgestrel-releasing intrauterine device (LNG-IUD) as one therapy option, either preoperatively or postoperatively. What is your perspective?

Dr. Hur: I reserve the LNG-IUD as a second-line therapy for patients, predominantly because it allows direct delivery of the medication to the womb (rather than systemic exposure of the medication). For patients who experience adverse effects due to systemic exposure to first-line treatments, it might be a great option. However, I do not believe that it consistently suppresses the ovaries, which we understand feeds the pathology of the hormonal stimulation, and so typically I will reserve it as a second-line treatment.

Dr. Brown: I utilize the LNG-IUD in a similar fashion. I may have patients who have had a diagnostic laparoscopy somewhere else and were referred to me because they now have known stage 3 or 4 endometriosis without endometriomas. Those patients, if they are going to need suppressive therapy after surgery and are not ready to get pregnant, do very well with the LNG-IUD, and I will place it during surgery under anesthesia. If a patient has endometriomas seen at the time of surgery, we could still place an LNG-IUD at the time of surgery. We may need to add on an additional medication, however, like another oral progesterone. I do have patients that use both an IUD and either combined oral contraceptive pills and/or oral progestins. Those patients usually have complicated cases with very deep infiltrative disease.

Read about managing endometriosis involving the bowel

Managing endometriosis involving the bowel

Dr. Advincula: Patients often are quite concerned when the words “endometriosis” and “bowel” come together. How do you manage disease that involves the bowel?

Illustration: Kimberly Martens for OBG Management

Dr. Hur: A lot of patients with endometriosis have what I call neighboring disease—it’s not limited just to the pelvis, but it involves the neighboring organs including the bowel and bladder. Patients can present with symptoms related to those adjacent organs. However, not all disease involving the bowel or bladder manifests with symptoms, and patients with symptoms may not have visible disease.

Typically, when a patient presents with symptoms of bowel involvement, where the bowel lumen is narrowed to more than 50% and/or she has functional manifestations (signs of obstruction that result in abnormal bowel function), we have serious conversations about a bowel resection. If she has full-thickness disease without significant bowel dysfunction—other than blood in her stool—sometimes we talk about more conservative treatment because of the long-term manifestations that a bowel resection could have.

Dr. Brown: I agree completely. It is important to have a good relationship with our colorectal surgeons. If I suspect that the patient has narrowing of the lumen of the large bowel or she actually has symptoms such as bloody diarrhea during menstruation—which is suggestive of deep, infiltrative and penetrative disease—I will often order a colonoscopy ahead of time to get confirmed biopsies. Then the patient discussion occurs with our colorectal surgeon, who operates with me jointly if we decide to proceed with a bowel resection. It’s important to have subspecialty colleagues involved in this care, because a low anterior resection is a very big surgery and there can be down-the-stream complications.

The importance of multidisciplinary care

Dr. Advincula: What are your perspectives on a multidisciplinary or interdisciplinary approach to the patient with endometriosis?

Dr. Brown: As I previously mentioned, it is important to develop a good relationship with colorectal surgery/urology. In addition, behavioral therapists may be involved in the care of patients with endometriosis, for a number of reasons. The disease process is fluid. It will change during the patient’s reproductive years, and you need to manage it accordingly based on her symptoms. Sometimes the diagnosis is not made for 5 to 10 years, and that can lead to other issues: depression, fibromyalgia, or irritable bowel syndrome.

The patient may have multiple issues plus endometriosis. I think having specialists such as gastroenterologists and behavioral therapists on board, as well as colorectal and urological surgeons who can perform these complex surgeries, is very beneficial to the patient. That way, she benefits from the team’s focus and is cared for from start to finish.

Dr. Hur: I like to call the abdomen a studio. It does not have separate compartments for each organ system. It’s one big room, and often the neighboring organs are involved, including the bowel and bladder. I think Dr. Brown’s observation—the multidisciplinary approach to a patient’s comprehensive care—is critical. Like any surgery, preoperative planning and preoperative assessment are essential, and these steps should include the patient. The discussion should cover not only the surgical outcomes that the surgeons expect, but also what the patient expects to be improved. For example, for patients with extensive disease and bowel involvement, a bowel resection is not always the right approach because it can have potential long-term sequelae. Balancing the risks associated with surgery with the long-term benefits is an important part of the discussion.

Dr. Advincula: Those are both excellent perspectives. Endometriosis is a very complicated disease state, does require a multidisciplinary approach to management, and there are implications and strategies that involve both the medical approach to management and the surgical approach.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Endometriosis is one of the more daunting diagnoses that gynecologists treat. In this roundtable discussion, moderated by OBG Management Board Member Arnold P. Advincula, MD, 2 leading surgeons discuss endometriosis diagnosis as well as medical and surgical management.

First-time evaluation

Arnold P. Advincula, MD: When a patient presents to your practice for the first time and you suspect endometriosis, what considerations tailor your evaluation, and what does that evaluation involve?

Hye-Chun Hur, MD, MPH: The diagnosis is contingent on a patient’s presenting profile. How symptomatic is she? How old is she? What are her reproductive goals? The gold standard for diagnosis is a histologic diagnosis, which is surgical. Depending on the age profile, however, and how close she is to menopause, the patient may be managed medically. Even women in the young reproductive age group may be managed medically if symptoms are responsive to medical treatment.

Douglas N. Brown, MD: I agree. When a patient presents without a laparoscopy, or a tissue diagnosis, but the symptoms are consistent with likely endometriosis (depending on where she is in her reproductive cycle and what her goals are), I think treating with a first-line therapy—hormonal treatments such as progestin-only oral contraceptive pills—is acceptable. I usually conduct a treatment trial period of 3 to 6 months to see if she obtains any symptom relief.

If that first-line treatment fails, generally you can move to a second-line treatment.

I have a discussion in which I either offer a second-line treatment, such as medroxyprogesterone (Depo-Provera) or leuprolide acetate (Lupron Depot), or get a tissue diagnosis, if possible, by performing laparoscopy. If first-line or even second-line therapy fails, you need to consider doing a diagnostic laparoscopy to confirm or deny the diagnosis.

Dr. Advincula: Are there any points in the evaluation of a patient who visits your practice for the first time where you would immediately offer a surgical approach, as opposed to starting with medical management?

Dr. Hur: A large percentage of my patients undergo surgical evaluation, as surgical diagnosis is the gold standard. If you look at the literature, even among surgeons, the accuracy of visual diagnosis is not great.^1,2 I target individuals who are either not responsive to medical treatment or who have never tried medical treatment but are trying to conceive, so they are not medical candidates, or individuals who genuinely want a diagnosis for surgical management—sometimes even before first-line medical treatment.

Dr. Brown: Your examination sometimes also dictates your approach. A patient may never have had a laparoscopy or hormone therapy, but if you find uterosacral ligament nodularity, extreme pain on examination, and suspicious findings on ultrasound or otherwise, a diagnostic laparoscopy may be warranted to confirm the diagnosis.

Endometrioma management

Dr. Advincula: Let’s jump ahead. You have decided to proceed with laparoscopy and you encounter an endometrioma. What is your management strategy, particularly in a fertility-desiring patient?

Dr. Hur: Even if a woman has not undergone first-line medical treatment, if she is trying to conceive or presents with infertility, it’s a different balancing act for approaching the patient. When a woman presents, either with an ultrasound finding or an intraoperative finding of an endometrioma, I am a strong advocate of treating symptomatic disease, which means complete cyst excision. Good clinical data suggest that reproductive outcomes are improved for spontaneous pregnancy rates when you excise an endometrioma.^3-6

Dr. Advincula: What are the risks of excision of an endometrioma cyst that patients need to know about?

Dr. Brown: Current standard of care is cystectomy, stripping the cyst wall away from the ovarian cortex. There is some concern that the stripping process, depending on how long the endometrioma has been present within the ovary, can cause some destruction to the underlying oocytes and perhaps impact that ovary’s ability to produce viable eggs.

Some studies, from France in particular, have investigated different energy sources, such as plasma energy, that make it possible to remove part of the cyst and then use the plasma energy to vaporize the rest of the cyst wall that may be lying on the cortex. Researchers looked at anti-Müllerian hormone levels, and there does seem to be a difference in terms of how you remove the cyst.^7-9 This energy source is not available to everyone; it’s similar to laser but does not have as much penetration. Standard of care is still ovarian stripping.

The conversation with the patient—if she is already infertile and this cyst is a problem—would be that it likely needs to be removed. There is a chance that she may need assisted reproduction; she might not be able to get pregnant on her own due either to the presence of the endometrioma or to the surgical process of removing it and stripping.

Dr. Advincula: How soon after surgery can a patient start to pursue trying to get pregnant?

Dr. Hur: I think there is no time restraint outside of recovery. As long as the patient has a routine postoperative course, she can try to conceive, spontaneously or with assisted reproduction. Some data suggest, however, that ovarian reserve is diminished immediately after surgery.^10–12 If you look at the spontaneous clinical pregnancy outcomes, they are comparable 3 to 6 months postsurgery.^4,12–14

Dr. Brown: I agree. Time is of the essence with a lot of patients, many of whom present after age 35.

Dr. Hur: It’s also important to highlight that there are 2 presentations with endometrioma: the symptomatic patient and the asymptomatic patient. In the asymptomatic patient, her age, reproductive goals, and the bilaterality (whether it is present on both sides or on one side) of the endometrioma are important in deciding on a patient-centered surgical plan. For someone with a smaller cyst, unilateral presentation, and maybe older age at presentation, it may or may not impact assisted reproductive outcomes.

If the patient is not symptomatic and she is older with bilateral endometriomas less than 4 cm, some data suggest that patient might be better served in a conservative fashion.^6,15–17 Then, once she is done with assisted reproduction, we might be more aggressive surgically by treating the finding that would not resolve spontaneously without surgical management. It is important to highlight that endometriomas do not resolve on their own; they require surgical management.

Read about managing endometriosis for the patient not seeking fertility

Endometriosis management for the patient not seeking fertility

Dr. Advincula: Let’s now consider a patient on whom you have performed laparoscopy not only to diagnose and confirm the evidence of endometriosis but also to treat endometriosis, an endometrioma, and potentially deeply infiltrative disease. But this person is not trying to get pregnant. Postoperatively, what is your approach?

Dr. Brown: Suppressive therapy for this patient could be first-line or second-line therapy, such as a Lupron Depot or Depo-Provera. We keep the patient on suppressive therapy (whatever treatments work for her), until she’s ready to get pregnant; then we take her off. Hopefully she gets pregnant. After she delivers, we reinitiate suppressive therapy. I will follow these women throughout their reproductive cycle, and I think having a team of physicians who are all on the same page can help this patient manage her disease through her reproductive years.

Dr. Hur: If a patient presented warranting surgical management once, and she is not menopausal, the likelihood that disease will recur is quite high. Understanding the nature and the pathology of the disease, hormonal suppression would be warranted. Suppression is not just for between pregnancies, it’s until the patient reaches natural menopause. It’s also in the hopes of suppressing the disease so she does not need recurrent surgeries.

We typically do not operate unless patients have recurrence of symptoms that no longer respond to medical therapy. Our hope is to buy them more time closer to the age of natural menopause so that medical repercussions do not result in hysterectomy and ovary removal, which have other nongynecologic manifestations, including negative impact on bone and cardiac health.

The role of the LNG-IUD

Dr. Advincula: Something that often comes up is the role of a levonorgestrel-releasing intrauterine device (LNG-IUD) as one therapy option, either preoperatively or postoperatively. What is your perspective?

Dr. Hur: I reserve the LNG-IUD as a second-line therapy for patients, predominantly because it allows direct delivery of the medication to the womb (rather than systemic exposure of the medication). For patients who experience adverse effects due to systemic exposure to first-line treatments, it might be a great option. However, I do not believe that it consistently suppresses the ovaries, which we understand feeds the pathology of the hormonal stimulation, and so typically I will reserve it as a second-line treatment.

Dr. Brown: I utilize the LNG-IUD in a similar fashion. I may have patients who have had a diagnostic laparoscopy somewhere else and were referred to me because they now have known stage 3 or 4 endometriosis without endometriomas. Those patients, if they are going to need suppressive therapy after surgery and are not ready to get pregnant, do very well with the LNG-IUD, and I will place it during surgery under anesthesia. If a patient has endometriomas seen at the time of surgery, we could still place an LNG-IUD at the time of surgery. We may need to add on an additional medication, however, like another oral progesterone. I do have patients that use both an IUD and either combined oral contraceptive pills and/or oral progestins. Those patients usually have complicated cases with very deep infiltrative disease.

Read about managing endometriosis involving the bowel

Managing endometriosis involving the bowel

Dr. Advincula: Patients often are quite concerned when the words “endometriosis” and “bowel” come together. How do you manage disease that involves the bowel?

Illustration: Kimberly Martens for OBG Management

Dr. Hur: A lot of patients with endometriosis have what I call neighboring disease—it’s not limited just to the pelvis, but it involves the neighboring organs including the bowel and bladder. Patients can present with symptoms related to those adjacent organs. However, not all disease involving the bowel or bladder manifests with symptoms, and patients with symptoms may not have visible disease.

Typically, when a patient presents with symptoms of bowel involvement, where the bowel lumen is narrowed to more than 50% and/or she has functional manifestations (signs of obstruction that result in abnormal bowel function), we have serious conversations about a bowel resection. If she has full-thickness disease without significant bowel dysfunction—other than blood in her stool—sometimes we talk about more conservative treatment because of the long-term manifestations that a bowel resection could have.

Dr. Brown: I agree completely. It is important to have a good relationship with our colorectal surgeons. If I suspect that the patient has narrowing of the lumen of the large bowel or she actually has symptoms such as bloody diarrhea during menstruation—which is suggestive of deep, infiltrative and penetrative disease—I will often order a colonoscopy ahead of time to get confirmed biopsies. Then the patient discussion occurs with our colorectal surgeon, who operates with me jointly if we decide to proceed with a bowel resection. It’s important to have subspecialty colleagues involved in this care, because a low anterior resection is a very big surgery and there can be down-the-stream complications.

The importance of multidisciplinary care

Dr. Advincula: What are your perspectives on a multidisciplinary or interdisciplinary approach to the patient with endometriosis?

Dr. Brown: As I previously mentioned, it is important to develop a good relationship with colorectal surgery/urology. In addition, behavioral therapists may be involved in the care of patients with endometriosis, for a number of reasons. The disease process is fluid. It will change during the patient’s reproductive years, and you need to manage it accordingly based on her symptoms. Sometimes the diagnosis is not made for 5 to 10 years, and that can lead to other issues: depression, fibromyalgia, or irritable bowel syndrome.

The patient may have multiple issues plus endometriosis. I think having specialists such as gastroenterologists and behavioral therapists on board, as well as colorectal and urological surgeons who can perform these complex surgeries, is very beneficial to the patient. That way, she benefits from the team’s focus and is cared for from start to finish.

Dr. Hur: I like to call the abdomen a studio. It does not have separate compartments for each organ system. It’s one big room, and often the neighboring organs are involved, including the bowel and bladder. I think Dr. Brown’s observation—the multidisciplinary approach to a patient’s comprehensive care—is critical. Like any surgery, preoperative planning and preoperative assessment are essential, and these steps should include the patient. The discussion should cover not only the surgical outcomes that the surgeons expect, but also what the patient expects to be improved. For example, for patients with extensive disease and bowel involvement, a bowel resection is not always the right approach because it can have potential long-term sequelae. Balancing the risks associated with surgery with the long-term benefits is an important part of the discussion.

Dr. Advincula: Those are both excellent perspectives. Endometriosis is a very complicated disease state, does require a multidisciplinary approach to management, and there are implications and strategies that involve both the medical approach to management and the surgical approach.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

PRENATAL SCREENING FOR SINGLE-GENE DISORDERS

Vistara^®, a non-invasive prenatal test (NIPT) from Natera, Inc, screens for single-gene disorders after 9 weeks’ gestation. Complementing the Panorama^® NIPT, Vistara tests for major anatomic abnormalities and chromosome imbalances that have a combined incidence rate of 1 in 600 (higher than Down syndrome). These mutations can cause severe conditions affecting skeletal, cardiac, and neurologic systems, such as Noonan syndrome, osteogenesis imperfecta, craniosynostosis syndromes, achondroplasia, and Rett syndrome. Standard NIPT commonly cannot detect these de novo (not inherited) mutations. Ultrasound exams may either completely miss the disorders or identify nonspecific findings later in pregnancy.

Natera says that Vistara has a combined analytical sensitivity of >99% and a combined analytical specificity of >99% in validation studies.

FOR MORE INFORMATION, VISIT: https://www.natera.com/vistara

ELECTROSTATIC SURGICAL SMOKE REMOVAL

The Ultravision^TM Trocar device from Alesi Surgical Technologies uses a low-energy electrostatic charge to eliminate the surgical smoke generated by cutting instruments during laparoscopic surgery. Electrostatic precipitation accelerates the natural process of sedimentation; Ultravision creates negatively charged gas ions that draw water vapor and particulate matter away from the surgical site toward “positive” patient tissue.

Alesi says that bench studies comparing Ultravision with a vacuum-system when using monopolar, bipolar, and ultrasonic instruments show that its device is faster and more efficient than smoke evacuation. When switched on before cutting, Ultravision precipitates 99% of particles within 30 seconds. After 1 minute of continuous use, Ultravision precipitates 99.9% of particles, independent of particle size, from 7 nm to 10 µm. Smoke evacuation removes 30.2% of particles after 1 minute, according to Alesi.

FOR MORE INFORMATION, VISIT: http://www.alesi-surgical.com

PRESSURE-SENSING TECHNOLOGY FOR EPIDURALS

The CompuFlo^®Epidural from Milestone Scientific uses pressure-sensing technology to identify the epidural space, and provides a computer-controlled drug delivery system.

Knowing the precise needle location during an epidural injection procedure provides a measure of safety not available to physicians who use conventional syringes. Milestone says that its CompuFlo Epidural allows anesthesiologists to use both hands to advance and direct the needle, and to confirm the epidural space with 99% accuracy on the first attempt.

CompuFlo Epidural differentiates tissue types for the medical professional via visual and audio feedback, leading to precise location guidance as the needle advances toward the intended area. It also allows for controlled needle exit pressure, precise flow rate and drug volumes, and patient treatment documentation.

FOR MORE INFORMATION, VISIT: https://www.milestonescientific.com/products/compuflo-epidural

OBGYN ULTRASOUND INNOVATIONS

Philips recently announced enhancements to its EPIQ 7 and 5 and Affiniti 70 ultrasound systems. According to Philips, the eL18-4 transducer provides high-detail resolution and image uniformity with penetration for enhanced diagnostic quality in 1st- and 2nd-trimester obstetric exams. aBiometry Assist^AI, with anatomical intelligence of fetal anatomy, streamlines fetal measurement by preplacing measurement cursors on selected structures. The new TouchVue control-panel interface on TrueVue allows practitioners to interact with finger gestures and to direct 3D-volume rotation and internal light-source position. The 2D Tilt feature offered on the 3D9-v3 transducer provides lateral scanning of anatomic structures that are off-axis without having to manually angle the transducer.

These new features complement the existing suite of Philips ObGyn ultrasound visualization tools: TrueVue, GlassVue, aReveal^AI, and MaxVue.

FOR MORE INFORMATION, VISIT: https://www.usa.philips.com/healthcare/resources/feature-detail/ultrasound-truevue-imaging

‌

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

PRENATAL SCREENING FOR SINGLE-GENE DISORDERS

Vistara^®, a non-invasive prenatal test (NIPT) from Natera, Inc, screens for single-gene disorders after 9 weeks’ gestation. Complementing the Panorama^® NIPT, Vistara tests for major anatomic abnormalities and chromosome imbalances that have a combined incidence rate of 1 in 600 (higher than Down syndrome). These mutations can cause severe conditions affecting skeletal, cardiac, and neurologic systems, such as Noonan syndrome, osteogenesis imperfecta, craniosynostosis syndromes, achondroplasia, and Rett syndrome. Standard NIPT commonly cannot detect these de novo (not inherited) mutations. Ultrasound exams may either completely miss the disorders or identify nonspecific findings later in pregnancy.

Natera says that Vistara has a combined analytical sensitivity of >99% and a combined analytical specificity of >99% in validation studies.

FOR MORE INFORMATION, VISIT: https://www.natera.com/vistara

ELECTROSTATIC SURGICAL SMOKE REMOVAL

The Ultravision^TM Trocar device from Alesi Surgical Technologies uses a low-energy electrostatic charge to eliminate the surgical smoke generated by cutting instruments during laparoscopic surgery. Electrostatic precipitation accelerates the natural process of sedimentation; Ultravision creates negatively charged gas ions that draw water vapor and particulate matter away from the surgical site toward “positive” patient tissue.

Alesi says that bench studies comparing Ultravision with a vacuum-system when using monopolar, bipolar, and ultrasonic instruments show that its device is faster and more efficient than smoke evacuation. When switched on before cutting, Ultravision precipitates 99% of particles within 30 seconds. After 1 minute of continuous use, Ultravision precipitates 99.9% of particles, independent of particle size, from 7 nm to 10 µm. Smoke evacuation removes 30.2% of particles after 1 minute, according to Alesi.

FOR MORE INFORMATION, VISIT: http://www.alesi-surgical.com

PRESSURE-SENSING TECHNOLOGY FOR EPIDURALS

The CompuFlo^®Epidural from Milestone Scientific uses pressure-sensing technology to identify the epidural space, and provides a computer-controlled drug delivery system.

Knowing the precise needle location during an epidural injection procedure provides a measure of safety not available to physicians who use conventional syringes. Milestone says that its CompuFlo Epidural allows anesthesiologists to use both hands to advance and direct the needle, and to confirm the epidural space with 99% accuracy on the first attempt.

CompuFlo Epidural differentiates tissue types for the medical professional via visual and audio feedback, leading to precise location guidance as the needle advances toward the intended area. It also allows for controlled needle exit pressure, precise flow rate and drug volumes, and patient treatment documentation.

FOR MORE INFORMATION, VISIT: https://www.milestonescientific.com/products/compuflo-epidural

OBGYN ULTRASOUND INNOVATIONS

Philips recently announced enhancements to its EPIQ 7 and 5 and Affiniti 70 ultrasound systems. According to Philips, the eL18-4 transducer provides high-detail resolution and image uniformity with penetration for enhanced diagnostic quality in 1st- and 2nd-trimester obstetric exams. aBiometry Assist^AI, with anatomical intelligence of fetal anatomy, streamlines fetal measurement by preplacing measurement cursors on selected structures. The new TouchVue control-panel interface on TrueVue allows practitioners to interact with finger gestures and to direct 3D-volume rotation and internal light-source position. The 2D Tilt feature offered on the 3D9-v3 transducer provides lateral scanning of anatomic structures that are off-axis without having to manually angle the transducer.

These new features complement the existing suite of Philips ObGyn ultrasound visualization tools: TrueVue, GlassVue, aReveal^AI, and MaxVue.

FOR MORE INFORMATION, VISIT: https://www.usa.philips.com/healthcare/resources/feature-detail/ultrasound-truevue-imaging

‌

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

PRENATAL SCREENING FOR SINGLE-GENE DISORDERS

Vistara^®, a non-invasive prenatal test (NIPT) from Natera, Inc, screens for single-gene disorders after 9 weeks’ gestation. Complementing the Panorama^® NIPT, Vistara tests for major anatomic abnormalities and chromosome imbalances that have a combined incidence rate of 1 in 600 (higher than Down syndrome). These mutations can cause severe conditions affecting skeletal, cardiac, and neurologic systems, such as Noonan syndrome, osteogenesis imperfecta, craniosynostosis syndromes, achondroplasia, and Rett syndrome. Standard NIPT commonly cannot detect these de novo (not inherited) mutations. Ultrasound exams may either completely miss the disorders or identify nonspecific findings later in pregnancy.

Natera says that Vistara has a combined analytical sensitivity of >99% and a combined analytical specificity of >99% in validation studies.

FOR MORE INFORMATION, VISIT: https://www.natera.com/vistara

ELECTROSTATIC SURGICAL SMOKE REMOVAL

The Ultravision^TM Trocar device from Alesi Surgical Technologies uses a low-energy electrostatic charge to eliminate the surgical smoke generated by cutting instruments during laparoscopic surgery. Electrostatic precipitation accelerates the natural process of sedimentation; Ultravision creates negatively charged gas ions that draw water vapor and particulate matter away from the surgical site toward “positive” patient tissue.

Alesi says that bench studies comparing Ultravision with a vacuum-system when using monopolar, bipolar, and ultrasonic instruments show that its device is faster and more efficient than smoke evacuation. When switched on before cutting, Ultravision precipitates 99% of particles within 30 seconds. After 1 minute of continuous use, Ultravision precipitates 99.9% of particles, independent of particle size, from 7 nm to 10 µm. Smoke evacuation removes 30.2% of particles after 1 minute, according to Alesi.

FOR MORE INFORMATION, VISIT: http://www.alesi-surgical.com

PRESSURE-SENSING TECHNOLOGY FOR EPIDURALS

The CompuFlo^®Epidural from Milestone Scientific uses pressure-sensing technology to identify the epidural space, and provides a computer-controlled drug delivery system.

Knowing the precise needle location during an epidural injection procedure provides a measure of safety not available to physicians who use conventional syringes. Milestone says that its CompuFlo Epidural allows anesthesiologists to use both hands to advance and direct the needle, and to confirm the epidural space with 99% accuracy on the first attempt.

CompuFlo Epidural differentiates tissue types for the medical professional via visual and audio feedback, leading to precise location guidance as the needle advances toward the intended area. It also allows for controlled needle exit pressure, precise flow rate and drug volumes, and patient treatment documentation.

FOR MORE INFORMATION, VISIT: https://www.milestonescientific.com/products/compuflo-epidural

OBGYN ULTRASOUND INNOVATIONS

Philips recently announced enhancements to its EPIQ 7 and 5 and Affiniti 70 ultrasound systems. According to Philips, the eL18-4 transducer provides high-detail resolution and image uniformity with penetration for enhanced diagnostic quality in 1st- and 2nd-trimester obstetric exams. aBiometry Assist^AI, with anatomical intelligence of fetal anatomy, streamlines fetal measurement by preplacing measurement cursors on selected structures. The new TouchVue control-panel interface on TrueVue allows practitioners to interact with finger gestures and to direct 3D-volume rotation and internal light-source position. The 2D Tilt feature offered on the 3D9-v3 transducer provides lateral scanning of anatomic structures that are off-axis without having to manually angle the transducer.

These new features complement the existing suite of Philips ObGyn ultrasound visualization tools: TrueVue, GlassVue, aReveal^AI, and MaxVue.

FOR MORE INFORMATION, VISIT: https://www.usa.philips.com/healthcare/resources/feature-detail/ultrasound-truevue-imaging

‌

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

More women die from pregnancy complications in the United States than in any other developed country. The United States is the only industrialized nation with a rising maternal mortality rate.

Those 2 sentences should stop us all in our tracks.

In fact, the United States ranks 47th globally with the worst maternal mortality rate. More than half these deaths are likely preventable, with suicide and drug overdose the leading causes of maternal death in many states. All this occurs despite our advanced medical system, premier medical colleges and universities, embrace of high-tech medical advances, and high percentage of gross domestic product spent on health care.

Need more numbers? According to a 2016 report in Obstetrics and Gynecology, the United States saw a 26% increase in the maternalmortality rate (unadjusted) in only 15 years: from 18.8 deaths per 100,000 live births in 2000 to 23.8 in 2014 (FIGURE 1).¹

Considerable variations by race and by state

The racial disparities in maternal mortality are staggering and have not improved in more than 20 years: African American women are 3.4 times more likely to die than non-Hispanic white women of pregnancy-related complications. In 2011–2013, the maternal mortality ratio for non-Hispanic white women was 12.7 deaths per 100,000 live births compared with 43.5 deaths for non-Hispanic black women (FIGURE 2).² American Indian or Alaska Native women, Asian women, and some Latina women also experience higher rates than non-Hispanic white women. The rate for American Indian or Alaska Native women is 16.9 deaths per 100,000 live births.³

Some states are doing better than others, showing that there is nothing inevitable about the maternal mortality crisis. Texas, for example, has seen the highest rate of maternal mortality increase. Its rate doubled from 2010 to 2012, while California reduced its maternal death rate by 30%, from 21.5 to 15.1, during roughly the same period.¹

This is a challenge of epic proportions, and one that the American College of Obstetricians and Gynecologists (ACOG), under the leadership of President Haywood Brown, MD, and Incoming President Lisa Hollier, MD, is determined to meet, ensuring that a high maternal death rate does not become our nation’s new normal.

Dr. Brown put it this way, “ACOG collaborative initiatives such as Levels of Maternal Care (LOMC) and implementation of OB safety bundles for hemorrhage, hypertension, and thromboembolism through the AIM [Alliance for Innovation on Maternal Health] Program target maternal morbidity and mortality at the community level. Bundles have also been developed to address the disparity in maternal mortality and for the opiate crisis.”

ACOG is making strides in putting in place nationwide meaningful, evidence-driven systems and care approaches that are proven to reduce maternal mortality and morbidity, saving mothers’ lives and keeping families whole.

Read about the AIM Program’s initiatives

ACOG’s AIM Program established to make an impact

The AIM Program (www.safehealthcare foreverywoman.org) is bringing together clinicians, public health officials, hospital administrators, patient safety organizations, and advocates to eliminate preventable maternal mortality throughout the United States. With funding and support from the US Health Resources and Services Administration, AIM is striving to:

• reduce maternal mortality by 1,000 deaths by 2018
• reduce severe maternal morbidity
• assist states and hospitals to improve outcomes
• create and encourage use of maternal safety bundles (evidence-based tool kits to guide the best care).

AIM offers participating physicians and hospitals online learning modules, checklists, work plans, and links to tool kits and published resources. Implementation data is shared with hospitals and states to further improve care. Physicians participating in AIM can receive Part IV maintenance of certification; continuing education units will soon be offered for nurses. In the future, AIM-participating hospitals may be able to receive reduced liability protection costs, too.

To date, 17 states are participating in the AIM initiative (FIGURE 3), with more states ready to enroll.⁴ States must demonstrate a commitment to lasting change to participate. Each AIM state must have an active maternal mortality review committee (MMRC); committed leadership from public health, hospital associations, and provider associations; and a commitment to report AIM data.

• reducing disparities in maternity care
• severe hypertension in pregnancy
• safe reduction of primary cesarean birth
• prevention of venous thromboembolism
• obstetric hemorrhage
• maternal mental health
• patient, family, and staff support following a severe maternal event
• postpartum care basics
• obstetric care of women with opioid use disorder (in use by Illinois, Massachusetts, Maryland, New Jersey, Maine, New Hampshire, Vermont, New York, Ohio, Oklahoma, Tennessee, Texas, and Virginia).

Read about how active MMRCS are critical to success

Review committees are critical to success

In use in many states, MMRCs are groups of local ObGyns, nurses, social workers, and other health care professionals who review specific cases of maternal deaths from their local area and recommend local solutions to prevent future deaths. MMRCs can be a critically important source of data to help us understand the underlying causes of maternal mortality.

Remember California’s success in reducing its maternal mortality rate, previously mentioned? That state was an early adopter of an active MMRC and has worked to bring best practices to maternity care throughout the state.

While every state should have an active MMRC, not every state does. ACOG is working with states, local leaders, and state and federal legislatures to help develop MMRCs in every state.

Dr. Brown pointed out that, “For several decades, Indiana had a legislatively authorized multidisciplinary maternal mortality review committee that I actively participated in and led in the late 1990s. The authorization for the program lapsed in the early 2000s, and the Indiana MMRC had to shut down. Bolstering the federal government’s capacity to help states like Indiana rebuild MMRCs, or start them from scratch, will help state public health officials, hospitals, and physicians take better care of moms and babies.”

Dr. Hollier explained, “In Texas, I chair our Maternal Mortality and Morbidity Task Force, which was legislatively authorized in 2013 in response to the rising rate of maternal death. The detailed state-based maternal mortality reviews provide critical information: verification of vital statistics data, assessment of the causes and contributing factors, and determination of pregnancy relatedness. These reviews identify opportunities for prevention and implementation of the most appropriate interventions to reduce maternal mortality on a local level. Support of essential review functions at the federal level would also enable data to be combined across jurisdictions for national learning that was previously not possible.”

Pending legislation will strengthen efforts

ACOG is working to enact into law the Preventing Maternal Deaths Act, HR 1318 and S1112. This is bipartisan legislation under which the Centers for Disease Control and Prevention would help states create or expand MMRCs and will require the Department of Health and Human Services to research ways to reduce disparities in maternal health outcomes.

Acknowledgement
The author thanks Jean Mahoney, ACOG’s Senior Director, AIM, for her generous assistance.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.