Faculty Bibliography

Surgical resection of endometriosis reduces pain symptoms and improves quality of life in women with chronic pelvic pain. Complete resection is contingent upon the accuracy of visual identification of endometriosis, which may be influenced by endometriosis stage, lesion appearance and location, and inter-observer variability. Indocyanine green (ICG) is a water soluble dye that binds to plasma proteins and can be used with the da Vinci Si near infrared fluorescence imaging system to measure tissue perfusion and for selective vessel identification. Angiogenesis is crucial in endometriosis as lesions need blood supply to survive in their ectopic locations. This video demonstrates the novel use of ICG to highlight areas of neovascularization in order to improve identification of peritoneal endometriosis in robotic-assisted laparoscopic excision of endometriosis. Future directions include analysis of overall accuracy of ICG identification of endometriosis and associated clinical outcomes after endometriosis excision with ICG use

OBJECTIVE: To compare cycle and clinical outcomes between natural or medicated FET cycles. DESIGN: Retrospective study in an academic institution. MATERIALS AND METHODS: There were 1177 FET cycles from 2005- 2012. FET included embryos created from autologous or donor oocytes. Embryo transfers from oocyte thaws were excluded. Groups were analyzed for % donor cycles, % vitrification, % preimplantation genetic diagnosis/ screening (PGD), number of monitoring days, embryos transferred (ET), embryos thawed, day of embryo transfer, maximal endometrial (EM) thickness before transfer, peak estradiol (E2) and progesterone (P4) in follicular cycle, clinical pregnancy rate (CPR), spontaneous abortion rate (SABR) and ongoing/live birth rate (OP/LBR). CPR was defined by fetal cardiac activity on 1st-trimester ultrasound. SABR was calculated per pregnancy with a sac. T-tests were performed with p<0.05. RESULTS: Subset analysis was performed excluding PGD cycles, confirming no difference between natural and medicated cycles except for days of monitoring, peak E2 and peak P4. CONCLUSION: There can be advantages to both natural FET (lack of medication costs and injections) and medicated cycles (flexibility). Natural and medicated FET are equally effective in terms of pregnancy outcomes and should be offered based on patient preference and suitability (Table Presented)

BACKGROUND: Ruptured ectopic pregnancy accounts for more cases of spontaneous hemoperitoneum than does the less frequently described acute bleeding from pedunculated uterine leiomyomata. When the latter does occur, management has consisted of laparotomy and either hemostatic suture or cauterization, myomectomy, or hysterectomy. CASE: We report a case of hemoperitoneum secondary to active bleeding from a pedunculated uterine fibroid notable for the presence of a concomitant tubal abortion as well as for the minimally invasive, fertility-sparing management approach. The patient underwent an uncomplicated laparoscopic myomectomy and was discharged home on the first postoperative day. CONCLUSION: Laparoscopic myomectomy is a safe, feasible alternative in the management of hemoperitoneum from pedunculated leiomyomata.

Study Objective: To evaluate the clinical value of office endometrial Pipelle biopsy (Embx) for detection of premalignant and malignant lesions in the presence of an endometrial polyp. Design: A retrospective study. Setting: A tertiary care academic hospital. Patients: 335 patients with a preoperative Embx and subsequent hysteroscopy (HSC), dilation and curettage (D&C), with or without polypectomy. Intervention: The accuracy of Embx was compared between the study group (with visible polyps on hysteroscopy) and control group (without visible polyps on hysteroscopy). Measurements and Main Results: Using final pathology (D&C +/- polypectomy specimen) as the gold standard, the accuracy of Embx was compared between the study (n = 217) and control groups (n = 118). After excluding all patients with an insufficient sample, results suggest improved sensitivity of Embx in detecting premalignant and malignant lesions in the absence of an endometrial polyp (control group 57% vs study group 36%, p = 0.314). Specificity, positive predictive value, and negative predictive value were comparable for both groups (96% vs 98%, 67% vs 69%, 94% vs 91%, respectively, p value not significant). Notably, discordance between Embx and final pathology was 13% for both groups and, of these cases, 71% in the control group and 84% in the study group had upgraded lesions on final pathology. Insufficient sampling by either Embx or D&C occurred significantly more frequently in postmenopausal women. Finally, Embx detected only 40% of premalignant and malignant lesions confined to polyps. Conclusion: The presence of an endometrial polyp may decrease the detection of premalignant and malignant endometrial lesions with Pipelle biopsy; further studies with a larger sample size are necessary to demonstrate statistical significance. Given the rates of discordance and upgraded lesions, endometrial Pipelle biopsy should not be used solely for counseling patients who desire conservative management

Abdominal myomectomies can be associated with a large amount of blood loss due to the vascular nature of fibroids. Laparoscopic management of fibroids is a difficult task in minimally invasive surgery given the extensive amount of suturing typically involved. The advantages of robotic surgery, including increased precision and fine motor coordination as well as excellent suturing capabilities, have led to its increased use in myomectomies. In comparision to conventional laparotomy, studies have shown reduced blood loss, complication rates, and length of stay with robotic myomectomies. This video demonstrates the improved precision in the enucleation of a myoma with attention to preserving fertility and the advantage of using monopolar and bipolar energy together to decrease blood loss. The ease of laparoscopic suturing shown in this robotic myomectomy due to increased fine motor coordination demonstrates a key advantage in robotic surgery in comparision to conventional laparoscopy

Minimally invasive surgery has been shown to decrease length of hospital stay, time to recovery, and postoperative pain scores. There has been a tremendous rise in the use of robotic surgery for high-precision surgeries, including gynecologic surgery for benign disease. It has been reported that one in nine women will eventually have a hysterectomy for benign indications, including symptomatic fibroids, adenomyosis, lower pelvic pain, and abnormal bleeding. Several studies have suggested advantages of robotic surgery over conventional laparotomy and laparoscopy regarding visualization, improved ergonomics, and fine motor coordination, although long-term patient outcomes have yet to be determined. This video explores the feasibility of robotic hysterectomy and the advantage of using monopolar and bipolar energy together with increased precision during dissection. In addition, we will show several conditions, including extensive pelvic adhesions and large uterine size, that can make a robotic hysterectomy more challenging