SURGICAL TUTORIAL 1: Before, During and After- Comprehensive Team Approach to Laparoscopic Management of Severe Endometriosis

Home , Cystocele, Endometriosis, Rectocele

SYLLABUS SURGICAL TUTORIAL 1: Before, During and After- Comprehensive Team Approach to Laparoscopic Management of Severe Endometriosis

Be a Surgical “Multiplier” in MIGS Inspire Brilliance Through Teamwork

Scientific Program Chair Honorary Chair President Jubilee Brown, MD Barbara S. Levy, MD Marie Fidela R. Paraiso, MD

Professional Education Information

Target Audience This educational activity is developed to meet the needs of surgical gynecologists in practice and in training, as well as other healthcare professionals in the field of gynecology.

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Table of Contents Course Description ...... 1 Disclosure ...... 2

Pre-op Workup and Inform Consent for Severe Endometriosis with Visceral Involvement T.T.M. Lee ...... 3

Multi-Disciplinary Team Approach Should Be the Way Forward for Complex Endometriosis A.M. Lam ...... 8

Rectosigmoid Endometriosis: Anterior Discoid Resection R.S. Furr ...... 11

Stepwise Strategies to Deal with Deep Infiltrative Endometriosis and Frozen Pelvis A.M. Lam ...... 24

Urinary Endometriosis: A Surgical Tutorial T.T.M. Lee ...... 27

Persistent Pain despite Aggressive Excision: Now What? S. As-Sanie ...... UNA

Cultural and Linguistics Competency ...... 31

Surgical Tutorial 1: Before, During and After- Comprehensive Team Approach to Laparoscopic Management of Severe Endometriosis

Chair: Ted T.M. Lee Faculty: Robert S. Furr, Alan M. Lam, Sawsan As-Sanie

Course Description This high-profile session will use a case study to illustrate many facets of care when managing patients with severe endometriosis with visceral involvement. Each expert will highlight various aspects of patient care before, during and after surgery which will include proper work-up, inform consent process, orchestrating a multidisciplinary team and understanding the potential etiologies of suboptimal symptom relief despite expert execution of surgical plan.

Course Objectives At the conclusion of this activity, the participant will be able to: 1) Articulate surgical planning for severe endometriosis with visceral involvement from work up, inform consent, fielding a multidisciplinary team, intraoperative decision making and management of persistent symptoms.

Course Outline

3:05 Welcome, Introductions, and Course Overview T.T.M. Lee 3:10 Pre-op Workup and Inform Consent for Severe Endometriosis with T.T.M. Lee Visceral Involvement 3:20 Multi-Disciplinary Team Approach Should Be the Way Forward for A.M. Lam Complex Endometriosis 3:35 Rectosigmoid Endometriosis: Anterior Discoid Resection R.S. Furr 3:50 Stepwise Strategies to Deal with Deep Infiltrative Endometriosis and A.M. Lam Frozen Pelvis 4:05 Urinary Endometriosis: A Surgical Tutorial T.T.M. Lee 4:20 Persistent Pain despite Aggressive Excision: Now What? S. As-Sanie 4:35 Question and Answer All Faculty 4:45 Adjourn

Page 1 PLANNER DISCLOSURE FACULTY DISCLOSURE The following members of AAGL have been The following have agreed to provide verbal involved in the educational planning of this disclosure of their relationships prior to their workshop (listed in alphabetical order by last presentations. They have also agreed to name). support their presentations and clinical Art Arellano, Professional Education Director, recommendations with the “best available AAGL* evidence” from medical literature (in Linda D. Bradley, Medical Director, AAGL* alphabetical order by last name). Erin T. Carey Sawsan As-Sanie Consultant: MedIQ Consultant: AbbVie, Myovant Mark W. Dassel Robert S. Furr* Contracted Research: Myovant Sciences Alan M. Lam* Erica Dun* Ted T.M. Lee* Adi Katz* Content Reviewer has nothing to disclose. Linda Michels, Executive Director, AAGL* Erinn M. Myers Asterisk (*) denotes no financial relationships to Speakers Bureau: Laborie Medical Technologies, disclose. Teleflex Medical Other: Unrestricted educational grant to support NC FPMRS Fellow Cadaver Lab: Boston Scientific Corp. Inc. Amy Park* Grace Phan, Professional Education Specialist, AAGL* Harold Y. Wu* Linda C. Yang Other: Ownership Interest: KLAAS LLC Ted T.M. Lee*

SCIENTIFIC PROGRAM COMMITTEE Linda D. Bradley, Medical Director, AAGL* Jubilee Brown* Nichole Mahnert* Shanti Indira Mohling* Fariba Mohtashami Consultant: Hologic Marie Fidela R. Paraiso* Shailesh P. Puntambekar* Matthew T. Siedhoff Consultant: Applied Medical, Caldera Medical, CooperSurgical, Olympus Amanda C. Yunker Consultant: Olympus Linda Michels, Executive Director, AAGL*

Page 2 Pre‐op Workup and Inform Disclosure Consent for Severe Endometriosis with Visceral Ihaveno financial relationships to disclose. Involvement

Ted Lee, M.D. Director, Minimally Invasive Gynecologic Surgery Magee Womens Hospital University of Pittsburgh Medical Center

Objectives History

• Age • Use the learning process to understand the nuances in history and physical exam to triage patients for proper diagnostic modalities • G and P: previous c‐sec, unexplained nullaparity and to assess the need for multidisciplinary treatment approach • Desire for Future Fertility for endometriosis surgery • Pain or Infertility or Both • Onset • Apply the results of the imaging studies and other diagnostic • 3 D’s –Dysmenorrhea , Dyspareunia (location, severity), modalities for optimal surgical planning and proper inform and Dyschezia (quality, location, temporality. ) consent. • Location: RLQ, LLQ, Midline, lower back , etc Lateralized pain worsen with menses • Temporality: intermittent, constant, relationship to menses and ovulation

History Symptoms Suggestive of Bowel Endometriosis

• Dyschezia with or without cyclic exacerbation. • Quality: Sharp, stabbing, crampy, dull ,achy,etc. ( Not so important except for the degree of dramatic descriptors) • Cyclic hematochezia or episodic hematochezia • Exacerbating factors: • Constipation and diarrhea with or without cyclic exacerbation • Associated menstrual symptoms: menorrhagia, • Asymptomatic metrorrhagia, menometrorrhagia, amenorrhea, oligomenorhea • Associated GI or GU symptoms‐dysuria, pain with full bladder, hematuria, hematochezia • Severity: mild, annoying, debilitating, absenteeism ,effect on relationship.

Page 3 Triggers for Further Workup for Deeply Workup for Rectosigmoid Endometriosis Invasive Endometriosis • Nodularity on exam. • Palpable nodule or unexplained cyclic • Suspected endometrioma on ultrasound hematochezia • Cyclic hematochezia without palpable nodularity • • Cyclic hematuria Transvaginal Ultrasound • Unexplained hydronephrosis. • Endorectal ultrasound

• MRI

MRI Images of MRI Images of Rectal Rectal Endometriosis Endometriosis

MRI Images of MRI Images of Rectal and Rectal Bladder Endometriosis Endometriosis

Page 4 Symptoms Suggestive of Urinary Endorectal Endometriosis Ultrasound • Dysuria with or without cyclic exacerbation. • Pain with full bladder with or without cyclic exacerbation. • Cyclic hematuria •Done in conjunction with • Flank pain sigmoidoscopy or • Asymptomatic colonoscopy. •Better for higher rectosigmoid lesions which are frequently missed by MRI.

Symptoms of Ureteral Endometriosis Workup for Bladder Endometriosis • High index of clinical suspicion. • Some present with symptoms of acute obstruction. Flank pain in 25% • Hematuria in 15% • Ultrasound or MRI. • Asymptomatic in 50% • Most with symptoms typical for endometriosis in • Cystourethroscopy. general. • Secondary hydronephrosis resulted from extrinsic as well as intrinsic obstruction. • Be vigilant of endometriosis elsewhere in the pelvis.

MRI Images of Bladder Endometriosis MRI Images of Bladder Endometriosis

Page 5 Ultrasound Images of bladder endometriosis

MRI Images of Bladder Endometriosis

Role of Cystoscopy Cystoscopy for Bladder Endometriosis

• Provide histopathologic diagnosis. Rule out other intravesical pathology.

• Assess the proximity of endometriotic nodule to the ureteral orifice.

Diagnosis of Ureteral Endometriosis Case Presentation

29 year old female G0P0 who present with pelvic pain. Pain began since 2 years ago. It is located in the • Screening renal ultrasound for patients with umbilical regions as well lower pelvic pain. Pt reports long history of severe dysmenorrhea since high school. suspected endometriosis. Pain can be severe at times that she cannot walk. She describes it as sharp and crampy . She describes the pain as being only during her menses, but she reports irregular frequent bleeding. Her pain is worsened by intercourse and bowel movement ( mostly during menses) and improved by heat pad and pain meds. She • IVP denies constipation, hematuria and hematochezia.

• Ureteroscopy Pt previously on OCP from age 19‐ 26. Pt still had some dysmenorrhea but not severe. Pt got married 3 years ago and stop OCP and her pain got progressive worse. Pt first noticed umbilical pain before and during menses in 10/2013. Pt first noticed bleeding first time last month. Pt had ultrasound which show persistent • Endoluminal ultrasound bilateral 5 cm debris filled ovarian cysts. Pt had laparoscopy 3 months ago. Pelvic endometriosis was diagnosed and pt was started on Lupron the same month. Pt was given Norethindrone add back. Pt's pelvic pain improved while Lupron but her umbilical pain continue to get worse. • Laparoscopy Pictures from her previous laparoscopy shows: two small endometriotic nodule over the bladder, Partial obliteration of cul de sac with both adnexa adherent to pelvic sidewall and posterior to the uterus, rectosigmoid colon adherent to the posterior uterus, Distension of left fallopian tubes consistent with hydrosalpinx.

Page 6 Case Presentation Case Presentation

Abdomen: Benign, soft, non‐tender, no hernia, masses, or lymphadenopathy, maroon color cystic area on the right side of of umbilicus Picture of her umbilicus when she was severely Severe endometriosis with multi visceral involvement as well as umbilical endometriosis. symptomatic show the cystic area to be approximately 2‐3 cm out of umbilus and bulging Optimal debulking of endometriosis may require surgery on the bowel, bladder or ureter. In toward the left terms of bowel surgery for endometriosis, discoid resection with two‐layer primary closure Pelvic examination: would be done typically and occasionally segmental resection and anastomosis maybe Vagina: Normal appearance, est effect, no discharge, lesions, cystocele or rectocele, necessary in esom cases if the nodule is bigger or if the disease is multifocal. There is about endometriosis noted on posterior fornix 1‐5 % risk of bowel leak with primary anastomosis and simple primary closure. In the event of Cervix: Normal appearance, no lesions, discharge or tenderness bowel leak, diverting colostomy or ileostomy may become necessary. Other risk of bowel Uterus: Normal size, contour, position, mobile, no tenderness and descensus surgery include stricture and fistula were also explained to the patient. In terms of bladder Adnexae:No masses, tenderness or nodularity endometriosis, usually simple two‐layer repair of bladder would be done to repair the No anterior vaginal wall tenderness, no levator obturator tenderness, large 3‐5 cm cystotomy created after excision of bladder endometriosis. If bladder endometriosis is located RV endometriotic nodule in the RV septum with ? Invasion into the rectum near where the ureter join the bladder, ureter may need to be implanted. Risk of bladder surgery include leak of from the repair, decreased bladder capacity and reflux from reimplantation. In terms of ureteral endometriosis, segmental resection of the diseased segment of ureter and anastomosis or ureteral reimplantation of ureter may be necessary. Risk of ureteral surgery also include leak from repair, fistula, ureteral stricture and reflux.

Case Presentation Case Presentation

Pt understand the risks and would like to have most of her endometriosis removed Pt is here with her husband to go over the result of her MRI and go over the extent of laparoscopically in the same setting if technically feasible. surgery. On MRI endometriosis was noted on the posterior fornix with extension to the rectum. Because of the sheer size of her endometriosis, anterior resection and Pt will also need partial resection of umbilicus for umbilical endometriosis. anastomosis will likely be necessary. sPt wa also noted to have endometriosis involving the bladder, the right side of umbilicus. Check MRI of pelvis and abdomen to assess for the degree and location of bowel, bladder and umbilical involvement . Pt will have consultation with colorectal surgery.. Do not recommend Pt is consented for laparoscopic excision of rectovaginal endometriosis with partial pt to undergo IVF before surgery as egg retrieval would be impossible due the presence of vaginectomy, anterior resection and anastomosis, excision of bladder endometriosis large rectovaginal nodule. with cystotomy repair as well as excision of umbilical endometriosis with revision of umbilicus. The specific risk of bowel surgery has been reviewed by the MIS colorectal surgeon. Risk and benefit of the procedure fully discussed with the patient and her husband. Pt fully informed and consented the aforementioned procedures.

Inform and Consent Conclusion

• Proper work up for severe endometriosis with visceral involvement start with good history and physical exam. Well chosen imaging will • Opportunity to set the expectation of the surgeries. refine the pathologies to be addressed. Meticulous preoperative • Readdress the objectives , priorities of the surgery. work up will facilitate surgical planning and optimize the inform and consent process. • Be upfront about the risk .Get patient fully invested in their own health.

Page 7 Disclosure Multi‐Disciplinary Team (MDT) Approach Should Be the Way I have no financial relationships to disclose. Forward for Complex Endometriosis

Alan Lam Associate Professor, Sydney Medical School, Royal North Shore Hospital Director, Centre for Advanced Reproductive Endosurgery (CARE) Past President, Australian Gynaecological Endoscopy& Surgery Society (AGES) Past Board member, American Association of Gynecologic Laparoscopists (AAGL), World Endometriosis Society (WES) & International Society Gynecologic Endoscopy (ISGE)

Objective General background regarding MDT

Discuss the benefits and barriers to multi‐disciplinary team in treating • Multidisciplinary team working has been implemented in cancer care complex endometriosis. systems throughout much of Europe, the United States, and Australia. • In the UK, multidisciplinary teams have also recently been recommended for the management of other conditions including diabetes, stroke and neurological rehabilitation, chronic obstructive pulmonary disease, and coronary heart disease.

Multidisciplinary team working in cancer: what is the evidence? Taylor C et al. BMJ 2010;340:743‐745.

What is the ‘best’ model of endometriosis care? Should Multi‐Disciplinary Team (MDT) approach be the way forward for Complex Endometriosis? • Globally, the best model of endometriosis care has received increasing attention. • There is a need for significant improvements in outcomes for individuals • Leading organisations such as National Institute for Health and Care with this condition, with earlier diagnosis and intervention, broader multi‐ disciplinary treatment options and clear care management pathways Excellence (NICE), World Endometriosis Society (WES) … have possible. promoted the concept that: ‘the care of women with complex endometriosis would benefit from a multidisciplinary network of experts sufficiently skilled in providing advice on and • Model of care (MOC) must be multidisciplinary and adaptable for various treatment of endometriosis and its associated symptoms, based on the best contexts and settings in the Australian healthcare landscape, including available evidence, their extensive experience and their transparent record of regional and rural service providers, must be implementation‐focused, and success rates’. should aid quality assurance and the nationalisation of standards across all services. NICE guideline Endometriosis: diagnosis and Management. September 2017. nice.org.uk/guidance/ng73 Consensus on current management of endometriosis. Johnson N, Hummelshoj L. Human Reproduction 2013; 28: 1552–1568. National Action Plan for Endometriosis July 2018 /Australian Government Department of Health

Page 8 Specialist endometriosis services Multifunctional purposes of MDT (endometriosis centres) • To ensure that all patients receive timely treatment and continuity of care • gynaecologists with expertise in diagnosing and managing endometriosis, including from appropriately skilled professionals • advanced laparoscopic surgical skills • To ensure that patients get adequate information and support. • a colorectal surgeon with an interest in endometriosis • To facilitate communication between primary, secondary, and tertiary care • a urologist with an interest in endometriosis • To collect reliable data for the benefit of individual patients and for audit • an endometriosis specialist nurse and research. • a multidisciplinary pain management service with expertise in pelvic pain • a healthcare professional with specialist expertise in gynaecological imaging of • To monitor adherence to clinical guidelines and promote the effective use of resources. • endometriosis • advanced diagnostic facilities (for example, radiology and histopathology) • To improve participants’ working lives, not least by providing opportunities • fertility services. for learning and development. NICE guideline Endometriosis: diagnosis and Management. September 2017. nice.org.uk/guidance/ng73 Multidisciplinary team working in cancer: what is the evidence? Taylor C et al. BMJ 2010;340:743‐745.

‘Complex’ endometriosis? Infertile woman with ‘complex’ endometrioma

• Infertile patient with ovarian Discussion and consideration: • Asymptomatic vs endometrioma • the benefits and risks of symptomatic • Urinary tract involvement laparoscopic surgery as a • Endometrioma size • Bowel involvement treatment option > 5 cm • Vascular involvement • whether laparoscopic surgery may • Unilateral vs alter the chance of future bilateral • Nerve involvement pregnancy Classic endometrioma Endometrioma with clot. Papillary serous carcinoma • Normal vs low arising in an endometriotic • Chronic pain • the possible impact on ovarian ovarian reserve cyst in a postmenopausal reserve (AMH) woman. • the possible impact on fertility if complications arise • Typical vs atypical ultrasound features • alternatives to surgery and raised CA‐125

NICE guideline Endometriosis: diagnosis and Management. September 2017. nice.org.uk/guidance/ng73 Variations in Appearance of Endometriomas. Asch E. J Ultrasound Med 2007; 26:993–1002

Urinary tract and Bowel involvement

• Asymptomatic vs symptomatic • Symptoms –types, severity, consistency • Fertility considerations • Extent of deep infiltration

Page 9 Bowel and ureteric endometriosis surgical management

Multi‐disciplinary approach to complex urinary tract, bowel, • 24 yo single woman pelvic sidewall endometriosis • Severe dysmenorrhoea, dyschezia, low back pain • Not responded to hormonal therapies • Rectovaginal endometriosis and left ureteric obstruction • Fertility desire but no partner

Should Multi‐Disciplinary Team (MDT) approach be the way forward for Complex Endometriosis? MDT –Benefits and Barriers • MDT working has been widely introduced around the UK for the provision of cancer care, but there is little evidence for its direct effect on the quality Benefits Barriers of patient care or that MDT meetings resulted in improvements in clinical outcomes • Evidence is growing that effective • Requires time multidisciplinary teams are Multidisciplinary teams in cancer care: are they effective in the UK? Fleissig A et al. Lancet Oncol • Requires resources 2006; 7: 935–43. associated with improved: (organisation, administration, • Evidence‐based clinical decision making documentation) • Future research should assess the impact of MDT meetings on patient • Clinical outcomes satisfaction and quality of life, as well as, rates of cross‐referral between • Patient experience • Requires collaboration disciplines. • Working lives of team members • Requires high‐quality evidence The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A systematic review of the literature. Pillay B et al . Cancer Treatment Reviews • Medico‐legal protection 2016; 42: 56–72. Multidisciplinary teams in cancer care: are they effective in the UK? Fleissig A et al. Lancet Oncol 2006; 7: 935–43

References

1. Multidisciplinary team working in cancer: what is the evidence? Taylor C et al. BMJ 2010;340:743‐745. 2. Multidisciplinary teams in cancer care: are they effective in the UK? Fleissig A et al. Lancet Oncol 2006; 7: 935–43. 3. NICE guideline Endometriosis: diagnosis and Management. September 2017. nice.org.uk/guidance/ng73 4. Consensus on current management of endometriosis. Johnson Neil P, Hummelshoj Lone. Hum Reprod. 2013;28(6):1552–68. Doi: 10.1093/humrep/det050. 5. The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A systematic review of the literature. Pillay B et al . Cancer Treatment Reviews 2016; 42: 56–72). 6. National Action Plan for Endometriosis July 2018 / Australian Government Department of Health

Page 10 Disclosure

I have no financial relationships to disclose.

Rectosigmoid Endometriosis: Anterior Discoid Resection

Robert S. Furr, MD

Objectives

• Outline the pathophysiologic pathway of endometriosis as it relates to pain • Classify endometriosis based on anatomic location and histology • Differentiate symptoms affecting patients with endometriosis and correlate them with surgical expectations • Describe the evidence that supports specific surgical approaches when managing endometriosis • Review surgical techniques for excision of endometriosis / peritoneal stripping

Falcone T, Flyckt R. Clinical Management of Endometriosis. Obstet Gynecol. 2018;131(3):557‐571.

PAIN An unpleasant sensory and emotional experience associated with actual or potential tissue damage Does endometriosis cause pain?

Page 11 Slide 6

1 Steve Radtke, 2/14/2018

Page 12 • Between 2‐43% asymptomatic women are found to have lesions • In contrast, 70‐90% of women with chronic pelvic pain will have • Majority of studies average around 10‐11% endometriosis • Most common study modality is identification at time of tubal ligation • Is this enough to establish causation? • In asymptomatic women with endometriosis, there is VERY low chance that it will become symptomatic over a 10 year period

Moen MH, Stokstad T. A long‐term followup study of women with asymptomatic endometriosis diagnosed incidentally at sterilization. Fertil Steril. 2002;78:773–776.

• Rules of causation • Multiple attempts to classify or • Consistency grade endometriosis based on • Temporality involvement, appearance, etc and • Biological Gradient find a correlation with symptoms • Plausibility have been made • Most widely known classification system is the rAFS staging diagram, but its association with severity of pain is weak at best

• 469 women enrolled completed pelvic pain surveys • Subsequently underwent laparoscopy by blinded physicians Is there any evidence that would lead to the conclusion that endometriosis causes pain?

Stage rAFS VAS menstrual vs non‐menstrual pain score I7.7 v 6.5 II 7.5 v 6.2 III 7.4 v 6.2 IV 7.6 v 6.3

Relationship between stage, site and morphological characteristics of pelvic endometriosis and pain. Hum Reprod. 2001;16(12):2668‐71.

Page 13 • 63 patients with pain (pelvic pain, dysmenorrhea, dyspareunia) randomized to laser ablation of endometriosis lesions/uterine nerve Not all endometriosis is equal ablation vs expectant management • Follow‐up at 3‐6 months after surgery • When only patients with mild‐moderate disease were analyzed, 73.7% achieved pain relief vs 22.6% in expectant management group

Sutton CJ, Ewen SP, Whitelaw N, Haines P. Prospective, randomized, double‐blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril. 1994;62(4):696‐700.

Endometrioma

• Menstrual debris encapsulated in ovarian tissue. “pseudocyst” • Present in approximately 17‐44% of patients with endometrisois Endometriosis • 83% sensitivity 89% specificity on ultrasound • Decision to operate based on size: cysts larger than 5 cm have a higher risk of ovarian torsion • Removal/Excision as opposed to drainage is recommended Deeply • Marana et al showed a recurrence rate of 4% with excision/cystectomy and Superficial Ovarian Infiltrating 84% with drainage/cystotomy

Zanelotti A, Decherney AH. Surgery and Endometriosis. Clin Obstet Gynecol. 2017;60(3):477‐484.

Deep infiltrating endometriosis

• Deep infiltrating lesions (DIE) occur approximately in 1‐2% of reproductive aged women and in 20% of patients with endometriosis • Defined as an invasion greater than 5 mm into the peritoneal surface • Most severe form of disease • DIE is associated with severe pain in more than 95% of women

Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J. Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril 2012;98:564–71.

Page 14 When looking at DIE only, does location of disease matter?

• 225 women with pelvic pain and DIE • Retrospective study where pain symptoms (dysmenorrhea, non‐cyclic pain, dyspareunia, dyschezia, urinary symptoms) were collected from medical records • Anatomic locations of DIE were coded from operative report

Fauconnier A, Chapron C, Dubuisson JB, Vieira M, Dousset B, Bréart G. Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis. Fertil Steril. 2002;78(4):719‐26. Fauconnier A, Chapron C, Dubuisson JB, Vieira M, Dousset B, Bréart G. Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis. Fertil Steril. 2002;78(4):719‐26.

Page 15 • Study concluded that different types of pelvic pain are associated Endometriosis with specific locations of DIE Deeply Superficial Ovarian • Deep dyspareunia –involvement of USL Infiltrating • Dyschezia – Involvement of vagina • Non‐cyclical pain –involvement of bowel USL • Lower urinary tract symptoms –involvement of bladder • Severe dysmenorrhea was correlated with adhesions in the Dogulas pouch Vagina

Bladder/ureter

Intestines

Fauconnier A, Chapron C, Dubuisson JB, Vieira M, Dousset B, Bréart G. Relation between pain symptoms and the anatomic location of deep infiltrating endometriosis. Fertil Steril. 2002;78(4):719‐26.

Appearance

• PPV of visually identified endometriosis has been reported to be as low as 45% • There is a body of literature reporting morphologic differences in lesions and their ability to elicit pain or produce inflammatory Does appearance of lesions correlate with symptoms? mediators • To this date there is no clear evidence of an association between endometriosis appearance matters

• Pelvic pain is most common symptom in symptomatic patients • Increase in inflammatory mediators (IL‐6, TNF) • Neurological dysfunction • Estrogen‐mediated neuromodulation of the peripheral sensory neurons

What is the physiologic explanation of endometriosis pain?

Page 16 Physiology of endometriosis related pain

Secondary to increased concentration of prostaglandins (E2 and F2a) COX catalyzes conversion of arachidonic acid to PGH2 which is converted to PGE2 and F2a by PG synthetase COX‐2 is expressed in higher concentration in endometrial implants compared to endometrial cells. Increased concentration of PGE2 also provides stimulus for estrogen production.

Attia GR, Zeitoun K, Edwards D, et al. Progesterone receptor isoform A but not B is expressed in endometriosis. J Clin Endocrinol Metab. 2000;85:2897– 2902.

Bulun SE, Cheng YH, Yin P, et al. Progesterone resistance in endometriosis: link to failure to metabolize estradiol. Mol Cell Endocrinol. 2006; 248:94–103.

Endometriosis is hormonal‐dependent (to some extent) • Infertility is proposed to be due to multiple mechanisms • Estrogen can come from multiple sources • Underlying adhesions • Intrinsic aromatase activity (cholesterol‐estradiol) • Ovarian cysts • Estradiol from ovary • Change in tubal anatomy • Estrone from adipose tissue • Inflammatory mediators that result in suboptimal oocyte and sperm • Decreased endometrial receptivity • Decreased ovarian reserve

Zhao H, Zhou L, Shangguan AJ, et al. Aromatase expression and regulation in breast and endometrial cancer. J Mol Endocrinol. 2016;57:R19–R33.

Summary of medical therapies

Rafique S, Decherney AH. Medical Management of Endometriosis. Clin Obstet Gynecol. 2017;60(3):485‐496.

Page 17 Does surgery improve symptoms?

Rafique S, Decherney AH. Medical Management of Endometriosis. Clin Obstet Gynecol. 2017;60(3):485‐496.

• 132 patients with pelvic pain and histologically confirmed DIE • Retrospective analysis • Patients had completed a preop and postop survey (median followup time 3.3 years)

Chopin N, Vieira M, Borghese B, et al. Operative management of deeply infiltrating endometriosis: results on pelvic pain symptoms according to a surgical classification. Chopin N, Vieira M, Borghese B, et al. Operative management of deeply infiltrating endometriosis: results on pelvic pain symptoms according to a surgical classification. J Minim Invasive Gynecol. 2005;12(2):106‐12. J Minim Invasive Gynecol. 2005;12(2):106‐12.

• Prospective observational study • 254 women referred with pelvic pain out of which 216 underwent surgery, and of these 176 had histologically confirmed endometriosis • Followed between 2 and 5 years

Chopin N, Vieira M, Borghese B, et al. Operative management of deeply infiltrating endometriosis: results on pelvic pain symptoms according to a surgical classification. J Minim Invasive Gynecol. 2005;12(2):106‐12.

Page 18 Long term pain • Laparoscopic excision significantly reduces pain and Improved 67% improves quality of life and sexual function in women Worsened 25% with all stages of endometriosis for up to 5 years Unchanged 8% 36%

Abbott JA, Hawe J, Clayton RD, Garry R. The effects and effectiveness of laparoscopic excision of endometriosis: a prospective study with 2‐5 year follow‐up. Hum Reprod. 2003;18(9):1922‐7.

Excision or ablation?

Pundir J, Omanwa K, Kovoor E, Pundir V, Lancaster G, Barton‐smith P. Laparoscopic Excision Versus Ablation for Endometriosis‐associated Pain: An Updated Systematic Review and Meta‐analysis. J Minim Invasive Gynecol. 2017;24(5):747‐756.

Dyspareunia

Dyschezia

Does COMPLETE excision make a difference?

Chronic pelvic pain

Page 19 • Recurrence rate in women with DIE varies between 2‐43.5% • 3 risk factors for recurrence identified • Age • Weight • Type of surgery score

pain Cumulative

Ianieri MM, Mautone D, Ceccaroni M. Recurrence in Deep Infiltrating Endometriosis: a Systematic Review of the Literature. J Minim Invasive Gynecol. 2018; Complete w/o Complete w Incomplete w/o Incomplete w

8.3% 8.3% Excision + Hyst + BSO

13.4% 23% Excision + Hyst Does performing a hysterectomy make a difference? Excision 46.6% 55.4%

Shakiba K, Bena JF, Mcgill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7‐year follow‐up on the requirement for further surgery. Obstet Gynecol. 2008;111(6):1285‐92.

• Patients who decline, do not respond, do not tolerate or have contraindications to medical therapy • Acute surgical or pain event • Deep endometriosis Who to operate on? • Concomitant management of disease • Pelvic pain and desire to conceive

Page 20 • Basic transvaginal ultrasound important in CPP patient in order to evaluate other sources of discomfort • Adenomyosis • Adnexal masses • Fibroids Is there a role for pre‐operative imaging? • Focused imaging has the goal of identifying DIE in specific locations in order to counsel patient and plan surgery • Obliterated cul‐de‐sac (sliding sign) • Nodules in USL (Sensitivity 75%) • Colorectal nodules (Sensitivity 95%) • Bladder nodules

Falcone T, Flyckt R. Clinical Management of Endometriosis. Obstet Gynecol. 2018;131(3):557‐571.

Bowel endometriosis Bowel endometriosis

• Transrectal sonography can diagnose low rectal nodules (below the level of the USLs) • Can asses infiltration to the muscularis layer but not so good detecting infiltration to submucosal and mucosal layer • Techniques for removal involve • Shaving of the nodule • Discoid resection • Segmental resection • Women with bowel occlusion of >50% or longer than 2‐3 cm should be scheduled for elective bowel resection

De Cicco C, Corona R, Schonman R, Mailova K, Ussia A, Koninckx P. Bowel resection for deep endometriosis: a systematic review. BJOG 2011;118:285–91.

Bladder/ureter endometriosis Bladder/ureter endometriosis

• Accuracy of transvaginal ultrasound to detect bladder lesions has • Ureterolysis is adequate for treating ureteral endometriosis been reported as high as 97% • Ureteral resection is necessary in case of hydroureteronephrosis with • When an endometriotic nodule of the bladder is suspected, a intrinsic localization of disease cystoscopy is performed to rule out a transitional epithelium • Segmental bladder resection represtents standard treatment for carcinoma, and measure the distance to ureteral meatus vesical endometriosis • Removal of nodules being closer than 2 cm is associated with higher rate of complications, and may require ureteroneocystostomy • When ureteral involvement is suspected, hydronephrosis must be ruled out

Page 21 Incidental appendectomy

Berlanda N, Vercellini P, Carmignani L, Aimi G, Amicarelli F, Fedele L. Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis. Obstet Gynecol Surv 2009;64:830–42.

Incidental appendectomy

• Majority of recent studies agree that prophylactic/incidental appendectomy during pelvic pain/endometriosis surgery may be worthwhile • Some form of pathology found in appendix in 10‐30% of cases Does adjuvant therapy improve outcomes?

HRT after surgery for endometriosis

• Low dose estrogen (0.625 premarin) has minimal impact on disease recurrence • Studies in patients taking GnRH agonists have demonstrated that pain does not begin until an E2 level of 40pg/mL, which will not be • 16 trials included in latest version of meta‐analysis reached with low dose preparations • There was no evidence of benefit for post‐surgical hormonal suppression of endometriosis compared to surgery alone for the outcomes of pain, disease recurrence or pregnancy rates (RR 0.84, 95% 0.59‐1.18)

Yap C, Furness S, Farquhar C. Pre and post operative medical therapy for endometriosis surgery. Cochrane Database Syst Rev. 2004;(3):CD003678.

Page 22 Conclusions

• DIE causes pelvic pain • Symptoms can orient towards location • Imaging (ultrasound, etc) can predict more extensive surgery • Hysterectomy/BSO alone is NOT adequate treatment Videos • Surgery for endometriosis (complete excision) appears to yield beneficial results • Excision performs better than ablation

Page 23 Disclosure

Step‐wise Strategies to deal with Frozen Pelvis I have no financial relationships to disclose. and Deep Infiltrative Endometriosis

Objective

Discuss step by step strategies in dealing with froze pelvis and deep Deep infiltrative endometriosis, often hidden endometriosis. below thick adhesions of a frozen pelvis, is one of the most difficult surgical procedures which consistently challenge the mind and skills of the most experienced open or endoscopic gynaecologic surgeons.

To deal with this disease entity

Navigate the way into the pelvis through the often grossly distorted anatomy caused by extensive fibrosis

Recognise the variable disease phenotypes

Excise the deeply infiltrative disease to the extent the surgeon feels ‘comfortable’

Prevent and appropriately manage inherent risk of damage to blood vessels, bowels, ureter, bladder and nerves

Page 24 Ten step‐wise strategies Ten strategies and pearls

1. Adequate assessment and counselling to define treatment goal(s), benefits and risks before surgery 2. Thorough communication and critical information exchange to colleagues (anaesthetist, colorectal, urological...) to plan procedure beforehand 3. Appropriate selection of energy sources for dissection and haemostasis 4. Routine mobilisation of rectosigmoid adhesions 5. Systematic identification and exposure of the ureters 6. Minimise use of energy when dissecting close to bowels and ureter 7. Limit the extent of bowel and /or urinary tract endometriosis excision to symptomatic, informed patient 8. Competent laparoscopic suturing skills to deal with tissue trauma 9. Multi‐disciplinary team approach to complex cases 10. Thorough post‐op. surveillance, communication and documentation

1. Adequate assessment, counselling and discussion to 2. Thorough communication and exchange of define treatment goal(s), benefits and risks information with colleagues before surgery • The ‘Google’ know‐all • The ‘reluctant’ • The ‘indecisive’ • The ‘chronic pain’ • The ‘infertile’ • The ‘atypical’ cyst • The ‘repeated’ surgical patient

3. Appropriate selection of energy sources for dissection and control of haemostasis

4. Routine mobilisation of rectosigmoid adhesions 6. Minimise use of energy when dissecting close to bowels and ureter 5. Systematic exposure and identification of the ureters using knowledge of the pelvic surgical layers

Page 25 7. Limit the extent of bowel and /or urinary tract endometriosis 9. Multi‐disciplinary team (Gyn‐Uro‐Colorectal‐Vascular) excision to symptomatic, informed patient Management of a very complex endometriosis 8. Competent laparoscopic suturing skills to deal with tissue trauma

10. Thorough postop. surveillance, communication and documentation

9. Multi‐disciplinary team (Gyn‐Uro‐Colorectal‐Vascular) Management of a very complex endometriosis

Page 26 Disclosure

Urinary Endometriosis- I have no financial relationships to disclose. A Surgical Tutorial

Ted Lee, M.D. Director, Minimally Invasive Gynecologic Surgery Magee Womens Hospital Unversity of Pittsburgh Medical Center

Objectives Bladder Endometriosis

Discuss anatomy-based principles on surgical management of bladder and ureteral endometriosis. Definition: endometriosis infiltrating detrusor muscle

Pathogenesis Surgical Treatment

• Simple partial cystectomy with two layer closure for bladder dome nodule. • Similar to other deep infiltrating • Ureteral stents are recommended especially for endometriosis. lower nodules. • Need to develop vesicovaginal space for nodule closer to the vesicouterine junction. Partial • It can be iatrogenic from previous c-sec. resection of myometrium maybe necessary for vesicouterine nodule • For large defect, retropubic space should be developed for tension free closure.

Page 27 Laparoscopic Treatment of Surgical Treatment Bladder Endometriosis

• If nodule is close to ureteral orifice, intravesical portion of ureter may be involved. Ureteroneocystostomy may be necessary especially in patients with known hydronephrosis. • Bladder is backfilled to ensure watertight closure. • Foley catheter is left in place for 7-10 days. Followed by VCUG.

Prognosis after Partial Cystectomy for Symptoms of Ureteral Endometriosis Deep Bladder Endometriosis

• Some present with symptoms of acute obstruction. • Dome lesions: symptom recurrence 7%, Flank pain in 25% objective recurrence 0% in 3 years. • Hematuria in 15% • Asymptomatic in 50% • Most with symptoms typical for endometriosis in • Bladder base lesions: symptom general. recurrence 37%, objective recurrence • Secondary hydronephrosis resulted from extrinsic 26%. as well as intrinsic obstruction. Fedele et al., Fertil Steril June 2005;83: 1729-1733

Distribution of Ureteral Endometriosis Diagnosis of Ureteral Endometriosis

• Screening renal ultrasound for patients with • Secondary hydronephrosis resulted from extrinsic as well as suspected endometriosis. intrinsic obstruction. • Extrinsic lesion 70-80% • IVP • Intrinsic lesion 20-30%. • Bilateral involvement 12% • Ureteroscopy • Unilateral involvement 88%. • Left 83% . Right 5% • Endoluminal ultrasound

• Laparoscopy

Page 28 Medical Treatment of Ureteral Endometriosis Surgical Treatment of Ureteral Endometriosis

• Uretolysis followed by double J stent • Largely ineffective as fibrosis does not respond to hormonal suppression. • Segmental ureteral resection with end to end anastomosis or ureteroneocystotomy with or without psoas hitch.

Laparoscopic Treatment for Outcome of Laparoscopic Uretolysis Ureteral Endometriosis.

• 33 patients underwent uretolysis for mod to severe hydronephrosis with median 16 month follow-up. • Bilateral involvement 12% • Unilateral involvement 88% with the left ureter involvement in 83% • Ureteral obstruction recurrence rate 12 %.

Ghezzi et al, Fertil Steril 2006 ;86:418-422

Laparoscopic Ureteral Reimplantation Surgical Treatment of Ureteral Endometriosis

• Regardless of types of surgical treatments ( uretolysis, segmental resection anastomosis, ureteroneocystomy), endometriosis should be excised in addition to the treatment of hydronephrosis to ensure pain/symptom relief as well as to minimize the risk of recurrent hydronephrosis.

Page 29 Summary and Recommendations Summary and Recommendations

• Urinary endometriosis is relatively rare. • Non specific urinary symptoms maybe present. Most • Endometriosis nodule near triagone may require patients have endometriosis elsewhere in the pelvis and ureteroneocystotomy. presents with typical symptoms of endometriosis. • Screening renal ultrasound in patients with suspected • High index of suspicion is often required to ensure proper endometriosis is useful to prevent silent loss of renal preoperative workup, which is useful for proper inform and function. consent. • Medical treatment of ureteral endometriosis associated with • Initial medical treatment for bladder endometriosis is persistent hydronephrosis is largely ineffective. reasonable after confirmation of diagnosis. • The majority of ureteral endometriosis is extrinsic in nature. • Most patients responds well to partial cystectomy especially Uretolysis can be attempted in most patients with if the nodule is located at the bladder dome. hydronephrosis but reparative ureteral surgeries may be required in some.

References

1. Fedele L, Bianchi S, Zanconato G, Bergamini V, Berlanda N, Carmignani L. Longterm follow-up after conservative surgery for bladder endometriosis. Fertil Steril 2005;83:1729-1733. 2. Ghezzi F, Cromi A, Bergamini V, Serati M, Sacco A, Mueller MD. Outcome of laparoscopic ureterolysis for ureteral endometriosis. Fertil Steril 2006;86:418-422. 3. Berlanda N, Vercellini P, Fedele L, Endometriosis of the urinary tract, Up to Date, 2015 4. Chamsy D, Lee T, The Use of Barbed Suture for Bladder and Bowel Repair. J Minim Invasive Gynecol 2015; 22:648–652

Page 30 CULTURAL AND LINGUISTIC COMPETENCY

Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians (researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

US Population California Language Spoken at Home Language Spoken at Home

Spanish English Spanish

Indo-Euro English Indo-Euro Asian Other Asian

Other 19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the program, the importance of the services, and the resources available to the recipient, including the mix of oral and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies, including those which provide federal financial assistance, to examine the services they provide, identify any need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every California state agency which either provides information to, or has contact with, the public to provide bilingual interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills. A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

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