Beyond Surgery

Minimal Access Surgery

Introduction We report medium-term outcomes for laparoscopic permanent suture sacrohysteropexy, a minimally invasive, meshless surgery for uterine prolapse. Methods We present retrospective audit data for our initial cohort of patients who underwent suture sacrohysteropexy at our centre. Baseline data were retrieved from electronic patient records. Postoperative data were collected at least one year after surgery at a face-to-face review. Anatomical outcomes were reported using the POP-Q system. Symptoms were assessed with validated instruments, including the International Consultation on Incontinence Vaginal Symptoms questionnaire (ICIQ-VS) and the Patient Global Impression of Improvement (PGI-I) questionnaire. Anatomical success was defined as apical prolapse of stage 1 or less, defined as postoperative point C more than 1 cm above the hymen (C Results Twenty procedures were undertaken between July 2019 and November 2022. Median follow up was 15.5 months (range 12- 35 months). Preoperative median point C was 0 (range -4 to +6) and point Aa was 0 cm (range -2 to +3). Postoperative median point C was -5 (range -8 to -1) and point Aa was -1 cm (range -3 to +2). Anatomical success at the apex was 95%. 75% of patients described their prolapse symptoms as ‘much better’ or ‘very much better’. The ICIQ-VS 53-point scale demonstrated a median reduction of 20 points (range 12-35). Conclusions These provisional data suggest that laparoscopic suture sacrohysteropexy is an effective treatment for uterine prolapse. It offers women a uterine-conserving, meshless alternative to existing surgical approaches.

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Minimal Access Surgery

Laparoscopic gynaecological training is a challenging process that requires a significant investment of time and resources. O&G trainees are facing challenges to access adequate laparoscopic surgical training following the implementation of EWTD, the postgraduate training reform and the recent Pandemic. Traditional training methods have limitations, which can make it difficult for trainees to develop the skills they need to perform laparoscopic surgery safely and effectively. Standard simulation although useful, it can be time-consuming, and may not provide realistic feedback. Cadaver training is limited by the cost, availability of cadavers, and experienced trainers. I would like to report on my experience that helped enhance my laparoscopic training following a comprehensive advanced simulation programme. The technology used in this programme included simulators equipped with sensors that can provide feedback on user’s performance, such as hand-eye coordination, depth perception, and instrument handling skills. Another aspect of the simulator is the use of Virtual reality (VR) which creates a more interactive and immersive training experience. Other available technologies such as VR headsets can be also used to create a realistic experience of procedures and allow trainees to practice their skills in a safe environment. Augmented reality; can be used to overlay digital information onto the real world. Digital technology is remodelling the delivery of training surgical care. Industry partners are providing educational programme in which high fidelity laparoscopic skills training could be delivered entirely remotely. These programmes can also help Standardize training amongst trainees, as well as assess their skills in a standardized and objective way.

Minimal Access Surgery

Introduction: Robotic assisted laparoscopic (RAL) surgery is a pioneering technological advancement. Benefits including reduced blood loss, shorter hospital stay, lower complication and conversion rates have been noted in the literature. We reviewed the cases of RAL across the gynaecological disciplines of Benign gynaecology, Endometriosis, Urogynaecology and Oncology performed at our hospitals from October 2021 to December 2023. Methods: Operative and clinical notes, console times and laboratory results were audited. Patient demographics, surgical data, operation timings, conversion, complication and readmission rates were analysed. Results: 182 robotic-assisted gynaecological procedures performed by 4 consultants. 2/3 of cases were Endomteriosis and Benign Gynaecology, 1/5 Gynaecology Oncology and 1/10 Urogynaecology. 60% of procedures performed were TRHBS/TRHBSO. 21% was adnexal surgery BSO, USO and Ovarian cystectomy. Endometriosis excision and adhesiolysis was performed in 14% of cases. Urogynaecological procedures accounted for 9% of cases (Sacrocolpopexy, Colposuspension and Iliopectineal Suspension) 24% of patients were morbidly obese (BMI over 40) Average EBL for TRHBS/TRHBSO/TRH was 155ml; adnexal surgery was 137ml; Resection of endometriosis was 50ml and urogynaecological procedures was 90ml. Average inpatient stay was 1.66 nights. Conversion to laparotomy was 1.6% Intraoperative complications encountered 2.7% Readmission rate was 4.4% Conclusion: RAL has been found to be safe and effective in benign gynaecology and urogynaecology procedures. Our regional data also compares with published data of the safety of RAL in gynae-oncology. We aim to improve productivity of lists by ensuring adequate numbers listed, investing in dual consoles for teaching and training and moving towards day case procedures.

Minimal Access Surgery

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Beyond Surgery

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Background: Ovarian torsion is a gynaecological emergency associated with significant diagnostic delay. The barriers to prompt surgical intervention are multi-factorial but include non-specific symptoms, access to expert diagnostic imaging, and lack of non-invasive diagnostic markers. This review will assess potential non-invasive biomarkers for the earlier detection of ovarian torsion. Methods: This review followed PRISMA guidelines and was registered with PROSPERO. The MeSH search terms (biomarker*), (blood*), (Ovar*), (torsion*) MeSH were used across six databases from inception until 01/10/2023. Studies selected included both animals and patients with ovarian torsion; there was no age, location, publication date or setting restrictions. Data collection and analysis: 24 articles were selected for analysis. Data extracted included study methodology, sample size, sensitivity, and specificity. This data was used to calculate likelihood ratios and meta-analysis was performed. Main results: Ten animal studies found a statistically significant increase of biomarker concentrations in the torsion group compared to the control. Sensitivity ranged from 16.4-92.3% and specificity ranged from 77-100%. IL-6 had the highest sensitivity. Three studies of humans with ovarian torsion presented biomarkers (IMA, d-dimer and SCUBE-1) with a positive likelihood ratio of >10 suggesting they could be potentially clinically useful markers. Conclusion: This review has identified multiple biomarkers that warrant further study as part of a broader diagnostic panel for ovarian torsion. These include SCUBE1, s-DD, IL-6, IMA and TNF-a. There is a need for further studies to identify novel biomarkers and assess diagnostic panels.

Beyond Surgery

Fertility

Introduction Borderline ovarian tumours (BOT) They have low malignant potential, show stromal invasion and have high survival rate. The management decisions are affected by age, fertility wishes, tumour type and stage of presentation. Methods A retrospective study of BOTs between 1st January 2018 to 31st December 2022 was conducted at Barts Health NHS Trust. Results A total of 70 patients were diagnosed and treated for BOT in this time period. The mean age was 44 years old (range 22-74) and size range was 3-40 cms. The majority of patients were diagnosed at an early stage, 88.57 % stage 1 and 4.28% stage 2, 4,28% stage 3 and 4; undetermined in 3%. Of the available Ultrasound reports, 75% (30/40) had findings suggestive of either borderline or malignant tumour. MRI was performed in 54 patients and 81.5% (44/54) had findings suggestive of borderline or malignant tumour. The remaining 16 patients did not have MRI and had CT scans instead. Of 70 cases, 32(47%) had unilateral oophorectomy. We found BOT in 4 cases after histological reporting following surgery for suspected benign pathology. The remaining 66 cases were planned surgeries for presumed borderline or malignant tumor. . Fifty six patients had an open surgery, 12 patients had laparoscopic procedure and 2 had robotic surgery. Of the patient who had a FIGO stage 1C, 8 had cyst rupture during surgery (1C1) , which included 2 laparoscopy and 6 open surgeries. Conclusion - Minimal invasive surgery can be performed in patients with suspected BOT planned to have an oophorectomy with precautions taken to reduce the risk of spillage of tumour cells and hence consideration given to the size of tumour at presentation.

Fertility

Surgical management of Deep Pelvic Endometriosis (DPE) presents significant surgical challenges, and can result in both short and long-term morbidity, particularly in relation to ureteric and bowel dissection. Over the last 20 years, the aim of treatment has been complete excision of disease, whilst medical management has been largely ignored, perhaps due to concerns regarding disease progression. More recently, a default surgical approach has been questioned, not least because of the significant recurrence rate. At our unit, we have historically used medical management as first line treatment. We report outcomes from our centre, which demonstrate that medical management is not only effective at providing symptom control, but can result in disease regression. Patients discussed at our tertiary centre Endometriosis MDT between 2018 - 2022 were followed up to monitor for response to their chosen treatment: conservative, medical or surgical. Interval imaging was compared to the index imaging to monitor disease burden. Of 379 patients discussed at the MDT 72% were confirmed to have deep pelvic endometriosis on imaging. 43% of patients opted for medical and 19% conservative treatment. Of those that had follow up imaging 87% had stable disease or reduction in disease volume. Only 6% had disease progression, mostly comprising small changes in endometriomata size. Medical management of endometriosis is a safe and effective alternative to surgery for patients with DPE. As well as providing symptom control, we show it can be associated with a reduction in disease burden, including the size of endometriomata. Most importantly, our data strongly suggests we can reassure patients that, in the absence of ureteric stenosis, bowel obstruction or fertility desires, the aim of treatment should be determined by symptoms.

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Uterine Surgery 2

Abstract: Uterine fibroids, the most common tumour in the female genital tract, affect up to 30% of women, with a significant proportion opting for myomectomy to alleviate symptoms. The selection for Laparoscopic Myomectomy (LM), considered the gold standard for suitably selected patients, hinges on pre-operative assessments of fibroid characteristics, primarily size, location, and site, often determined through imaging or hysteroscopy. Aim To evaluate the accuracy of pre-operative imaging in detecting submucosal fibroids to ascertain the necessity of hysteroscopic cavity assessment for all patients undergoing LM. Methods We conducted a retrospective analysis of electronic patient records (EPR) for 144 patients who underwent LM from July 2014 to September 2023, with 73 (51%) undergoing hysteroscopic assessment either concurrently with myomectomy or within the preceding six months. Results Our findings show that MRI predicted the presence of submucous fibroids with 100% accuracy when compared to hysteroscopic observations. However, a 32% discrepancy was noted between transvaginal ultrasound scan (TVUS) findings and hysteroscopic results, false positives (43%) and false negatives (57%), without significant impact from sonographer expertise. Conclusion These results underscore MRI's superiority over TVUS in identifying submucous fibroids prior to LM. Despite the higher costs, MRI offers more accurate patient counselling and potentially obviates the need for pre-operative hysteroscopy, streamlining the pre-surgical evaluation process.

Endometriosis 2

Background: Caesarean scar endometriosis (CSE) is a rare form of extra-pelvic endometriosis, thought to arise from iatrogenic transplantation of pelvic lesions at the time of abdominal surgery. There are hormonal and surgical treatment options, however surgical excision should be considered the gold standard due to high recurrence rates associated with medical therapy. In this series we review ten cases presenting to a tertiary referral centre. Cases: In a BSGE-accredited endometriosis centre, there were ten cases of CSE over a 24-month period. All cases presented with a painful lump at the level of their caesarean scar, with or without cyclical swelling. The range from caesarean to presentation was 2-17 years and the mean number of caesareans was two. All cases underwent imaging (either ultrasound or MRI) prior to excision; 50% of cases also had needle-aspiration biopsy providing histological confirmation prior. Surgical excision consisted of wide-local excision in 50% of cases, 40% underwent concurrent laparoscopy. One case was combined with subtotal hysterectomy. There were no recorded complications and the estimated blood loss averaged 19ml. To date, there have been no episodes of recurrence with complete resolution of reported symptoms. Discussion: Caesarean SE is an unusual complication following abdominopelvic surgery. In this case series, only one patient had a pre-existing diagnosis of endometriosis and none of those involved had findings of deep infiltrating endometriosis on MRI or at laparoscopy. More research needs to be done into the pathophysiology of endometriotic deposit transplantation and what steps could be taken to minimise risk of development.

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Objective: To evaluate the role of preoperative GnRHa (Pre-GnRHa) use on complications at the time of surgery for deep rectovaginal/colorectal endometriosis. Design: Analysis of British Society for Gynaecological Endoscopy (BSGE) data from a large international multicentre prospective cohort of patients undergoing deep rectovaginal/colorectal endometriosis surgery. Setting: BSGE-accredited endometriosis centres Population: Patients undergoing surgery for deep rectovaginal/colorectal endometriosis between 2009-2021 Methods Multivariable logistic regression analysis was performed to model the odds of each complication by pre-operative GnRH analogue use, controlling for patient age, BMI, smoking status, whether a hysterectomy was performed, history of previous endometriosis surgery and surgical complexity. Main outcome measures: Rate of perioperative and postoperative complications. Results We included 9433 patients aged xx-xx from 101 specialist endometriosis centres across seven countries. Patients receiving preoperative GnRHa experienced greater perioperative complications (OR:1.31, 95% CI:1.08-1.59, p=0.007), late complications (OR:1.477, 95% CI:1.15-1.9, p=0.002) and pelvic haematoma (OR:2.251, 95% CI:1.41-3.64, p Conclusion Preoperative GnRHa use is associated with greater perioperative and late complications. Further research is required to determine whether this is due to an effect of Pre-GnRHa or due to group differences which were not controlled-for.

Uterine Surgery 2

Introduction The Getting It Right First Time (GIRFT) Report (2021) emphasised that minimally invasive hysterectomies reduce hospital stay by an average of 3.97 days. Nationally, GIRFT aims for 75% of hysterectomies to be minimally invasive, and of these, for half to be completed as a day case procedure.These recommendations have the potential to unlock 22,698 bed days. With co-morbidities traditionally used to exclude patients of day case procedures, our unit practices an 'opt out' approach. Thereby patients are removed from the day case laparoscopic hysterectomy (DCLH) pathway only if they fail surgical or anaesthetic assessment, rather than set criteria. Our study reviewed whether patients with co-morbidities had different outcomes whilst on an ‘opt out’ DCLH pathway. Methods Retrospective study conducted from November 2021 to January 2024 of DCLH performed at St Richards Hospital, Chichester. Outcomes such as operative time, blood loss, complications, failed discharge and readmission were reviewed to ascertain whether patients with ASA 3, BMI >30, age >65 had a significant difference to their ‘lower risk’ counterparts. Results During this time period, 188 patients underwent a DCLH. Of these, 85 had a ’comorbidity’ including age >65, ASA >3 and BMI>35. Outcomes such as operative time, estimated blood loss, surgical complications, unsuccessful same day discharge or readmission were audited. No statistical difference (p>0.05) was found in any audited outcome for the patients with co-morbidities vs the remaining DCLH patients. Conclusion To aid the establishment of a robust DCLH pathway and to be more patient inclusive, co-morbidities should not be a barrier to an 'opt out' approach to day case hysterectomies.

Uterine Surgery 2

Background: Post-endometrial ablation, patients may exhibit symptoms due to incomplete ablation[1], adenomyosis[2], or new pathologies, complicating uterine cavity assessment. The altered anatomy increases the risk of further invasive procedures. Our survey in BSGE ACN 2023 revealed a wide variation in practice when managing these cases. Method: This retrospective audit spanned 2 years and 4 months (August 2020 to December 2022), involving 47 patients with abnormal bleeding post-ablation. It aimed to standardize care through the collection and analysis of patient demographics, symptoms, diagnostic findings, and management outcomes. Results: The audit identified significant variability in managing post-ablation bleeding, with a 93% failure rate in outpatient hysteroscopy and only 3% obtaining satisfactory views. Pipelle biopsy was feasible in 25% of cases but inadequate 70% of the time. Seventy-five percent of patients required further evaluation, with 11 undergoing GA hysteroscopy, yielding an 18.2% perforation rate. Conclusion: The audit led to the development of a management pathway for failed outpatient hysteroscopy post-ablation, categorizing patients based on their suitability for GA. Those suitable were recommended for ultrasound-guided hysteroscopy, possibly with synechiae division. Patients unsuitable for GA had repeat ultrasound assessments to determine the need for discharge, MRI, or multidisciplinary team (MDT) consultation. This pathway addresses diagnostic dilemmas and reduces the variability in care, suggesting ultrasound-guided hysteroscopy as a preferred method for safer and more effective post-ablation uterine assessment. References 1.Turnbull LW, Jumaa A.. et al. Magnetic resonance imaging of the uterus after endometrial resection. Br J Obstet Gynecol. 1997;104:934-938. 2. McCausland AM, McCausland VM. Depth of endometrial penetration in adenomyosis helps determine outcome of rollerball ablation. Am J Obstet Gynecol. 1996;174:1786-1793)

Endometriosis 2

Endometriosis is a common, non-malignant, estrogen-dependent, chronic gynecological disorder associated with pelvic pain and infertility. The prevalence of pelvic endometriosis approaches 6-10% in women of reproductive age; in women with pelvic pain, infertility, or both, the frequency is 35-50% [Guidice LC, et al. 2004]. AMY109 is a non-hormonal, humanized monoclonal antibody that binds to and selectively neutralizes IL-8. In pre-clinical studies of surgically induced endometriosis in cynomolgus monkeys, AMY109 showed a significant reduction of the relative volume of nodular lesions and improved the endometriosis score [Ayako NK, et al 2023]. AMY109 was generally well tolerated in patients with endometriosis in Phase I study [World Congress on Endometriosis, Edinburg, 2023]. The Phase II study of AMY109 is ongoing, which is randomized, double-blind study to evaluate efficacy and safety of AMY109 in women with endometriosis. Approximately 120 eligible patients will be enrolled and randomized in a 3:3:2 ratio to receive either (i) AMY109 and desogestrel-placebo or (ii) AMY109 and desogestrel or (iii) AMY109-placebo and desogestrel for 52 weeks. The primary objective is to evaluate the efficacy of (i) AMY109 and (ii) AMY109 and desogestrel compared with (iii) desogestrel in disease severity assessed by laparoscopic appearance. In the laparoscopy cohort conducted in the UK, patients who have had laparoscopic diagnosis, but have not yet received any surgical treatment can be enrolled. Surgical treatment via laparoscopy will be performed after completion of the treatment period to assess their lesions and for treatment of endometriosis. Participants will be followed-up for 52 weeks after the last dose of study drugs.

Endometriosis 2

Uterine Surgery 2

Introduction Fatigue affects the majority of people with endometriosis with debilitating effects on daily activities and quality of life. However, current literature often focuses on pain management rather than fatigue. This study aims to better understand the perceived effectiveness of current endometriosis treatments on fatigue. Methods An anonymous, international cross-sectional survey was disseminated through social media in 2023. The survey included the validated Brief Fatigue Inventory and questions related to demographic information. Changes in fatigue symptoms from various endometriosis treatments over the past five years were measured using the Patient’s Global Impression of Change scale. Results There were 5,241 people who accessed the survey, and 2,907 respondents included in the analysis. Over 12 countries were represented. Endometriosis was diagnosed surgically in 71%, by imaging in 17%, and based on clinical symptoms in 12%. Fatigue was found to be mild in 12%, moderate in 78%, and severe in 10%. Fatigue was much worse during menstruation and minimally worsened during ovulation. Following spontaneous/surgical-induced menopause, patients reported no change in symptoms. The median response for all analgesia and hormonal treatments was “no change” in fatigue except for GnRH-analogues which “minimally worsened” symptoms. Only laparoscopic excision/ablation and changes in rest patterns had a median response of “minimally improved” fatigue. Discussion This study demonstrates that most endometriosis treatment modalities available seem to be ineffective in managing fatigue. Current literature on how current therapies influence fatigue is scarce and further research is needed. Personalised management cannot simply be pain-focused and should consider the holistic needs of the patient.

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