{"paper_id":"b307682e-24de-4483-8e5f-f591186e2623","body_text":"UPDATE\nIN THIS  \nARTICLE\nmdedge.com/obgyn  Vol. 35  No. 12  |  December 2023  |  OBG Management   E5\nCONTINUED ON PAGE E6\nClassifying CSP\nthis page\nLaparoscopic \nhysterectomy \ncomplications\npage E7\nDiaphragmatic \nendometriosis\npage E8\nMinimally invasive gynecologic surgery\nFocused guidance on treating cesarean scar pregnancy, \npreventing complications from laparoscopic hysterectomy \nfor endometriosis, and large study outcomes on the \nprevalence of diaphragmatic endometriosis\nI\nt has been an incredible year for complex \ngynecology and minimally invasive gyne -\ncologic surgery (MIGS), with several out -\nstanding new findings and reviews in 2023. \nThe surgical community continues to push \nthe envelope and emphasize the value of this \nspecialty for women’s health.\nEndometriosis and adenomyosis were at \nthe center of several large cohort studies and \nsystematic reviews that reassessed what we \nknow about how to evaluate and treat these \nchallenging diseases, including both surgi -\ncal and nonsurgical approaches, with an \nemphasis on fertility-sparing modalities. 1-8 \nIn addition, a focus on quality of life, patient-\ncentered care, and racial biases allowed us to \nreflect on our own practice patterns and keep \nthe patient at the center of care models. 9-13 \nFinally, there was a clear expansion in the use \nof technologies such as artificial intelligence \n(AI) and machine learning for care and novel \nminimally invasive tools.14\nIn this Update, we highlight and expand \non how several particularly important devel -\nopments are likely to make a difference in our \nclinical management.\nSierra J. Seaman, MD \nDr. Seaman is Assistant Professor, Division of \nGynecologic Specialty Services, Department \nof Obstetrics and Gynecology, Columbia \nUniversity Irving Medical Center,  \nNew York-Presbyterian Hospital,  \nNew York, New York. \nJessica Chaoul, MD \nDr. Chaoul is Fellow, Minimally Invasive \nGynecologic Surgery, Department of \nObstetrics and Gynecology, Columbia \nUniversity Irving Medical Center,  \nNew York-Presbyterian Hospital. \nArnold P. Advincula, MD \nDr. Advincula is Richard U. Levine Professor \nand Chief, Gynecologic Specialty Surgery, \nColumbia University Irving Medical Center, \nNew York-Presbyterian Hospital. He serves on \nthe OBG Management  Board of Editors.\nDr. Advincula reports serving as a consultant to ConMed, CooperSurgical, Intuitive, and Medtronic and receiving royalties from CooperSurgical. The other authors \nreport no financial relationships relevant to this article.\ndoi: 10.12788/obgm.0336\nNew classification system for  \ncesarean scar ectopic pregnancy \nwith defined surgical guidance  \nhas 97% treatment success rate\nBan Y, Shen J, Wang X, et al. Cesarean scar ectopic preg-\nnancy clinical classification system with recommended \nsurgical strategy. Obstet Gynecol. 2023;141:927-936. \ndoi:10.1097/AOG.0000000000005113\nILLUSTRATION: VECTORESSA/SHUTTERSTOCK\n\nUPDATE Minimally invasive gynecologic surgery\nE6  OBG Management  |  December 2023  |  Vol. 35  No. 12  mdedge.com/obgyn\nCONTINUED FROM PAGE E5\nA \nlarge multiarmed study by Ban and \ncolleagues used multivariable mod -\neling to formulate and test a classi -\nfication system and recommended surgical \ntreatment strategies for patients with a cesar-\nean scar ectopic pregnancy (CSP). 15 In the \nstudy, 273 patients were included in the pre -\ndictive modeling group, 118 in the internal \nvalidation group, and 564 within the model \ntesting cohort. Classifications were based on \n2 independent risk factors for intraoperative \nhemorrhage: anterior myometrial thickness \nand mean diameter of gestational sac (MSD).\nClassification types\nThe 3 main CSP types were defined based \non the anterior myometrial thickness at \nthe cesarean section scar (type I, > 3 mm; \ntype II, 1–3 mm; type III, ≤ 1 mm) and sub -\ntyped based on the MSD (type IIa, MSD  \n≤ 30 mm; type IIb, MSD > 30 mm; type IIIa, MSD  \n≤ 50 mm; type IIIb, MSD > 50 mm).\nThe subgroups were matched with  \nrecommended surgical strategy using expert \nopinion: Type I CSP was treated with suction \ndilation and aspiration (D&A) under ultra -\nsound guidance, with or without hysteros -\ncopy. Type IIa CSP was treated with suction \nD&A with hysteroscopy under ultrasound \nguidance. Type IIb CSP was treated with \nhysteroscopy with laparoscopic monitoring \nor excision, or transvaginal excision. Type \nIIIa CSP was treated with laparoscopic exci -\nsion or transvaginal excision. Type IIIb CSP \nwas treated with laparoscopic excision after \nuterine artery embolization or laparotomy \n(TABLE).15\nTreatment outcomes\nThese guidelines were tested on a cohort \nof 564 patients between 2014 and 2022. \nUsing these treatment guidelines, the over -\nall treatment success rate was 97.5%; 85% \nof patients had a negative serum ß-human \nTABLE  Clinical classification of CSP and surgical treatment strategy  \nas recommended by Ban et al15\nClassification\nAnterior  \nmyometrium  \nthickness, mm\nAverage diameter of \nthe massa, mm Recommended surgical treatment\nType I > 3 Suction curettage (with or  \nwithout hysteroscopyb) guided  \nby ultrasonography\nType II 1–3 IIa: ≤ 30 \nIIb: > 30\nSuction curettage with hysteroscopyb \nguided by ultrasonography\nHysteroscopy with laparoscopic \nmonitoring or excisionc  \n(or transvaginal excision)\nType III ≤ 1 IIIa: ≤ 50\nIIIb: > 50 or with \nuterine arteriovenous \nfistula\nLaparoscopic excision (or  \ntransvaginal excision)\nLaparoscopic excision after uterine \nartery embolization or laparotomy\nAbbreviation: CSP , cesarean scar ectopic pregnancy.\naMass or gestational sac.\nbHysteroscopy is used to evaluate whether products of conception have been removed completely, with hysteroscopic resection of \nresidual products when indicated.\ncDuring laparoscopy, if the products of conception could not be removed completely by hysteroscopy, hemorrhage occurred, or \nmyometrial layer bulge or thin-appearing myometrium was found, laparoscopic excision with scar defect repair was performed.\n\nmdedge.com/obgyn  Vol. 35  No. 12  |  December 2023  |  OBG Management   E7\nUPDATEMinimally invasive gynecologic surgery\nWHAT THIS EVIDENCE MEANS FOR PRACTICE\nAlthough the incidence of CSP is reported to be around 1:2,000 pregnancies, these rare \nfindings frequently cause a clinical conundrum.16 This thoughtful study by Ban and colleagues \nprovides guidance with the creation of a classification system aimed at decreasing the severe \nmorbidity that can come from mismanagement of these problematic pregnancies using \npredictive quantitative measures. In our own practice, we have used classification (type 1 \nendogenic or type 2 exogenic), mean gestational sac diameter, and overlying myometrial \nthickness when weighing options for treatment. However, decisions have been made on a \ncase-by-case basis and expert opinion without specific cutoffs. Having defined parameters \nto more accurately classify the type of ectopic pregnancy is essential for communicating risk \nfactors with all team members and for research purposes. The treatment algorithm proposed \nand tested in this study is logical with good outcomes in the test group. We applaud the \nauthors of this study on a rare but potentially morbid pregnancy outcome. Of note, this study \ndoes not discuss nonsurgical alternatives for treatment, such as intra-sac methotrexate \ninjection, which is another option used in select patients at our institution.\nchorionic gonadotropin (ß-hCG) level \nwithin 3 weeks, and 95.2% of patients \nresumed menstrual cycles within 8 weeks. \nSuccessful treatment was defined as:\n• complete resection of the products of  \nconception\n• no need to shift to a second-line surgical \nstrategy\n• no major complications\n• no readmission for additional treatment\n• serum ß-hCG levels that returned to  \nnormal within 4 weeks.\nPre-op hormonal treatment of  \nendometriosis found to be protective \nagainst post-op complications\nCasarin J, Ghezzi F , Mueller M, et al. Surgical out -\ncomes and complications of laparoscopic hysterec -\ntomy for endometriosis: a multicentric cohort study. J \nMinim Invasive Gynecol. 2023;30:587-592. doi:1016  \n/j.jmig.2023.03.018\nI\nn a large European multicenter retrospec -\ntive cohort study, Casarin and colleagues \nevaluated perioperative complications \nduring laparoscopic hysterectomy for endo -\nmetriosis or adenomyosis in 995 patients \ntreated from 2010 to 2020.2\nReported intraoperative data included \nthe frequency of ureterolysis (26.8%), deep \nnodule resection (30%) and posterior \nadhesiolysis (38.9%), unilateral salpingo-\noophorectomy (15.1%), bilateral salpingo-\noophorectomy (26.8%), estimated \nblood loss (mean, 100 mL), and adverse \nevents. Intraoperative complications \noccurred in 3% of cases (including bladder/\nbowel injury or need for transfusion).\nPostoperative complications occurred in \n13.8% of cases, and 9.3% had a major event, \nincluding vaginal cuff dehiscence, fever, \nabscess, and fistula.\nFactors associated with \npostoperative complications\nIn a multivariate analysis, the authors found \nthat increased operative time, younger age \nat surgery, previous surgery for endome -\ntriosis, and occurrence of intraoperative  \nILLUSTRATION: AMAB/SHUTTERSTOCK\n\nUPDATE Minimally invasive gynecologic surgery\nE8  OBG Management  |  December 2023  |  Vol. 35  No. 12  mdedge.com/obgyn\ncomplications were associated with  \nClavien-Dindo score grade 2 or greater \npostoperative complications.\nMedical treatment for endometriosis \nwith estro-progestin or progestin medica -\ntions, however, was found to be protective, \nwith an odds ratio of 0.50 (95% confidence \ninterval, 0.31–0.81).\nWHAT THIS EVIDENCE MEANS FOR PRACTICE\nIt is well known that endometriosis is a risk factor for surgical complications. The reported \ncomplication rates in this cohort were relatively high, with nearly 10% of patients sustaining \na major event postoperatively. While surgical risk is multifactorial and includes factors that \nare difficult to capture, including surgeon experience and patient population baseline risk, the \nrelatively high incidence reported should be cause for pause and be incorporated in patient \ncounseling. Of note, this cohort did undergo a large number of higher order dissections and \na high number of bilateral salpingo-oophorectomies (26.8%), which suggests a high-risk \npopulation.\nWhat we found most interesting, however, was the positive finding that medication \nadministration was protective against complications. The authors suggested that the anti-\ninflammatory effects of hormone suppressive medications may be the key. Although this was \na retrospective cohort study, the significant risk reduction seen is extremely compelling. A \nrandomized clinical trial corroborating these findings would be instrumental. Endometriosis \nacts similarly to cancer in its progressive spread and destruction of surrounding tissues. As \nis increasingly supported in the oncologic literature, perhaps neoadjuvant therapy should be \nthe standard for our “benign” high-risk endometriosis surgeries, with hormonal suppression \nserving as our chemotherapy. In our own practices, we may be more likely to encourage \npreoperative medication management, citing this added benefit to patients.\nDiaphragmatic endometriosis  \nprevalence higher than  \npreviously reported\nPagano F , Schwander A, Vaineau C, et al. True \nprevalence of diaphragmatic endometriosis \nand its association with severe endometriosis: \na call for awareness and investigation. J Minim \nInvasive Gynecol. 2023;30:329-334. doi:10.1016 \n/j.jmig.2023.01.006\nP\nagano and colleagues conducted an \nimpressive large prospective cohort \nstudy that included more than  \n1,300 patients with histologically proven \nendometriosis. 1 Each patient underwent \na systematic evaluation and reporting of \nintraoperative findings, including bilateral \nevaluation for diaphragmatic endometrio -\nsis (DE).\nPatients with DE had high  \nrates of infertility and  \nhigh-stage disease\nIn this cohort, 4.7% of patients were found to \nhave diaphragmatic disease; 92.3% of these \ncases had DE involving the right diaphragm. \nPatients with DE had a higher rate of infertil -\nity than those without DE (nearly 50%), but \notherwise they had no difference in typical \nendometriosis symptoms (dysmenorrhea, \ndyspareunia, dyschezia, dysuria). In this \ncohort, 27.4% had diaphragmatic symptoms \n(right shoulder pain, cough, cyclic dyspnea).\nPatients found to have DE had higher rates \nof stage III/IV disease (78.4%), and the left pel-\nvis was affected in more patients (73.8%).\nPHOTO: DRAGANA GORDIC/SHUTTERSTOCK\nCONTINUED ON PAGE E9\n\nUPDATEMinimally invasive gynecologic surgery\nmdedge.com/obgyn  Vol. 35  No. 12  |  December 2023  |  OBG Management   E9\nCONTINUED ON PAGE E10\nCONTINUED FROM PAGE E8\nWHAT THIS EVIDENCE MEANS FOR PRACTICE\nThe prevalence of DE in this large cohort evaluated by endometriosis surgeons was far \nhigher than previously reported rates of DE (0.19%–1.5% for abdominal endometriosis \ncases).17,18 Although admittedly this center cares for a larger portion of women with high-stage \ndisease than many nonspecialty centers do, it still begs the question: Are we as a specialty \nunderdiagnosing diaphragmatic endometriosis, especially in our patients with more severe \nendometriosis? Because nearly 5% of endometriosis patients could have DE, a thoughtful \nand systematic approach to the abdominal survey and diaphragm should be performed for \neach case. Adding questions about diaphragmatic symptoms to our preoperative evaluation \nmay help to identify about one-quarter of these complicated patients preoperatively to aid in \ncounseling and surgical planning. Patients to be specifically mindful about include those with \nhigh-stage disease, especially left-sided disease, and those with infertility (although this could \nbe a secondary association given the larger proportion of patients with stage III/IV disease \nwith infertility, and no multivariate analysis was performed). This study serves as a thoughtful \nreminder of this important subject.\nA word on fertility-sparing  \ntreatments for adenomyosis\nS\neveral interesting and thoughtful \nstudies were published on the fertil -\nity-sparing management of adeno -\nmyosis.6-8 These included a comparison of \nfertility outcomes following excisional and \nnonexcisional therapies,6 a systematic review \nof the literature that compared recurrence \nrates following procedural and surgical treat-\nments,8 and outcomes after use of a novel \ntherapy (percutaneous microwave ablation) \nfor the treatment of adenomyosis.7\nAlthough our critical evaluation of \nthese studies found that they are not robust \nenough to yet change our practice, we want \nto applaud the authors on their discerning \nquestions and on taking the initial steps to \nanswer critical questions, including:\n• What is the best uterine-sparing method for \ntreatment of diffuse adenomyosis?\n• Are radiofrequency or microwave ablation \nprocedures the future of adenomyosis care?\n• How do we counsel patients about fertility \npotential following procedural treatments?\n• How likely are symptoms to recur with \nglobal treatments such as uterine artery \nembolization? ●\nReferences\n1. Pagano F , Schwander A, Vaineau C, et al. True prevalence \nof diaphragmatic endometriosis and its association with \nsevere endometriosis: a call for awareness and investiga -\ntion. J Minim Invasive Gynecol. 2023;30:329-334. doi:10.1016 \n/j.jmig.2023.01.006\n2. Casarin J, Ghezzi F , Mueller M, et al. Surgical outcomes and \ncomplications of laparoscopic hysterectomy for endome -\ntriosis: a multicentric cohort study. J Minim Invasive Gynecol. \n2023;30:587-592. doi:1016/j.jmig.2023.03.018\n3. Abrao MS, Andres MP , Gingold JA, et al. Preoperative ultra-\nsound scoring of endometriosis by AAGL 2021 endome -\ntriosis classification is concordant with laparoscopic surgi -\ncal findings and distinguishes early from advanced stages. \nJ Minim Invasive Gynecol.  2023;30:363-373. doi:10.1016  \n/j.jmig.2022.11.003\n4. Meyer R, Siedhoff M, Truong M, et al. Risk factors for major \ncomplications following minimally invasive surgeries for \nendometriosis in the United States. J Minim Invasive Gynecol. \n2023;30:820-826. doi:10.1016/j.jmig.2023.06.002\n5. Davenport S, Smith D, Green DJ. Barriers to a timely diag -\nnosis of endometriosis. Obstet Gynecol.  2023;142:571-583. \ndoi:10.1097/AOG.0000000000005255\n6. Jiang L, Han Y, Song Z, et al. Pregnancy outcomes after \nuterus-sparing operative treatment for adenomyosis: a sys -\ntematic review and meta-analysis. J Minim Invasive Gynecol. \n2023:30:543-554. doi:10.1016/j.jmig.2023.03.015\n7. Li S, Li Z, Lin M, et al. Efficacy of transabdominal ultrasound–\nguided percutaneous microwave ablation in the treatment \nof symptomatic adenomyosis: a retrospective cohort study. \nJ Minim Invasive Gynecol.  2023;30:137-146. doi:10.1016  \n\nUPDATE Minimally invasive gynecologic surgery\nE10  OBG Management  |  December 2023  |  Vol. 35  No. 12  mdedge.com/obgyn\nCONTINUED FROM PAGE E9\n/j.jmig.2022.11.004\n8. Liu L, Tian H, Lin D, et al. Risk of recurrence and reinter -\nvention after uterine-sparing interventions for symp -\ntomatic adenomyosis: a systematic review and meta-\nanalysis. Obstet Gynecol.  2023;141:711-723. doi:10.1097  \n/AOG.0000000000005080\n9. Chang OH, Tewari S, Yao M, et al. Who places high value on \nthe uterus? A cross-sectional survey study evaluating pre -\ndictors for uterine preservation. J Minim Invasive Gynecol.  \n2023;30:131-136. doi:10.1016/j.jmig.2022.10.012\n10. Carey ET , Moore KJ, McClurg AB, et al. Racial disparities in \nhysterectomy route for benign disease: examining trends \nand perioperative complications from 2007 to 2018 using the \nNSQIP database. J Minim Invasive Gynecol. 2023;30:627-634. \ndoi:10.1016/j.jmig.2023.03.024\n11. Frisch EH, Mitchell J, Yao M, et al. The impact of fertility goals \non long-term quality of life in reproductive-aged women \nwho underwent myomectomy versus hysterectomy for \nuterine fibroids. J Minim Invasive Gynecol. 2023;30:642-651. \ndoi:10.1016/j.jmig.2023.04.003\n12. Robinson WR, Mathias JG, Wood ME, et al. Ethnoracial dif -\nferences in premenopausal hysterectomy: the role of symp -\ntom severity. Obstet Gynecol. 2023;142:350-359. doi:10.1097 \n/AOG.0000000000005225\n13. Harris HR, Peres LC, Johnson CE, et al. Racial differences in \nthe association of endometriosis and uterine leiomyomas \nwith the risk of ovarian cancer. Obstet Gynecol. 2023;141:1124-\n1138. doi:10.1097/AOG.0000000000005191\n14. Atia O, Hazan E, Rotem R, et al. A scoring system devel -\noped by a machine learning algorithm to better predict \nadnexal torsion. J Minim Invasive Gynecol. 2023;30:486-493. \ndoi:10.1016/j.jmig.2023.02.008\n15. Ban Y, Shen J, Wang X, et al. Cesarean scar ectopic pregnancy \nclinical classification system with recommended surgi -\ncal strategy.  Obstet Gynecol.  2023;141:927-936. doi:10.1097  \n/AOG.0000000000005113\n16. Rotas MA, Haberman S, Levgur M. Cesarean scar ecto -\npic pregnancies. Obstet Gynecol.  2006;107:1373-1381. \ndoi:10.1097/01.AOG.0000218690.24494.ce\n17. Scioscia M, Bruni F , Ceccaroni M, et al. Distribution of \nendometriotic lesions in endometriosis stage IV supports \nthe menstrual reflux theory and requires specific preop -\nerative assessment and therapy. Acta Obstet Gynecol Scand. \n2011;90:136-139. doi:10.1111/j.1600-0412.2010.01008.x\n18. Wetzel A, Philip C-A, Golfier F , et al. Surgical management of \ndiaphragmatic and thoracic endometriosis: a French mul -\nticentric descriptive study. J Gynecol Obstet Hum Reprod. \n2021;50:102147. doi:10.1016/j.jogoh.2021.102147","source_license":"CC0","license_restricted":false}