2023 Update on minimally invasive gynecologic surgery

UPDATE IN THIS ARTICLE mdedge.com/obgyn Vol. 35 No. 12 | December 2023 | OBG Management E5 CONTINUED ON PAGE E6 Classifying CSP this page Laparoscopic hysterectomy complications page E7 Diaphragmatic endometriosis page E8 Minimally invasive gynecologic surgery Focused guidance on treating cesarean scar pregnancy, preventing complications from laparoscopic hysterectomy for endometriosis, and large study outcomes on the prevalence of diaphragmatic endometriosis I t has been an incredible year for complex gynecology and minimally invasive gyne - cologic surgery (MIGS), with several out - standing new findings and reviews in 2023. The surgical community continues to push the envelope and emphasize the value of this specialty for women’s health. Endometriosis and adenomyosis were at the center of several large cohort studies and systematic reviews that reassessed what we know about how to evaluate and treat these challenging diseases, including both surgi - cal and nonsurgical approaches, with an emphasis on fertility-sparing modalities. 1-8 In addition, a focus on quality of life, patient- centered care, and racial biases allowed us to reflect on our own practice patterns and keep the patient at the center of care models. 9-13 Finally, there was a clear expansion in the use of technologies such as artificial intelligence (AI) and machine learning for care and novel minimally invasive tools.14 In this Update, we highlight and expand on how several particularly important devel - opments are likely to make a difference in our clinical management. Sierra J. Seaman, MD Dr. Seaman is Assistant Professor, Division of Gynecologic Specialty Services, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York. Jessica Chaoul, MD Dr. Chaoul is Fellow, Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York-Presbyterian Hospital. Arnold P. Advincula, MD Dr. Advincula is Richard U. Levine Professor and Chief, Gynecologic Specialty Surgery, Columbia University Irving Medical Center, New York-Presbyterian Hospital. He serves on the OBG Management Board of Editors. Dr. Advincula reports serving as a consultant to ConMed, CooperSurgical, Intuitive, and Medtronic and receiving royalties from CooperSurgical. The other authors report no financial relationships relevant to this article. doi: 10.12788/obgm.0336 New classification system for cesarean scar ectopic pregnancy with defined surgical guidance has 97% treatment success rate Ban Y, Shen J, Wang X, et al. Cesarean scar ectopic preg- nancy clinical classification system with recommended surgical strategy. Obstet Gynecol. 2023;141:927-936. doi:10.1097/AOG.0000000000005113 ILLUSTRATION: VECTORESSA/SHUTTERSTOCK UPDATE Minimally invasive gynecologic surgery E6 OBG Management | December 2023 | Vol. 35 No. 12 mdedge.com/obgyn CONTINUED FROM PAGE E5 A large multiarmed study by Ban and colleagues used multivariable mod - eling to formulate and test a classi - fication system and recommended surgical treatment strategies for patients with a cesar- ean scar ectopic pregnancy (CSP). 15 In the study, 273 patients were included in the pre - dictive modeling group, 118 in the internal validation group, and 564 within the model testing cohort. Classifications were based on 2 independent risk factors for intraoperative hemorrhage: anterior myometrial thickness and mean diameter of gestational sac (MSD). Classification types The 3 main CSP types were defined based on the anterior myometrial thickness at the cesarean section scar (type I, > 3 mm; type II, 1–3 mm; type III, ≤ 1 mm) and sub - typed based on the MSD (type IIa, MSD ≤ 30 mm; type IIb, MSD > 30 mm; type IIIa, MSD ≤ 50 mm; type IIIb, MSD > 50 mm). The subgroups were matched with recommended surgical strategy using expert opinion: Type I CSP was treated with suction dilation and aspiration (D&A) under ultra - sound guidance, with or without hysteros - copy. Type IIa CSP was treated with suction D&A with hysteroscopy under ultrasound guidance. Type IIb CSP was treated with hysteroscopy with laparoscopic monitoring or excision, or transvaginal excision. Type IIIa CSP was treated with laparoscopic exci - sion or transvaginal excision. Type IIIb CSP was treated with laparoscopic excision after uterine artery embolization or laparotomy (TABLE).15 Treatment outcomes These guidelines were tested on a cohort of 564 patients between 2014 and 2022. Using these treatment guidelines, the over - all treatment success rate was 97.5%; 85% of patients had a negative serum ß-human TABLE Clinical classification of CSP and surgical treatment strategy as recommended by Ban et al15 Classification Anterior myometrium thickness, mm Average diameter of the massa, mm Recommended surgical treatment Type I > 3 Suction curettage (with or without hysteroscopyb) guided by ultrasonography Type II 1–3 IIa: ≤ 30 IIb: > 30 Suction curettage with hysteroscopyb guided by ultrasonography Hysteroscopy with laparoscopic monitoring or excisionc (or transvaginal excision) Type III ≤ 1 IIIa: ≤ 50 IIIb: > 50 or with uterine arteriovenous fistula Laparoscopic excision (or transvaginal excision) Laparoscopic excision after uterine artery embolization or laparotomy Abbreviation: CSP , cesarean scar ectopic pregnancy. aMass or gestational sac. bHysteroscopy is used to evaluate whether products of conception have been removed completely, with hysteroscopic resection of residual products when indicated. cDuring laparoscopy, if the products of conception could not be removed completely by hysteroscopy, hemorrhage occurred, or myometrial layer bulge or thin-appearing myometrium was found, laparoscopic excision with scar defect repair was performed. mdedge.com/obgyn Vol. 35 No. 12 | December 2023 | OBG Management E7 UPDATEMinimally invasive gynecologic surgery WHAT THIS EVIDENCE MEANS FOR PRACTICE Although the incidence of CSP is reported to be around 1:2,000 pregnancies, these rare findings frequently cause a clinical conundrum.16 This thoughtful study by Ban and colleagues provides guidance with the creation of a classification system aimed at decreasing the severe morbidity that can come from mismanagement of these problematic pregnancies using predictive quantitative measures. In our own practice, we have used classification (type 1 endogenic or type 2 exogenic), mean gestational sac diameter, and overlying myometrial thickness when weighing options for treatment. However, decisions have been made on a case-by-case basis and expert opinion without specific cutoffs. Having defined parameters to more accurately classify the type of ectopic pregnancy is essential for communicating risk factors with all team members and for research purposes. The treatment algorithm proposed and tested in this study is logical with good outcomes in the test group. We applaud the authors of this study on a rare but potentially morbid pregnancy outcome. Of note, this study does not discuss nonsurgical alternatives for treatment, such as intra-sac methotrexate injection, which is another option used in select patients at our institution. chorionic gonadotropin (ß-hCG) level within 3 weeks, and 95.2% of patients resumed menstrual cycles within 8 weeks. Successful treatment was defined as: • complete resection of the products of conception • no need to shift to a second-line surgical strategy • no major complications • no readmission for additional treatment • serum ß-hCG levels that returned to normal within 4 weeks. Pre-op hormonal treatment of endometriosis found to be protective against post-op complications Casarin J, Ghezzi F , Mueller M, et al. Surgical out - comes and complications of laparoscopic hysterec - tomy for endometriosis: a multicentric cohort study. J Minim Invasive Gynecol. 2023;30:587-592. doi:1016 /j.jmig.2023.03.018 I n a large European multicenter retrospec - tive cohort study, Casarin and colleagues evaluated perioperative complications during laparoscopic hysterectomy for endo - metriosis or adenomyosis in 995 patients treated from 2010 to 2020.2 Reported intraoperative data included the frequency of ureterolysis (26.8%), deep nodule resection (30%) and posterior adhesiolysis (38.9%), unilateral salpingo- oophorectomy (15.1%), bilateral salpingo- oophorectomy (26.8%), estimated blood loss (mean, 100 mL), and adverse events. Intraoperative complications occurred in 3% of cases (including bladder/ bowel injury or need for transfusion). Postoperative complications occurred in 13.8% of cases, and 9.3% had a major event, including vaginal cuff dehiscence, fever, abscess, and fistula. Factors associated with postoperative complications In a multivariate analysis, the authors found that increased operative time, younger age at surgery, previous surgery for endome - triosis, and occurrence of intraoperative ILLUSTRATION: AMAB/SHUTTERSTOCK UPDATE Minimally invasive gynecologic surgery E8 OBG Management | December 2023 | Vol. 35 No. 12 mdedge.com/obgyn complications were associated with Clavien-Dindo score grade 2 or greater postoperative complications. Medical treatment for endometriosis with estro-progestin or progestin medica - tions, however, was found to be protective, with an odds ratio of 0.50 (95% confidence interval, 0.31–0.81). WHAT THIS EVIDENCE MEANS FOR PRACTICE It is well known that endometriosis is a risk factor for surgical complications. The reported complication rates in this cohort were relatively high, with nearly 10% of patients sustaining a major event postoperatively. While surgical risk is multifactorial and includes factors that are difficult to capture, including surgeon experience and patient population baseline risk, the relatively high incidence reported should be cause for pause and be incorporated in patient counseling. Of note, this cohort did undergo a large number of higher order dissections and a high number of bilateral salpingo-oophorectomies (26.8%), which suggests a high-risk population. What we found most interesting, however, was the positive finding that medication administration was protective against complications. The authors suggested that the anti- inflammatory effects of hormone suppressive medications may be the key. Although this was a retrospective cohort study, the significant risk reduction seen is extremely compelling. A randomized clinical trial corroborating these findings would be instrumental. Endometriosis acts similarly to cancer in its progressive spread and destruction of surrounding tissues. As is increasingly supported in the oncologic literature, perhaps neoadjuvant therapy should be the standard for our “benign” high-risk endometriosis surgeries, with hormonal suppression serving as our chemotherapy. In our own practices, we may be more likely to encourage preoperative medication management, citing this added benefit to patients. Diaphragmatic endometriosis prevalence higher than previously reported Pagano F , Schwander A, Vaineau C, et al. True prevalence of diaphragmatic endometriosis and its association with severe endometriosis: a call for awareness and investigation. J Minim Invasive Gynecol. 2023;30:329-334. doi:10.1016 /j.jmig.2023.01.006 P agano and colleagues conducted an impressive large prospective cohort study that included more than 1,300 patients with histologically proven endometriosis. 1 Each patient underwent a systematic evaluation and reporting of intraoperative findings, including bilateral evaluation for diaphragmatic endometrio - sis (DE). Patients with DE had high rates of infertility and high-stage disease In this cohort, 4.7% of patients were found to have diaphragmatic disease; 92.3% of these cases had DE involving the right diaphragm. Patients with DE had a higher rate of infertil - ity than those without DE (nearly 50%), but otherwise they had no difference in typical endometriosis symptoms (dysmenorrhea, dyspareunia, dyschezia, dysuria). In this cohort, 27.4% had diaphragmatic symptoms (right shoulder pain, cough, cyclic dyspnea). Patients found to have DE had higher rates of stage III/IV disease (78.4%), and the left pel- vis was affected in more patients (73.8%). PHOTO: DRAGANA GORDIC/SHUTTERSTOCK CONTINUED ON PAGE E9 UPDATEMinimally invasive gynecologic surgery mdedge.com/obgyn Vol. 35 No. 12 | December 2023 | OBG Management E9 CONTINUED ON PAGE E10 CONTINUED FROM PAGE E8 WHAT THIS EVIDENCE MEANS FOR PRACTICE The prevalence of DE in this large cohort evaluated by endometriosis surgeons was far higher than previously reported rates of DE (0.19%–1.5% for abdominal endometriosis cases).17,18 Although admittedly this center cares for a larger portion of women with high-stage disease than many nonspecialty centers do, it still begs the question: Are we as a specialty underdiagnosing diaphragmatic endometriosis, especially in our patients with more severe endometriosis? Because nearly 5% of endometriosis patients could have DE, a thoughtful and systematic approach to the abdominal survey and diaphragm should be performed for each case. Adding questions about diaphragmatic symptoms to our preoperative evaluation may help to identify about one-quarter of these complicated patients preoperatively to aid in counseling and surgical planning. Patients to be specifically mindful about include those with high-stage disease, especially left-sided disease, and those with infertility (although this could be a secondary association given the larger proportion of patients with stage III/IV disease with infertility, and no multivariate analysis was performed). This study serves as a thoughtful reminder of this important subject. A word on fertility-sparing treatments for adenomyosis S everal interesting and thoughtful studies were published on the fertil - ity-sparing management of adeno - myosis.6-8 These included a comparison of fertility outcomes following excisional and nonexcisional therapies,6 a systematic review of the literature that compared recurrence rates following procedural and surgical treat- ments,8 and outcomes after use of a novel therapy (percutaneous microwave ablation) for the treatment of adenomyosis.7 Although our critical evaluation of these studies found that they are not robust enough to yet change our practice, we want to applaud the authors on their discerning questions and on taking the initial steps to answer critical questions, including: • What is the best uterine-sparing method for treatment of diffuse adenomyosis? • Are radiofrequency or microwave ablation procedures the future of adenomyosis care? • How do we counsel patients about fertility potential following procedural treatments? • How likely are symptoms to recur with global treatments such as uterine artery embolization? ● References 1. Pagano F , Schwander A, Vaineau C, et al. True prevalence of diaphragmatic endometriosis and its association with severe endometriosis: a call for awareness and investiga - tion. J Minim Invasive Gynecol. 2023;30:329-334. doi:10.1016 /j.jmig.2023.01.006 2. Casarin J, Ghezzi F , Mueller M, et al. Surgical outcomes and complications of laparoscopic hysterectomy for endome - triosis: a multicentric cohort study. J Minim Invasive Gynecol. 2023;30:587-592. doi:1016/j.jmig.2023.03.018 3. Abrao MS, Andres MP , Gingold JA, et al. Preoperative ultra- sound scoring of endometriosis by AAGL 2021 endome - triosis classification is concordant with laparoscopic surgi - cal findings and distinguishes early from advanced stages. J Minim Invasive Gynecol. 2023;30:363-373. doi:10.1016 /j.jmig.2022.11.003 4. Meyer R, Siedhoff M, Truong M, et al. Risk factors for major complications following minimally invasive surgeries for endometriosis in the United States. J Minim Invasive Gynecol. 2023;30:820-826. doi:10.1016/j.jmig.2023.06.002 5. Davenport S, Smith D, Green DJ. Barriers to a timely diag - nosis of endometriosis. Obstet Gynecol. 2023;142:571-583. doi:10.1097/AOG.0000000000005255 6. Jiang L, Han Y, Song Z, et al. Pregnancy outcomes after uterus-sparing operative treatment for adenomyosis: a sys - tematic review and meta-analysis. J Minim Invasive Gynecol. 2023:30:543-554. doi:10.1016/j.jmig.2023.03.015 7. Li S, Li Z, Lin M, et al. Efficacy of transabdominal ultrasound– guided percutaneous microwave ablation in the treatment of symptomatic adenomyosis: a retrospective cohort study. J Minim Invasive Gynecol. 2023;30:137-146. doi:10.1016 UPDATE Minimally invasive gynecologic surgery E10 OBG Management | December 2023 | Vol. 35 No. 12 mdedge.com/obgyn CONTINUED FROM PAGE E9 /j.jmig.2022.11.004 8. Liu L, Tian H, Lin D, et al. Risk of recurrence and reinter - vention after uterine-sparing interventions for symp - tomatic adenomyosis: a systematic review and meta- analysis. Obstet Gynecol. 2023;141:711-723. doi:10.1097 /AOG.0000000000005080 9. Chang OH, Tewari S, Yao M, et al. Who places high value on the uterus? A cross-sectional survey study evaluating pre - dictors for uterine preservation. J Minim Invasive Gynecol. 2023;30:131-136. doi:10.1016/j.jmig.2022.10.012 10. Carey ET , Moore KJ, McClurg AB, et al. Racial disparities in hysterectomy route for benign disease: examining trends and perioperative complications from 2007 to 2018 using the NSQIP database. J Minim Invasive Gynecol. 2023;30:627-634. doi:10.1016/j.jmig.2023.03.024 11. Frisch EH, Mitchell J, Yao M, et al. The impact of fertility goals on long-term quality of life in reproductive-aged women who underwent myomectomy versus hysterectomy for uterine fibroids. J Minim Invasive Gynecol. 2023;30:642-651. doi:10.1016/j.jmig.2023.04.003 12. Robinson WR, Mathias JG, Wood ME, et al. Ethnoracial dif - ferences in premenopausal hysterectomy: the role of symp - tom severity. Obstet Gynecol. 2023;142:350-359. doi:10.1097 /AOG.0000000000005225 13. Harris HR, Peres LC, Johnson CE, et al. Racial differences in the association of endometriosis and uterine leiomyomas with the risk of ovarian cancer. Obstet Gynecol. 2023;141:1124- 1138. doi:10.1097/AOG.0000000000005191 14. Atia O, Hazan E, Rotem R, et al. A scoring system devel - oped by a machine learning algorithm to better predict adnexal torsion. J Minim Invasive Gynecol. 2023;30:486-493. doi:10.1016/j.jmig.2023.02.008 15. Ban Y, Shen J, Wang X, et al. Cesarean scar ectopic pregnancy clinical classification system with recommended surgi - cal strategy. Obstet Gynecol. 2023;141:927-936. doi:10.1097 /AOG.0000000000005113 16. Rotas MA, Haberman S, Levgur M. Cesarean scar ecto - pic pregnancies. Obstet Gynecol. 2006;107:1373-1381. doi:10.1097/01.AOG.0000218690.24494.ce 17. Scioscia M, Bruni F , Ceccaroni M, et al. Distribution of endometriotic lesions in endometriosis stage IV supports the menstrual reflux theory and requires specific preop - erative assessment and therapy. Acta Obstet Gynecol Scand. 2011;90:136-139. doi:10.1111/j.1600-0412.2010.01008.x 18. Wetzel A, Philip C-A, Golfier F , et al. Surgical management of diaphragmatic and thoracic endometriosis: a French mul - ticentric descriptive study. J Gynecol Obstet Hum Reprod. 2021;50:102147. doi:10.1016/j.jogoh.2021.102147