June 1999 Volume 5, Issue 1 Editor: James E. Carter, M.D., Ph.D., F.A.C.O.G Inside this Issue Letter from the President The Editor's Corner ISGE 8th Annual Congress Chair Report ISGE 8th Annual Congress Coordinator's Report ISGE 8th Annual Congress Highlights and Summary Report Laparoscopic Management of Genital Prolapse Evolution in Laparoscopy Letters to the Editor Preliminary Announcement: ISGE 10th Annual Congress 2001 Report from Thai Society for (TSGE) to the ISGE ISGE Secretariat Spaarne Hospital P.O. Box 1644 2003 BR Haarlem The Netherlands

THE ISGE NEWS ISGE 8th Annual Congress Highlights and Summary Report James E. Carter, M.D., Ph.D., F.A.C.O.G. Summary first day morning sessions: New Thoughts on Laparoscopic Entry The ISGE 8th annual Congress, held April 25-28, 1999, in Montreal, Canada was the site of many exciting presentations. The early morning program on new thoughts on laparoscopic entry provided a venue for Dr. Harry Reich to demonstrate his technique of high pressure trocar insertion, allowing for a safer entry of the primary trocar by pressurizing to 25 mm of mercury at the time of the first insertion. Dr. Duncan Turner presented the radially expanding access system, submitting data for its claim of safer entry. Dr. Alain Audebert demonstrated that the incidence of intra-abdominal umbilical adhesions is correlated with past surgical history. However, even patients with no past history had 0.68% adhesions and 0.45% severe adhesions (2 of 440 patients) at the umbilicus. Patients with a past surgical history with a midline incision had a 51.7% adhesion rate with 30.6% of the patients (26 of 85) having severe adhesions. Visualization of the umbilical area before introducing the umbilical trocar and eventually introduction of the trocar under visual control may prove to be useful in order to reduce the risk of injury during the installation phase of the laparoscope. Dr. Ray Garry presented images of endometriosis, a multi-media educational tool which demonstrated the effectiveness of this tool in teaching the appropriate techniques in endoscopic surgery for both recognition and treatment of endometriosis. While not presented in that symposium, the Endo-Tip system developed by Dr. Art Ternamian was presented at the Congress as a second generation access system with several innovative safety features that may help to decrease further the incidence of laparoscopic access complications. The highly talented members of the International Society of Gynecologic Endoscopy are addressing the issue of trocar safety and we are looking forward to further reports at our next annual Congress. Adenomyosis, Endometrial Ablation, Hysterectomy This session was opened by Dr. A. Ferenczy from McGill University with an illuminating discussion of the pathophysiology of adenomyosis. The advances in radiographic recognition using MRI imaging with T2 weighted images (sometimes assisted by fat suppression) now provides us with a substitute for the extirpated specimen diagnosis. However, as Dr, Ferenczy pointed out, the gold standard for the diagnosis of adenomyosis is still the removed uterine specimen. Adenomyosis is a relatively frequent endomyometrial pathology discovered in multiparous between 40 and 50 years of age. About 2/3 of women are symptomatic with menorrhagia and dysmenorrhea; 80% of adenomyotic cases are associated with leiomyomata uteri; and in women with endometrial adenocarcinoma, adenomyosis is relatively often seen. The aetiology and pathogenic mechanisms responsible for adenomyosis are poorly understood. Human and experimental studies favor the theory of endomyometrial invagination of the endometrium. Relatively high estrogen concentration and impaired immune related growth control in ectopic endometrium may be necessary for the maintenance of adenomyosis. Dr. Milton H. Goldrath presented clinical data on over 300 patients treated at 90º C for 10 minutes with a hysteroscopic installation of hot solution for endometrial ablation. The amenorrhea rate was greater than 44% and the failure rate was only 5%. Loss of fluid through the fallopian tubes was demonstrated not to be a problem. The procedure can be performed under local anesthesia. Dr. F. Loffer presented data that demonstrated that the ThermaChoice™ balloon therapy is as effective as roller ball endometrial ablation and in fact that there was a slightly higher hysterectomy rate with roller ball endometrial ablation than with the thermal balloon. Dr. J.L. Mergui presented the hysteroscopic signs of adenomyosis which are diverticula orifices or blue submucosal cysts with focal hypervascularization zones, rigid sides or straight and fibrosed uterine cornua. Dr. Mergui demonstrated that mild and medium adenomyosis can be treated with endometrial resection. Severe adenomyosis, diffuse and often deeper than 10 mm, resulted in therapeutic failures of endometrial ablation. These patients would benefit from a preoperative evaluation; especially MRI with T2 weighted imaging. Contemporary Use of GnRHa and Endometriosis Dr. Andre LeMay presented the consensus on ovarian suppression for endometriosis. The main benefit of ovarian suppression in endometriosis is the relief of pain which is achieved in almost every patient by GnRH agonists or high doses of danazol compared to medroxyprogesterone acetate (MPA). Oral contraceptives are less effective. The efficacy of ovarian suppression before and after surgery for pain has not been established. The recurrence rate is proportional to the severity of the disease and the symptom-free interval is related to the degree of estrogen suppression. Repeated GnRH agonist treatment is possible for recurrences provided that the initial treatment endometriosis is the relief of pain which is achieved in almost every patient by GnRH agonists or high doses of danazol compared to medroxyprogesterone acetate (MPA). Oral contraceptives are less effective. The efficacy of ovarian suppression before and after surgery for pain has not been established. The recurrence rate is proportional to the severity of the disease and the symptom-free interval is related to the degree of estrogen suppression. Repeated GnRH agonist treatment is possible for recurrences provided that the initial treatment has been short (3 months) and/or that bone density measurement has shown no significant bone loss from baseline. Dr. S.K. Agarwal presented the underlying basis for the estrogen threshold hypothesis, which is the premise that tissues differ in their sensitivity in estrogen. Since tissue responsiveness to estrogens may vary, it may well be possible to manage endometriosis with GnRH agonists and provide estrogen add-back therapy for conservation of bone mineral density. Dr. Debra Bush presented the New Zealand Endometriosis Foundation educational program on menstrual health and endometriosis for young women age 15 to 24. 40,000 young women have been involved in this program with significant numbers of these women suffering from undiagnosed menstrual disorders. This program is designed to decrease the 7-year delay between onset of symptoms and treatment of endometriosis by providing increased educational opportunities for young women. Dr. Ray Garry presented the effect of endometriosis and its radical laparoscopic excision upon quality of life indicators demonstrating that very meaningful improvements in clinical symptoms and quality of life with acceptable levels of operative morbidity. Computer, Gas-less and Robotic Surgery Dr. T. Falcone presented the very exciting use of ZEUS robotic surgical system for laparoscopic tubal reanastomosis using robotically assisted instrumentation. The procedure was performed successfully in 10 patients with patency demonstrated in each tube and no conversion to laparotomy. The surgeon uses 2 Castro-Viejo type handles, one for each hand, to control the movements of the instruments. The computer control boxes can eliminate hand tremor, scale movements and give the surgeon a sense of touch from the grasping instruments. Dr. L.K. Yap of Singapore presented the use of voice control as an ultimate interface using the HERMES system allowing the means of achieving centralized control by the surgeon of devices in the operating theater. M. Fung Kee Fung, M.D. presented a computerized telecommunication system for in-training evaluation in laparoscopy. This interactive voice response system recorded teachers and students self-assessment of resident performance of laparoscopic procedures. This system is a useful adjunct in the assessment of resident surgical skills. Dr. D. Kruschinski presented the gas less laparoscopic hysterectomy with the main advantages of the gas less system being the use of conventional laparotomy instruments (clamps, scissors, needle drivers). The operative time in total hysterectomy procedures decreased to about 60% of the time of total hysterectomy in conventional gas techniques. Laparoscopic and Hysteroscopic Techniques S. Spoori, M.D. presented tubal sterilization by means of endoluminal coagulation: an in vivo study in rabbits in which a negative methylene blue indicated occlusion in 51 of 52 tubes (a tubal occlusion rate of 98.1%) and a contraception rate of 100% in all 17 uteri in which the tube had been treated. Two different heat sources endoluminally were used. Endoluminal tubal coagulation was induced over a length of 3 cm in the proximal, extramural part of the fallopian tube by using a heated (68.5º C + or - 1.5º) stainless steel cannula or a cylindrical diffusing tip emitting Argon laser energy (1.5 and 2.7 watts, respectively) for 1 to 5 minutes. Dr. N. K. Y. Leong presented reproductive outcome after hysteroscopic surgery for infertility and recurrent miscarriage. Forty-five patients who underwent 46 hysteroscopic procedures for infertility or recurrent miscarriage were studied. Four of these patients presented with recurrent miscarriage, two due to uterine synechiae and two due to uterine septum. After hysteroscopic surgery, three patients conceived and carried pregnancies to term. Hysteroscopic treatment of uterine septi and synechiae for recurrent miscarriage has good success with subsequent pregnancy outcome. An asymptomatic intrauterine lesion discovered on routine investigation of infertility are usually of a minor extent and are simpler to resect. Dr. G. Ventolini presented hysteroscopy and direct biopsy in the diagnosis of postmenopausal bleeding, a problem, which occurs in 1% of women over the age of 45 in the primary care setting. A pathological diagnosis was achieved in 85% of cases. Common causes of bleeding were endometrial hyperplasia (25%), endometrial polyps (22%), and leiomyoma (22%). 2 patients in the study had cancer, 1 endometrial and 1 endocervical. Dr. Ventolini recommends both hysteroscopy, endometrial biopsy and an endocervical sampling which should be performed as part of the initial evaluation. Dr. J. B. DuBuisson presented laparoscopic lateral colpo-uterine suspension for the treatment of genital prolapse, a very exciting approach to the laparoscopic surgical treatment of genital prolapse. The technique involves the use of 2 composite meshes: one of which is applied to the upper portion of the anterior wall of the vagina and the other the upper portion of the posterior wall of the vagina and posterior aspect of the cervix. The lateral ends of the two meshes are pulled through a retroperitoneal tunnel and fixed respectively to the fascia of the right and left external oblique muscle. Dr. J. Parker presented the results of a critical review of the laparoscopic Burch colposuspension, demonstrating its effectiveness as a procedure and the importance of this approach to the treatment of stress urinary incontinence. James E. Carter, M.D., Ph.D., F.A.C.O.G presented an approach to the uterine suspension procedure using the Carter-Thomason needle point suture passer in a presentation of the Uterine Positioning by Ligament Investment, Fixation, and Truncation (UPLIFT). The procedure took an average of 12 minutes to perform. All procedures were performed as outpatient with same day discharge and there were no intraoperative complications. For all 75 patients, the pain with periods decreased from an initial 8.4 to 1.7 with 0 being no pain and 10 being the worse pain that the patient has ever experienced. (p<0.01) Pain with intercourse decreased from 8.1 to 1.5. (p< 0.01) When dyspareunia, dysmenorrhea and pelvic pain are associated with retroverted uterus, the uterus can be repositioned to a slightly anteverted position by the UPLIFT procedure using the Carter-Thomason needlepoint suture passer. Results with this anatomically correct technique are consistent with reports previously given for other uterine suspension procedures. Dr. Victor Gomel presented the keynote lecture: "Endoscopy Facing the Year 2000" in a truly marvelous event, which all participants enjoyed. As Dr. Gomel demonstrated, most of the gynecologic procedures that require access to the peritoneal cavity can now be performed by laparoscopy. In the new millennium, gynecologic surgery will experience dramatic changes. These changes will be shaped by technological developments, especially in imaging and robotics; and biological advances, particularly immunology, targeted therapy and gene therapy. Dr. Y. Wang presented the intelligent operating room with new devices, which will have many benefits including better precision and the ability to enable new procedures. The intelligent operating room with give the surgeon optimal control allowing for more efficient use of OR personnel, resulting in improved ergonomics and better data management. Microwave endometrial ablation using a microwave applicator was presented by Dr. N. Sharp demonstrating an 85.1% chance of avoiding hysterectomy at 4 years by utilizing this device for the treatment of menorrhagia. Dr. L. Mettler elegantly presented the developments and applications of new technologies in gynecologic, urologic and general surgical applications of endoscopy. The interaction of the specialties is critical to the further improvement of endoscopic surgical techniques. Additional sessions will be summarized in our next ISGE newsletter.