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Catarina Ang FRANZCOG 20 May 2011

Dr W. Catarina Ang MBBS DSHR (UK) DUE AFSA (France) Dip Epid FRANZCOG MBS MRepMed

Gynaecology Advanced Laparoscopy Infertility

Head of Gynaecology Unit 1, Royal Women’s Hospital

affil Cabrini & Epworth Hospitals, City Fertility Centre Catarina Ang FRANZCOG

New & old procedures for symptomatic fibroids

Myosure for SM fibroids

MRgFUS and UAE for conservative management of fibroids

Malignancy & fibroids – recent controversies & surgical

management

Anything new in pelvic pain/dysmenorrhoea?

Dienogest for endometriosis

The endometriosis assessment scan

Catarina Ang FRANZCOG

Common – 1 in 2

Benign growths of muscle cells in uterus

Different manifestations

asymptomatic

HMB

Pressure sx, pain

↓ fertility

Prolonged PVB (hypermenorrhoea) ↑ with endometritis

frequent histologically

IMB by ulcerating through endometrial lining / distorting cavity & causing congestion of surrounding

Rarely, may prolapse through cervix resulting in profuse bleeding

Catarina Ang FRANZCOG

Catarina Ang FRANZCOG

First reported 1976 (Neuwirth and Amin) monopolar current & 32% dextran 70

1987 Hallez Also converted urologic

resectoscope

0 scope, 1.5% glycine

Evolved into standard

surgical procedure, several

techniques Excision of intramural component by

slicing

‘Cold loop’ myomectomy

Complete excision of fibroid by two-step

procedure

‘Enucleation in toto’

‘hydromassage’

Catarina Ang FRANZCOG

• 0 - Fibroids totally in cavity

• I - sessile with <50%

intramural extension i.e. More

than 50% in cavity

• II – sessile with >50%

intramural extension i.e. Less

than 50% in cavity Wamsteker K, 1993

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Catarina Ang FRANZCOG

STEP-W Classification

Size

(cm)

Topography Extension

Base

Penetration Lateral

Wall T

O

T

A

L

0 ≤ 2 Low ≤ 1/3 0

+1 1 > 2 to 5 Middle >1/3 - 2/3 ≤ 50%

2 > 5 Upper > 2/3 > 50%

= Catarina Ang FRANZCOG

T. Score Group Indication

0 to 4 I Low complexity hysteroscopic myomectomy

5 to 6 II High complexity hysteroscopic myomectomy GnRH? Two-step hysteroscopic myomectomy

7 to 9 III Hysteroscopic myomectomy is not indicated

Catarina Ang FRANZCOG

Inconsistent results for RBA/TCRE

Req. well developed hand-eye-foot coordination

Can be assoc. w signif intraop/post op cx

To use 2nd/3rd generation devices

Quicker

Safer

J Gynecol Obstet Biol Reprod (Paris) 2011 Endocavitary surgical procedures, an alternative to myomectomy in patients with symptomatic fibroids

Catarina Ang FRANZCOG

Not much data

Use 2nd generation EA devices for

<3 cm

Preferably type II

Novasure/Thermachoice > Thermablate

>> Cavaterm

Catarina Ang FRANZCOG

Both work on normal saline

Catarina Ang FRANZCOG

smaller 2.5 mm inner blade

combination rotary and reciprocating blade (simultaneous action)

within 3 mm outer tube

blade & hand piece combined into single-use device attached to suction & motor control unit

hysteroscope sheath also 0° offset lens, 6.25 mm

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Catarina Ang FRANZCOG Catarina Ang FRANZCOG http://www.thewomens.org.au/uploads/downloads/HealthProfessionals/CSD/Imaging/MRgFUS_for_Uterine_Fib

roid_Treatment.pdf

Catarina Ang FRANZCOG

How does it work? MRI to locate the fibroids

direct, high-intensity ultrasound energy to destroy fibroid tissue

+ve less invasive than hysterectomy & myomectomy

Which carries a <1% chance of unplanned hysterectomy

with faster recovery

-ve Not suitable for all e.g. Haemodynamic compromise, abdominal scars

Risks inc burns, nerve injury, fibroid migration, pain

Takes time for fibroid to decrease in size (months)

Not permanent

Uncertainty re subsequent fertility / evolving technology

Catarina Ang FRANZCOG

NPV ratio

92%

54.4c

c

15.7c

c

71% volume & 75% symptom reduction at 24 months

SSS-QOL:

62.5

SSS-QOL:

15.6

57 sonications

Acknowledgements to Dr A Dobrotwir

Catarina Ang FRANZCOG

17 pregnancies

13 live births

4 NVD, 7 elective LUSCS, 2 emerg LUSCS

1 miscarriage

3 ongoing

Baby Neroli

Fertility Enhancement

– 9 successful pregnancies

– 10 live births

– Mean age 38yo

– Mean time to conception 9 months

– Mean birth weight 2.9 kg

– Mean gestational age 38 weeks

Acknowledgements to Dr A Dobrotwir Catarina Ang FRANZCOG

good improvement >85% sx of menstrual loss

– mean dominant fibroid volume ↓ 30-46%

min invasive qv surgery for LOS, ADLs

“angiogram”

overnight stay

Fibroid may regrow

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Catarina Ang FRANZCOG Acknowledgements to Dr J Druce & Cabrini Radiology Catarina Ang FRANZCOG

good improvement >85% sx of menstrual loss

– mean dominant fibroid volume ↓ 30-46%

min invasive qv surgery for LOS, ADLs

but assoc. with ↑ minor post procedural cx – vaginal discharge

– post puncture haematoma

– post embolization syndrome (pain, fever, nausea, vomiting)

– ↑ # unscheduled visits

– ↑ readmission rates

– ↑FSH levels post UAE ?ovarian dysfunction

Catarina Ang FRANZCOG Catarina Ang FRANZCOG

Preoperative clinical assessment inadequate for differentiation

Diagnosis only at histopathology

Benign Atypical STUMP Sarcoma

Catarina Ang FRANZCOG

Incidence of unexpected uterine sarcoma / LMS with presumed benign fibroids 0.08-0.49%1

Upstaging/peritoneal dissemination of disease after morcellation reported up to 64%2

Benign variants also poses risk of metastatic behaviour and adverse outcomes2, 4

FDA cites risk increased up to 1: 350, not 1-5: 10001

1 Food and Drug Administration, FDA 2014

2 Seidman, PLoS One, 2012

3 Giuntoli, J Reprod Med, 2007 Catarina Ang FRANZCOG

10 year retrospective audit (2004-2013) Demographic and clinical data

Operative outcomes

Histopathology

Outcomes data

Inclusion criteria All hysterectomies or myomectomies performed for symptomatic fibroids

abnormal bleeding, pelvic pain/pressure, abdominal mass

Exclusion criteria Cases with preoperative surgical indication of endometrial hyperplasia with atypia or suspected cancer

Acknowledgements to Dr K Chan

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Catarina Ang FRANZCOG

Total cases symptomatic fibroids = 1149

Median age 45 (22-76)

Premenopausal n=1119 (97%)

Postmenopausal n=30 (2.6%)

Catarina Ang FRANZCOG

1149 cases = review of histopathology

5 (0.43%) unexpected gynaecologic malignancy

Benign

Fibroid

Variant

55

(4.8%)

STUMP

4

(0.35%)

LMS

0

(0.00%)

ESS

3

(0.26%)

Other

Gynae Ca

2

(0.17%)

751g 1185g 847g Mean specimen

weight

Catarina Ang FRANZCOG

Age Pathology Stage Operation Morcellation

Completion

surgery,

adjuvant rx

Outcome

Follow Up

49 ESS1 3a TAH3 N

BSO5

Provera

Alive at

82m

47 ESS 3a TAH N

BSO

Provera

Alive at

34m

48 ESS 3a TAH/LSO4

Y (manual)

Pelvic RT

MPA6

Alive at

24m

47 EAC2 1a TAH Y (manual) BSO Alive at

74m

49 Adeno-

sarcoma

cervix

1b TAH Y (manual) BSO Alive at

37m

1 ESS = endometrial stromal sarcoma, 2 EAC = endometrial adenocarcinoma, 3 TAH = total

abdominal hysterectomy, 4 LSO = L salpingo-oophorectomy, 5 BSO = bilateral salpingo-

oophorectomy, 6 MPA = medroxyprogesterone acetate

Catarina Ang FRANZCOG

Unexpected gynaecologic malignancy in those with symptomatic fibroids req surgery <0.5%

ESS 0.26%, other 0.17%

Zero cases LMS in 10y retrospective audit of standard practice

Denominator likely higher since not all patients with sx fibroids req surgery ie less risk

None of gynaecologic cancers power-morcellated / upstaged, unlike other recent studies

Substitution of power for manual morcellation does not eliminate risk

Appropriate case selection for power morcellation intra-operatively, possibly under-utilised

Patients should be informed of

Risks & benefits of power morcellation

Small but potential risk of finding and spreading non-benign tumour vs

Having laparotomy and hysterectomy to avert all risk

Catarina Ang FRANZCOG 20 May 2011 Catarina Ang FRANZCOG

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Catarina Ang FRANZCOG Catarina Ang FRANZCOG

Catarina Ang FRANZCOG

2010 TGA approved

Selective progestogen receptor agonist combining NET and other progestogen properties with less side effects eg hyperandrogenic, BTB

pain (65 w), continuing 24 w post cessation factors PGE2, IL6, IL8, NGF, VEGF

dysmen, pre-menstrual pain, dyspareunia, CPP

Moderate ovarian activity

Equivalent at least to GnRH analogues

Favourable safety and tolerability profile, <5% cessation

Reduction of endometriotic lesions

Catarina Ang FRANZCOG

No research into contraceptive efficacy

More costly qv COC Or other progestogens, GnRH analogues

Does not assist endometriosis-associated infertility

<5% cessation fr ADRs, most commonly abnormal bleeding (improves if persist)

headache

breast discomfort,

depressed mood

acne

1998 Eur J Endocrinol Effects of dienogest, a synthetic steroid, on experimental endometriosis in rats.

2010 IJGO A dose-ranging study to determine the efficacy and safety of 1, 2, and 4mg of dienogest daily for endometriosis.

2010 EJOGRB Dienogest in treatment of endometriosis-associated pelvic pain: a 12-week, randomized, double-blind, placebo-controlled study

2010 HR Dienogest is as effective as leuprolide acetate in treating the painful symptoms of endometriosis: 24-week, randomized, multicentre,

open-label trial.

Catarina Ang FRANZCOG

Superficial lesions cannot be diagnosed on ultrasound

Deep infiltrating endometriosis (DIE) causes more anatomical distortion

May see “lumps” or nodules

May see adhesions between organs

Why do it then?

May need a 2nd operation

May need a colorectal surgeon involved

Best for patients with cyclical dyschezia, painful defaecation during menses

Catarina Ang FRANZCOG 20 May 2011

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Catarina Ang FRANZCOG 20 May 2011 Catarina Ang FRANZCOG 20 May 2011

Catarina Ang FRANZCOG 20 May 2011 Catarina Ang FRANZCOG

Catarina Ang FRANZCOG Catarina Ang FRANZCOG 20 May 2011

Dr W. Catarina Ang MBBS DSHR (UK) DUE AFSA (France) Dip Epid FRANZCOG MBS MRepMed

Gynaecology Advanced Laparoscopy Infertility

Head of Gynaecology Unit 1, Royal Women’s Hospital

affil Cabrini & Epworth Hospitals, City Fertility Centre

Thank

you