Endometriosis Foundation of America (EFA): Annual Medical Conference and Awareness Day

NEW YORK – In the first prospective study of endometriosis in teenagers undergoing complete laparoscopic excision of all areas of abnormal peritoneum, no recurrence was found during up to 5 years of follow-up, according to Dr. Patrick Yeung Jr., director of the center for endometriosis at St. Louis University.

These findings support one of the key themes of the annual congress of the Endometriosis Foundation of America, as expressed by cofounder Dr. Tamer Seckin: Early diagnosis and complete excision are "the best prevention."

In this observational study conducted by Dr. Yeung and his colleagues at an Atlanta-based specialty endometriosis practice, 20 young women aged 12-19 years with symptoms suspicious for endometriosis underwent complete laparoscopic excision of all areas of abnormal peritoneum. The most common suspicious symptoms included moderate to severe chronic pelvic pain, dysmenorrhea, and dyschezia; other symptoms reported were painful bladder, pain with exercise, and intestinal cramping. Quality of life was described as "awful" or "poor" for 65% of the girls. The majority had previous hormonal (82.4%) or surgical (76.5%) treatment (Fertil. Steril. 2011;95:1909-12).

At surgery, histologic analysis confirmed endometriosis in 17 of the 20 (85%) patients. Using the revised American Society for Reproductive Medicine staging criteria (Fertil. Steril. 1997;67:817-21), 29.5% of patients had stage I disease, 64.7% had stage II, and 5.9% had stage III.

After surgery, fewer girls reported pain symptoms such as dysmenorrhea (82.4% before surgery, reduced to 41.2% after surgery), dyschezia (76.5%, reduced to 17.6%), painful exercise (70.6%, reduced to 5.8%), intestinal cramping (58.8%, reduced to 5.8%) and bladder pain (52.9%, reduced to 11.8%) (all P less than .05). Quality of life scores also significantly improved (P less than .05).

During follow-up of up to 66 months (average, 23.1 months), 8 of 17 (47%) patients underwent a subsequent laparoscopy for persistent recurrent pain. None of these patients had endometriosis diagnosed visually or histologically. Half of the girls had pelvic adhesions.

One-third of the girls in the study took postoperative hormonal suppression medication; no recommendations were made about such treatment by the surgeons. The zero recurrence rate of endometriosis observed did not depend on postoperative hormonal suppression. "Postoperative suppression was not specifically recommended because it was felt [that] complete excision was achieved," said Dr. Yeung.

Dr. Yeung is an advocate of "see and treat" laparoscopy. He echoes the American College of Obstetricians and Gynecologists’ position that that diagnosis of endometriosis cannot be made by determining the response to empiric therapy (such as Lupron), but rather by seeing the lesions and getting histological confirmation of the diagnosis (Obstet. Gynecol. 2010;116:223-36).

Noting that younger women with endometriosis often have more atypical and subtle findings, such as red or white lesions and clear papules, he emphasized that it is critical to visualize the field well using high-definition optics with laparoscopy that can provide the benefits of both magnification and illumination. "In the younger patient, you have to look closely and systematically with ‘near contact’ laparoscopy to find it all." (Near contact laparoscopy refers to the camera tip’s being brought close to the tissue being examined to allow for adequate magnification and illumination of all peritoneal surfaces.)

Dr. Yeung uses the noncontact carbon dioxide (CO₂)laser as his "cutting tool of choice," but states that complete excision of all abnormal areas of peritoneum (both typical and atypical) is the most important. "Half the battle is finding it all, especially in younger women, and the other half of the battle is cutting it all out wherever it is found."

During the meeting, several patients recounted their difficult journeys with endometriosis. A common complaint was that their symptoms – including severe menstrual-related pelvic pain – were considered to be "normal."

Dr. Yeung confirmed that the average time from symptom onset to surgical diagnosis of endometriosis is nearly 12 years (Hum. Reprod. 1996:11;878-80).

Some believe that "invisible endometriosis" exists, so that endometriosis will always come back. This idea came from an article published 25 years ago when endometriosis was identified with the naked eye at open surgery (Fertil. Steril. 1986:46;522-4). Dr. Yeung cited a graph by Dr. David B. Redwine, an ob.gyn in Bend, Ore., who specializes in endometriosis, that shows that the more closely one looks at the tissue and the more one knows what endometriosis looks like in all of its forms (typical and atypical or subtle), the rate of "invisible endometriosis approaches zero especially by experienced surgeons" (Gynecol. Obstet. Invest. 2003;63-7).

It is important to note that pain is only one aspect of endometriosis as a disease, and, therefore, the potential benefits of removing of endometriosis cannot be fully described in terms of pain relief or quality of life benefit alone. Eradication of disease may prevent progression of disease (which may include formation of endometriomas and distortion of anatomy), and may have profound benefits on present or future fertility (Fertil. Steril. 2011;95:1909-12), he commented.

To screen for patients at high risk for having endometriosis, Dr. Yeung asks them several important questions, such as "Have you missed school or work due to pelvic pain or painful periods?" When a patient is asked these questions, "if she has any symptoms, her face lights up as she say ‘yes,’ " said Dr. Yeung. "These symptoms are not normal."

Dr. Yeung said he had no relevant disclosures.

NEW YORK – In the first prospective study of endometriosis in teenagers undergoing complete laparoscopic excision of all areas of abnormal peritoneum, no recurrence was found during up to 5 years of follow-up, according to Dr. Patrick Yeung Jr., director of the center for endometriosis at St. Louis University.

These findings support one of the key themes of the annual congress of the Endometriosis Foundation of America, as expressed by cofounder Dr. Tamer Seckin: Early diagnosis and complete excision are "the best prevention."

In this observational study conducted by Dr. Yeung and his colleagues at an Atlanta-based specialty endometriosis practice, 20 young women aged 12-19 years with symptoms suspicious for endometriosis underwent complete laparoscopic excision of all areas of abnormal peritoneum. The most common suspicious symptoms included moderate to severe chronic pelvic pain, dysmenorrhea, and dyschezia; other symptoms reported were painful bladder, pain with exercise, and intestinal cramping. Quality of life was described as "awful" or "poor" for 65% of the girls. The majority had previous hormonal (82.4%) or surgical (76.5%) treatment (Fertil. Steril. 2011;95:1909-12).

At surgery, histologic analysis confirmed endometriosis in 17 of the 20 (85%) patients. Using the revised American Society for Reproductive Medicine staging criteria (Fertil. Steril. 1997;67:817-21), 29.5% of patients had stage I disease, 64.7% had stage II, and 5.9% had stage III.

After surgery, fewer girls reported pain symptoms such as dysmenorrhea (82.4% before surgery, reduced to 41.2% after surgery), dyschezia (76.5%, reduced to 17.6%), painful exercise (70.6%, reduced to 5.8%), intestinal cramping (58.8%, reduced to 5.8%) and bladder pain (52.9%, reduced to 11.8%) (all P less than .05). Quality of life scores also significantly improved (P less than .05).

During follow-up of up to 66 months (average, 23.1 months), 8 of 17 (47%) patients underwent a subsequent laparoscopy for persistent recurrent pain. None of these patients had endometriosis diagnosed visually or histologically. Half of the girls had pelvic adhesions.

One-third of the girls in the study took postoperative hormonal suppression medication; no recommendations were made about such treatment by the surgeons. The zero recurrence rate of endometriosis observed did not depend on postoperative hormonal suppression. "Postoperative suppression was not specifically recommended because it was felt [that] complete excision was achieved," said Dr. Yeung.

Dr. Yeung is an advocate of "see and treat" laparoscopy. He echoes the American College of Obstetricians and Gynecologists’ position that that diagnosis of endometriosis cannot be made by determining the response to empiric therapy (such as Lupron), but rather by seeing the lesions and getting histological confirmation of the diagnosis (Obstet. Gynecol. 2010;116:223-36).

Noting that younger women with endometriosis often have more atypical and subtle findings, such as red or white lesions and clear papules, he emphasized that it is critical to visualize the field well using high-definition optics with laparoscopy that can provide the benefits of both magnification and illumination. "In the younger patient, you have to look closely and systematically with ‘near contact’ laparoscopy to find it all." (Near contact laparoscopy refers to the camera tip’s being brought close to the tissue being examined to allow for adequate magnification and illumination of all peritoneal surfaces.)

Dr. Yeung uses the noncontact carbon dioxide (CO₂)laser as his "cutting tool of choice," but states that complete excision of all abnormal areas of peritoneum (both typical and atypical) is the most important. "Half the battle is finding it all, especially in younger women, and the other half of the battle is cutting it all out wherever it is found."

During the meeting, several patients recounted their difficult journeys with endometriosis. A common complaint was that their symptoms – including severe menstrual-related pelvic pain – were considered to be "normal."

Dr. Yeung confirmed that the average time from symptom onset to surgical diagnosis of endometriosis is nearly 12 years (Hum. Reprod. 1996:11;878-80).

Some believe that "invisible endometriosis" exists, so that endometriosis will always come back. This idea came from an article published 25 years ago when endometriosis was identified with the naked eye at open surgery (Fertil. Steril. 1986:46;522-4). Dr. Yeung cited a graph by Dr. David B. Redwine, an ob.gyn in Bend, Ore., who specializes in endometriosis, that shows that the more closely one looks at the tissue and the more one knows what endometriosis looks like in all of its forms (typical and atypical or subtle), the rate of "invisible endometriosis approaches zero especially by experienced surgeons" (Gynecol. Obstet. Invest. 2003;63-7).

It is important to note that pain is only one aspect of endometriosis as a disease, and, therefore, the potential benefits of removing of endometriosis cannot be fully described in terms of pain relief or quality of life benefit alone. Eradication of disease may prevent progression of disease (which may include formation of endometriomas and distortion of anatomy), and may have profound benefits on present or future fertility (Fertil. Steril. 2011;95:1909-12), he commented.

To screen for patients at high risk for having endometriosis, Dr. Yeung asks them several important questions, such as "Have you missed school or work due to pelvic pain or painful periods?" When a patient is asked these questions, "if she has any symptoms, her face lights up as she say ‘yes,’ " said Dr. Yeung. "These symptoms are not normal."

Dr. Yeung said he had no relevant disclosures.

NEW YORK – In the first prospective study of endometriosis in teenagers undergoing complete laparoscopic excision of all areas of abnormal peritoneum, no recurrence was found during up to 5 years of follow-up, according to Dr. Patrick Yeung Jr., director of the center for endometriosis at St. Louis University.

These findings support one of the key themes of the annual congress of the Endometriosis Foundation of America, as expressed by cofounder Dr. Tamer Seckin: Early diagnosis and complete excision are "the best prevention."

In this observational study conducted by Dr. Yeung and his colleagues at an Atlanta-based specialty endometriosis practice, 20 young women aged 12-19 years with symptoms suspicious for endometriosis underwent complete laparoscopic excision of all areas of abnormal peritoneum. The most common suspicious symptoms included moderate to severe chronic pelvic pain, dysmenorrhea, and dyschezia; other symptoms reported were painful bladder, pain with exercise, and intestinal cramping. Quality of life was described as "awful" or "poor" for 65% of the girls. The majority had previous hormonal (82.4%) or surgical (76.5%) treatment (Fertil. Steril. 2011;95:1909-12).

At surgery, histologic analysis confirmed endometriosis in 17 of the 20 (85%) patients. Using the revised American Society for Reproductive Medicine staging criteria (Fertil. Steril. 1997;67:817-21), 29.5% of patients had stage I disease, 64.7% had stage II, and 5.9% had stage III.

After surgery, fewer girls reported pain symptoms such as dysmenorrhea (82.4% before surgery, reduced to 41.2% after surgery), dyschezia (76.5%, reduced to 17.6%), painful exercise (70.6%, reduced to 5.8%), intestinal cramping (58.8%, reduced to 5.8%) and bladder pain (52.9%, reduced to 11.8%) (all P less than .05). Quality of life scores also significantly improved (P less than .05).

During follow-up of up to 66 months (average, 23.1 months), 8 of 17 (47%) patients underwent a subsequent laparoscopy for persistent recurrent pain. None of these patients had endometriosis diagnosed visually or histologically. Half of the girls had pelvic adhesions.

One-third of the girls in the study took postoperative hormonal suppression medication; no recommendations were made about such treatment by the surgeons. The zero recurrence rate of endometriosis observed did not depend on postoperative hormonal suppression. "Postoperative suppression was not specifically recommended because it was felt [that] complete excision was achieved," said Dr. Yeung.

Dr. Yeung is an advocate of "see and treat" laparoscopy. He echoes the American College of Obstetricians and Gynecologists’ position that that diagnosis of endometriosis cannot be made by determining the response to empiric therapy (such as Lupron), but rather by seeing the lesions and getting histological confirmation of the diagnosis (Obstet. Gynecol. 2010;116:223-36).

Noting that younger women with endometriosis often have more atypical and subtle findings, such as red or white lesions and clear papules, he emphasized that it is critical to visualize the field well using high-definition optics with laparoscopy that can provide the benefits of both magnification and illumination. "In the younger patient, you have to look closely and systematically with ‘near contact’ laparoscopy to find it all." (Near contact laparoscopy refers to the camera tip’s being brought close to the tissue being examined to allow for adequate magnification and illumination of all peritoneal surfaces.)

Dr. Yeung uses the noncontact carbon dioxide (CO₂)laser as his "cutting tool of choice," but states that complete excision of all abnormal areas of peritoneum (both typical and atypical) is the most important. "Half the battle is finding it all, especially in younger women, and the other half of the battle is cutting it all out wherever it is found."

During the meeting, several patients recounted their difficult journeys with endometriosis. A common complaint was that their symptoms – including severe menstrual-related pelvic pain – were considered to be "normal."

Dr. Yeung confirmed that the average time from symptom onset to surgical diagnosis of endometriosis is nearly 12 years (Hum. Reprod. 1996:11;878-80).

Some believe that "invisible endometriosis" exists, so that endometriosis will always come back. This idea came from an article published 25 years ago when endometriosis was identified with the naked eye at open surgery (Fertil. Steril. 1986:46;522-4). Dr. Yeung cited a graph by Dr. David B. Redwine, an ob.gyn in Bend, Ore., who specializes in endometriosis, that shows that the more closely one looks at the tissue and the more one knows what endometriosis looks like in all of its forms (typical and atypical or subtle), the rate of "invisible endometriosis approaches zero especially by experienced surgeons" (Gynecol. Obstet. Invest. 2003;63-7).

It is important to note that pain is only one aspect of endometriosis as a disease, and, therefore, the potential benefits of removing of endometriosis cannot be fully described in terms of pain relief or quality of life benefit alone. Eradication of disease may prevent progression of disease (which may include formation of endometriomas and distortion of anatomy), and may have profound benefits on present or future fertility (Fertil. Steril. 2011;95:1909-12), he commented.

To screen for patients at high risk for having endometriosis, Dr. Yeung asks them several important questions, such as "Have you missed school or work due to pelvic pain or painful periods?" When a patient is asked these questions, "if she has any symptoms, her face lights up as she say ‘yes,’ " said Dr. Yeung. "These symptoms are not normal."

Dr. Yeung said he had no relevant disclosures.

NEW YORK – With improvements in light sources, hand instrumentation, and energy devices, robot-assisted minimally invasive surgery now offers a level of precision and finesse for treating endometriosis that was not previously available, according to Dr. Arnold Advincula.

"We know that endometriosis tends to compromise anatomical spaces," he said. "Robot-assisted minimally invasive surgery allows you to dissect in the plane of the compromised tissue, thereby minimizing trauma, which is advantageous when dissecting around the ureter or bowel."

Photo Courtesy Dr. Arnold Advincula

Conventional laparoscopic techniques offer limited degrees of motion for the surgeon and 2-D visualization. With robot-assisted surgery, the surgeon sees a 3-D view of the operating field. Additionally, the "endowrist" laparoscopic instruments used in the da Vinci surgical system mimic the full range of human wrist movement, allowing the surgeon 7 degrees of movement compared with 4 degrees of movement with conventional or "straight-stick" laparoscopic surgery; the conventional approach is limited by the "fulcrum effect" in which the hands move left as the instrument tip moves right. With robotic-surgery, the instruments follow the exact movements of the surgeon’s hands. The instrumentation also filters tremors and scales motion, improving precision.

Robotic surgery also offers ergonomic advantages. The surgeon can sit with arms rested. If the surgeon’s arms become hyperextended or flexed during surgery, the arm controls can be temporarily disengaged from the instrument tips to allow a change to a more comfortable position.

Robotic surgery makes it possible to get around obstacles and offers such control that surgeons can carefully dissect and excise diseased tissue layer by layer, said Dr. Advincula, medical director of gynecologic robotics at the Celebration Health Endometriosis Center at Florida Hospital. Robot-assisted surgery can be particularly useful for deeply infiltrating endometriosis of the pelvic peritoneum or ovary (endometriomas). A major strength lies in the robotic system’s ability to be an excellent tool for anatomical surgical dissection. It also can be helpful when accessing difficult-to-reach areas, such as endometriosis within the rectovaginal septum, which can be quite challenging with rigid nonarticulating instrumentation, Dr. Advincula said at the annual congress of the Endometriosis Foundation of America.

In cases where safe peritoneal access cannot be accomplished or significant comorbidities preclude an endoscopic approach, robot-assisted surgery may not be useful.

One criticism of robot-assisted surgery is the lack of tactile cues (haptic feedback). In addition to changes in coloration, endometriosis can be fibrotic, nodular, or cystic and feel thicker than normal tissue, especially if it is infiltrative. Dr. Advincula said he relies on visual cues combined with the knowledge of anatomical structures and dissection planes when performing excisional surgery via robotics. He cautioned that several years of robotic surgery experience are needed to understand and overcome this limitation.

Outcomes research comparing traditional laparoscopic surgery and robotic-assisted endometriosis surgery is limited, he noted. ACOG’s 2009 Technology Assessment in Obstetrics and Gynecology No. 6 on robot-assisted surgery suggested that randomized trials were needed to compare the respective outcomes and costs of robot-assisted surgery with those of traditional laparoscopic, vaginal, or abdominal surgery, and to pinpoint the best applications of robotic technology (Obstet. Gynecol. 2009;114:1153-5). A systematic review published in 2011 (Int. J. Med. Robot. 2011 Dec. 9 [doi:10.1002/rcs.451]) identified only three case reports and one cohort study that used the da Vinci surgical system for endometriosis, and concluded that few studies had been published in the field to date and evidence regarding long-term outcomes was lacking.

In a not-yet-published review of the literature, Dr. Advincula and his colleagues found 21 publications, mostly single cases or case series and one comparative controlled cohort study. The literature is clearly lacking in the area of using robotics for endometriosis surgery, he said. That is why the Celebration Health Endometriosis Center is involved in a multicenter collaboration to track outcomes and determine where advantages and disadvantages exist. As robotic technology evolves, it must be critically evaluated to determine its appropriate applications in endometriosis surgery.

Another problem for patients is that access to surgeons well trained in both the management of endometriosis and the proper use of robotics in gynecologic surgery is limited. "Clearly, when you have 10-20 million women affected by the disease, you can’t have just a handful of people capable of treating the disease. We need skilled surgeons who understand reproductive medicine, are familiar with applying surgical principles to complex cases, and who work in a multidisciplinary fashion in a specialized center to take advantage of a technology like this," said Dr. Advincula.

He said he encourages gynecologists and surgeons who wish to learn more about robot-assisted gynecologic surgery to attend conferences and workshops, such as the World Robotic Gynecology Conference, which provides opportunities to engage in both hands-on training and classroom teaching. Other alternatives are working with a surgical mentor or completing a fellowship in minimally invasive surgery that incorporates the surgical management of endometriosis.

"In the right hands and within the right infrastructure, robotics has the potential to provide women better options and access to cutting-edge care, especially in the area of endometriosis surgery. But as a new surgical frontier, don’t be lulled into thinking robotics per se will make you a better surgeon without the proper training and skill set," cautioned Dr. Advincula.

He said he is a consultant for Cooper Surgical, Ethicon Women’s Health and Urology, and Intuitive Surgical, and that he has received royalties from Cooper Surgical.

NEW YORK – With improvements in light sources, hand instrumentation, and energy devices, robot-assisted minimally invasive surgery now offers a level of precision and finesse for treating endometriosis that was not previously available, according to Dr. Arnold Advincula.

"We know that endometriosis tends to compromise anatomical spaces," he said. "Robot-assisted minimally invasive surgery allows you to dissect in the plane of the compromised tissue, thereby minimizing trauma, which is advantageous when dissecting around the ureter or bowel."

Photo Courtesy Dr. Arnold Advincula

Conventional laparoscopic techniques offer limited degrees of motion for the surgeon and 2-D visualization. With robot-assisted surgery, the surgeon sees a 3-D view of the operating field. Additionally, the "endowrist" laparoscopic instruments used in the da Vinci surgical system mimic the full range of human wrist movement, allowing the surgeon 7 degrees of movement compared with 4 degrees of movement with conventional or "straight-stick" laparoscopic surgery; the conventional approach is limited by the "fulcrum effect" in which the hands move left as the instrument tip moves right. With robotic-surgery, the instruments follow the exact movements of the surgeon’s hands. The instrumentation also filters tremors and scales motion, improving precision.

Robotic surgery also offers ergonomic advantages. The surgeon can sit with arms rested. If the surgeon’s arms become hyperextended or flexed during surgery, the arm controls can be temporarily disengaged from the instrument tips to allow a change to a more comfortable position.

Robotic surgery makes it possible to get around obstacles and offers such control that surgeons can carefully dissect and excise diseased tissue layer by layer, said Dr. Advincula, medical director of gynecologic robotics at the Celebration Health Endometriosis Center at Florida Hospital. Robot-assisted surgery can be particularly useful for deeply infiltrating endometriosis of the pelvic peritoneum or ovary (endometriomas). A major strength lies in the robotic system’s ability to be an excellent tool for anatomical surgical dissection. It also can be helpful when accessing difficult-to-reach areas, such as endometriosis within the rectovaginal septum, which can be quite challenging with rigid nonarticulating instrumentation, Dr. Advincula said at the annual congress of the Endometriosis Foundation of America.

In cases where safe peritoneal access cannot be accomplished or significant comorbidities preclude an endoscopic approach, robot-assisted surgery may not be useful.

One criticism of robot-assisted surgery is the lack of tactile cues (haptic feedback). In addition to changes in coloration, endometriosis can be fibrotic, nodular, or cystic and feel thicker than normal tissue, especially if it is infiltrative. Dr. Advincula said he relies on visual cues combined with the knowledge of anatomical structures and dissection planes when performing excisional surgery via robotics. He cautioned that several years of robotic surgery experience are needed to understand and overcome this limitation.

Outcomes research comparing traditional laparoscopic surgery and robotic-assisted endometriosis surgery is limited, he noted. ACOG’s 2009 Technology Assessment in Obstetrics and Gynecology No. 6 on robot-assisted surgery suggested that randomized trials were needed to compare the respective outcomes and costs of robot-assisted surgery with those of traditional laparoscopic, vaginal, or abdominal surgery, and to pinpoint the best applications of robotic technology (Obstet. Gynecol. 2009;114:1153-5). A systematic review published in 2011 (Int. J. Med. Robot. 2011 Dec. 9 [doi:10.1002/rcs.451]) identified only three case reports and one cohort study that used the da Vinci surgical system for endometriosis, and concluded that few studies had been published in the field to date and evidence regarding long-term outcomes was lacking.

In a not-yet-published review of the literature, Dr. Advincula and his colleagues found 21 publications, mostly single cases or case series and one comparative controlled cohort study. The literature is clearly lacking in the area of using robotics for endometriosis surgery, he said. That is why the Celebration Health Endometriosis Center is involved in a multicenter collaboration to track outcomes and determine where advantages and disadvantages exist. As robotic technology evolves, it must be critically evaluated to determine its appropriate applications in endometriosis surgery.

Another problem for patients is that access to surgeons well trained in both the management of endometriosis and the proper use of robotics in gynecologic surgery is limited. "Clearly, when you have 10-20 million women affected by the disease, you can’t have just a handful of people capable of treating the disease. We need skilled surgeons who understand reproductive medicine, are familiar with applying surgical principles to complex cases, and who work in a multidisciplinary fashion in a specialized center to take advantage of a technology like this," said Dr. Advincula.

He said he encourages gynecologists and surgeons who wish to learn more about robot-assisted gynecologic surgery to attend conferences and workshops, such as the World Robotic Gynecology Conference, which provides opportunities to engage in both hands-on training and classroom teaching. Other alternatives are working with a surgical mentor or completing a fellowship in minimally invasive surgery that incorporates the surgical management of endometriosis.

"In the right hands and within the right infrastructure, robotics has the potential to provide women better options and access to cutting-edge care, especially in the area of endometriosis surgery. But as a new surgical frontier, don’t be lulled into thinking robotics per se will make you a better surgeon without the proper training and skill set," cautioned Dr. Advincula.

He said he is a consultant for Cooper Surgical, Ethicon Women’s Health and Urology, and Intuitive Surgical, and that he has received royalties from Cooper Surgical.

NEW YORK – With improvements in light sources, hand instrumentation, and energy devices, robot-assisted minimally invasive surgery now offers a level of precision and finesse for treating endometriosis that was not previously available, according to Dr. Arnold Advincula.

"We know that endometriosis tends to compromise anatomical spaces," he said. "Robot-assisted minimally invasive surgery allows you to dissect in the plane of the compromised tissue, thereby minimizing trauma, which is advantageous when dissecting around the ureter or bowel."

Photo Courtesy Dr. Arnold Advincula

Conventional laparoscopic techniques offer limited degrees of motion for the surgeon and 2-D visualization. With robot-assisted surgery, the surgeon sees a 3-D view of the operating field. Additionally, the "endowrist" laparoscopic instruments used in the da Vinci surgical system mimic the full range of human wrist movement, allowing the surgeon 7 degrees of movement compared with 4 degrees of movement with conventional or "straight-stick" laparoscopic surgery; the conventional approach is limited by the "fulcrum effect" in which the hands move left as the instrument tip moves right. With robotic-surgery, the instruments follow the exact movements of the surgeon’s hands. The instrumentation also filters tremors and scales motion, improving precision.

Robotic surgery also offers ergonomic advantages. The surgeon can sit with arms rested. If the surgeon’s arms become hyperextended or flexed during surgery, the arm controls can be temporarily disengaged from the instrument tips to allow a change to a more comfortable position.

Robotic surgery makes it possible to get around obstacles and offers such control that surgeons can carefully dissect and excise diseased tissue layer by layer, said Dr. Advincula, medical director of gynecologic robotics at the Celebration Health Endometriosis Center at Florida Hospital. Robot-assisted surgery can be particularly useful for deeply infiltrating endometriosis of the pelvic peritoneum or ovary (endometriomas). A major strength lies in the robotic system’s ability to be an excellent tool for anatomical surgical dissection. It also can be helpful when accessing difficult-to-reach areas, such as endometriosis within the rectovaginal septum, which can be quite challenging with rigid nonarticulating instrumentation, Dr. Advincula said at the annual congress of the Endometriosis Foundation of America.

In cases where safe peritoneal access cannot be accomplished or significant comorbidities preclude an endoscopic approach, robot-assisted surgery may not be useful.

One criticism of robot-assisted surgery is the lack of tactile cues (haptic feedback). In addition to changes in coloration, endometriosis can be fibrotic, nodular, or cystic and feel thicker than normal tissue, especially if it is infiltrative. Dr. Advincula said he relies on visual cues combined with the knowledge of anatomical structures and dissection planes when performing excisional surgery via robotics. He cautioned that several years of robotic surgery experience are needed to understand and overcome this limitation.

Outcomes research comparing traditional laparoscopic surgery and robotic-assisted endometriosis surgery is limited, he noted. ACOG’s 2009 Technology Assessment in Obstetrics and Gynecology No. 6 on robot-assisted surgery suggested that randomized trials were needed to compare the respective outcomes and costs of robot-assisted surgery with those of traditional laparoscopic, vaginal, or abdominal surgery, and to pinpoint the best applications of robotic technology (Obstet. Gynecol. 2009;114:1153-5). A systematic review published in 2011 (Int. J. Med. Robot. 2011 Dec. 9 [doi:10.1002/rcs.451]) identified only three case reports and one cohort study that used the da Vinci surgical system for endometriosis, and concluded that few studies had been published in the field to date and evidence regarding long-term outcomes was lacking.

In a not-yet-published review of the literature, Dr. Advincula and his colleagues found 21 publications, mostly single cases or case series and one comparative controlled cohort study. The literature is clearly lacking in the area of using robotics for endometriosis surgery, he said. That is why the Celebration Health Endometriosis Center is involved in a multicenter collaboration to track outcomes and determine where advantages and disadvantages exist. As robotic technology evolves, it must be critically evaluated to determine its appropriate applications in endometriosis surgery.

Another problem for patients is that access to surgeons well trained in both the management of endometriosis and the proper use of robotics in gynecologic surgery is limited. "Clearly, when you have 10-20 million women affected by the disease, you can’t have just a handful of people capable of treating the disease. We need skilled surgeons who understand reproductive medicine, are familiar with applying surgical principles to complex cases, and who work in a multidisciplinary fashion in a specialized center to take advantage of a technology like this," said Dr. Advincula.

He said he encourages gynecologists and surgeons who wish to learn more about robot-assisted gynecologic surgery to attend conferences and workshops, such as the World Robotic Gynecology Conference, which provides opportunities to engage in both hands-on training and classroom teaching. Other alternatives are working with a surgical mentor or completing a fellowship in minimally invasive surgery that incorporates the surgical management of endometriosis.

"In the right hands and within the right infrastructure, robotics has the potential to provide women better options and access to cutting-edge care, especially in the area of endometriosis surgery. But as a new surgical frontier, don’t be lulled into thinking robotics per se will make you a better surgeon without the proper training and skill set," cautioned Dr. Advincula.

He said he is a consultant for Cooper Surgical, Ethicon Women’s Health and Urology, and Intuitive Surgical, and that he has received royalties from Cooper Surgical.

NEW YORK – High rates of endometriosis and symptoms indicative of possible future endometriosis have been noted in adolescents and young women based on prevalence data from the United States.

Stacey A. Missmer, Sc.D., reported results from the prospective GUTS (Growing Up Today Study), which includes 15,000 daughters of enrollees of the second Nurses’ Health Study.

GUTS participants were enrolled at 9-15 years of age, and the study was started in 1996 as a long-term prospective investigation of factors that influence weight change, she said at the annual congress of the Endometriosis Foundation of America.

So far, there have been 250 incident cases of endometriosis in GUTS enrollees, and 3,000 others (20%) have reported symptoms indicative of possible future endometriosis, including moderate to severe dysmenorrhea, chronic pelvic pain resistant to analgesics, and lower back pain, according to Dr. Missmer, director of epidemiologic research in reproductive medicine at Brigham and Women’s Hospital in Boston and senior endometriosis investigator for the Nurses’ Health Study.

Also at the meeting, Dr. Thomas D’Hooghe, a professor at the Catholic University of Leuven and director of the Leuven (Belgium) University Fertility Center, presented the results of a systematic literature review of 1,014 publications over a 30-year span, with 15 studies found to examine the prevalence of endometriosis in adolescents.

Of 893 girls who presented for laparoscopy with chronic pelvic pain or dysmenorrhea and were resistant to treatment with oral contraceptives or NSAIDS, 62% were diagnosed with endometriosis. In the subpopulation of those with chronic pelvic pain alone, the prevalence of endometriosis was 49%, he reported.

In the studies that evaluated disease severity, 32% (82 of 249) of adolescent patients had moderate to severe endometriosis. Laparoscopic findings included rectal lesions and tubo-ovarian adhesions, extensive disease of the peritoneum, ovaries and surrounding structures, and rectovaginal, bowel and ureteric endometriosis.

Not much data are available on endometriosis in adolescents. A common thread of adult endometriosis patient testimonials during the conference was the dismissal of their severe menstrual pain as "normal" by family members and health professionals. Many said that they were not diagnosed until 12 years or more after the onset of symptoms.

Dr. D’Hooghe additionally reported unpublished findings from a survey. Among 12-year-olds (n = 792) who completed a semistructured questionnaire, 363 had achieved menarche and 42% of them reported painful menstruation that correlated with duration of menstrual flow and the amount of blood loss. Among girls with painful menstruation, 41% said that it had a negative toll on social activities. Among girls without menstrual-related pain, 14% said menstruation impaired their social activities (P <.001).

Among the 13- to 16-year-olds (n = 172), 40% reported menstrual pain and 17% reported severe menstrual pain. In the 17- to 21-year-olds (n = 1,028), 52% reported menstrual pain and 16% reported severe menstrual pain. Over 40% in each age group used hormonal contraception for analgesia.

Menstrually related nongynecologic complaints included lower back pain reported by 26% of the 13- to 16-year-olds and by 38% of the 17- to 21-year-olds; urological symptoms reported by 26% and 23%, respectively; and gastrointestinal problems reported by 14% and 24% respectively.

"This group of girls who not only present with typical gynecological problems but also with lower back pain, urological symptoms, and gastrointestinal problems are the girls we want to see in our clinics for early diagnosis and treatment," said Dr. D’Hooghe.

Known factors that are linked to the risk of endometriosis include early dysmenorrhea, family history of endometriosis, high frequency and long duration of oral contraceptive use for severe dysmenorrhea, and frequent absences from school during menstruation. Reaching menarche after the age of 14 years is associated with a decreased risk of endometriosis, he said.

Dr. Missmer and Dr. D’Hooghe had no relevant financial disclosures.

NEW YORK – High rates of endometriosis and symptoms indicative of possible future endometriosis have been noted in adolescents and young women based on prevalence data from the United States.

Stacey A. Missmer, Sc.D., reported results from the prospective GUTS (Growing Up Today Study), which includes 15,000 daughters of enrollees of the second Nurses’ Health Study.

GUTS participants were enrolled at 9-15 years of age, and the study was started in 1996 as a long-term prospective investigation of factors that influence weight change, she said at the annual congress of the Endometriosis Foundation of America.

So far, there have been 250 incident cases of endometriosis in GUTS enrollees, and 3,000 others (20%) have reported symptoms indicative of possible future endometriosis, including moderate to severe dysmenorrhea, chronic pelvic pain resistant to analgesics, and lower back pain, according to Dr. Missmer, director of epidemiologic research in reproductive medicine at Brigham and Women’s Hospital in Boston and senior endometriosis investigator for the Nurses’ Health Study.

Also at the meeting, Dr. Thomas D’Hooghe, a professor at the Catholic University of Leuven and director of the Leuven (Belgium) University Fertility Center, presented the results of a systematic literature review of 1,014 publications over a 30-year span, with 15 studies found to examine the prevalence of endometriosis in adolescents.

Of 893 girls who presented for laparoscopy with chronic pelvic pain or dysmenorrhea and were resistant to treatment with oral contraceptives or NSAIDS, 62% were diagnosed with endometriosis. In the subpopulation of those with chronic pelvic pain alone, the prevalence of endometriosis was 49%, he reported.

In the studies that evaluated disease severity, 32% (82 of 249) of adolescent patients had moderate to severe endometriosis. Laparoscopic findings included rectal lesions and tubo-ovarian adhesions, extensive disease of the peritoneum, ovaries and surrounding structures, and rectovaginal, bowel and ureteric endometriosis.

Not much data are available on endometriosis in adolescents. A common thread of adult endometriosis patient testimonials during the conference was the dismissal of their severe menstrual pain as "normal" by family members and health professionals. Many said that they were not diagnosed until 12 years or more after the onset of symptoms.

Dr. D’Hooghe additionally reported unpublished findings from a survey. Among 12-year-olds (n = 792) who completed a semistructured questionnaire, 363 had achieved menarche and 42% of them reported painful menstruation that correlated with duration of menstrual flow and the amount of blood loss. Among girls with painful menstruation, 41% said that it had a negative toll on social activities. Among girls without menstrual-related pain, 14% said menstruation impaired their social activities (P <.001).

Among the 13- to 16-year-olds (n = 172), 40% reported menstrual pain and 17% reported severe menstrual pain. In the 17- to 21-year-olds (n = 1,028), 52% reported menstrual pain and 16% reported severe menstrual pain. Over 40% in each age group used hormonal contraception for analgesia.

Menstrually related nongynecologic complaints included lower back pain reported by 26% of the 13- to 16-year-olds and by 38% of the 17- to 21-year-olds; urological symptoms reported by 26% and 23%, respectively; and gastrointestinal problems reported by 14% and 24% respectively.

"This group of girls who not only present with typical gynecological problems but also with lower back pain, urological symptoms, and gastrointestinal problems are the girls we want to see in our clinics for early diagnosis and treatment," said Dr. D’Hooghe.

Known factors that are linked to the risk of endometriosis include early dysmenorrhea, family history of endometriosis, high frequency and long duration of oral contraceptive use for severe dysmenorrhea, and frequent absences from school during menstruation. Reaching menarche after the age of 14 years is associated with a decreased risk of endometriosis, he said.

Dr. Missmer and Dr. D’Hooghe had no relevant financial disclosures.

NEW YORK – High rates of endometriosis and symptoms indicative of possible future endometriosis have been noted in adolescents and young women based on prevalence data from the United States.

Stacey A. Missmer, Sc.D., reported results from the prospective GUTS (Growing Up Today Study), which includes 15,000 daughters of enrollees of the second Nurses’ Health Study.

GUTS participants were enrolled at 9-15 years of age, and the study was started in 1996 as a long-term prospective investigation of factors that influence weight change, she said at the annual congress of the Endometriosis Foundation of America.

So far, there have been 250 incident cases of endometriosis in GUTS enrollees, and 3,000 others (20%) have reported symptoms indicative of possible future endometriosis, including moderate to severe dysmenorrhea, chronic pelvic pain resistant to analgesics, and lower back pain, according to Dr. Missmer, director of epidemiologic research in reproductive medicine at Brigham and Women’s Hospital in Boston and senior endometriosis investigator for the Nurses’ Health Study.

Also at the meeting, Dr. Thomas D’Hooghe, a professor at the Catholic University of Leuven and director of the Leuven (Belgium) University Fertility Center, presented the results of a systematic literature review of 1,014 publications over a 30-year span, with 15 studies found to examine the prevalence of endometriosis in adolescents.

Of 893 girls who presented for laparoscopy with chronic pelvic pain or dysmenorrhea and were resistant to treatment with oral contraceptives or NSAIDS, 62% were diagnosed with endometriosis. In the subpopulation of those with chronic pelvic pain alone, the prevalence of endometriosis was 49%, he reported.

In the studies that evaluated disease severity, 32% (82 of 249) of adolescent patients had moderate to severe endometriosis. Laparoscopic findings included rectal lesions and tubo-ovarian adhesions, extensive disease of the peritoneum, ovaries and surrounding structures, and rectovaginal, bowel and ureteric endometriosis.

Not much data are available on endometriosis in adolescents. A common thread of adult endometriosis patient testimonials during the conference was the dismissal of their severe menstrual pain as "normal" by family members and health professionals. Many said that they were not diagnosed until 12 years or more after the onset of symptoms.

Dr. D’Hooghe additionally reported unpublished findings from a survey. Among 12-year-olds (n = 792) who completed a semistructured questionnaire, 363 had achieved menarche and 42% of them reported painful menstruation that correlated with duration of menstrual flow and the amount of blood loss. Among girls with painful menstruation, 41% said that it had a negative toll on social activities. Among girls without menstrual-related pain, 14% said menstruation impaired their social activities (P <.001).

Among the 13- to 16-year-olds (n = 172), 40% reported menstrual pain and 17% reported severe menstrual pain. In the 17- to 21-year-olds (n = 1,028), 52% reported menstrual pain and 16% reported severe menstrual pain. Over 40% in each age group used hormonal contraception for analgesia.

Menstrually related nongynecologic complaints included lower back pain reported by 26% of the 13- to 16-year-olds and by 38% of the 17- to 21-year-olds; urological symptoms reported by 26% and 23%, respectively; and gastrointestinal problems reported by 14% and 24% respectively.

"This group of girls who not only present with typical gynecological problems but also with lower back pain, urological symptoms, and gastrointestinal problems are the girls we want to see in our clinics for early diagnosis and treatment," said Dr. D’Hooghe.

Known factors that are linked to the risk of endometriosis include early dysmenorrhea, family history of endometriosis, high frequency and long duration of oral contraceptive use for severe dysmenorrhea, and frequent absences from school during menstruation. Reaching menarche after the age of 14 years is associated with a decreased risk of endometriosis, he said.

Dr. Missmer and Dr. D’Hooghe had no relevant financial disclosures.

NEW YORK – Almost one-third of 132 women with endometriosis had a genetic mutation affecting expression of the KRAS gene, compared with only 5.8% of the general population, according to Dr. Hugh S. Taylor, who presented the findings at the annual congress of the Endometriosis Foundation of America.

"This is the only clearly identified genetic cause of endometriosis," explained Dr. Taylor. The KRAS oncogene produces a protein involved primarily in regulating cell division. The defect found in the women with endometriosis has been localized to a regulatory region of the KRAS gene: the let-7 microRNA (miRNA) binding site in the 3’-untranslated region (UTR).

A high proliferation and invasion rate was seen in endometrial cells from women with the variant allele. These properties may facilitate the invasion of endometrial cells into peritoneum and ovarian cortex.

"This mechanism supports the most accepted theory for the origin of endometriosis – retrograde menstruation and subsequent implantation and invasion of susceptible tissues ... The fact that only a portion of women develop this disease despite the nearly universal occurrence of retrograde menstruation could be explained by the presence of this allele," said Dr. Taylor, director of the division of reproductive endocrinology and infertility at Yale University, New Haven, Conn. The findings were published in the March issue of EMBO Molecular Medicine (EMBO Mol. Med. 2012;4:206-17) (Olga Grechukhina is the first author).

Since the mutation occurs only in a subgroup of women with endometriosis, genetic testing cannot be used as a screening tool. However, the recognition of KRAS-related endometriosis may allow for screening of family members and may have value for personalizing treatment of endometriosis, said Dr. Taylor.

Several lines of evidence reported by Dr. Taylor pinpoint the importance of this genetic mutation. In addition to the clinical observation that 31% of the sample of 132 women with endometriosis had this polymorphism compared with 5.8% of the control population, KRAS mRNA and protein levels were significantly increased in cultured endometrial stromal cells of women with the KRAS variant.

Dr. Taylor also looked at the behavior of endometrial stromal cells from women with and without the variant. Compared with cells from women without endometriosis, cells from women with endometriosis but without the variant were more invasive and proliferative. But cells from women with endometriosis and the variant had even higher levels of invasiveness and proliferation.

In another experiment, cells taken from women with endometriosis were transplanted under the kidney capsules of immunodeficient mice. Cells from the women with the mutation proliferated faster and had a lower expression of the progesterone receptor. "Progesterone resistance is characteristic of some women with endometriosis," commented Dr. Taylor.

Women with the mutation have a much lower expression of all let-7 miRNAs, not just let-7a. "Let-7 doesn’t just bind KRAS – it binds and generally downregulates many genes. When let-7 is inhibited, it no longer stops the expression of many genes involved in mitotic signaling, cell cycling and cell adhesion and migration," explained Dr. Taylor.

Dr. Taylor had no relevant financial disclosures.

NEW YORK – Almost one-third of 132 women with endometriosis had a genetic mutation affecting expression of the KRAS gene, compared with only 5.8% of the general population, according to Dr. Hugh S. Taylor, who presented the findings at the annual congress of the Endometriosis Foundation of America.

"This is the only clearly identified genetic cause of endometriosis," explained Dr. Taylor. The KRAS oncogene produces a protein involved primarily in regulating cell division. The defect found in the women with endometriosis has been localized to a regulatory region of the KRAS gene: the let-7 microRNA (miRNA) binding site in the 3’-untranslated region (UTR).

A high proliferation and invasion rate was seen in endometrial cells from women with the variant allele. These properties may facilitate the invasion of endometrial cells into peritoneum and ovarian cortex.

"This mechanism supports the most accepted theory for the origin of endometriosis – retrograde menstruation and subsequent implantation and invasion of susceptible tissues ... The fact that only a portion of women develop this disease despite the nearly universal occurrence of retrograde menstruation could be explained by the presence of this allele," said Dr. Taylor, director of the division of reproductive endocrinology and infertility at Yale University, New Haven, Conn. The findings were published in the March issue of EMBO Molecular Medicine (EMBO Mol. Med. 2012;4:206-17) (Olga Grechukhina is the first author).

Since the mutation occurs only in a subgroup of women with endometriosis, genetic testing cannot be used as a screening tool. However, the recognition of KRAS-related endometriosis may allow for screening of family members and may have value for personalizing treatment of endometriosis, said Dr. Taylor.

Several lines of evidence reported by Dr. Taylor pinpoint the importance of this genetic mutation. In addition to the clinical observation that 31% of the sample of 132 women with endometriosis had this polymorphism compared with 5.8% of the control population, KRAS mRNA and protein levels were significantly increased in cultured endometrial stromal cells of women with the KRAS variant.

Dr. Taylor also looked at the behavior of endometrial stromal cells from women with and without the variant. Compared with cells from women without endometriosis, cells from women with endometriosis but without the variant were more invasive and proliferative. But cells from women with endometriosis and the variant had even higher levels of invasiveness and proliferation.

In another experiment, cells taken from women with endometriosis were transplanted under the kidney capsules of immunodeficient mice. Cells from the women with the mutation proliferated faster and had a lower expression of the progesterone receptor. "Progesterone resistance is characteristic of some women with endometriosis," commented Dr. Taylor.

Women with the mutation have a much lower expression of all let-7 miRNAs, not just let-7a. "Let-7 doesn’t just bind KRAS – it binds and generally downregulates many genes. When let-7 is inhibited, it no longer stops the expression of many genes involved in mitotic signaling, cell cycling and cell adhesion and migration," explained Dr. Taylor.

Dr. Taylor had no relevant financial disclosures.

NEW YORK – Almost one-third of 132 women with endometriosis had a genetic mutation affecting expression of the KRAS gene, compared with only 5.8% of the general population, according to Dr. Hugh S. Taylor, who presented the findings at the annual congress of the Endometriosis Foundation of America.

"This is the only clearly identified genetic cause of endometriosis," explained Dr. Taylor. The KRAS oncogene produces a protein involved primarily in regulating cell division. The defect found in the women with endometriosis has been localized to a regulatory region of the KRAS gene: the let-7 microRNA (miRNA) binding site in the 3’-untranslated region (UTR).

A high proliferation and invasion rate was seen in endometrial cells from women with the variant allele. These properties may facilitate the invasion of endometrial cells into peritoneum and ovarian cortex.

"This mechanism supports the most accepted theory for the origin of endometriosis – retrograde menstruation and subsequent implantation and invasion of susceptible tissues ... The fact that only a portion of women develop this disease despite the nearly universal occurrence of retrograde menstruation could be explained by the presence of this allele," said Dr. Taylor, director of the division of reproductive endocrinology and infertility at Yale University, New Haven, Conn. The findings were published in the March issue of EMBO Molecular Medicine (EMBO Mol. Med. 2012;4:206-17) (Olga Grechukhina is the first author).

Since the mutation occurs only in a subgroup of women with endometriosis, genetic testing cannot be used as a screening tool. However, the recognition of KRAS-related endometriosis may allow for screening of family members and may have value for personalizing treatment of endometriosis, said Dr. Taylor.

Several lines of evidence reported by Dr. Taylor pinpoint the importance of this genetic mutation. In addition to the clinical observation that 31% of the sample of 132 women with endometriosis had this polymorphism compared with 5.8% of the control population, KRAS mRNA and protein levels were significantly increased in cultured endometrial stromal cells of women with the KRAS variant.

Dr. Taylor also looked at the behavior of endometrial stromal cells from women with and without the variant. Compared with cells from women without endometriosis, cells from women with endometriosis but without the variant were more invasive and proliferative. But cells from women with endometriosis and the variant had even higher levels of invasiveness and proliferation.

In another experiment, cells taken from women with endometriosis were transplanted under the kidney capsules of immunodeficient mice. Cells from the women with the mutation proliferated faster and had a lower expression of the progesterone receptor. "Progesterone resistance is characteristic of some women with endometriosis," commented Dr. Taylor.

Women with the mutation have a much lower expression of all let-7 miRNAs, not just let-7a. "Let-7 doesn’t just bind KRAS – it binds and generally downregulates many genes. When let-7 is inhibited, it no longer stops the expression of many genes involved in mitotic signaling, cell cycling and cell adhesion and migration," explained Dr. Taylor.

Dr. Taylor had no relevant financial disclosures.