Advancing the Science and Surgery of Endometriosis
Monday and Tuesday, April 18-19, 2016
The Union Club, New York
Harry Reich, MD: We have many homeless people in New York City. I am wondering if we could teach them how to do surgery? Medical school is tough. You would have to go through all those years of education, to be a robotic surgeon maybe not. It is for you all to ask whatever you would like. We have a question in the back from Dr. Seckin.
Tamer Seckin, MD: Well I just want to animate the crowd here so my question let us start with the endometrioma session. I forgot, was there any endometrioma session?
Harry Reich, MD: Yes, yes, most definitely. Okay, let us ask a question about endometrioma. I will follow it up.
Tamer Seckin, MD: I am very concerned about the way we treat endometriomas. I think we are interrupting coming to the game very, very late and many of these ovaries are basically endangered of being dysfunctional already after surgery and not functioning very well. I am asking the whole crowd here, the experts over there, do you think we should intervene maybe with the endometriomas earlier than what has been proposed as far as size? Because many times endometrioma do have symptoms and your IVF friends really do not want to do anything with the endometrioma even though there are symptoms. When they catch the patient the patient are infertile but in the general population private practitioners see these endometrioma early and they are often misdiagnosed too. So, we have a huge duty for endometriomas – maybe we should enforce some different approach clinically for them? I want the panel’s opinion on this.
Harry Reich, MD: Who had endometrioma?
Maurice Abrao, MD: She is not here.
Harry Reich, MD: Okay, go ahead. Let us start at one end and go right through.
Vladimir Nikifarouk, MD: You are absolutely right because I have seen people wait and wait with endometrioma and they grow and at the end the patient might lose her ovaries and her fertility. The sooner you start treating it, not letting the disease progress, the better outcome. The problem is with infertility specialist nowadays is that they are not as well trained to do surgery as in the beginning of infertility revolution in this country. I really think that the sooner you diagnose, the younger you diagnose, excision should be to preserve in the future.
Jin Hee (Jeannie) Kim, MD: I really think it depends on the whole picture. If pain is the presenting symptom then I think that is really when it really drives to do the surgery, especially if the patient has failed medical management. I think in terms you were alluding to is that infertility doctors referring you someone who is completely asymptomatic or not referring, excuse me, somebody who is completely asymptomatic. If it is just for fertility purposes and it is just very, very small then I think that is when I think delay surgery just to decrease the chance of even further decreasing your AMH and…
Harry Reich, MD: As a cul-de-sac surgeon we tend now to leave the endometrioma, the easy part of the case to the last thing we do. I say that because the next two guys specialize in the cul-de-sac. And lastly, what baffles me is there is no oocytes in endometrioma fibrotic cyst wall so how could we be ruining taking care of all these eggs when we take out an endometrioma? We should still have the same number of oocytes in that ovary as we started with. That is my concept.
Maurice Abrao, MD: What we are doing nowadays is to start the evaluation of the anti-muellerian hormone and we are doing more and more cryopreservation of oocytes or embryos when it is appropriate. We truly think that the endometrioma per se is not associated with pain. There is a very interesting study from the group of Chapron three years ago showing that when a patient has an endometrioma and pain we must look for deep disease because this is the main cause of pain.
Harry Reich, MD: Agreed.
Juan Salgado Morales, MD: And even in the best hands of a good surgeon when you are stripping the endometrioma you will remove some follicles. That is why we have to be sure that if you do MHA and it is slow we have to talk to the patient and try to see if we can tell the REI to do the retrieval. If we remove both endometriomas and it creates the possibility that patient then we are going to have trouble also.
Harry Reich, MD: Have there been any studies by people that we would consider really good endometriosis surgeons showing oocytes and all these follicles in the endometrioma removed?
Maurice Abrao, MD: Yes, there is a very interesting I think Italian study comparing the removal of endometrioma and removal of teratomas. When we remove an endometrioma we remove primordial follicles and much more than when we remove teratomas.
Harry Reich, MD: Okay, now again getting back to the concept endometrioma is a piece of fibrotic tissue basically where is the endometriosis and the endometrioma full of fibrotic tissue. Most of the endometriosis is on the pelvic sidewall. I saw on that slide today where they were tacking the endometrioma while it was still stuck to the pelvic sidewall. I never considered that a good technique because to me the area where the endometrioma has gotten into the ovary is usually on the pelvic sidewall and to remove endometriosis and lower your recurrence rate you have to look at that site and remove the endometriosis there. Forget about the ovary. More and more studies are showing with different types of plasma things and other things that you can superficially coagulate this as well. Any opinions?
Juan Salgado Morales, MD: It depends if you want to remove the ovary with the endometrioma or if you want to just do the cystectomy. Because if you want to remove the complete ovary you have got to deal with the peripheral inflammatory process that you have and all the fibrotic tissue.
Harry Reich, MD: But to prevent recurrence certainly you have to take out that area where it egressed into the ovary on the pelvic sidewall.
Juan Salgado Morales, MD: But if you only need to do a conservative surgery, so they could do the IVF you just go there, open the ovary, remove the cyst and go away.
Harry Reich, MD: Why would you do that? Why not give the patient a chance to get pregnant without IVF?
Juan Salgado Morales, MD: If they could do it they will but if not you will do it the correct way, which is remove the cyst with minimally invasive surgery and just do what you have to do.
Maurice Abrao, MD: This is a very wise consideration Harry. I think so because you must remember that we had a discussion like this recently when I was presenting a video at the AAGL showing the ten commandments for the removal of the endometrioma. I truly agree with you that we need to look for the tissue on the sidewall. But just one comment about a recent study that we are finalizing now. We think that there are two types of endometriomas. There is the cystic endometrioma that is very easy to remove and there is a different kind of ovarian disease where we have an intra-parenchymatous endometriosis. It corresponds to 30 percent of all endometriomas according to our experience and it is much more difficult for us. It is a sort of “deep” endometriosis compromising the ovary.
Jin Hee (Jeannie) Kim, MD: I just have one comment about there are some fertility physicians who have concerns about at the time of aspiration if there is a large endometrioma infection and also clogging their tubes in terms of aspiration of the oocyte. I think those are some of the considerations I think especially if it is a large endometrioma potentially intervening…
Harry Reich, MD: That should be a big concern because as we know many times the ovary is stuck on the rectum and the people doing retrieval are going through the rectum to get to the ovary. I am sure if you were to scope more of these people you would find that that is a major contributor to infection after procedures. Other questions? We are going to go into the cul-de-sac but for now let us see if anybody else has ovarian endometrioma questions. Dr. Shin.
Ja Hyun Shin, MD: I do not know who does robotics but Dr. Kim and Dr. Nikifarouk?
Harry Reich, MD: They all do.
Ja Hyun Shin, MD: Okay, then all of you can go up and down again. I think over the past five or six years I have used the robot for endometrioma surgery one time. I almost never perform any kind of adnexal surgery robotically. I know that when you have endometriomas like Dr. Patzkowsky said and other people have now spoken about it, it is rarely just isolated cysts and it is often associated with advanced disease. I recently wrote a review on the role of robotics and adnexal surgery and I was really surprised to find there is not one paper out there that looks just at that. There is robotics versus laparoscopy and DIE, robotics versus laparoscopy and this and that but there is nothing specifically about management of endometriomas. I was just wondering what your views were on that, if you maybe think that these benefits of the robot, the magnification and maybe that translates to better dissection does that necessarily translate to less follicles and ovarian tissue? Is that worth looking at?
Vladimir Nikifarouk, MD: Yes, excellent question. Like I said, I was skeptical, skeptical of robotic surgery and I will give you benefits. There are three, patient and the physician and the outcome. If I can do precise surgery like that little grape, and I can do it cold surgery, and I can reconstruct that ovary, and not be tired and my back does not hurt and my hands are okay, I think that the patient will have a huge benefit future outcome . If you are comfortable with doing that laparoscopically, great. But in my opinion the patients that come to me usually they have seen five, six people they already have advanced endometriosis. They already have several C-sections, so by using the robot I know that it can be a great case, can be done laparoscopically but if the patient will benefit by me using the robot? That is just preference, availability and comfort.
Harry Reich, MD: Let us go down the line.
Jin Hee (Jeannie) Kim, MD: I think you are completely right in terms of making that point that there is just a lack of data out there in terms of looking at that particular point of robot versus laparoscopically in terms of endometrioma. I think it is, personally I think I am probably in your camp in terms of if it is just a pure endometrioma resection, not having to deal with DIE or other involvement. Then I think it is more about surgical skill potentially I am not quite sure if there would be added benefit unless – you are right, in terms of the whole thing about microscopic and fine motor in terms of the robot, in terms of the advantage but I think that just needs to be looked at.
Maurice Abrao, MD: I only see advantages if the surgeon is not trained for advanced laparoscopy.
Juan Salgado-Morales, MD: The same.
Harry Reich, MD: One comment, we should do about two minutes on cul-de-sac before we quit. You have a question? I just want to say I find the use of the term DIE deploring because it is not cancer. DIE – deep infiltrating endometriosis; the original that we called it back in the 1980s was deep fibrotic endometriosis because as surgeons we are dealing with a fibrotic reaction. We are not dealing with invasive reaction. And as I will get to tomorrow, I think if you remove that fibrotic reaction you cure the patient.
Tamer Seckin, MD: Harry, I just want to make a comment on that. I one hundred percent agree with Dr. Reich. Deep fibrotic endometriosis is really not to be mixed with DIE, deep infiltrative endometriosis. Endometriosis never really infiltrates it basically sinks in and is has a different way of involving organs, the way you are seeing it. When you look at the curves of the pelvis it really basically advances at the expense of the potential space it covers and basically fills it up. It retains inside. So many of the pelvic sidewall curves and caves at the cul-de-sac, which is the cul-de-sac space rather than cul-de-sac pararectal area is different than pararectal space as you know. Those areas are filled with the deep fibrotic nodules before rectal nodules or other things are considered. I think there is obviously organ involvement. Maybe we should really separate organ involvement including the uterine involvement as a pure separate concept that requires organ removal surgery. There is also deep fibrotic surgery on the pelvic sidewalls that does not really directly invade ____ but causes significant pain and difficulty in surgery.
Harry Reich, MD: We have a colorectal surgeon. What do you think of that concept? It is not cancer.
Alexis Grucela, MD: I agree and maybe we should reconsider sort of the classifications. Can I ask a question actually? I just was curious to know if the introduction of the XI platform has changed sort of the ability now with multi-quadrant surgery, the management. Are more people moving to manage endometriosis robotically because you can now access all quadrants and you do not have to re-dock and you can get to all the different areas? And then my follow up to that is have you guys noticed a difference in management as far as resection and anastomosis for like low rectal infiltrating endometriosis versus disc excision now with robotics available and suturing techniques becoming more facile versus laparoscopically resecting a disc and suturing and closing. I think it is much easier with the robot. Our management style is changing just because of pure technical ability.
Vladimir Nikifarouk, MD: You just said it. Robot is much easier than laparoscopy in it is an art that made a revolution in gyn. We are as gynecologists invented laparoscopy. We stayed behind for years and now we are way better than general surgeons. What I want to say is the robot is great but I had a case or two where the robot malfunctioned. So, what do I do when the robot does not work? You have to go back and use the laparoscope. You can be as good with the laparoscope as with the robot. The problem we have we need to train our young generation to be good. Some people are not born to be good surgeons, let us admit it.
Harry Reich, MD: Vlad, the robot does not have fingers.
Vladimir Nikifarouk, MD: It is not the robot that operates it is who the robot assists that operates. I like to look good in the operating room so I operate the machine well, my team is so well trained so it is a pleasure to invite you or anybody else and say “Wow! That looks great”. That is the answer. We all trained and people who are in this room are one the best or future best surgeons who have a passion for endometriosis gyn laparoscopy.
Harry Reich, MD: Sometimes we forget that we are dealing with endometriosis in this meeting and we have to be able to feel a little bit to. With a robot you are sitting at the end of the room.
Vladimir Nikifarouk, MD: It is a sixth sense if you believe in that. I have it.
Gerard DeGregoris, MD: That is a great position to move on to our next final session of the day.