What’s new: A recap of AAGL’s 50th Global Congress on MIGS

There was so much to learn, see, and do at the American Association of Gynecologic Laparoscopists’ (AAGL) 50th Global Congress on minimally invasive gynecologic surgery (MIGS) held both virtually and live in Austin, Texas from November 14-17.

Contemporary OB/GYN® covered the meeting live onsite and attended multiple informational panel discussions, debates, and presentations. From discovering the best practices to perform a successful myomectomy to utilizing radiofrequency ablation for uterine fibroids, Contemporary OB/GYN® was there to cover it all.

If you were unable to attend virtually or live, continue reading and check out the links below for our extensive coverage of AAGL’s 50th Global Congress on MIGS to catch up on anything you might have missed.

How to perform a successful myomectomy

In this presentation, Devin Garza, MD, FACOG, provided strategies on how to perform a successful myomectomy.

Garza discussed reproducible strategies to facilitate an efficient and safe robotic approach to myomectomy and demonstrated operative strategies through clinical video examples.

“When it comes to fibroids, everybody knows not everyone in the US has the same amount of fibroid incidence, but it all depends on key factors—the size, the number, the location,” Garza said. “And so, your strategy with myomectomies is the same thing. How many are there? How big is their weight? Where are they located?”

To set yourself up for a successful robotic myomectomy, Garza suggests implementing patient selection, utilizing magnetic resonance imaging (MRI) for preoperative planning, and minimizing blood loss during the procedure, maximizing efficiency, and tissue extraction strategy.

The superior method for pelvic organ prolapse repair: Mesh or native tissue repair?

The outcomes of native tissue repair versus mesh augmented repairs became the topic of much debate over the past several years. The US Food and Drug Administration FDA removed vaginal mesh kits from the market, which then refocused attention on the outcomes of native tissue repairs. In a debate on November 15, Peter L. Rosenblatt, MD, and Cheryl B. Iglesia, MD, FACOG, presented evidence to determine the superior method in pelvic reconstructive surgery.

Rosenblatt began the debate by asserting his position on vaginal mesh. His first argument discussed a prospective analysis in Female Pelvic Medicine & Reconstructive Surgery, in which researchers presented 5-year results of robotic sacrocolpopexy, defining success as no retreatment with surgery or pessary, no pelvic organ prolapse (POP) beyond the hymen, no apical descent greater than -5, and no POP symptoms.

They had a success rate of almost 90% and there were no mesh-related complications. His point being that this is where the industry came from. It used to be a salvage procedure when you were out of options.

Igelsia, issued her rebuttal in support of native tissue repair. She cited numerous studies, including a paper by the Pelvic Floor Disorders Network that showed significant quality of life improvement after 2 years.

“The bottom line is that these techniques should not be abandoned for mesh procedures, and the native tissues are considered the gold standard,” Iglesia said.

She continued with her experience in a tertiary care center. “Patients are more willing to accept failure from a prolapse repair over a mesh-related complication,” she said.

Revolutionizing laparoscopy

Marcello Ceccaroni, MD, PhD, spoke about how the revolution of laparoscopy relates to the revolution of rock and roll in his AAGL MED Talk.

“Rock and roll is a way of life and so is laparoscopy. It is not merely a surgery, it’s a revolution,” Ceccaroni said.

Previously, laparoscopy was an underground method, just like rock and roll, that eventually came to the forefront of the industry. Ceccaroni said people were not ready for laparoscopy, and those who initially performed it faced persecution, compared to rock stars being called crazy for stage diving and other revolutionary aspects that make up the rock and roll we know today.

Eventually, laparoscopy was integrated into the specialty thanks to the efforts of its pioneers, which are now teaching the next generation of minimally invasive gynecologic surgeons, which Ceccaroni calls “the children of the revolution.”

Radiofrequency ablation for uterine fibroids

In a panel discussion, Kimberly Kho, MD, MPH, along with Jessica Shepherd, MD, MBA, FACOG, and Craig Sobolewski, MD, discussed utilizing radiofrequency ablation for the treatment of uterine fibroids.

Hysterectomies are the most performed procedure on patients, according to Kho. However, the long-term effects are unknown if hysterectomies are offered as the only treatment option for uterine fibroids. Also, Kho said multiple studies have shown women are at an increased risk for developing anxiety and depression following hysterectomy. Because of this, women want a treatment for uterine fibroids that don’t involve hysterectomies.

As an alternative treatment for uterine fibroids outside of myomectomy and hysterectomy, there is radiofrequency ablation (RFA). Currently, there are 2 RFA devices approved to treat uterine fibroids in the US—Acessa (Hologic) approved in 2012 and Sonata (Gynesonics) approved in 2018.

“I’ve been doing this procedure, specifically Acessa, since 2015/2016, so it’s nice to see the evolution of this technology and energy into what we have today. And it’s really eloquent and profound that we are at the cutting-edge of something that is not new technology,” said Shepherd.

Some of the benefits of this procedure include that it can be delivered through a transvaginal or transcervical approach and all approaches are similarly effective. Also, there is no morcellation, no uterine incisions, faster recovery time, minimally invasive, improved symptoms, and low complication rate just to name a few.

AGL announces new endometriosis classifications

During his presentation on his endometriosis journey, Mauricio S. Abrão, MD, PhD, 2021 scientific program chair and incoming president of AAGL, announced a new AAGL classification for endometriosis.

The launch of this new classification was created based on scientific research Abrão led along with his fellow researchers.

The AAGL endometriosis classification is as follows:

• Level A- Excision or desiccation of superficial implants, and simple thin avascular adhesions.
• Level B- Stripping of ovarian endometriomas, appendectomy, deep endometriosis nonevolving the bowel, vagina, ureter, or bladder (not requiring suture), dense adhesions not involving the bowel or the ureter.
• Level C: Dense adhesions involving the bowel or the ureter; bladder surgery requiring suture, ureterolysis, bowel surgery without resection.
• Level D: Bowel resection or ureteral reimplantation or anastomosis.

“[This is] the news that will impact the world positively, changing, from now on, the journey of the treatments and the diagnosis of endometriosis,” said Abrão.

The need for office hysteroscopies in your practice

“My hysteroscope is my stethoscope. I use it in every opportunity when the story doesn’t match,” Linda D. Bradley, MD, said during her presentation.

Bradley’s message was clear: hysteroscopies are necessary, urgent, and underutilized procedures. During her presentation, Bradley passionately made a compelling case for embracing office hysteroscopy in your practice, using patient pictures and videos to illustrate the many situations in which performing hysteroscopies led to better care.

With hysteroscopies, you can evaluate the patient immediately. You can do them in the office without pain medication. Patients don’t have to take off for work and can serve as their own transportation. They also contribute greatly to informed consent. That is, you can immediately let the patient know—with confidence and accuracy—what is going on in her body and begin necessary treatment.

Exploring the potential of AI for gynecologic surgery

The world of artificial intelligence (AI) is ever-evolving and diverse. With its multitude of uses, AI can be a useful tool to implement into your practice. Gaby Moawad, MD, FACOG, spoke about the benefits of using AI for minimally invasive gynecologic surgery and its future potential in the specialty.

“We have been using virtual reality for quite some time to help surgeons, whether in training or proacting surgeons, to be accustomed to operating room scenarios in a safer way. Virtual reality can also be incorporated into preoperative planning of surgery when used in unison with AI, it helps map the surgery beforehand,” Moawad said.

With AI, there is no creative scenario, and instead, there is an actual event that is being altered in real-time, according to Moawad, helping surgeons optimize their visual field or surgery. These scenarios are created through preoperative construction that uses any available data and disruptive technology based on computer vision and AI. “The surgeon in their OR can now have an enhanced vision of an anatomy they could not see with their bare eyes,” he added.

Building a framework for a multidisciplinary approach to chronic pelvic pain therapy

In her session, “An Island of One: Providing Comprehensive Chronic Pelvic Pain Therapy,” Jean Uy-Kroh, MD, FACOG, emphasized the importance of a multidisciplinary approach to chronic pelvic pain therapy, and shared strategies for clinicians to identify assets and barriers to program building, map out a strategic framework, and construct a continuous self-learning program. She also highlighted the struggles she endured in the beginning and offered solutions to common pitfalls.

The 2 main ingredients for a successful program are knowledgeable colleagues and local and national resources. To begin creating a robust, strategic plan, Uy-Kroh said, it’s imperative to know what drives your clinical landscape, and what drives you personally.

Additionally, pain pathways are very complex, making chronic pelvic pain a difficult diagnosis and treatment process. How can you fix it? Uy-Kroh outlined the framework in 5 steps:

• Identify patients’ needs
• Be honest with colleagues and your administration about what you’re trying to achieve
• Get the resources you need to be successful
• Determine how your program will be set up
• Consider: Is it going to be formal or informal? Will it be self-directed, where you are making personal calls in between patients?
• Build your network of colleagues and don’t be afraid to ask for help

How to master robotic hysterectomy for difficult pathology

When it comes to hysterectomies, it can be cumbersome to perform robotic hysterectomies on larger uteri or other difficult pathology. However, Kristin Patzkowsky, MD, provided a few tips and tricks for mastering robotic hysterectomy on this type of pathology in her presentation “Go Big or Go Home: Mastering Robotic Hysterectomy for Difficult Pathology.”

During her presentation, Patzkowsky said the biggest trick is to master the simple hysterectomy first before performing robotic hysterectomies on more difficult pathology. Some other tricks she mentioned include avoiding being instantly overwhelmed, knowing your limits, going back to basics, getting comfortable with the retroperitoneum, and setting yourself up for success through case and equipment selection, trocar placement, and maximizing arm and assistant use.

When selecting a case for robotic hysterectomy, Patzkowsky recommends asking yourself 3 questions:

• Where are the anatomic landmarks (anterosuperior iliac spine [ASIS], umbilicus, and inferior costal margin)?
• Where is her pathology relative to these landmarks?
• What is the width of the torso based on bony landmarks, not pannus?

Robotic platforms also make a big difference when dealing with larger pathology. When using a da Vinci Xi/X vs a Si, the Xi/X’s 8 mm camera is more useful for camera/port hopping vs the Si’s 12 mm camera, according to Patzkowsky.

Endometriosis in children and adolescents

Smitha Vilasagar, MD, FACOG, highlighted the importance of practitioners recognizing the negative impact endometriosis has on children and adolescents, reviewed clinical and surgical presentations of the disease to reduce delay in diagnosis, and described differences in treatment options for this age group.

Vilasagar discussed the symptoms doctors should watch out for, including “urinary symptoms—frequency, urgency; gastrointestinal issues—nausea, vomiting, diarrhea; and comorbidities,” which can include migraines, myofascial pain, vulvodynia, depression, and anxiety. Noncyclic/nongynecologic pain symptoms are common in this age group, and something clinicians should also watch out for, advised Vilasagar.

She also suggests starting off treatment with conservative management, including coping skills, support groups, physical therapy for myofascial pain, acupuncture, and more. First-line therapies should include NSAIDS, combo estrogen/progestin and progestins, and most importantly, “don’t delay initiation.” With an estrogen/progestin combination, the goal, reminded Vilasagar, was menstrual suppression, with pill and ring options and continuous administration of these interventions.

When it came to surgical management, “a minimally invasive approach is best,” said Vilasagar. “Between excision or ablation, excision is the goal. Hysterectomy or oophorectomy is NOT recommended for teens.”

More coverage of AAGL’s 50th Global Congress on MIGS can be found at contemporaryobgyn.net/conferences/AAGL.