An update on laparoscopic paraaortic lymphadenectomy in a fellowship training program

Poster Presentations

Patients. Forty-two sterile women (ages 24-41 years) with tubal occlusion. Intervention. Falloposcopic tuboplasty with laparoscopy or laparotomy. Measurements and Main Results. We examined the relationship between efficacy of FF and Chlamydia trachomatis (CT) infection. Of the 42 patients (44 cases) who had surgery and were followed-up, 21 had preoperative CT infection, 17 were not infected, and 6 were not tested. In the CT infected group (CT+), 38 tubes were performed to FT, and in the no-infection group (CT-), 29 tubes were performed to FT. Recanalization rate per tubes were 60% in CT+ group and 79% in CT- group. During follow-up of tubes by hysterosalpingography or second-look laparoscopy, postoperative patency rate were 38% in the CT+ group and 62% in the CT- group. In patients who were followed-up for six months or more, five patients (35%) became pregnant except IVF/ET in the CT+ group, and eight patients (53%) became pregnant except IVF/ET in the CT- group. These data show better tendency in the CT- group, but there were no significant differences between two groups. Conclusion. CT infection is negative factor of FT. However, in CT+ group, postoperative pregnancy rate was 35% and was by no means inferior to those of IVF-ET. This research shows that a CT infection is a negative factor of FT, but FT is recommended to patients who have tubal occlusion before IVF/ET even if the patients were infected by CT.

224. An Update on Laparoscopic Paraaortic Lymphadenectomy in a Fellowship Training Program FR Nezhat, J Yadav, GJ Gardner, H Gretz, J Rahaman, CJ Cohen, Mount Sinai School of Medicine, New York, New York,

Study Objective. To provide an update on the development of the technique of laparoscopic paraaortic lymphadenectomy in a fellowship training program. Methods. During a 4-year period (January 2000 through December 2003), a strategy was implemented to incorporate laparoscopic lymphadenectomy training in the surgical experience of gynecologic oncology fellows. Forty-four consecutive cases of laparoscopic paraaortic lymph node retrieval were performed for various gynecologic malignancies. Lymph node retrievals were performed from the common iliac arteries, cephalad to the level of the right ovarian vein and the inferior mesenteric artery (IMA). Lymphadenectomy was extended up to the left renal vein depending on the primary disease site. Peri- and postoperative data was collected prospectively to monitor surgical performance. Results. The present series includes 15 cervical, 18 endometrial, 7 ovarian, 2 fallopian tube, 1 synchronous ovarian and endometrial, and 1 vaginal cancer. Twenty-nine patients had a complete lymphadenectomy, 12 had selective lymph node sampling, and 3 had debulking of enlarged paraaortic nodes. The average patient age was 55 years. Average nodal yield was 14 for all nodal retrievals. Among 29 patients with complete lymphadenectomy, 6 had left-sided infra-renal nodes removed as well. The mean number of nodes removed for the complete lymphadenectomies was 19, 25 for

infrarenal, and 17 for below IMA lymphadenectomies. The average blood loss and operative time for the lymphadenectomies was 123 mL and 63 min respectively. Linear regression analysis showed no significant trend in lymph node yield, operative time, and blood loss over the study period. Overall complication rate was 9%. There was only one intraoperative vascular complication in the early cases, which was managed laparoscopically. One patient developed port-site metastasis in a case with positive nodes. There were no cases of lymphocele. There were no unplanned conversions to laparotomy. On comparing the present data (group 1) with our initial experience from November 1992 to March 1998 (group 2), the average number of nodes for group 1 (n = 44) was 14 versus 4.5 for group 2 (n = 39). Conclusion. Implementation of a consistent strategy allows incorporation of laparoscopic paraaortic lymphadenectomy training in the surgical curriculum of gynecologic oncology fellows, while maintaining adequate nodal yield and an acceptable safety profile. Comparison with our initial experience shows that once the learning curve is achieved, a consistent and high lymph node yield can be achieved laparoscopically.

225. Essure Hysteroscopic Sterilization Long-Term Follow-up JE Nichols. Simpsonville, South Carolina.

Study Objective. To evaluate and measure the safety and long-term effectiveness of Essure, the only currently FDA approved hysteroscopic sterilization procedure for women. Design. Nonrandomized, prospective multicenter international clinical trials were undertaken to determine safety, effectiveness and microinsert wearing tolerance in women desiring sterilization. In previous clinical evaluations, demonstration of microinsert integration resulting in benign tubal occlusion was confirmed by histologic evaluation. Long-term evaluations in clinical trial patients are reported here. Measurements and Main Results. A total of 664 of 745 (90%) women achieved bilateral microinsert placement for permanent sterilization. 643 of 664 (97%) patients were able to rely on Essure for permanent birth control. As of November 26, 2003, there have been no observed pregnancies in women relying on the device for contraception. In the Pivotal trial, 464 of 507 (92%) patients ultimately achieved bilateral placement after the second attempt. A total of 461 patients have reached 1 year, 403 reached 2 years and 38 have reached 3 years of wearing. In the Phase II trial, 196 of 206 patients have reached 1 year, 195 patients have reached 2 years; 182 patients have reached 3 years and 45 patients have reached 4 years of device wearing. Tolerance to microinsert wearing in the Phase II trial was rated as "good" to "excellent" in over 99% of women at these visits. Women in the study consistently rated overall satisfaction with the microinserts as very high. Overall satisfaction was rated as "somewhat" to "very satisfied" in at least 98% of women through 2 years of follow-up and at 3-year follow-up (n = 37 reporting). 92% of women rated their overall satisfaction as "somewhat" to "very satisfied" in the $82