Objective: We aim to review the incidence, location, and management of bowel endometriosis and demonstrate relevant surgical principles while emphasizing anatomic considerations for minimally invasive resection of ileocolic lesions.Design: This video briefly reviews the background of bowel endometriosis and indications for surgical excision. We present a case of a patient diagnosed with symptomatic terminal ileum endometriosis and review the preoperative imaging. We demonstrate the steps of a medial-to-lateral surgical approach for ileocolic resection and highlight the relevant surgical anat-omy. Institutional review board approval was not required.Setting: This procedure was performed at a large academic institution with a multidisciplinary team of minimally invasive gynecologic and colorectal surgeons.Patients or Participants: The case presented is a 44-year-old female with a known history of stage IV endometriosis. She presented with acute abdominal pain and was found to have a small bowel obstruction from a 3-centimeter lesion thought to be an endometrioma. She failed conservative management and was thoroughly counseled about the need for surgical inter-vention. Pelvic magnetic resonance imaging was performed for preoperative planning.Intervention: Laparoscopic ileocolic resection is performed using a medial-to-lateral approach for excision of a symptom-atic 3-centimeter ileocecal endometrioma. The following techniques are highlighted: (1) Evaluation of the entire small bowel starting at the ligament of Treitz (2) Entry into the retroperitoneum below the ileum with cranial and caudal dissection (3) Mobilization of the ascending colon to the level of the falciform ligament (4) Extension of the umbilical incision to perform an extracorporeal ileocecal resection and anastomosisConclusion: The bowel is the most common extragenital site for endometriosis to occur, with the highest rate of lesions located in the rectosigmoid colon [1]. Lesions can be either superficial or deeply infiltrative and can lead to a range of symp-toms. A serious sequela of bowel endometriosis includes bowel obstruction requiring surgical intervention. Journal of Mini-mally Invasive Gynecology (2023) 30, 445.& COPY; 2023 AAGL. All rights reserved.

Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Acute pelvic pain is a common presenting complaint in both the emergency room and outpatient settings. Pelvic pain of gynecologic origin in postmenopausal women occurs less frequently than in premenopausal women; however, it has important differences in etiology. The most common causes of postmenopausal pelvic pain from gynecologic origin are ovarian cysts, uterine fibroids, pelvic inflammatory disease, and ovarian neoplasm. Other etiologies of pelvic pain are attributable to urinary, gastrointestinal, and vascular systems. As the optimal imaging modality varies for these etiologies, it is important to narrow the differential diagnosis before choosing the initial diagnostic imaging examination. Transabdominal and transvaginal ultrasound are the best initial imaging techniques when the differential is primarily of gynecologic origin. CT with intravenous (IV) contrast is more useful if the differential diagnosis remains broad. MRI without IV contrast or MRI without and with IV contrast, as well as CT without IV contrast may also be used for certain differential considerations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Endometriosis is the most common gynecological condition leading to pelvic pain and often it is the only one recognized by gynecologists. In many cases it coexists with pelvic floor muscle spasm, interstitial cystitis/bladder pain syndrome and irritable bowel syndrome and often all four are called “evil quadruplets.” Endometriosis can be diagnosed only surgically, and pathology confirmed tissue biopsy is by far the most accurate way of diagnosis. Unfortunately, all medical treatments of endometriosis are quite inadequate because they all rely on causing a hypoestrogenic state that only provides temporary relief of pain, and soon after medication is discontinued, symptoms return. Development of drugs addressing the cause of the disease is currently not possible because the cause of the disease is known. Multiple existing theories fail to explain all the cases, leading to the possibility that different etiologies may lead to a presence of endometrial glands and stroma in the peritoneal cavity and outside. Surgical resection of endometriosis in skilled hands is effective but patients need to be warned that disease will most likely return within a few years of initial surgery. Deep infiltrating endometriosis requires a very knowledgeable surgeon and often specialized center for treatment. Additional procedures such as presacral neurectomy, although controversial and potentially risky, may alleviate dysmenorrhea symptoms in some patients. Meticulous removal of ovarian endometriomas is a must in all infertility patients and most pelvic pain patients as simple drainage will result in almost immediate return of endometrioma.

STUDY OBJECTIVE:Learning to evaluate and treat chronic pelvic pain (CPP) is an established curriculum objective within the Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS). Our aim was to investigate current educational experiences related to the evaluation and management of CPP and the impacts of those experiences on FMIGS fellows and recent fellowship graduates, including satisfaction, confidence in management, and clinical interest in CPP.DESIGN:The AAGL-Elevating Gynecologic Surgery Special Interest Group for pelvic pain developed a 33-item survey tool to investigate the following topics: (1) current educational experiences with the assessment and management of patients with CPP, (2) satisfaction with fellowship training in CPP, (3) perceived preparedness to treat patients with CPP, (4) plans to incorporate management of CPP into clinical practice, and (5) perceived desires to expand CPP exposure. Composite scores were created to examine experiences related to diseases associated with CPP and pharmaceutical and procedural treatment options.SETTING:Electronic survey.PATIENTS:Not applicable.INTERVENTIONS:The survey was distributed via AAGL email lists and offered on FMIGS social media sites from August 2017 to November 2017 to all active FMIGS fellows and individuals who graduated the fellowship during the preceding 5 years.MEASUREMENTS AND MAIN RESULTS:Fifty-three of 82 (65%) current FMIGS fellows and 104 of 169 (62%) recent fellowship graduates completed the survey. Only 66% of current fellows endorsed working with a fellowship faculty member whose clinical work focused on CPP. Most current fellows reported having a "good amount" of experience or "extensive" experience with superficial endometriosis (39/53, 74%) and deeply infiltrative endometriosis (34/53, 64%), whereas the majority reported having "no" or "little" experience with frequently comorbid conditions like irritable bowel syndrome (68%), pelvic floor tension myalgia (55%), and interstitial cystitis/painful bladder syndrome (51%). For both current fellows and recent graduates, increased CPP Disease Experience composite scores were associated with satisfaction with CPP training (current fellows odds ratio [OR] 1.9, p =.002; recent graduates OR 1.5, p < .001), perceived preparedness to treat patients with CPP (current fellows OR 2.0, p = .0021; recent graduates OR 1.5, p <.001), and the desire to incorporate the treatment of CPP into future clinical practice (current fellows OR 1.8, p = .0099; recent graduates OR 1.3, p = .0178). More than 80% (43/53) of current fellows indicated that they believed an expanded pelvic pain curriculum should be part of the FMIGS fellowship.CONCLUSION:This needs assessment of FMIGS fellows and recent graduates suggests that there are gaps between FMIGS curriculum objectives and current educational experiences, and that fellows desire increased CPP exposure. Expansion and standardization of the CPP educational experience is needed and could lead to increased focus on this disease process among subspecialty benign gynecologic surgeons.

Study Objective: To present updated information regarding compensation patterns for Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS)-graduated physicians in the United States beginning practice during the last 10 years, focusing on the variables that have an impact on differences in salary, including gender, fellowship duration, geographic region, practice setting, and practice mix. Design: An online survey was sent to FMIGS graduates between March 15, 2019 and April 12, 2019. Information on physicians' demographics, compensation (on the basis of location, practice model, productivity benchmarks, academic rank, and years in practice), and attitudes toward fairness in compensation was collected. Setting: Online survey. Participants: FMIGS graduates practicing in the United States. Intervention: E-mail survey. Measurements and Main Results: We surveyed 298 US FMIGS surgeons who had graduated during the last 10 years (2009-2018). The response rate was 48.7%. Most of the respondents were women (69%). Most of the graduates (84.8%) completed 2- or 3-year fellowship programs. After adjustment for inflation, the median starting salary for the first postfellowship job was $252 074 ($223 986-$279 983) (Table 1). The median time spent in the first job was 2.6 years, and the median total salary at the current year rose to $278 379.4 ($241 437-$ 350 976). The median salary for respondents entering a second postfellowship job started at $280 945 ($261 409-$ 329 603). Significantly lower compensation was reported for female FMIGS graduates in their initial postfellowship jobs and was consistently lower than for that of men over time. Most FMIGS graduates (59.7%) reported feeling inadequately compensated for their level of specialization. Conclusion: A trend toward higher self-reported salaries is noted for FMIGS graduates in recent years, with significant differences in compensation between men and women. Among obstetrics and gynecology subspecialists, FMIGS graduates earn significantly less than other fellowship-trained physicians, with median salaries that are lower than those of generalist obstetrics and gynecology physicians. (C) 2020 AAGL. All rights reserved.

Pelvic congestion syndrome is another condition causing pelvic pain for which there is no consensus on diagnosis or treatment; moreover, some physicians don’t even believe it causes pelvic pain. Pain from pelvic congestion is multifactorial and may be caused by hypoxia and mechanical stretching of pelvic veins. It usually occurs after pregnancy (may be full term, ectopic, or miscarriage) and presents as a sensation of heaviness in the lower abdomen with upright body position. On the background of this sensation there is intermittent sharp lower pelvic pain. In our practice we diagnose pelvic pain based on symptoms but confirm it with transfundal venography preformed in the operating room immediately prior to surgery. We treat pelvic congestion syndrome either by referring the patient to interventional radiology for embolization of the pelvic veins or by surgical selective pelvic vein ligation. In this procedure we separate ovarian veins from arteries and legate them and then legate any significantly enlarged veins in the broad ligament. Outcomes from this treatment are effective; however, pain and congestion may return with time, especially if the patient becomes pregnant again.

Procedure Appropriateness Category Relative Radiation Level US duplex Doppler pelvis Usually Appropriate O US pelvis transabdominal Usually Appropriate O US pelvis transvaginal Usually Appropriate O US sonohysterography May Be Appropriate (Disagreement) O MRI pelvis without and with IV contrast Usually Not Appropriate O MRI pelvis without IV contrast Usually Not Appropriate O CT pelvis with IV contrast Usually Not Appropriate ☢☢☢ CT pelvis without IV contrast Usually Not Appropriate ☢☢☢ CT pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢

This publication summarizes the relevant literature for the imaging of patients with symptoms of abnormal uterine bleeding, including initial imaging, follow-up imaging when the original ultrasound is inconclusive, and follow-up imaging when surveillance is appropriate. For patients with abnormal uterine bleeding, combined transabdominal and transvaginal ultrasound of the pelvis with Doppler is the most appropriate initial imaging study. If the uterus is incompletely visualized with the initial ultrasou2nd, MRI of the pelvis without and with contrast is the next appropriate imaging study, unless a polyp is suspected on the original ultrasound, then sonohysterography can be performed. If the patient continues to experience abnormal uterine bleeding, assessment with ultrasound of the pelvis, sonohysterography, and MRI of the pelvis without and with contrast would be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The most common known causes of female infertility are male factor (26%), ovulatory failure (21%), and tubal damage (14%), while in 28% a couple's infertility remains unexplained. Female-specific causes of infertility include deterioration of oocyte quality with increasing maternal age; ovulatory disorders, most notably polycystic ovarian syndrome; history of salpingitis such as that caused by chlamydia infection; endometriosis; and uterine cavity abnormalities interfering with implantation causing inability to become pregnant or causing recurrent pregnancy loss. These potential causes of female infertility are discussed in this document and the appropriate imaging recommendations for each variant are provided. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

PURPOSE:Treating uterine fibroids with less invasive therapies such as magnetic resonance-guided focused ultrasound (MRgFUS) is an attractive alternative to surgery. Treatment planning can improve MRgFUS procedures and reduce treatment times, but the tissue properties that currently inform treatment planning tools are not adequate. This study aims to develop an ex vivo uterine fibroid model that can emulate the in vivo environment allowing for characterization of the uterus and fibroid MR, acoustic, and thermal tissue properties while maintaining viability for the necessary postsurgical histopathological assessments. METHODS:Women undergoing a hysterectomy due to fibroid-related symptoms were invited to undergo a preoperative pelvic MRI and to permit postoperative testing of their uterine specimen. Patients that declined or could not be scheduled for a pre-operative MRI were still able to allow post-operative testing of their excised tissue. Following surgical removal of the uterus, nonmorcellated tissues were reperfused with a Krebs-Henseleit buffer solution. An MR-compatible perfusion system was designed to maintain tissue viability inside the MR suite during scanning. MR imaging protocols utilized preoperatively were repeated on whole sample, reperfused ex vivo uterus specimens. Thermal properties including thermal diffusivity and thermal conductivity of the uterus and fibroids were determined using an invasive needle sensor device in 50% of the specimens. Acoustic property measurements (density, speed of sound and attenuation) were obtained for approximately 20% of the tissue samples using both through-transmission and radiation force balance techniques. Differences between fibroid and uterus and in vivo and ex vivo measurements were evaluated with a two-tailed Student t test. RESULTS:Fourteen patients participated in the study and measurements were obtained from 22 unique fibroids. Of the 16 fibroids available for preoperative MRI testing, 69% demonstrated classic hypo-intensity relative to the myometrium, with the remainder presenting with iso- (25%) or hyper-intensity (6%). While thermal diffusivity was not significantly different between fibroid and myometrium tissues (0.217 ± 0.047 and 0.204 ± 0.039 mm2 /s, respectively), the acoustic attenuation in fibroid tissue was significantly higher than myometrium (0.092 ± 0.021 and 0.052 ± 0.023 Np/cm/MHz, respectively). When comparing in vivo with ex vivo MRI T1 and T2 measurements in fibroids and myometrium tissue, the only difference was found in the fibroid T2 property (P < 0.05). Finally, the developed perfusion protocol successfully maintained tissue viability in ex vivo tissues as evaluated through histological analysis. CONCLUSIONS:This study developed an MR-compatible extracorporeal perfusion technique that effectively maintains tissue viability, allowing for the direct measurement of patient-specific MR, thermal, and acoustic property values for both fibroid and myometrium tissues. These measured tissue property values will enable further development and validation of treatment planning models that can be utilized during MRgFUS uterine fibroid treatments.

Study Objective The Fellowship in Minimally Invasive Gynecology Surgery (FMIGS) is the most competitive fellowship in Obstetrics and Gynecology with 1.9 applicants per position and a 50% match rate in 2019. Yet, only one prior study, conducted in 2012- 2013, has examined trends in MIGS salaries and found widely variable levels of compensation. There is no current published data on the compensation and practice of this growing field. Here, we present updated information regarding compensation patterns for FMIGS physicians in the United States. Design An online survey sent to FMIGS graduates between March -April 2019. We collected information on physicians’ demographics, compensation trend and physician attitudes towards fairness in compensation. Setting Online Survey Patients or Participants FMIGS Graduates practicing within the United States. Interventions E-mail Survey Measurements and Main Results Of 391 former FMIGS fellows surveyed, 204 responded (response rate =52%). 66.5% of respondents graduated from FMIGS fellowship in the last 5 years and 79.4% completed fellowship programs of 2 or 3 years duration. Median total salary in year 1 after fellowship was $230000 [range 130000-400000], increasing to a median salary of $260000 in current year for individuals at this job for more than 1 year [average years at job 1=3.6]. The majority of first post-fellowship jobs were described as academic (51.26%), in urban settings (82.56%) and gynecology only (52.58%), however most (72.02%) were comprised of 50% or fewer surgical referrals. For FMIGS graduates moving to a second job post-fellowship, median current year salary increased to $287500, while for the 3 respondents listing a third post-fellowship job, median current salary was $450000. For the 33.68% of respondents who currently practice at their second or third post-FMIGS fellowship position, 72.31% hold gynecology only positions and 60% have a practice that is comprised of greater than 50% surgical referrals. Conclusion A trend toward higher salaries is noted for FMIGS fellowship graduates in recent years. The Fellowship in Minimally Invasive Gynecology Surgery (FMIGS) is the most competitive fellowship in Obstetrics and Gynecology with 1.9 applicants per position and a 50% match rate in 2019. Yet, only one prior study, conducted in 2012- 2013, has examined trends in MIGS salaries and found widely variable levels of compensation. There is no current published data on the compensation and practice of this growing field. Here, we present updated information regarding compensation patterns for FMIGS physicians in the United States. An online survey sent to FMIGS graduates between March -April 2019. We collected information on physicians’ demographics, compensation trend and physician attitudes towards fairness in compensation. Online Survey FMIGS Graduates practicing within the United States. E-mail Survey Of 391 former FMIGS fellows surveyed, 204 responded (response rate =52%). 66.5% of respondents graduated from FMIGS fellowship in the last 5 years and 79.4% completed fellowship programs of 2 or 3 years duration. Median total salary in year 1 after fellowship was $230000 [range 130000-400000], increasing to a median salary of $260000 in current year for individuals at this job for more than 1 year [average years at job 1=3.6]. The majority of first post-fellowship jobs were described as academic (51.26%), in urban settings (82.56%) and gynecology only (52.58%), however most (72.02%) were comprised of 50% or fewer surgical referrals. For FMIGS graduates moving to a second job post-fellowship, median current year salary increased to $287500, while for the 3 respondents listing a third post-fellowship job, median current salary was $450000. For the 33.68% of respondents who currently practice at their second or third post-FMIGS fellowship position, 72.31% hold gynecology only positions and 60% have a practice that is comprised of greater than 50% surgical referrals. A trend toward higher salaries is noted for FMIGS fellowship graduates in recent years.

Pelvic pain is common in both reproductive age and postmenopausal women, and the major etiologies change throughout the life cycle. Chronic pain is defined as lasting for at least 6 months. There are many gastrointestinal and urinary disorders associated with chronic pain in this age group, which are not discussed in this guideline. Pain may be localized to the deep pelvis, with potential causes including pelvic congestion syndrome, intraperitoneal adhesions, hydrosalpinx, chronic inflammatory disease, or cervical stenosis. Ultrasound is the initial imaging modality of choice, while CT and MRI may be appropriate for further characterization of sonographic findings. Alternatively, pain may be localized to the vagina, vulva, or perineum, with potential causes including vaginal atrophy, vaginismus, vaginal or vulvar cysts, vulvodynia, or pelvic myofascial pain. Imaging is primarily indicated in context of an abnormal physical exam and ultrasound is the initial modality of choice, while MRI may be appropriate for further characterization in select cases. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

This project uses an ex vivo human perfusion model for studying transport in benign, fibrous tumors. The uterine arteries were cannulated to perfuse the organ with a buffer solution containing blood vessel stain and methylene blue to analyze intratumoral transport. Gross examination revealed tissue expansion effects and a visual lack of methylene blue in the fibroids. Some fibroids exhibited regions with partial methylene blue penetration into the tumor environment. Histological analysis comparing representative sections of fibroids and normal myometrium showed a smaller number of vessels with decreased diameters within the fibroid. Imaging of fluorescently stained vessels exposed a stark contrast between fluorescence within the myometrium and relatively little within the fibroid tissues. Imaging at higher magnification revealed that fibroid blood vessels were indeed perfused and stained with the lipophilic membrane dye; however, the vessels were only the size of small capillaries and the blood vessel coverage was only 12% that of the normal myometrium. The majority of sampled fibroids had a strong negative correlation (Pearson's r = − 0.68 or beyond) between collagen and methylene blue staining. As methylene blue was able to passively diffuse into fibroid tissue, the true barrier to transport in these fibroids is likely high interstitial fluid pressure, correlating with high collagen content and solid stress observed in the fibroid tissue. Fibroids had an average elevated interstitial fluid pressure of 4 mm Hg compared to − 1 mm Hg in normal myometrium. Our findings signify relationships between drug distribution in fibroids and between vasculature characteristics, collagen levels, and interstitial fluid pressure. Understanding these barriers to transport can lead to developments in drug delivery for the treatment of uterine fibroids and tumors of similar composition.