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Direct Visualization Can Transform Your Practice
Originally Broadcast: Thursday, January 21, 2021 at 7:00 pm (EST)
Presenter
David B. Schwartz
Course objectives:
Discover the ways direct visualization can advance your practice
Identify focal pathology more precisely than EMB, SIS or TVUS1
Efficient workflow with in-office exams that reduce OR visits
Low-cost investment for reimbursed procedures
Grimbizis GF, Tsolakidis D, Mikos T, et al. Fertil Steril . 2010; 94: 2721-2725
welcome and thank you for attending this event is brought to you by Cooper Surgical, a leading provider of medical devices for women's health care. For 30 years, Cooper Surgical has worked with health care providers to provide highly effective clinic and practice based contraceptive, surgical and obstetrics solutions to complement our portfolio of trusted and reliable medical devices. We have also broadened our offerings, investing in the areas of reproductive genomics and in vitro fertilization. We're fully committed to helping improve the delivery of health care to women and their families. Cooper Surgical manufacturers over 600 clinically relevant medical devices used by health care providers in offices, clinics, operating rooms, labor and delivery suites and reproductive IVF clinics worldwide. Clinicians overwhelmingly say they trust our products for their reliability, innovation and efficiency. Here's some other interesting facts you may not know about Cooper Surgical. Since our inception in 1990 our focus has always been women's health care. With more than 600 medical devices and over 3200 product numbers across a broad range of market segments, physicians know and trust our products. We ship over 1400 orders per day, of which 99.7% are shipped the same day. Our customer service department handles over 2000 enquiries per day. We employ 1750 people worldwide. We're pleased to provide this educational opportunity on behalf of Cooper Surgical. Welcome and thank you for participating in tonight's event. My name is Alan Ships. I'll be the meeting manager for this evening's event. A couple of notes on how the presentation will run will have approximately 35 minute time limit for the presentation, which will be followed by a 15 minute Q and a session with Dr Schwartz to submit a question during the presentation, please click the Ask the question button located at the bottom of the player window and fill out the form. If we aren't able to get to your question tonight, you will receive a response from Cooper Surgical after tonight's event. Tonight's presentation is entitled. Direct visualization can transform your practice. Presented by Dr David B. Schwartz, Dr Schwartz is board certified in obstetrics and gynecology. It is a fellow of the American College of Obstetrics and Gynecology, and I'll turn it over to you, Dr Schwartz. Well, welcome, everybody, and, uh, it's a pleasure to be here to discuss, uh, direct visualization and how it can transform your practice in taking care of women in this time of co vid. And after I'm David Schwartz. I'm a No Bijan in Cincinnati, Ohio, and I'm a paid consultant and speaker for Cooper Surgical Inc. The ability to look inside the uterus and to diagnosis the abnormalities that are there affecting the reproductive health of our patients is an invaluable tool for the modern gynecologist in this time of cove. It we haven't been able to gain access to the hospital is often as we want Thio. And so doing that in our office in the office environment is not on Lee a convenience for the patient and for the surgeon. But it's for a way to us to continue practicing safe and effective health care for our patients. And what we have found is another tremendous benefit. The overall reduction in health care costs, abnormal bleeding is going to affect one out of three patients that present to your practice, and it is a very common problem. We used to call it men garage mena, meta raja hyper memory of parliamentary A. We now classify it according to Palm Coin as abnormal bleeding, with structural abnormalities being polyp, adenoma, aosis, Leo, my oma and malignancy or hyperplasia and then the non structural abnormalities. The coin Caligula Apathy, Abdullah Torrey dysfunction, endometrial I atra genic and those that are not yet classified the primary causes of abnormal uterine bleeding. And most of our patients are going to be the structural abnormalities 20 to 40% of the time, and then the non structural abnormalities or dysfunctions 60 to 80% of the time. And it's up to us is purveyors of health care to determine which category the abnormal bleeding is and then to appropriately treat and counsel our patients. Polyps is one of the big causes. As a source of bleeding 20 to 40% of the time, we're going to see polyps in patients who have abnormal bleeding. Unfortunately, we're used to doing blind endometrial biopsies going in and sampling the lining of the uterus, and this has a false negative rate of close to 90% and polyp diagnosis. You miss it, you don't see it. In addition, polyps with abnormal bleeding or a common presenting symptom for patients with endometrial cancer as a matter of fact, the presence of polyp malignancy and women with abnormal bleeding is almost 24% with pre malignant changes and 1.5% with actual malignant degeneration. And we want to see to visualized these polyps to make that diagnosis fibroids or lie on. My Omagh's are also a significant source of abnormal uterine bleeding. Uterine fibroids occur anywhere from 25 to 40% of the time, and sub mucosal fibroids are diagnosed in up to 10 11% of women presenting with abnormal uterine bleeding. Once again, blind endometrial biopsies have been shown to have a false negative rate of up to 95 98% of the time, and fibroids can be associated with bleeding, pain, pressure and infertility hyperplasia. Malignancy is part of the palm coin structural abnormalities, and, unfortunately, and a mutual dying hyperplasia is diagnosed up to 4% of the time in your patients who are presenting with abnormal bleeding again. The blind biopsy is not going to be that good because it has up to a 75% false negative rate for diagnosing endometrial hyperplasia. Why? Because we're biopsy in an area where we really don't know where the abnormal tissue is in the risk of progression of endometrial hyperplasia to occult carcinoma. Well in complex hyperplasia without a Tippee, it's less than 5%. But when you have endometrial hyperplasia with a tip AEA, it's up to 28% progression to occult cancer in 20 years. We need to prevent this. We need to diagnosis. We need to treat this office. Sister a Skopje is much more accurate. Then a biopsy alone once again with the blind biopsy. We're not seeing where to biopsy the abnormal tissue and when we can look inside and then biopsy as we're visualizing the abnormal area. Well, that's the state of the art. Now, if you look at the evidence from this slide, the buying, biopsy and diagnosing polyps was 11% compared to history A a Skopje almost 90% sensitivity for diagnosing fibroids, 13% with a blind biopsy and ah, 100% with history A a Skopje hyperplasia, 25% versus when we can actually visualize where the abnormal tissue is 74% of the time, we will make the correct diagnosis. The American Congress of Obstetrics and Gynecology confirms that biopsy may be insufficient. Why? Well, if the biopsy comes back positive, we know for sure that the patient has that disease entity. But if the biopsy comes back negative, we could have missed the polyp. We could have missed the fibroid. We could have missed the abnormal hyper plastic area. So a positive result is much more accurate for ruling out disease than a negative test. And the positive result is on Lee an end point when it reveals cancer or a typical complex hyperplasia. Unfortunately, we're not going to see that with a blind biopsy. We're gonna need toe look and biopsy. The areas that we see are a typical that are abnormal, and that's going to increase our ability to find the disease and treat the disease. A cog also supports advanced diagnostic imaging. What are we talking about? What we're talking about a trans vaginal ultrasound. We're talking about a sailing infused sonogram, and we're talking about history a a skopje So the S I s or Sano history Oscar P is much, much better the trans vaginal, ultra ultra sonography because we could detect the inter cava Terry lesions as I'll show you in some slides in the coming up much easier, however, the next step and again the current state of the art this history A, a Skopje and Mr Askey be can be performed in an office setting. It could be formed in an operating room. However, in the office it's more convenient. It's more comfortable for the patient, its overall less expensive for the health care system and the purveyor of healthcare. You, the doctor, is being reimbursed more for two, so it's a win win for everyone. In a meta analysis that evaluated diagnostic accuracy history, Rosco P had an overall success rate of almost 97%. Once again, we've got to stop the blind biopsy. We've gotta look inside, and we have to sample what we can see with our eyes, and that will empower us to be better physicians and better health care providers. There is a systematic review of imaging studies by McHugh Lacroix, and he showed that the saline infused sonogram was superior to the trans vaginal ultrasound specificity of 92 89% compared with 64 90%. However, it lacked the sensitivity to be used alone. History a a Skopje on the other hand provides direct visualization of the uterine cavity. And when you combine that with your biopsy, not a blind biopsy but a visual proven biopsy that you're seeing the abnormal tissues. This has now become the criterion standard for the diagnosis of intra uterine abnormalities and subsequently used to treat abnormal uterine bleeding. This is a study showing the comparison of the diagnostic performance of trans vaginal ultrasound versus saline infused pornography versus diagnostic history. Oscar P. And if you look at the D. H. The Diagnostic History A A Skopje column, it is far superior than the other two modalities for diagnosing abnormal uterine bleeding. Once again, we have definitive evidence based medicine that shows blind biopsy is not appropriate. Diagnostic history. Oscar P and visually biopsy in the abnormal pathology is much more sensitive and much more specific. So as we can see in this slide, why aren't we seeing it well, traditional history A. A Skopje requires patients to go to the hospital that space consuming and time consuming. It's inconvenient for the patient. It's inconvenient for the doctor. It's really not patient centric. Um, it's It's a nuisance for the patient, it's painful. It requires anesthesia and the overall cost to the health care system. It is expensive. Not anymore. The traditional abnormal uterine bleeding clinical pathway required an initial consultation in the office with the patient. A trans vaginal ultrasound and endometrial biopsy, which was blind. A saline infused sonogram. Another visit to plan the following treatment and then diagnostic history a a Skopje in the hospital and or treatment. We don't have to do all this anymore. We have simplified it, and we can bring a lot of these procedures to the office to make it more convenient for the patient to make it more convenient for the health care provider and more cost effective for the entire health care system. The cost effectiveness of office sister a Skopje is phenomenal. Number one. They did a study with 130 patients with abnormal bleeding. 42% were in the O. R. 58% were in the doctor's office. And by performing the procedure in the physician's clinic or office, $3500 per patient was safe. It was done with a flexible history scope minimal to no pain, and the physician was able to counsel the patients before the procedure during the procedure after the procedure and plan for additional treatment all at the same time and all at the same visit. How do we do this? Well, thankfully, Cooper Surgical has a vision, has a mission and has values. And this is to create a world of healthy women and their family to deliver impactful solutions that will improve the health care of our patients all at the same time being ethical, passionate, innovative and respectful. How do we do that? We have something called the End. OSI advanced and the NSC advanced is the state of the art direct visualization. I like to refer to it as something like the best thing since sliced bread. There is a camera and a docking station. There's a video monitor that sits on the docking station. It is not very big, but it's big enough for us to visualize. It's larger than the largest iPhone that you have. There is a single sterile use cannula that you'll be used to insert into the end of mutual cavity. It's flexible, but it's also stiff enough so it makes it easy to insert. And if the sit cervix is a little cyanotic. You use a little hydro bill it ation while you're inserting it 4.3 millimeters. That's less than a half of a centimeter outside diameter. With this, you can press a button and there will be still images and video capture. The camera is disposable. The video monitor is reusable, and in addition, there is a working channel. So as you're visualizing your pathology of your patient, you can actually do a biopsy or remove Apollo, and nothing is blind. Everything is visible. It has changed the way we practice medicine, especially during this time of Cove. It when patients don't want to go to the hospital and patients air, fearful of coming in multiple visits. We can do so many things in one visit in our office, which benefits our patients, their health care and really society in general. Broad range of uses air going to include evaluating abnormal uterine bleeding. Deciding where we are on the palm coin diagnosis. We can also look a infertility and recurrent miscarriages. I've seen, um, abnormal cavities. I've seen Sepp. Um, I've seen by corn oy uteruses all with the end asi in my office. Of course, we can identify polyps and fibroids. If somebody is postpartum and continues to bleed, you can look inside and actually see retained products of conception. You can see in the mutual thickening and actress or atrophy in postmenopausal bleeders and any tissue that is in need of biopsy. No longer a blind biopsy but a visual biopsy. In addition, we can do actual diagnostic measures and transect adhesions or a SEPTA remove. Apollo remove a retained I u D, where the string is lost or the string is absent. Do actual directed biopsies all the time planning for additional pre surgical and surgical activities. I'm going to show some actual Sano history Grams and History a Skopje's and show how they work together, um, but also show how there could be false negatives and false positives. You see, in this slide is a Sino history Graham, and it shows an inter cava terry lesion. We think, however, when we proceed to diagnostic history Oscar P with the end OSI. It's a perfectly normal cavity and retrospectively that was probably a blood clot, um, inside the end of mutual cavity that looked like an inter cava terry lesion, and it was indeed a false positive Sano history Graham. This could always delay treatment for a patient In the top view. You see Asano history Graham number two. And there appears to be a lesion in the cavity. However direct visualization, there's nothing there in a very similar Sano history. Graham number three, you see another lesion in the cavity and yes, in the end, OSI history A a skopje with direct visualization, you can actually see the polyp that is in that cavity. Now, that polyp would be appropriate to remove at the time off the end asi procedure. Here we have a Sano history, Graham that shows perhaps a thickened endometrium, um, and an irregular uterine lining. But lo and behold, when we put a camera inside and we actually look in the end of mutual cavity Wow, it's just loaded with polyps, multiple polyps that this patient would require a procedure that's gonna need to remove all of those polyps and then clean that lining of the uterus, um, to help control her abnormal uterine bleeding. You can see here that a picture is worth 1000 words. This was a patient of mine that had a trans vaginal ultrasound, and we always do the trans vaginal ultrasound at the same time we do the Sano history. Graham. It's just the initial part of the procedure, but you can see there may or in the in the left slide, the left part of the slide, the first sonogram where it says TV us. It looks like there may be an increased density in the center of the uterus, so there's possibly a mass there when we then do the Sano history. Graham the sailing into sonogram There's definitely the appearance of a structural abnormality that looks like a large, solitary polyps. And then the NDC advances done, and lo and behold, there is that large solitary. The embassy advance provides the clearest image of the inside of the end of mutual cavity, and one can easily see both Austria, the areas of the normal endometrium and, in this case, a large, solitary polyps that's going to require a polyp ectomy in the future. In this next slide, it's talking about post menopausal bleeding in a patient who has a cyanotic cervix. I I mentioned earlier that we can use hydro dilation as we're inserting the end OSI device. The embassy advanced into the endometrial cavity. Here we have a 61 year old G three p one with postmenopausal spotting, and there's some questionable echo densities on the trans vaginal ultrasound. So in office, Mr A. Skopje has performed and we're trying to get into the end of mutual cavity. Were now injecting a little more fluid, a little more pressure. As we push in, you can see the end of material canal opening up. And lo and behold, we're now in the end of mutual cavity, and we could see that in the mutual cavity is beautiful. There's no hyperplasia up. Yes, there's something there up at the right correction. The left carnival, and there's a small polyp up there. And so now we have a diagnosis for this patient who has a polyp, and this Paul can be removed at the point of care. When we're doing this, Endo's because it's small enough this patient did not require anesthesia. This is done with the Paris cervical block. Once again, the hydro Tillett ation injecting fluid while you're inserting the scope into the cervix into the end of cervical canal empowers you. Is the physician to be able to do this procedure, and again, this is going to be patient centric. It's going to be a reduction and cost for the health care system, and this patient's going to be cured at this one visit in your office here we have a patient with a lost I U D. Now most of the time of patient comes in and is requesting or I u D removed. We'll put the speculum inside and we'll see the strings. We'll go ahead and grab it. Have the patient give me a hard cough and pull it out. If we don't see the strings, we can take a I u D Hook and gently insert that into the enemy troll cavity and see if we can feel the I u D Unfortunately, um, many times, that is unsuccessful. So here we have another opportunity to use the NFC advance. This is a 27 year old prime Nolan gravity who wants to get pregnant and need crud out, but we can't find it. So in the office, we go ahead and insert the end OSI advance. We're now in the end of mutual cavity. We see the I u d. And we're gonna look for the string on. There is the blue string over there on the right side of the slide, and we're taking our grass spurs, and we're going to try to manipulate them to grab the string, which is inside the end. Mutual cavity. There's no way this string is outside of the uterus, and as we're manipulating them, we'll grab the spring and then we can pull the I u D out. We have saved this patient a bundle of money, save the health care system, a lot of money, the convenience of getting this done in the office when the patient showed up to have her eye you d removed because there's no pre op planning, um, is just remarkable. This patient was able to have a successful I u D removal on the same day she requested it done, despite non visible strings, huge patients satisfying much more comfortable i u D retrieval without the hassle of going to the operating room. What about reimbursement for this procedure? Well, fortunately, the reimbursement is remarkable because it's going to save the entire health care system thousands of dollars while at the same time rewarding the health care provider for performing this procedure. So it's a win win for our patient, for our physician and for the health care system. I know in my practice, I received anywhere from 1200 to $1600 when I do a end to see advance in the office and remove tissue or Apollo or an I. U D String. And so I am comfortable saving the health care system money, saving the patient money while at the same time getting an appropriate reimbursement for the work I dio. So what are some of the advantages of our end OSI advance that we use in the office? Well, it's an end in mutual imaging guided by direct visualization. Once again, we're going to take the word blind out of our vocabulary, and everything is now going to be direct visualization. We can see it and weaken biopsy it, and this can all be done at the same time. This device provides a very clear color display with accurate visualization. Patients experience little or no discomfort. I use a para cervical block because I grabbed the cervix with a 10 AK. It's very efficient in terms of the office flow, because this could be done in any exam room, and it takes 2 to 5 minutes, and there is a low cost investment in this procedure that is going to be reimbursed. So once again, it's a win win not only for the patient, not only for the health care system but also for you, the purveyor of health care. So a new clinical pathway is available. As I showed you earlier in the first part of this slide, the patient would come in for an initial visit, her history, physical exam and laboratory values. Then she would come back for a trans vaginal ultrasound and an enemy troll biopsy. Then she'll come back for a saline infused sonogram, and then we will prepare for an outpatient procedure, and then she will come to the o'er in the second part of the slide. You can see now the history and physical and the trans vaginal ultrasound and the history Oscar P with the NDC advance and plus or minus the biopsy can all be done with the first or second visit. Treatment may be done at that point, or the patient could then be set up for treatment, so we're also minimizing potential multiple visits something that is also important in this time of co vid, when patients don't want to keep coming to the doctor's office and when patients don't want to come to the hospital. So we have something that's accurate, that's efficient, that's convenient. That's patient centric, and that's cost effective. Telemedicine is something we're all using. We're talking to our patients on the phone much more. We are able to build for this, which is nice. Um, however, patients don't wanna have procedures in the hospital, and lately it's been very difficult getting patients scheduled in the hospital multiple times over the past year. Elective surgeries, air canceled or are put off for a period of time, and having the ability to work up and perform these procedures in your office has been a godsend for our patients. I explain to my patients that I don't have to bring you into the hospital to make your diagnosis and in many times to treat you're abnormal bleeding. Thanks to the embassy advanced, I could do most of it in the office. So is Steven, Goldstein said. This new approach to gynecologic diagnosis is having a transformative effect on the management of patients with a variety of gynecologic disorders. We have come away from operating in a closed space in a closet, doing blind biopsies where we can actually visualize everything in the end of mutual cavity. And we can do this in our office with low cost to the patient and the health care system. It's remarkable what we're able to offer our patients now. So in summary, the NBC advance provides direct visualization into the uterine cavity. So any time we have something going on in the endometrium and we want to see it, we can easily slide this instrument, which is only 4.3 millimeters through the cervix, into the end of mutual cavity and see what's going on in there, providing us with a high accuracy of diagnosis, a decrease time to treatment and a tremendous improvement in patients. Care on a personal note. It maximizes my time, and also it's cost effective both for my practice and my patients. At this point, I'm gonna open up to questions, and I thank you for the time you've given us. And I hope I provided you with some food for thought. Thank you. Thank you, Dr Schwartz. I'm not going to turn over the Q and a portion of the program over to Christopher Kahn for Cooper Surgical. Thank you. Excellent talk, Dr Schwartz. And it's great to speak with you again. Thank you, Christopher. Great. And thank you to our audience to for your time this evening. My name is Chris Kahn. I'm the senior global product director at Cooper Surgical. I'm seeing your questions as they're coming in and feel free to keep them coming in. I see them in real time. We're going to try to get through a Zeman E of these as possible this evening and for any additional questions we don't get to or for additional follow up. Please do check the box for a sales representative. Follow up in the polling questions at the end. Okay, let's get started. So my first question, Dr Schwartz, is what is the most important factor for you in choosing to use embassy advance? I think that the fact that it it's so convenient to use and empowers me to perform a high quality of medical care right in my office. Okay. Excellent. Thank you. We've had some questions about pre medication. When if ever do you choose to pre medicate your patients before using NBC. Advance. I rarely ever pre medicate my patients because the actual cannula is so narrow and so flexible. It's extremely easy to insert into the end of mutual cavity. I would say of the last 100 patients that I've done in the office, I may have pre medicated two of them with a mild dose of Valium that they took the day be the night I gave it to them to take early that morning. But it's extremely rare, and those are the same patients that might need Valium just for regular pelvic examination. But pre medication is not really an issue with this product, okay? And if you had a patient that was concerned about pain, do you use any sort of pain medication? I dio I'm one of those physicians who use a para cervical block for anything that I'm putting in and out of the uterus. I even use it for an I U D. And the patients are always saying, Well, the last time I had that done, nobody gave me pain medicine. So I think number one, psychologically, it's extremely helpful. What I do is a para cervical block. I use 2% lighter. Kane. I put about four ccs a 12 o'clock, four ccs at four o'clock, four ccs at eight o'clock into the cervix. I have them cough like that as I injected, so they never feel the actual needle. Then I put an additional eight ccs between four and eight o'clock a little deeper. Um, and then I'm getting the product set up, so I will, um, turn on the machine, turn on the camera, turn on the video monitor, hook it up, attach the tubing to it, and and put the information the patient's social security number, etcetera. So that's all about a minute or two minutes. It gives a chance for that block to set. Then I do the procedure and the patients tolerate it extremely well. Okay. And do you ever find the need for lubrication of the cannula? I have never found the need for lubrication. I really don't want to use. I know, sir. Jialu, um or that, uh, gasoline. All those things could be used, but I You're just gonna be pushing mawr bacteria into the end of mutual cavity. I've never had an issue again. with this cannula because of the size of it. Now, another tip and trick is if you inject a little saline, so that's hi, Joe. Debilitation as you're inserting the can, you'll in. It kind of gives you your lubrication that you need or even dilates minimally, uh, the end of cervical canal as you're doing the procedure. And when you use that technique, do you find that you're successful in most cases? Or you know what percentage of patients do you find that to be a successful strategy for? Well, I also have a OSCE finder, Aziz, part of my set up in the office. And if there's difficulty inserting the cannula, then I will go ahead and use the OSCE finder and then insert the cannula. But I can't remember the last time I tried to do an embassy. I can't remember any time I tried to do an embassy in the office that I was not successful in entering the endometrial cavity, with the exception of someone who had an ablation and was bleeding and we were making an attempt to look and there wasn't a cavity to look into okay, and we've had a few questions about distended in the uterus. Do you have a preferred method, Bond? Why do you choose it? As far as using a syringe or an I V bag. So my preferred method is 60 cc syringe. Um, in the kit, we have these little baskets in our office and in the basket. They put all the equipment we need and they're just set up the day before or there's a couple always available and we will go ahead and have to 60 cc syringes most of the time. I just use one. Rarely do I need a 2nd 60 cc syringe. Um, and then very few times, If I'm actually doing a polyp ectomy and it's going to take me longer than a minute or two, um, I will have ah, bag of 500 cc sailing and just hang it with gravity. And that's more than enough. Thio provide distension and the fluid. But in answer to your question, my preferred method is going to be, um, just using the 60 cc syringe. It's just so convenient. Okay, great. Thank you. And then there's been a couple of questions also about clearing the view that the visualization during a procedure. How do you handle that? Okay, so there's sometimes there's a little bit of blood on the end of the camera. I will insert, um, the end of sea all the way up to the fund. This and I'll push it on the fund this a little bit and essentially toe wipe off the camera and then pull it back. And that's usually all it takes to clear it. Okay, and there's a couple questions about how you use the images after the procedure, both from showing the patient any pictures or videos you took and also up loading into an E h r. Um, can you speak to your, you know, preferred way of handling that? Sure, um, one of the beauties of this is that the patients awake, the patient gets dressed, and then I go back in the room and I talked to the patient with her with her clothes on, and I actually show her the pictures that we took. I show her the pathology or the lack there off, um, then that the actual video monitor goes to the front desk where it's downloaded into my m R. And it's just part of her medical record. It's simple, okay? And you were showing some cases about therapeutic procedures. Can you speak to your experience removing a pile up and how successful you are in doing that? Is there any, you know, criteria you use in terms of size of paolo up that's appropriate for office use? Sure. First, I'll say, one of the best benefits of this is you can see where the pathology is, and you can sample the pathology that you're seeing, and I think that's very, very important. Um, gynecologist in the past have always been operating in a dark space in the closet and doing DNC s and Paul effect. Amis with are really blind. We didn't see what we were doing. Now we're able to see exactly what we're doing. So, um, diagnostically we can sample the endometrial lining an area that Cyprus plastic. If there's a small polyp one or two centimeters, I will go ahead and remove it. Um, at the same time, If it's a little larger than 1.5 to 2 centimeters, I will then probably reschedule them for a procedure in which I have some type of Morse elation device Thio. Remove it just because it will be a lot quicker. Um, I probably could remove a two or 2.5 centimeter polyp. However, I think it would take a long time. And it would be easier with a one of the more insulation devices that I have in my office. And I do these procedures in my office. And if you are going to do it in your office with NBC Advance, do you have a preferred instrument that you use? Well, the NSC advance has a polyp, forceps that comes that you can purchase. And I have one or two of those. There's a disposable one and a reusable one. I use that for biopsy in and for removing small polyps. Okay, Okay. Here's one from a doctor asking about the postpartum uterus and difficulty maintaining distension. How do you approach that? So, um, I would think that this physician is thinking about retain products of conception. And, um, any time you do a history A a skopje, we want the cervix tight around the history scope. And so whether it's a usual history scope, that's six point to, um, millimeters or this very tiny essentially history scope We have to have the cervix tight around it so we can distended uterus. I will many times take a tin Oculus, um, and grabbed the cervix at 12. And then again, it's six and maybe a three and maybe at nine. So that's 14 Akyel, Um, or it might be called 10. A key ally. Excuse me if I'm wrong, and that will cause the cervix to tighten around the history scope. I'm in the O. R. I've put stitches around the cervix I put in the loops around the cervix, but it's just a ZZ to go ahead and grab with the two NAC. Another tip and trick is to go ahead and grab it at 12 o'clock and then re grab where you grabbed it and then re grab it again. And if you just have to 10 acts and each time you're tightening that cervix around your operating device, the end OSI in this situation and then you're gonna distended uterus with fluid. Okay, this next one is a concept I'm not familiar with. But I assume you you will be. Do you ever use Lamine area ahead of time for difficult patients? So the problem with the lamb in area is it's going to dilate the cervix much more than the diameter of the end. OSI. So you're gonna have the problem. We were just talking about with fluid leaking out. I always have an OSCE finder available with me. And, um usually, I can use the US finer, which is a very, very narrow dilator. And then gradually it gets bigger as you push it in. Now, in those rare circumstances with a post menopausal woman with a very cyanotic cervix, I would probably rather than put a lamb in area because that's going to dilate the cervix too much is give her some side attack the evening before. And then I've never had difficulty getting the OSCE finder in. Okay, Speaking of ass finders, where do you order yours? Do you Do you order them in bulk or do you get them through the convenience? Get I ordered them through bulk. I think I apologize. I'm answering this question, and I'm not 100% sure because my office staff takes care of that for me. I'm sorry. Okay. Um, here's a question about patients on blood thinners. Are you comfortable doing this? procedure in this population. And do you do anything different? I don't do anything different. I am very comfortable doing this in this population. We're not cutting anything. We're not causing any bleeding. Um, there might be a little bit of bleeding from dilating the cervix, but it's never been an issue. Okay, um, can you tell us about your experience removing MALP positioned I U D s with. This is an excellent device for that patient comes in once or I u d removed. I go ahead and put the speculum in and lo and behold, I can't see the i u D strength. So the first thing I'll do is take an i u d hook and see if I can feel for twisted around and pull the i u D out. If that's not possible, all then and many times, I'll just do it at the same visit. Get the end. OSI set up. But the endo CNN And then, as you saw in my talk today, you can easily see the I u D string, which sometimes is taking a sharp right turn and going back up to the fund ist and you just go ahead and grab it. And then you pull the whole end OSI and the grasp er out at the same time. Okay, Thank you. We've had a couple of questions about reimbursement. What is your experience with these procedures being reimbursed in the office? Um, especially during the times of cove. It This has been a godsend for me. I have not been able to do a lot of minors or at least back in April, May, June and July in the operating room. They're starting to open up now, but it has really empowered me to continue practicing medicine at, ah, level of excellence. Um, we're able to do these procedures and get appropriate reimbursement. The trick is, you build for the procedure and you build for the facility. There's a facility fee and the anthem in southwestern Ohio. Many times will pay $1600 but even Medicaid, we'll pay six or $700. We have care source here, and we have negotiated with them. And so, um, if I went into the hospital and did this procedure in the hospital, it would be five or $10,000 and I might get 150 to 300. I do it in my office. And, um, it's a win win for both the insurance company and us as physicians. And, of course, for the patient because of the convenience for the patient. Thank you. In which ways have you found this product to make your office your practice more efficient? Well, it empowers me to do things when they need to be done. I don't have toe go ahead and spend time having my staff called the O. R. Getting the patient to do pre op, scheduling, pre op testing and come into the O. R. This is a simple, um, procedure like putting an I u d and like doing an endometrial biopsy that we could do in the office without any pre medication without any pre authorizations. Um, and, um, it's so convenient not only for the patient, but for my practice. Okay, this next question is about doing biopsies. And when you're using undersea advance with an M B. Do you use the embassy advanced first and then m e m B or vice versa. How do you approach that? I always do the end OSI advance first because I want to see where the abnormal tissue is. If there is generally no abnormal tissue, I'll put a pipe, Ellen and just get a general sampling just to confirm that there is no pre cancerous changes, no hyperplasia, no issues going on. And I can proceed with whatever procedure we're going to do, like an ablation or a hysterectomy. If there's a specific area I'm concerned about, I will use the end OSI biopsy forceps and actually go in and visually biopsy this suspicious area. And this is now the, um, standard of care. It should be the standard of care. It's a state of art with medicine rather than doing blind biopsy. So you want to see first biopsy seconds. Thank you. And thank you for for your time this evening. Dr Schwartz, this last one is more of a comment. I think Dr Karen Stewart is looking to reconnect with you. Rinne Network with you. She was in Cincinnati back in the eighties, and she was wondering how long you've been there practicing in Cincinnati. I started. I finished my residency in 1982 went on the faculty of the university for two years, and I've been in private practice ever since. So my email is Dia's and David B. As in Bruce Doc, that's D O. C. The number eight at a o. L dot com and Karen reach out to me and anyone else that may have a question. Feel free to reach out to me. Excellent. Thank you so much, Dr Schwartz. Excellent talk tonight and thank you for your time with the question and answer. Thank you so much for the opportunity. Have a good evening. Alright, thanks, everybody. That's going to conclude our Q and A for this evening. As a reminder, Cooper Surgical will follow up with any questions that the speaker could not get to this evening. Please take a few minutes to complete a brief survey about tonight's program. It is in the bottom of the screen and says, Post program survey, Just click that button and you can fill out the form. Thank you for joining us and have a fantastic evening
David B. Schwartz