Chapters Transcript Direct Visualization Can Transform Your Practice - with Dr. Ethan Goldstein Dr. Ethan Goldstein demonstrates how direct visualization can advance your practice with Endosee. 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 are 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 and 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 inquiries per day. We employ 1750 people worldwide. We are pleased to provide this educational opportunity on behalf of Cooper Surgical. Good evening, everyone. Hello. My name is Kelly McKeon and I am your event manager and will assist in running the virtual presentation this evening. I'd like to welcome you all and thank you very much for your participation. First, I'll go over a few notes on how this presentation will run. We have our presentation tonight with questions and answers to follow. Please keep in mind that all participants will be a mute for the duration of the meeting. However, you'll have the ability to submit any questions to the Q and A feature during the entire presentation, which you'll see at the bottom of your screen. Dr. Goldstein will participate in a Q and A session upon conclusion of the presentation for any questions that we do not get to. This evening, you'll receive a response from Cooper Surgical or the speaker following the meeting. I now like to introduce our speaker for this evening. Dr Ethan Goldstein, Dr Goldstein is an obstetrician and gynecologist at Detroit Medical Center Medical Group Tenant Physician Resources. He is also the founder and president of Z Pak Surgical Service PLC, as well as the director of G by in robotics and minimally invasive surgery at Huron Valley Cyanide Hospital. I'll now through the presentation over to our speaker, Dr Goldstein, Dr Goldstein, you now have present your privileges Good evening and thank you all for attending tonight's talk on direct visualization and how it can transform your practice. I hope all of you and your families have been safe, and our making your way safely out of this pandemic and back into practice sure has been an interesting time. So thanks for carving out a little moment this evening to go over something that I think is very, very important. Well, you can really be sure that when we visit our primary care providers for a sore throat that he or she will use no to scope to help make the best diagnosis possible. And this gynecologists, we now have the same point of care ability to evaluate our patients with abnormal uterine bleeding and you'll see advanced by Cooper Surgical provides a convenient, efficient, economical and well tolerated platform to bring direct visualization into your practice. The state of the art uterine assessment tool will provide your patients with the standard of care they deserve and greatly reduce the time from presentation to treatment. So after 12 years of practice, I'm proud to say that I've done independent work only for those companies that have really fundamentally changed or improved the way I practice medicine. And Cooper Surgical stands alone as being one of the companies that I feel is so dedicated to women's health through the tremendous products they offer. An NDC advance only makes their portfolio that much stronger while direct his risk. OPIC evaluation is the gold standard for the diagnosis of abnormal uterine bleeding because it offers an improved sensitivity and specificity for both benign and malignant contribute in pathology. Previously, looking inside the uterus often meant a trip to the operating room or surgery center and usually meant the need for significant patient analgesia or anesthesia, expensive equipment and more time for US physicians. Now, while offices microscopy has been has become more common, it still comes with many of the same limitations, and you see advance is not a history scope as we know it. And that's probably one of the most important things that I can hammer in tonight is that Embassy advance is not a history scope as we know it, because when we think of it as a history scope, it changes our ability to understand how it can be used. Earlier in our pathway for the diagnosis of abnormal bleeding, This portable handheld device simplifies our ability to extend our exam into the uterus without the need for expensive equipment. So abnormal uterine bleeding or a ubi is defined as menstrual flow outside the normal volume, duration, regularity or frequency. And it's very common. It makes up about a third of our outpatient G Y N visits and represents over $12 billion in direct and indirect health care costs. In 2011, Figo, as we know, introduced the palm coding classification system to help better categorize understand the causes of a job. Now, when approaching the ideology that you'd be in our patients, it's important to remember that at least 20% and up to 40% will be the result of structural abnormalities. Well under Metropole, apps are commonly the cause of abnormal uterine bleeding. They could easily be missed by routine trans vaginal ultrasound and blind endometrial biopsy. So even though most polyps are benign overgrowth of just normal tissue, we all know they can also harbor hyperplasia or cancer. Leo McComas or fibroids have a lifetime prevalence of over 60% and or another common cause of bleeding, pain, discomfort and also infertility. Now these two can also be easily missed with blind biopsy. Trans vaginal ultrasound is very helpful for the evaluation of the Avonex A and the geometry. Um, but direct visualization of the uterine cavity is the best way to understand how sub mucosal melanomas they impact the endometrium. Now, when considering the structural causes the palm side of the equation after polyps, endometriosis, Leo myeloma comes the M, which incorporates both pre malignant like hyperplasia and malignant uterine pathology. While we cannot rely only on direct visualization to make these diagnoses, there are specific endometrial features that may lead us to consider one of these ideologies when working up are a ubi patients. I will show you an example of this later on, and direct realization will distinguish global from focal endometrial processes when the process is global. Suction piston biopsy, like with a pipe L is no longer really blind. If there are focal findings, however, then such a biopsy has too high a false negative rate to be relied upon. So the question is, a blind endometrial biopsy is so poor. Why is it still being used as a diagnosis tool for a job? Well, the answer lies. In 1991 a small study was published. They looked at 40 patients with known carcinoma, put an office people one week prior to Total Game a hysterectomy. Stovall reported in this study that cancer was diagnosed in 39 of the 40 patients and published that E M B had an efficacy and accuracy of 97.5%. Now, further investigations that were published after Stovall were never able to support his claim, but rather demonstrated just how unreliable blind endometrial biopsy is in diagnosing and treatment pathology, as can be seen here in the results of the Ngoni study published in 2000 and eight, which compared the sensitivity of out patient history. Skopje with flying endometrial biopsy despite the poor sensitivity of land Endometrial biopsy, it continues to be front and center in the diagnostic pathway for many gynecologists. Now, what's really alarming is that pipe L samples, on average 4% of the endometrial cavity, and the only time an endometrial biopsy is even accurate in detecting cancer is when the tumor occupies at least 50% of the endometrial surface area. So because endometrial lesions are often focal, they can be easily missed without direct visualization. And that's why a cock in 2000 and 12 and their practice bulletin stated that endometrial biopsy is only an end point when it reveals atypical endometrial hyperplasia or cancer. Many of us utilize trans vaginal ultrasound and our diagnostic pathway for a U. B. But studies report that ultrasound may miss up to half of inter cafeteria pathology. Ultrasound continues, like I mentioned before to be important modality for imaging the Avonex and the geometry, Um, but is less sensitive for finding endometrial pathology and is less sensitive than something better that came after sailing sonography or S I s Sana sonography or saline sonography and now office history. Skopje, with its further benefits, have been shown to be superior to trans vaginal ultrasound for identifying intra uterine pathology. So I want you to pay close attention to this slide because it shows that while s I s certainly improves and the mutual evaluation, it has been shown to have inferior specificity as compared with direct visualization. This comprehensive, systematic review of imaging modalities by Mayhew Lacroix was one that was actually required on our maintenance of certification in 2017. And it concluded. And I quote, the history asked, Could be provides direct visualization of the uterine cavity and combined with hissed a pathologic evaluation is the criterion standard in the diagnosis of interviewed anomalies. And this is something when I talk to new doctors who are taking on Ngoc Advance and utilizing any material evaluation with direct visualization earlier in their pathway, it's hard to sort of break away from some of the patterns that were used to and s. I s has been around a long time, and it's a great modality. But as someone once told me, If you're going to put sailing in the uterus, why not exactly see what you're looking at, as opposed to just having a duty grayscale image, and that couldn't be more true, and I'll show you that, uh, to come. This is another really impactful slide because as physicians, we rely a lot on anecdotal experience. But really, it's evidence based medicine that should be driving our decision making. Now, this group easy study was a prospective comparison of the diagnostic performance of trans vaginal ultrasound s s and his ferocity in the detection of endometrial lesions in 105 symptomatic patients. These data clearly demonstrate the superiority of direct visualization and making the correct diagnosis. Patients experience many different uterine disorders, which may appear similar from an outside in evaluation. So whenever you're thinking about traditional history, a Skopje is being more of an end diagnostic tool. The whole point of this talk is to sort of explain a new paradigm of bringing inter cavity reunion assessment to the forefront of our evaluation for abnormal bleeding and that used to be very prohibitive for many reasons, which I'll go into in a few minutes. However, having this portable repos herbal system allows endometrial evaluation to be used easily at any time and really promotes utilization the early in the early diagnostic pathway for abnormal bleeding. So if direct visualization is the best way to diagnose endometrial pathology. Why aren't most of us employing it sooner in our evaluation of abnormal bleeding? Now? Simply put, Until now, throughout, visualization meant a history Skopje, and there are some really big drawbacks to historiography as we know it. Like we mentioned before, many gynecologists take patients to the operating room. But even if you have a traditional rigid scope and tower system in the office, this requires dedicated procedure room. Specially trained staff necessitates longer office visits, is definitely more costly, can be inconvenient for patients and physicians. And it is uncomfortable, often requiring pain management like a para cervical block and also for practices that are considering obtaining offices microscopy equipment. For the first time. There is a considerable cost barrier obtaining a tower and rigid scope system. The most important component of this whole discussion really surrounds the patient. Because patient convenience is paramount, our patients are often putting their own health needs on the back burner to address the many needs of their family members or their career. By the time they present to our office, they really want answers. Now the above diagnostic pathway may be familiar to a lot of us because it's how many of us work up abnormal uterine bleeding. Some practices don't even have ultrasound, which can further prolong the time for presentation to treatment is they have to send these patients out for ultrasounds. Traditional history of Skopje in the O. R. Is also inefficient for the provider, especially if there ends up being nothing found. And there's not one of us that can say they have never taken a patient back and found nothing on history. Skopje has happened to every one of us, so there's got to be a better way. Knowing the endometrial pathology is the cause of abnormal bleeding. And 20 and up to 40% of our patients means that in 60 to 80% of our patients, we have to consider the cooling causes. Now there is just as much significance to finding nothing on direct visualization as there is to diagnosing uterine pathology and ideally, would like to know this before going to the O. R. This is a point I really want to drive home because some people say, Well, what if I put a patient through this procedure in the office and I see nothing? Well let me tell you something in my experience, having a postmenopausal patients in the office and doing an NDC advance and finding nothing but a trophic endometrium you've now just made that patient's day. They don't have to wait around for another procedure or to find out if everything is going to be okay. You've reassured them right there that the endometrial atrophy or politics is more than likely to cause of their bleeding. And I've had countless hugs and tears with patients that are just so relieved to find nothing. So don't think that if you look inside and don't see anything, but somehow this is a failure because you've just saved that patient's possible. Oh, our visit and you've given them a definite pathway by which to take them down. Now this slide is also a really crucial study. Milad study in 2014 makes a compelling financial argument for utilizing office history Skopje to triage those patients that need to go to surgery. In this study, As you can see, 60% of patients avoided the operating room by utilizing diagnostic history Skopje in the office, which resulted in significant cost savings for the patients. Cooper surgical is a name that we're all familiar with because they provide many products that we use in women's health care. Today, our offices, operating rooms stocked their trusted and reliable products, and it's no surprise that they were the ones to bring embassy to market to meet the need for an even easier, patient, centered and affordable way to directly evaluate the endometrial cavity. In 2014, the first generation of Ngoc was released, and in May of 2019, Ngoc Advance, which really improved on the success of its predecessor, finally arrived. So let me take a minute to describe the NBC advance. It really is comprised of three components, the first being a reusable display module with a large, high resolution color LCD touch screen. There is also the sterile single use cannula, which balances flexibility and stiffness for ease of insertion, with a rounded tip that's 4.3 millimeters in outside diameter. The working channel is great for therapeutic instruments that are five French diameter. You have a very ergonomic positioning of a still image and video captured button, which can then transfer to the computer and M R. And you have an ergonomic, pistol like grip handheld design for ease of control and insertion. And then, when you're all done, there's a docking station for efficient image transfer in charging and to see Advance offers a broad range of uses, which may include evaluating patient presentations for abnormal bleeding as we discussed, but also pelvic pain, infertility identifying pathologies such as polyps, fibroids, endometrial, thickening and even atrophy, and performing in office procedures such as transaction of adhesions, small Politicked Amis or removal of retained I E. DS. And there are many patient cases where this makes sense. So now we're going to talk about some cases, and these cases really illustrate the impact of Endo see as a triage tool for direct endometrial evaluation. In Case number one, I want you to look closely. Does this on a history Graham show an inter cavity lesion. It really looks like it does. But upon direct visualization and the same patient, the cavity was normal. So as we know, false positives can complicate and even delay the evaluation and treatment process for our patients. In cases two and three s I s N o c. Both you sailing in the uterine cavity, but clearly there is no substitute for seeing exactly what may or may not be within the endometrium. Similar images on S I s can appear very different from an inside and up close evaluation. So in case number four, it's difficult to see what's truly going on the picture on the right, believe it or not, is that the same patient and even the most seasoned among us can be fooled by an A C as our ultrasound image. This is one of my favorite slides because it does show three imaging technologies ultrasound S I s and NBC advance and the same patient. So with the trans vaginal ultrasound image on the left, it's difficult to see. Is there something going on the center? Is it just thickened endometrium with Isis using some sailing? Now there definitely appears to be a structural abnormality, but it could be a fibroid. It could be a polyp, really not sure. And then, with direct visualization on the right, using embassy advance, we can now achieve the clearest image possible and give the patient the diagnosis of a polyp and explain our next steps in terms of taking into the operating room for politics to me. So if you remember before early on in this talk I mentioned there are times when direct and mutual evaluation may actually help diagnose an immaterial disease. And even though we can always rely on what we see, we have to back it up with a pathologic diagnosis. This isn't on such example. This is actually a patient of mine who was 42 years old, presented with Admiral uterine bleeding. The end of C demonstrated hyper vascular polyps and the endometrial biopsy was actually benign, proliferated endometrium and some pilot point tissue. But because of what we saw on the industry, advanced photographs and the fact that those polyps did look normal, I took her back for a mile shirt, which was consistent with simple endometrial hyperplasia with utopia. She eventually went on to have a hysterectomy and did fine. But this is a really good example of how had I not looked before, I biopsied. I would have missed the diagnosis and delayed the diagnosis for this patient. So after having NBC and NBC advance for some time, I became much more comfortable utilizing and deploying this technology. Uh, sooner in my evaluation of patients with the multitude of conditions. So this is a patient that you may not think about in terms of an early utilization of Ngoc Advance. But this is a perfect patient that I think in the future we will see NBC advance become really the standard of care for the diagnosis of products of conception tissue because we know we all know how frustrating it can be. This is a 21 year old with abnormal uterine bleeding. Eight weeks status post a normal, spontaneous vaginal delivery. She actually stopped bleeding six weeks after delivery and then began having some irregular bleeding after the fact and came into the office. And I think a lot of us, including myself, may have just kind of blown it off. But something just didn't seem right, so I didn't have ultrasound in the office. We all know how inconsistent and unreliable ultrasound findings can be with retain privacy conception. So I consented her for an embassy advance. And now I've done this several more times, and I really have just decided to replace trans vaginal ultrasound entirely and with these patients and go right to undersea advance, because now I know right there and then what I'm dealing with, and we can take them back and do a D and C and get them back with their family back with their newborn, uh, and on the road to feeling better. So, like many of us getting an embassy advance in our hands, it doesn't take long to realize some of the benefits of using this device with some of our I E. D complications. And this is what cases number eight and nine demonstrates. Case number eight is an I. U D retrieval, and we've all put patients through the discomfort of trying to do this blind or with ultrasound guidance. It's very, very difficult. So why not put an embassy advance in, use the working channel with a five French instrument and directly visualize the strings and remove it right there? And then, if patients are so much happier, it takes so much less time and is very, very, very tolerable in the office. So again, somewhere you may not think about using this technology. After a while, you really realize what a broad range of options you have with NBC advance. So in case number 10, this is a 24 year old that presented with a history of SEPTA plastic remote history of septa plastic that really wanted an I u d. And we all know that I E. D. S are contraindicated in patients with cavity irregularities and congenital anomalies because they may not sit properly and they still run the risk of becoming pregnant. So I decided before going any further with this patient, let's just take a quick moment to an embassy, advanced extend my exam into the uterine cavity and lo and behold, as you can see, even though she had a SEPTA plastic that drastically improved the contour of her endometrium and still wasn't sufficient for i e. D placement, she went on to, um, using some other form of birth control in case number 11. This is one of my favorite cases. This was a 51 year old with my garage and fibroids, and she was here to have a pre op endometrial biopsy. And like I said, I don't like doing things blind. So I wanted to look beforehand in my work up with this patient. She mentioned that she had to mid trimester losses in her youth, but never really understood why and actually taking the time afterwards to sit down and show her that she had a congenital heart anomaly in this case, a bike on your uterus Really help that patient understand her unfortunate obstetrical past. So why not leave the best for last? And that's exactly what we did here. This is one of my very favorite slides and videos to show This is a 51 year old who came in with abnormal uterine bleeding and I kid you not the patient was staying there on her phone texting or updating or whatever she was doing, and we just dropped this industry advance in and lo and behold, this beautiful type zero myeloma greeted us and lower uterine segment. And as we traversed around it very easily, she kept texting or doing whatever. We got to see this beautiful fungal pollen, and I can't tell you how much fun this was. Two more sleep. But this was a great example of not waiting for ultrasound and having given the patient and answer right there and then, and I thought she'd be so impressed with this because obviously his physicians were impressed and she was just sort of like Okay, what we have to do and I'm like, you know, But look how beautiful this is. This is absolutely amazing. So the best for last is a combination of a lion, myeloma and, uh, policy. So, as we've discussed multiple times throughout this presentation, this is really about the patient. And then does he advances a very patient centered tool that really helps us do our job better for our patients, say, but it's really even cooler in the fact that it actually has a benefit for us and our practice, our efficiency and economically. Now many of you may not know, but in July of 2017, CMS increased the reimbursement for cpt code 58558 by 237%. And I believe this was done to keep patients out of the O. R necessarily and reduce the overall financial drain on our health care system. Now employed physicians such as myself who generate the same our views, regardless of where we do our procedures. Using NFC advance can stay in the office while providing patients and efficient and more comfortable way for enemy true evaluation. So let me just review with you some of the advantages of embassy advance. It provides instant endometrial imaging guided by direct visualization, which we know is the gold standard. We can even do a biopsy at the same time, using the working channel. There is a clear color display for accurate visualization across a wide range of conditions. Like we discussed. Patients experience little or no discomfort, and I can go into this more later. But I don't use para cervical blocks with these patients, and they'll all tell you that endometrial biopsy is much more uncomfortable than the NDC. It provides an efficient workflow within office exams, and that reduces operating room visits, which is a win win. It's convenient, and you can use it in any room at any time, with an average procedure length of about less than three minutes. And it's also a low cost investment used in really reimbursable procedures. So for those doctors who are looking to start off with offices microscopy, it's a great way to do with NBC advance. So I think we can all agree that direct visualization ultimately provides patients a better way to reach them. Diagnosis Sooner Now we have to also take into account cycle timing, office policies and pear restrictions. But it's even possible to Usembassy advance as a point of care diagnostic tool to immediately extend our physical exam into the uterine cavity. And I'll tell you, this is not something I expect you guys to just pick up and do Day one. And I'll tell you a funny story. And that is when I first got embassy advance. When my partner and I saw before even Cooper Surgical acquired this device, I wanted it like right then and there. It's kind of like the newest iPhone or android you wanted. The next day you want as soon as possible. I saw this NBC and I was like this. I gotta have it so fast forward a few more months we finally obtained the end of see the first generation. It's in my office, and, uh, my rep comes to see me a couple months later and says, You know, how do you like the industry? And I actually had forgotten about it here. I was so excited to get it. I forgot about it. So what I did is I put it right next to my work station and I actually put the hand held piece in my white coat, took my stethoscope out, which I don't use that often. It was just a reminder just so I could start utilizing the this piece of equipment and lo and behold, didn't take very long for me to get very comfortable with it and start employing it as a point of care device. And I've never looked back, so I don't expect this paradigm to change overnight for any of us, it's something that takes time. We have to understand the evidence behind it, which I think we've discussed. And you see the drug visualization is better for our patients and for us. Keep people out of the operating room. And if we do go to the operating room and know exactly what we're going for, it's not something that's going to happen overnight. The learning curve is relatively short, Um, but just put it somewhere where you remember that it's there because it's very easy to forget and go right back into a normal routine. And Demetrio biopsy ultrasound O R. And when you see it in front of you, remember? Yes, You know what? Let's take a look before we biopsy, and maybe we can, uh, definitely changed the way we work up and evaluate our patients. Well, prior to March, I would say that most of us may have just kind of heard of telemedicine that I'm pretty sure that now status Post covid 19 A lot of us are very intimately involved with telemedicine incorporating into our practices. Interestingly enough, telemedicine actually started as a way to provide remote clinical services and an audio or visual format to those communities that were not within reach of medical centers. And it was used to initially to improve health care in rural areas. So now we're utilising telemedicine to reduce patient exposure in clinical settings and make it more convenient in the in this new world that we face. Even though there are multiple telemedicine platforms that exist, and early on in this pandemic were allowed to pretty much do anything that allowed us to have face to face contact and improve patient continuity. It's really important going forward that we pick and stick with one the tip of compliance, and there are many out there. How do we use telemedicine in terms of our assessment for a U B well, much in the way you would talk to a patient in the room anyway. Before doing an exam, you get a detailed history, and telemedicine provides a great way to do that in the comfort of the patients home. So you can initiate your diagnostic pathway by obtaining your history of present illness. And then you can triage that patient to imaging and to see advance both maybe labs, and go from there. And it's really has allowed us to increase, um, our ability to keep our patients safe, to keep social distancing and our practices to reduce the volume initially and just bring those patients in that have to be seen. And it's important. Obviously, as we know, if we have a patient that's got heavy bleeding to the point of having to change a sanitary napkin every hour, or who shows signs or symptoms of Ortho synthesis that those patients need to be seen immediately and sometimes in an emergency setting. So telemedicine may not always be the right, Uh, maybe I'd be the route for everybody, but at least it's a great triage tool to get our patients where they need to be for the next step along the same lines. Embassy Advance provides an efficient way to triage our candidates. Like we discussed, up to 60% of patients can avoid the operating room with NBC Advance, and this can really help reduce the burden on the health care system. If there's anything that we've learned right now, it's that are health care. Our healthcare system has been burdened. And even though we now have more supplies and more ventilators and such, it's still important to utilize our equipment efficiently, effectively and smartly, making sure we're utilizing it for the right reasons. And that being said, now that we're able to do electric procedures in the hospital again, there is such a rush backlog of patients. We're going to find it harder and harder to get operative time. And for me, I'd much rather use my operative time for operative procedures and keep the diagnostic ones like NBC advance in the office. So although he's not related to me, doctor Steven Goldstein, who is arguably one of the world's leading experts and trans vaginal ultrasound and S I s has also embraced direct visualization using Embassy advance and refers to this technology as transformative and the new standard of care for any mutual evaluation. So for those of us who are not maybe so much early adapters but need the stamp of approval from those people that have studied and done a lot of research in this area who have given oral exams, who have written numerous papers and published in a cog and many other, um, many other important journals in our industry, we have a stamp of approval from somebody who is very, very important who really brought to the forefront the use of S I s for office evaluation of endometrial pathology who now sees the benefit using NBC. Advance for direct visualization. So the best. Summarize our wrap up this talk. I think we can all agreed that direct visualization is not only the gold standard for evaluating uterine cavity, but now is the standard of care for early evaluation to help triage our patients to get to a diagnosis and treatment sooner because, as we've learned, direct visualization of the uterine cavity provides a high accuracy of diagnosis. It decreases the time from presentation to treatment, making our patients happier. It improves their care and it maximizes our time as physicians. And since we are so busy and even busier now coming out of this pandemic, it's really important that we're able to keep our diagnostic procedures in the office with a tool that's cost effective, easy to use and comfortable for our patients. So I want to take this time to thank you all for attending tonight's talk. I hope you got something out of it, and I hope that you have more comfort and understanding about using a direct enemy true evaluation with NBC advance earlier and your diagnostic pathway for your patients with a multitude of conditions. Um, I'd like to open up for questions. Thank you so much, Doctor Goldstein. I will now turn the Q and a portion of our program over to Christopher Kahn from Cooper Surgical, who will present the questions to luminary Christopher. The Q and A is all yours. Thank you and good evening. My name is Chris Kahn, and I'm the senior product director at Cooper Surgical, responsible for the industry advanced product line. I'd first like to thank Dr Bronstein for a very excellent presentation, and I'd like to thank each of our audience members as well for taking time out of your busy schedules to this event. I've been calling in question submitted throughout the presentation, and I'd like to do as many of these as possible. If we do run out of time, we will follow up with the individuals who said that any remaining questions. So let's jump right in. Dr. Goldstein, our first question is, how do you explain embassy? Advance to your patients to put their minds at ease? That's a great question, Chris. Um, and I do take the time to explain to them, um, whether it's point of care at the time that they're presenting for the first time with a complaint of, let's Say, abnormal bleeding. I describe it as a way to, like I mentioned in the talk, extend my exam into the uterine cavity. I compare it somewhat to an arthroscope, although obviously it's a little different. I have diagrams up in my office to demonstrate the female anatomy, which many patients are not really aware of, especially the internal anatomy, and explain how different imaging modalities help look at different parts of the anatomy and how NDC is very important to look inside the uterus where other things such as ultrasound can miss things. And so, um, most patients are very understanding of this. Uh, they see the point right away. And I'll tell you what's really great. I did. I did a few today in the office where I turned around and showed the patient video of Of what I found. And both had really interesting findings. And they were just mesmerized to walk out to the same day with that knowledge and understanding of what was causing their issue and then how to go forward from there. So I do take the time. Obviously, we do get informed consent. Um, we go through all that same process. Um, but it's very, very easy. It takes a little time to explain and show them with the diagram exactly what it's for and how we're going to use it. Thank you. The next question is you mentioned covid 19 and the Hello medicine. How do you see undersea advanced? Fitting into your office practice during these times of social distancing? What changes have you done and especially, how do you see this evolving? Well, that's that's great. We kind of touched on that a little bit, but to expand on that, you know, certainly It fits in nicely. Um, you know, uh, first of all to triage are patients who have to go to the operating room because, you know, patients have concerns about going to the hospital, the O R. And they should, um and and so if we can eliminate those people that we don't have to take that we may not find anything in the operating room to do all those diagnostic procedures in the office, we've saved them the anxiety and time, uh, to do that, um, And then when we do go, we know exactly what we're going to encounter. So just the other day, I had a patient who I, you know, evaluated during this time initially with telemedicine as her initial visit, and then decided based on her symptoms pathology and what she was explaining to have her come in to do an ultrasound and possibly an endo, see, And on the day of our ultrasound, it really didn't show much. And I was a little bit may be reluctant to do the end of C, but her symptoms really concerned me for intruding. And, um, you know, pathology, So I did. And sure enough, she had a, uh, about a two centimeter fibroid, uh, mucosal fibroids that we just then took her back to the operating room earlier this week, um, to yesterday to address so again, taking someone who had to go to the O. R for something that was surgical in nature. I knew exactly what equipment I needed. It wasn't a possible possible, uh, scenario taking it more time, more personnel, more equipment. It was very, very quick and efficient. Um, and in terms of in general, in our office, we were quick to hop on under telemedicine. I thank tenant for that because they really wasted no time getting us up and running on that and utilizing patients really like it. I think it's very convenient for people, even our older patients who may not be so tech savvy. Um, some of these newer technologies are pretty user friendly. Um, and when explained, they're they're very happy to sit in the comfort of their home, to not have to go out and about and to go through the initial process of the history of present illness. So we know exactly how to proceed good, Thank you. Our next question. It's actually two questions that are related. How do you handle pain management the same day and a half years? And also do you do any other pre medications? Do you use side attacks? These are questions Chris that we hear all the time, and it's, uh yeah, give me one second. So, first of all the Cytotec question, let me go backwards and how you asked it. There are certain patients that are not candidates for, you know, first of all in office procedures. So knowing your patients and knowing their pain, threshold and understanding who may or may not fit that category is important. That being said, I would say most patients can tolerate an end of C in the office. Um, because most of time we would do it and mutual biopsy in the office and undoubtedly endometrial biopsies more uncomfortable. Cytotec is something I will use for a patient. If I know they're coming in with post menopausal bleeding, I'll try to Anyway, um uh, the staff will direct them to me ahead of time to get music process. I use 200 micrograms the night before and the morning of their procedure. Um, in terms of pain management, whether it's a point of care or, um, you know, coming in for a scheduled Endo. See, it's ibuprofen. Um, you know, at the time that they arrive, Um, I don't use para cervical blocks. I mean, I could count on one hand and the hundreds of cases I've done where I've used a parasitical block, parasitical blocks tend to be uncomfortable. Um, a lot of people don't really know how to do a good para cervical block or uncomfortable. I know many of us are just not comfortable doing office based procedures in general, but you'd be surprised if you put I u d s in or you do any mutual biopsies. Ngoc really is less uncomfortable than these common procedures and really requires nothing more. That's an ibuprofen that will kick in post procedurally to allow them some relief from cramping. Thank you. How do you achieve and maintain cavity distension? And can you specifically talk about the use of an I V bag versus syringe? Um, certainly. So I started off my pathway with N O. C. The first generation using, uh, 60 cc 60 cc syringe. We'd have maybe an extra one or two on hold if we needed it. I have found over the years that a 500 or leader bag of sailing on pressure is definitely superior to that. It allows me to have less personnel in the room. So it's just me and the Emma. Reducing exposure risk reducing traffic in the in the in the room, making the patient more comfortable. It allows me to have control the in flow of the saline, so the distension and relaxation of the cavity, depending if they have a patch list or pair of cervix. Um, you know we can control the flow and gives us more time, especially if we see something that we want to biopsy or remove instead of having to kind of fiddle around with more than one thing that's just happening, just like it would in the O. R. And then you can take the by French instrument guided down the working channel to take care of what you need to. Um, actually, you can reduce the flow at that time to reduce the discomfort until you are ready to your biopsy. So just having that control and that dramatically improves visualization. I think, um, I used it today, actually, on a patient who was still, um, having bleeding. And it was just because scheduling for this patient, she really wanted to have this evaluation today. Uh, and so having that saline bag running allowed me to kind of flush out. Um, you know, some of the endometrial tissue to better see what was going on. So, you know, patients who have larger uteruses or who are like this who are bleeding, um, also very helpful. So just having that bag, I think, eliminates that question of Well, I need more, uh, and frees up hands to do more while you're looking okay. Thank you. How does one handle the procedure and then the reimbursement code Also, when doing a biopsy after seeing pathology on the industry visit? So that's going to be regionally specific based on payer mix. Um, and you know, that's a great question. I I have All my patients are pre, you know, pre screened by the front, uh, in terms of those patients, they know what to look for. If a patient calls coming with the problem visit who may or may not even Endo C. And even if I find that in talking to someone that I think they need one, I make sure the front goes through the process to get authorization. If their insurance allows it, then we will go ahead and do it. And the patient obviously will understand what but financial responsibility may or may not have at that time. You know, we explain to them in this era of high deductible plans, it's not uncommon for patients, especially early on in the year have to pay more for procedures. But I really can't tell you that I've had anybody complain about that because again they understand why we're doing it. It gives them an answer that much sooner, you know, take. You know, when you do something like this point of care or sooner in the path where you've reduced the number of visits that they're having to make to get to the end diagnosis and resolution, that means the less time they have to take off of work or the less they have to try to get childcare and the less inconvenient. So even though there may be an expense and there is often an expense associated with it. They're willing to accept that because really getting something of value for it. Um, so it's it's never been an issue. And I check in with my builders every once in a while. Hey, we had a pushback. Patients sometimes, you know, we all know have we'll get to less finally, with a question about hey, I got this bill for whatever I've gotten those questions for lab bills or for weird cultures or things like this. But never have I gotten a question or concern about payment or reimbursement for NDC advance. Okay? You showed a number of interesting cases, but you didn't show any case where you avoided surgery except for a trophic vaginitis. Can you Do you have examples? Can you give examples of avoiding surgery? Well, sure. I mean, absolutely. There's, uh Well, there was a couple of cases in there where if you looked at the S I s image or ultrasound image, it looked like there was something. And, you know, if you didn't have s I s in the office or even if you did and you saw some of that cavity irregularity or it looked like, um, abnormal tissue, you might have taken that patient to the operating room and a lot of us have. I certainly have to find really nothing. So those are those are examples themselves. But the postmenopausal leader with the A trophic endometrium is one example. Another example would be someone who comes in. Um, you know who you think may have interviewed and pathology. You take a look and you see nothing at all. No matter what her age is, you're not taking her to the operating room for the same diagnostic procedure. And that that same visit you say, You know, let's go ahead and check a hormone panel. Let's check labs, uh, see where things are at because, you know, you're you're one of those 20 to 40% that don't fall into the palm side of the equation. And there's some other issue going on that we need to then try to hunt down an address. So no, correct. We didn't really show much, except for the, uh, a trophic endometrium for the placement of possibly because I think that's a really profound one and one that I can really relate to in terms of patient satisfaction, Uh, and really kind of made the point that I was trying to explain of finding nothing is just as important as finding something, especially in these patients. Um, so, yeah, if it's a younger patient and you look in and don't see anything of, you know, um, concerning lesion wise, uh, I'll still do an endometrial biopsy a lot of times because let's say we're just kind of mine came to mind as somebody I know. Who Young gal, 38 who just last week was having has a next one on and was having unexplained bleeding. And, you know, we worked up ultrasound was fine. Labs are fine. Um, you know, she had the next month for quite some time, was very happy with it. I was expecting her to find a trophic endometrium. Because sometimes progestin only birth control can do that. That was not the case. Um, so I didn't end to see, um, and didn't show much at all, To be honest with you. A little bit of hyper emmick endometrium. And, you know, I sort of said, I don't know. I don't have much for you. This is what we saw. I did a pretty thorough, um, you know, uh, kind of a DNC with the explorer cure. It got a lot of tissue back came back. Chronic endometriosis. So that's another example of something where you may not you know, you know, you don't see anything, but you now save that patient on the operating room and also come up with a diagnosis that you can treat and improve their symptoms. Ontology. Thank you for this next one. I will combine. Combine two questions into into one What disposables are needed for a procedure with Ngoc, including instrumentation. And what advice do you have for first time users? Good questions. So, disposables. Really? Um, you know, we used under buttocks drape the actual NDC cannula like I showed in the in the presentation there is disposable, um, the the extension tubing and saline bag. Obviously, those things, um, everything else, you know, I use a disposable speculum, sometimes with the light on the end of it. Sometimes I don't like to use an open side. Expect because you can take the open side, expect out, and then patients more comfortable. Plus, you have more flexibility to move around and look while the patients more comfortable. Um, repeat the last part of the question. Well, first time users advice. I would utilize your, um, your local Cooper Surgical embassy reps because they are invaluable in terms of their experience. Um, their knowledge base and their ability to sort of help you through that learning curve. Um, and so, you know, the first 5 to 7, maybe even 10 cases having them, um, available trying to, you know, maybe book a few cases in one day. Um, so that you can kind of just get that repetition down. That familiarity kind of work out the kinks, so to speak is really important. And, you know, in terms of trying to get comfortable with it, think about utilizing in any patient that you would do an endometrial biopsy. Because, really, as the evidence shows, we really shouldn't be relying on blind and mutual biopsy. Nowhere else in medicine that we just blindly biopsy things. Oh, she's got a breast lesion. Let's just blindly math, put a needle in the mass. We don't do that. We image and guys have guided biopsies and everything else we do. Why not have a guided biopsy in the uterus? It just makes sense. So think about it that way. Okay? This patient needs an endometrial biopsy. Well, let's go ahead and take a look first. Um, that would be my advice. Thank you. How do you handle patients with circles? That's another great question. So, um, again, pre medicate in these patients with Cytotec and this is a 4.3 millimeter device and hydro dissection is really important. So I start off. I used the OSCE finder. Oz Finder allows me It's actually another Cooper product that I never knew about before I started doing Endo CNBC advance. That's a real flexible soft tip dilator that really allows me to. Basically, it's my It's my pre op pre procedural assessment device. And if I can pass that easily enough that I know I can get an embassy. Um, and even if I can't and there have been times, like, even this morning, and it's kind of funny that this happened on a day I actually had some some cases in the office had a menopausal woman with 59 year old post menopausal bleeding, and she had the longest, most tortuous, uh, cervical canal. As a matter of fact, at one point, I actually thought the internal cervical loss was one of her, you know, trouble Austria. And I just maybe missed the other one. Or maybe she had a, um, an anomaly. I spent time coming back and forth and back and forth, and sure enough, that was actually the internal cervical loss. And I just kind of gently pressed through and voila. Here we were in the cavity assessing this, um, this lesion that she had her primary care had picked up on ultrasound. So the hydro dissection is key. If you can get the finder to start the way and use the hydro dissection with the with the cannula, Uh, it does it for you, and it's beautiful, just kind of opens up that pathway. So I find it actually easier to do it with this because you also have that pistol grip that you can kind of used to move around the curves and turns and the end of cervix to overcome most stenosis. Okay, if you have an endometrial polyp and you're trying to remove it with in advance, how do you manipulate your instrument to optimize removal? Well, because of the way that the the instrument comes out below the device is basically just positioning. Um, you know, with with the pathology as clear in front of you as possible, um, and then, you know, positioning that, you know, watch So you can watch the the grasshopper or whatever you're using A spoon, Forceps come out of the tip and and then you got to move things together. So you kinda have to to sort of marry your hands together. It's kind of similar to how we used to do issue procedures, how we'd have to kind of, you know, married the scope and the hand that was feeding the device at the same time. It's no different than that, but, you know, we're surgeons. And so, as surgeons, you know, we're very capable and proficient and doing things like this. Um, and I think having the ergonomics of the grip and the screen now in front of us like this with the working channel where it is, it makes it very easy and sort of in intuitive as to how we, uh, moving position to grasp pathology. It's important to remember that, unlike maybe with a rigid, wider bore scope that we have to kind of take things out together. So once you've actually grasp the pathology, both hands have to come out together, and then you go ahead and drop it off and then come back in if you want to, So don't put it. Won't. It won't put you and pull through the cannula by itself. Thank you. How do you handle sterilization of operative instruments when you're faced with back to back cases, or do you use disposal points? Um, so, like I said, most of the stuff we uses disposable. Um, you know, we use disposable speculum. So, um, and the NDC is charging on Jack, you know, we just take it off and run with it. Um, you know, has enough juice for for our day. Uh, we may do, you know, up to, you know, for four or five cases, I think the most I've done it six in a day. And a lot of those cases are being sent to me. So it's not like these are just coming out of the woodwork. Um, and so we're looking at, you know, I use it's an actual, um So sometimes we may I've had places where we've run out soon. Oculus and we have to switch to Alice. Is, uh, to do what we need to do for cervical stabilization or someone's, you know, Paris. Enough spatulas. Enough. You don't need to do that. That's fine. Some people prefer not to. Um, so you know, I haven't really had an instance where I've run out of things like this. The the we do have enough of the sterilized five French instruments. I think you know, three or four. We have two offices in each office. Uh, now, I know Cooper has come out with a disposable, um, operative instrument grasshopper, to fit through that working channel, which I'm eager to to use. Um, so I think that will help, you know that we're not having a turnover? Um, reusable instrumentation if we have a really busy day and Christmas. Chris. Sorry to interrupt. We have time for one more question this evening. Okay? For patients with high out of pockets, Do you do the procedures in office, or do you go straight to the O. R. To avoid two procedures? Well, you know, that's that's a great question. And that's sort of a judgment call. But if I can, you know, in out of pocket expense. Coming from my office doing an endo see, with one code is a lot less than hospital. Um, you know, with a pre op in the anesthesia anesthesiology fee in the O r fi facility fee is much more of a burden than basically doing it in the office. So, um, you know, if I against the benefits of knowing exactly what I'm going to be seeing, um, you know, knowing if I'm going to do an operative, more isolation type procedure, which blade I need to have what set up I need to have which fluid management system I want having all that, you know, knowing that ahead of time makes me more efficient in the operating room and saves time on that side as well. So you know, again we go through with our patients. We explain to them the importance of it, give them the option, but said most people are very willing and happy to have an answer and a pathway right there and then. And that's, uh that's why I find utilizing mutual evaluation with NBC earlier in the pathway to really be superior to how we used to do things. Thank you. Thank you. Once again, Dr Goldstein, for your excellent presentation and for sharing your in depth experience with our audience. Created by Related Presenters Ethan Goldstein, MD, FACOG Director, Robotic and Minimally Invasive GYN SurgeryHuron Valley-Sinai Hospital, Commerce Twp. MI
