Endometriosis is currently defined as the presence of endometrial glands and stroma outside the uterus. Unfortunately this definition, whilst widely utilised, is also widely recognised as only a part of the underlying disease process. At this point in time the underlying etiology of endometriosis is unknown despite large bodies of research. The simplistic use of the current definition creates major problems for patients, healthcare workers and society. It has been known for some time that there are multiple other abnormalities present in individuals with endometriosis and these abnormalities have the potential for clinical effects. There is therefore an expectation mismatch in the way the disease is represented. If endometriosis is only ectopic endometrium, then removal of this tissue is all that is required to deal with it. Whilst often treatment is suggested as either medical or surgical it is becoming increasingly apparent that surgery alone is insufficient and that ideally progestogenic support ideally via pregnancy or via some other form such as Mirena results in better long term outcomes. Surgery, when indicated, should involve excision of all the disease. Possibly the current definition should be expanded to incorporate some of the myriad other abnormalities these patients have such that we can begin to address some of their other concerns.
There are multiple abnormalities not covered in the definition but which have been noted in research. The following paragraphs gives a very brief outline of some of the issues in an attempt to illustrate that the simple current definition is inadequate.
The eutopic endometrium in patients with endometriosis is known to be abnormal. One feature is the presence of small unmyelinated nerve fibres identified by a specific nerve marker, PGP 9.5 1. These are not found to any great extent in a control group without endometriosis. It is postulated that these nerve fibres may contribute to the pain of endometriosis and may also be present adjacent to endometriotic lesions.
There is substantial evidence to support alterations in both cell-mediated and humoral immunity which could contribute to the pathogenesis of endometriosis. The disease has been considered to be autoimmune and has been linked with the presence of autoantibodies, other autoimmune disease and possibly with recurrent immune-mediated abortion2.
A genetic association has been identified3. Genome-wide association studies have also identified loci associated with endometriosis and also other traits such as fat distribution 4. The latter may help to explain the often seen relationship between the presence of endometriosis and low BMI5.
Advances in the field of epigenetics adds further information to the underlying disease process with endocrine disruptors such as dioxin and Bisphenol A implicated in the development of endometriosis 6,7. These findings further demonstrate that surgery alone is unlikely to be the key to complete treatment.
Epidemiological studies of large populations provide further evidence of the myriad of associations with other clinical diseases and endometriosis. Cancer associations include breast, ovary and melanoma. Other chronic disease associations include cardiovascular disease and autoimmune diseases such as asthma, atopy, lupus and rheumatoid arthritis8-10. Endometriosis sufferers often note irritable type bowel symptoms and it may be the underlying pathology in many patients who have been diagnosed with irritable bowel syndrome11.
In future is possible that endometriosis may be considered an obstetric disorder. One recent large scale linkage study has revealed increased rates of miscarriage, ectopic pregnancies, prematurity, placenta praevia, antepartum and postpartum haemorrhage12. It was postulated that these outcomes may relate to endometriosis induced inflammation in the pelvis and structural and functional changes within the uterus. A further hypothesis along this line has indicated that endometriosis may be associated with a decreased risk of pre-clampsia13. It has been postulated that menstruation preconditions the uterus for successful pregnancy and that endometriosis via its effect on the eutopic endometrium assists this process14. It may thus be that endometriosis assists pregnancies for younger patients particularly in the teenage years but may be problematic for older patients.
It has been known for some years that laparoscopic surgery for minimal or mild endometriosis improves pregnancy rates15 and meta-analysis reveals that endometriosis decreases IVF success rates for patients with endometriosis16. More recently data have emerged confirming the same if not more pronounced effect for patients with more advanced disease. It is probable that surgical treatment particularly of severe endometriosis significantly increases the chance of both natural and assisted pregnancy post operatively. This also includes patients with bowel involvement17,18.
More recent concern has surrounded the issue of ovarian reserve in patients with endometriomas. Several studies have suggested that cystectomy may result in an up to 50% reduction. There has been a change in thinking in several units to be more conservative with the ovary with the possibility of staged procedures encompassing oocyte or embryo vitrification and then definitive surgery prior to embryo transfer19.
In relation to assisted conception cycles evidence is emerging around the world that frozen transfers may be more successful than fresh transfers as a consequence of the adverse effect of ovarian stimulation on the underlying endometrium. Studies have revealed improved maternal and perinatal outcomes in the frozen cycles as compared to the fresh transfers20. In the knowledge the underlying eutopic endometrium is abnormal in patients with endometriosis it would not be unreasonable to consider these differences more marked in the setting of endometriosis and possibly this sub group would benefit even more from frozen transfers.
Clearly further data are required but the evolving nature of the wider implications of a diagnosis of endometriosis should be considered when discussing these issues with patients so that expectations are being managed accordingly.
1. Al-Jefout M, Dezarnaulds G, Cooper M, et al. Diagnosis of endometriosis by detection of nerve fibres in an endometrial biopsy: a double blind study. Hum Reprod 2009; 24(12): 3019-24.
2. Olovsson M. Immunological Aspects of Endometriosis: An Update. American Journal of Reproductive Immunology 2011; 66: 101-4.
3. Painter JN, Anderson CA, Nyholt DR, et al. Genome-Wide Association Study Identifies a Locus at 7p15.2 Associated With Endometriosis. Obstetrical & Gynecological Survey 2011; 66(4): 214-6.
4. Rahmioglu N, Macgregor S, Drong AW, et al. Genome-wide enrichment analysis between endometriosis and obesity-related traits reveals novel susceptibility loci. Human Molecular Genetics 2015; 24(4): 1185-99.
5. Ferrero S, Anserini P, Remorgida V, Ragni N. Body mass index in endometriosis. European Journal of Obstetrics Gynecology and Reproductive Biology 2005; 121(1): 94-8.
6. Zhang J, Huang FY. Epigenetics: an emerging research field of infertility associated with endometriosis. International Journal of Clinical and Experimental Medicine 2016; 9(10): 18883-9.
7. Borghese B, Zondervan KT, Abrao MS, Chapron C, Vaiman D. Recent insights on the genetics and epigenetics of endometriosis. Clinical Genetics 2017; 91(2): 254-64.
8. Harris HR, Costenbader KH, Mu F, et al. Endometriosis and the risks of systemic lupus erythematosus and rheumatoid arthritis in the Nurses’ Health Study II. Annals of the Rheumatic Diseases 2016; 75(7): 1279-84.
9. Kvaskoff M, Mu F, Terry KL, et al. Endometriosis: a high-risk population for major chronic diseases? Human Reproduction Update 2015; 21(4): 500-16.
10. Poole EM, Lin WT, Kvaskoff M, De Vivo I, Terry KL, Missmer SA. Endometriosis and risk of ovarian and endometrial cancers in a large prospective cohort of US nurses. Cancer Causes & Control 2017; 28(5): 437-45.
11. Maroun P, Cooper MJ, Reid GD, Keirse MJ. Relevance of gastrointestinal symptoms in endometriosis. AustNZJObstetGynaecol 2009; 49(4): 411-4.
12. Saraswat L, Ayansina DT, Cooper KG, Bhattacharya S, Miligkos D, Horne AW. Pregnancy outcomes in women with endometriosis: a national record linkage study. Bjog-an International Journal of Obstetrics and Gynaecology 2017; 124(3): 444-52.
13. Brosens IA, De Sutter P, Hamerlynck T, et al. Endometriosis is associated with a decreased risk of pre-eclampsia. Hum Reprod 2007; 22(6): 1725-9.
14. Brosens JJ, Parker MG, McIndoe A, Pijnenborg R, Brosens IA. A role for menstruation in preconditioning the uterus for successful pregnancy. American Journal of Obstetrics and Gynecology 2009; 200(6).
15. Marcoux S, Maheux R, Berube S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian Collaborative Group on Endometriosis [see comments]. New England Journal of Medicine 1997; 337(4): 217-22.
16. Barnhart K, Dunsmoor-Su R, Coutifaris C. Effect of endometriosis on in vitro fertilization. FertilSteril 2002; 77(6): 1148-55.
17. Wills HJ, Reid GD, Cooper MJW, Morgan M. Fertility and pain outcomes following laparoscopic segmental bowel resection for colorectal endometriosis: A review. Australian & New Zealand Journal of Obstetrics & Gynaecology 2008; 48(3): 292-5.
18. Nesbitt-Hawes EM, Campbell N, Maley PE, et al. The Surgical Treatment of Severe Endometriosis Positively Affects the Chance of Natural or Assisted Pregnancy Postoperatively. BioMed research international 2015; 2015: 438790.
19. Psaroudakis D, Hirsch M, Davis C. Review of the management of ovarian endometriosis: paradigm shift towards conservative approaches. Current opinion in obstetrics & gynecology 2014; 26(4): 266-74.
20. Bhattacharya S. Maternal and perinatal outcomes after fresh versus frozen embryo transfer-what is the risk-benefit ratio? Fertility and Sterility 2016; 106(2): 241-3.
The tables display all procedures and major complications to the end of May 2017. It should be noted that considerable care should be taken when interpreting these numbers. Associate Professor Cooper operates on a large number of patients with significant endometriosis and the risk profile of this group of patients for complications is higher than the general population. Secondly he may not be aware of some complications and as such these figures may under represent the true numbers.
Since commencing practice as a specialist gynaecologist in 1995 Associate Professor Cooper has undertaken over 10,000 operative procedures. He has performed over 5,500 laparoscopies most being of an operative rather than a diagnostic nature. Over the last 10-15 years his practice has predominantly moved towards endometriosis and he has performed over 1,500 interventions for the excision of endometriosis. Of these at the time of writing 388 have had bowel resections of various forms of being performed. These procedures represent the most difficult and complex of gynaecological surgery including cancer. The significant complications and issues are listed in the table.
There were 3 significant vascular complications all of which were treated by immediate laparotomy and oversewing of various vessels.
Fourteen patients required laparotomy to deal with some form of issue involving the bowel. There was an overall colostomy rate of 12 with a rate of 0.2% of all laparoscopies. Ten of the stomas related to patients with endometriosis and 6 of these were planned intra-operatively with a rate of 0.36% per endometriosis patient. Four unplanned stomas were performed in the post operative period at a rate of 0.24% Two patients who had procedures unrelated to endometriosis required stomas with an overall rate of 0.04%. An additional patient with endometriosis had a recto-vaginal fistula which healed spontaneously (0.02%).
Three patients required laparotomy for bladder injuries (0.05%) and of these 1 patient had endometriosis (0.06%).
Twelve patients required some form of intervention in relation to the ureter. All of these patients had endometriosis as an underlying condition. Delayed recognition of the injury occurred in 2 patients (0.12%) and 10 required some form of intra-operative repair or stent. Five stents were placed as prophylaxis to ensure against a possible leak in the post operative period.
Twenty nine patients had to return to theatre with an overall rate of 0.28%. These included the 3 bladder and 4 bowel patients mentioned above. Other issues included 7 post operative bleeds, 7 abscesses and infected areas, 2 patients who ultimately had no abnormality detected, 1 patient with a small bowel obstruction following a bowel resection, 1 omental herniation at a trocar site, 1 perforation at a hysteroscopic myomectomy, a vault dehiscence in a patient who initiated sexual activity in the early post operative period following a hysterectomy, a recurrent Bartholin’s abscess and 1 patient who had a microscopic needle identified in the recovery room following laparoscopic tubal reversal with a needle which had initially been counted as outside the patient.
There were no patient deaths. The overall major complication rate was 0.36% (38/10423). The rate per laparoscopy was 0.64% (35/5487). Specifically for endometriosis cases the rate was 0.78% (13/1674).
Associate Professor Cooper believes this complication profile is appropriate for the type of surgery he performs and is happy to discuss this analysis.
Occasionally patients ask if they can be put in a particular time on a list usually first in the morning. I usually attempt to accommodate these requests although other considerations such as the availability of equipment, staffing and health issues of other patients also come into play. More recently I was reading the book “Thinking Fast and Slow” by Daniel Kahneman. Some of this work resulted in the 2011 Noble Memorial Prize in Economics for Kahneman. In the book he describes a paper published in The Proceedings of the National Academy of Sciences describing how Shai Danziger and colleagues followed 8 Israeli judges for 10 months as they ruled on over 1000 applications made by prisoners to parole boards. The plaintiffs were asking either to be allowed out on parole or to have the conditions of their incarceration changed. The team found that at the start of the day the judges granted around two thirds of the applications before them and as the hours passed that number fell sharply and eventually reaching zero. The clemency returned after each of two daily breaks during which the judges retired for food. The approval rate shot back up to near its original value before falling again as the day wore on. Kahneman opined that this decision process mostly related to blood sugar levels.
If true this finding casts significant concern on the structure of the judicial system and clearly many others also. The situation can probably be stretched to the operating theatre and the performance of a surgeon during the course of the day. It is tempting to think that food is a major issue but other studies as outlined in an article aired in The Economist reveal that decision making is mentally taxing and if forced to keep deciding things people tend to get tired and start looking for easy answers. Whilst it would be nice to consider surgeons as simply technicians clearly they are humans and subject to all sorts of biases which may interfere with decision making.
The medical literature has attempted to look at performance after surgeons have been on call the night before with variable outcomes. I am not aware of any strong studies from a surgical perspective in relation to meals and rests during the day although common sense suggests it is probable that surgeons perform better after a rest and a meal. My personal view is that some degree of exercise before a list is also beneficial. I suspect those patients wanting to be first on the list are asking the right question. It is probably best for patients to have their surgery either first in the morning or immediately after a lunch break.
A recent editorial article in the American literature has called for the separation of obstetrics from gynaecology. This sentiment has been raised increasingly around the western world as a consequence of a decrease in the overall number of operations performed and an increase in the number of surgeons.
The situation has arisen as a result of multiple factors. Technological advances such as the development of the Mirena IUCD and improved imaging have meant a dramatic reduction in the number of procedures performed. Hysterectomy rates in the UK have more than halved with similar changes in both Australia and America. The number of laparoscopies and overall procedures has also been falling. Procedures once exceedingly common such as laparoscopic sterilisation are now virtually never performed. At the same time there has been a significant increase in the number of trainees and ultimately surgeons. The American literature looking at the period from 1979 to 2006 revealed a 46% decrease in the number of operations with a 54% increase in the number of surgeons and an 81% decrease in the number of operations per fellow. Similar statistics are available for Australia.
One measure is the number of hysterectomies per gynaecologist. In the United States from 1980 to 2007 this number has fallen from 28 to 9.8. I reviewed the Australian literature recently and the Medicare data as of 4 years ago revealed the average number of hysterectomies per fellow and trainee was less than 8. Another way of looking at this would be to consider another operation. If the average number of caesarians per fellow was only 8 it would be laughable and clearly dangerously inadequate. It is quite clear that in the current climate the average gynaecologist does not perform sufficient surgical procedures to safely maintain skills and it is completely untenable that they should be training upcoming surgeons.
I agree with the Americans. It is time that obstetrics and gynaecology split.
Our recent paper has just been published: Bowel and bladder function after resection of deeply infiltrating endometriosis. Responding to our questionnaire, women reported significant improvement in urinary and bowel dysfunction postoperatively.
Clinical indicators to end June 2013. During this period I had major shoulder surgery and did not operate for almost 3 months. As a consequence the numbers are less than normal. There was one patient who was transfused unexpectedly. She had very substantial endometriosis and required a significant section of bowel to be removed and a semi-planned stoma. She ultimately recovered well and the stoma has been reversed. A second patient had substantial endometriosis with the rectosigmoid adherent to the posterior aspect of the uterus. She underwent hysterectomy and the bowel was thought to be only superficially involved so no area of bowel was removed. The bowel was leak tested successfully but on postoperative day 6 a rectovaginal fistula developed and she required a defunctioning colostomy.
A recent consensus statement on endometriosis and infertility indicates that some women may benefit from a combination of assisted reproduction and surgery. Unfortunately the data are limited and somewhat conflicting. This is not uncommon when surgery is involved as there is inevitably a degree of operator (or surgeon) dependence. It is self-evident with diseases such as endometriosis that the surgeon can be a major differentiator in terms of successful operations. The situation is vastly different from the removal of an appendix or a gallbladder where it is easier to define success and also easier to track and define complication data. Endometriosis can take many forms and stages and it may at times be difficult to perceive the extent of disease. By way of example I am quite sure that many patients have been labelled as having pelvic inflammatory disease (PID) when in fact they have severe endometriosis with cul de sac obliteration which has not been recognized as such. Experience may not necessarily be advantageous. Many surgeons may have had a long “experience” dealing with endometriosis but if their understanding of the disease and surgical techniques are limited outcomes will be suboptimal. At this time, certainly in Australia, most generalist obstetricians and gynaecologists would consider that they have the surgical skills to cope with all but the most severe cases. Whilst this may have been the case in the past I believe the situation is evolving rapidly particularly in the management of those infertile patients with severe endometriosis. It is worth considering that in virtually every other surgical discipline the trend has been to move towards sub specialization. By way of example I have just had my shoulder operated on and made very sure my orthopaedic surgeon only operated on shoulders.
Ovarian endometriosis or endometriomas (chocolate cysts) are fortunately rare but represent the more severe stage of disease. They are rarely isolated, often associated with more significant disease and it is not uncommon for the bowel to be involved. In some respects they serve as a marker for severe disease and certainly bowel involvement should be suspected. In this group in particular it makes sense to actively look for the most common form of bowel involvement. Recently new techniques in ultrasound have allowed the identification of bowel involvement although this can be difficult particularly in the presence of large endometriomas. The technique offers the tantalizing possibility of decreasing the number of diagnostic laparoscopies that are performed.
The published literature in relation to the treatment of ovarian endometriomas particularly with regard to fertility is limited. It is controversial as to whether removing endometriomas improves pregnancy rates although there are data to support this and the Cochrane review lists ovarian cystectomy as a preferred surgical option to simple drainage and ablation. The data have revealed an increase in the pregnancy rates when the endometriosis is removed and ovarian cystectomy performed.
Recent data from our own unit and others around the world have unfortunately changed the dynamics. Previously the surgical plan was to deal with all of the endometriosis including the ovarian cyst and possibly bowel resection and then attempt spontaneous conception. Should this not have occurred within a timely fashion IVF was then employed. This new data creates particular difficulties with this strategy. It appears there is an up to 50% decrease in the AMH level of patient’s with endometriosis and this clearly has significant effects in terms of ovulatory reserve and the subsequent chance of conception. This is a particularly difficult scenario if people already have a depressed AMH or for those patients over the age of 35 where age is also depressing the levels. It then becomes exceedingly difficult to decide the most appropriate path of management. This group in particular would benefit from consulting with a practitioner who practices both surgery for endometriosis and assisted conception. We have been contemplating simple drainage of the endometrioma with, if at all possible, removal of further endometriosis encountered within the pelvis (including bowel resection) and then either spontaneous conception or IVF. Particularly in those with limited ovarian reserve we have been utilising strategies to as far as possible decrease any ovarian damage thus further decreasing ovarian reserve. At times this strategy may require resort to repeat surgery, hopefully following conception, to deal with the ovarian endometriosis. In those patients who are younger or not in a relationship further difficulties are encountered and this may be a group where oocyte vitrification (egg freezing) may be a reasonable strategy to consider also.
At this stage the situation is far from clear as to what the preferred approach is although increasingly I am beginning to treat ovarian endometriosis more conservatively especially when fertility is a concern.
It has been well established that oncogenic (cancer causing) strains of HPV are the cause of cancer of the cervix and in fact it could probably be considered a form of sexually transmitted disease. Over the last few years vaccines have become available (Gardasil and Cervarix) for the prevention of HPV related cervical cancer. Gardasil covers 4 strains of the virus and Cervarix covers 2. Within Australia Gardasil has been made available for young women up to the age of 26 on the Pharmaceutical Benefits Scheme. It is expected that over the next few years we are likely to see a fall in abnormal pap smears (pre-cancer) and frank cancers of the cervix and early indications in my practice over the last few years would support this.
A recent patient who attended with an abnormal pap smear asked about other types of cancers implicated with HPV which prompted this blog. Broadly there are a large number of strains of HPV and certain strains (HPV 16 and 18 in particular) have been associated with the development of cervical cancer and increasing evidence is indicating these agents in the development of oropharyngeal and anal cancer.
Oropharyngeal cancer is now the sixth most common cancer in the world and over the last few decades there have been an increasing number of oropharyngeal cancers in a younger population. It appears there may be two types of this cancer. Firstly a traditional HPV negative type cancer which appears to be associated with the use of tobacco and alcohol and secondly an HPV positive form which is linked to oral sex. Epidemiological studies indicate increasing lifetime numbers of vaginal sex partners (26 or more) and oral sex partners (6 or more) significantly increase the risk. Unfortunately there is no screening test for oropharyngeal cancer as the early phase of the disease is not well understood.
HPV has also been associated with an increasing number of anal cancers and again the risks relate to sexual activity with increasing numbers of anal sexual partners heightening the risk. Recipients of anal sex whose partners are HPV positive are at a higher risk. There have been attempts to screen with this and in some clinics anal pap smears are performed as there does appear to be a pre-invasive course to this particular cancer.
With this increasing evidence there have been calls around the world to extend the range of vaccination to include boys and young men. Australia has recently introduced HPV vaccination for boys. There is also evidence to show that vaccination is useful for both men and women over the age of 26 although it is known that the effectiveness of the vaccine decreases with age. Depending on your circumstances and past exposure to HPV, it may be reasonable to consider vaccination for men and women over the age of 26.
HPV vaccination is likely to lead to a reduction in rates of cervical, oropharyngeal and anal cancers. If you have not already been vaccinated it is certainly worth considering.
Please note that the current figures to the end of 2012 should be interpreted with caution. In particular it is possible that the reoperation rates reflects a lower number than reality as some patients may have had repeat surgery of which A/Prof Cooper is not aware. Some patients may have had more than one procedure.
A significant number of patients had severe endometriosis (501) and this will influence the complication rate.
Significant injuries in the series include the following:
1. Vascular: 3. Two damage to the right common iliac vessels (one with a trocar, the other from dissection adjacent to the great vein in a patient with a partially blocked ureter). One trocar damage to a major blood vessel in the bowel (inspected at an open procedure but no repair required)
2. Bowel: 8 stomas. Of these 7 were patients with endometriosis. Five of the stomas were semi-planned at the time of the procedure. A primary reanastomosis was planned but intra-operative problems required a stoma. Three other patients had postoperative leaks requiring return to theatre for stoma. Unplanned stoma rate for endometriosis patients is 2/1250. Overall stoma rate for endometriosis patients is 7/1250 (these include all the bowel resection cases) or 0.6%. The overall stoma rate for the series is 8/7750 (0.1%).
3. Bladder: 27 perforations: 25 of these were repaired via laparoscopy. The vast majority of these cases involved endometriosis invading the bladder and the perforation was required to remove the endometriosis. One patient required an open incision early in the experience (1994). One patient developed a vesico-vaginal fistula following a hysterectomy which was ultimately repaired successfully.
4. Ureter: 8 Two required placement of prophylactic stents for presumed damage, two were repaired at laparoscopy, three required conversion to laparotomy and one was noted 18 months after the initial procedure and required reimplantation.
5. Return to OT: 15 6 returned for postoperative control of haemorrhage, 4 for drainage of a collection, 2 for pain where no surgical problem could be identified, 1 for a lost needle and 2 for oversew of an incisional hernia.
With these comments I attempt to explain all of my complications that I know of. I have been tracking this since commencing practice and find it a sobering yet highly educational experience. I am sure that I have become a better surgeon as a result of tracking these numbers.
Further information can be provided by A/Prof Cooper.
Hello. I’m Andrew Kaunitz, Professor and Associate Chair of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine in Jacksonville, Florida. Today I’d like to discuss the promotion of robotic gynecologic surgery by hospitals: Are our patients being misled?
Driving around Jacksonville, Florida, I often encounter billboards on which local hospitals promote robotic hysterectomy. In a recent article, investigators analyzed Web-based marketing for hospitals with 200 or more beds located in 6 large states.
Of more than 400 Websites evaluated, almost half included marketing for robotic gynecologic surgery. Manufacturer-based images and text, as well as the robot’s brand name, were noted in many of these Websites. More than three quarters of Websites indicated that robotic surgery was associated with less pain, shorter recovery time, and less blood loss. Furthermore, robotic surgery was often referred to as better overall or the most effective surgical approach.
Evidence-based data, cost, and operative time associated with robotic gynecologic surgery were rarely addressed by these Websites.
As the results of randomized trials comparing robotic with conventional surgical approaches have become available,[2,3] we recognize that while the benefits of robotics in gynecologic surgery are limited, use of the robot clearly increases costs and operating times.
This survey indicates that much of the information hospitals disseminate with regard to robotic gynecologic surgery is not evidence-based, and in fact is influenced by the manufacturer. I am concerned that this approach to promoting robotic technology for gynecologic surgery drives up healthcare costs while misleading our patients.
Thank you. I am Andrew Kaunitz.