Direct Visualization Can Transform Your Practice

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 thirty years, Cooper Surgical has worked with health care providers to provide highly effective clinic and practice based contraceptive, surgical, and obstetric solutions.

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We are 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 Chips, and I’ll be the meeting manager for this evening’s event. A couple of notes on how the presentation will run. We’ll have approximately thirty five minute time limit for the presentation, which will be followed by a fifteen minute q and a session with doctor 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 doctor David b Schwartz. Doctor Schwartz is board certified in obstetrics and gynecology and is a fellow of the American College of Obstetrics and Gynecology.

And I’ll turn it over to you, doctor Schwartz.

Well, welcome everybody, and, it’s a pleasure to be here to discuss, direct visualization and how it can transform your practice in taking care of, women in this time of, COVID and, after.

I’m David Schwartz. I’m an OB GYN in Cincinnati, Ohio, and I’m a paid consultant and speaker for Cooper Surgical Inc.

The ability to look inside a uterus and to diagnose the abnormalities that are there affecting the reproductive health of our patients is an invaluable tool for the modern gynecologist.

In this time of COVID, we haven’t been able to gain access to the hospital as often as we want to.

And so doing that in our office in the office environment is not only, 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 menorrhagia, menometrorrhagia, hypermenorrhea, polymenorrhea.

We now classify it, according to palm coin as abnormal bleeding with structural abnormalities being polyp, adenomyosis, leiomyoma, and malignancy or hyperplasia.

And then the nonstructural abnormalities, the coin, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and those that are not yet classified.

The primary causes of abnormal uterine bleeding in most of our patients are going to be the structural abnormalities twenty to forty percent of the time, and then the nonstructural abnormalities or dysfunctions sixty to eighty percent of the time.

And it’s up to us as 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.

Twenty to forty percent of the time, we are 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 ninety percent in polyp diagnosis.

You miss it. You don’t see it.

In addition, polyps with abnormal bleeding are a common presenting symptom for patients with endometrial cancer.

As a matter of fact, the presence of polyp malignancy in women with abnormal bleeding is almost twenty four percent with premalignant changes and one point five percent with actual malignant degeneration.

And we want to see to visualize these polyps to make that diagnosis.

Fibroids or leiomyomas are also a significant source of abnormal uterine bleeding.

Uterine fibroids occur anywhere from twenty five to forty percent of the time, and submucosal fibroids are diagnosed in up to ten, eleven percent of women presenting with abnormal uterine bleeding.

Once again, blind endometrial biopsies have been shown to have a false negative rate of up to ninety five, ninety eight percent 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, endometrial diag hyperplasia is diagnosed up to four percent 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 seventy five percent false negative rate for diagnosing endometrial hyperplasia. Why? Because we’re biopsying an area where we really don’t know where the abnormal tissue is.

And the risk of progression of endometrial hyperplasia to a cold carcinoma well, in complex hyperplasia without atypia, it’s less than five percent.

But when you have endometrial hyperplasia with atypia, it’s up to twenty eight percent progression to a cold cancer in twenty years.

We need to prevent this. We need to diagnose this. We need to treat this.

Office hysteroscopy is much more accurate than 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 blind biopsy and diagnosing polyps was eleven percent compared to hysteroscopy, almost ninety percent.

Sensitivity for diagnosing fibroids, thirteen percent with a blind biopsy and a hundred percent with hysteroscopy.

Hyperplasia, twenty five percent versus when we can actually visualize where the abnormal tissue is seventy four percent 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 hyperplastic area.

So a positive result is much more accurate for ruling out disease than a negative test, and the positive result is only an endpoint when it reveals cancer or atypical complex hyperplasia.

Unfortunately, we’re not gonna see that with a blind biopsy.

We’re gonna need to look and biopsy the areas that we see are atypical that are abnormal, and that’s gonna increase our ability to find the disease and treat the disease.

ACOG also supports advanced diagnostic imaging. What are we talking about? Well, we’re talking about a transvaginal ultrasound.

We’re talking about a saline infused sonogram, and we’re talking about hysteroscopy.

So the SIS or sonohysteroscopy is much, much better to transvaginal ultrasonography because we can detect the intracavitary 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, is hysteroscopy.

And hysteroscopy can be performed in an office setting. It can be formed in an operating room. However, in the office, it’s more convenient.

It’s more comfortable for the patient.

It’s overall less expensive for the health care system, and the purveyor of health care, you, the doctor, is being reimbursed more for it too. So it’s a win win for everyone.

In a meta analysis that evaluated diagnostic accuracy, hysteroscopy had an overall success rate of almost ninety seven percent.

Once again, we’ve gotta 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 Mahieu Lacroix, and he showed that the saline infused sonogram was superior to the transvaginal ultrasound.

Specificity of ninety two and eighty nine percent compared with sixty four and ninety percent.

However, it lacked the sensitivity to be used alone.

Hysteroscopy, 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 intrauterine abnormalities and subsequently used to treat abnormal uterine bleeding.

This is a study showing the comparison of the diagnostic performance of transvaginal ultrasound versus saline infused sonography versus diagnostic hysteroscopy.

And if you look at the DH, the diagnostic hysteroscopy 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 hysteroscopy, and visually biopsying 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 hysteroscopy requires patients to go to the hospital.

That’s space consuming and time consuming. It’s inconvenient for the patient. It’s inconvenient for the doctor.

It’s really not patient centric.

It’s it’s a nuisance for the patient. It’s painful. It requires anesthesia.

And the overall cost to the health care system is expensive.

Not anymore.

The traditional abnormal uterine bleeding clinical pathway required an initial consultation in the office with the patient, a transvaginal ultrasound, an endometrial biopsy, which was blind, a saline infused sonogram, another visit to plan the following treatment, and then diagnostic hysteroscopy in the hospital and or treatment.

We don’t have to do all this anymore.

We had 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 hysteroscopy is phenomenal.

Number one, they did a study with a hundred and thirty patients with abnormal bleeding. Forty two percent were in the OR. Fifty eight percent were in the doctor’s office.

And by performing the procedure in the physician’s clinic or office, thirty five hundred dollars per patient was saved.

It was done with a flexible hysteroscope, 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, while at the same time being ethical, passionate, innovative, and respectful.

How do we do that?

We have something called the EndoSee Advanced.

And the EndoSee 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’s a single sterile use cannula that you’ll be used to insert into the endometrial cavity.

It’s flexible, but it’s also stiff enough, so it makes it easy to insert.

And if the cervix is a little stenotic, you use a little hydrodilatation while you’re inserting it.

Four point three 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 a polyp, and nothing is blind. Everything is visible.

It has changed the way we practice medicine, especially during this time of COVID when patients don’t wanna go to the hospital, when patients are 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 are going to include evaluating abnormal uterine bleeding, deciding where we are on the palm coin diagnosis.

We can also look at infertility and recurrent miscarriages.

I’ve seen, abnormal cavities. I’ve seen septum. I’ve seen bicornoid uteruses, all with the EndoSee 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 endometrial thickening and at 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 a polyp, remove a retained IUD where the string is lost or the string is absent, do actual directed biopsies, all the time planning for additional presurgical and surgical activities.

I’m gonna show some actual sonohistograms and hysteroscopies and show how they work together, but also show how there can be false negatives and false positives.

You see in this slide is a sonohistogram, and it shows an intracavitary lesion, we think.

However, when we proceed to diagnostic hysteroscopy with the EndoC, it’s a perfectly normal cavity. And retrospectively, that was probably a blood clot inside the endometrial cavity that looked like an intracavitary lesion, and it was indeed a false positive sonohistogram.

This could always delay treatment for a patient.

In the top view, you see a sonohistogram, number two, and there appears to be a lesion in the cavity.

However, direct visualization, there’s nothing there. In a very similar sonohistogram, number three, you see another lesion in the cavity. And, yes, in the endo c hysteroscopy 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 of the endosy procedure.

Here we have a sonohistogram that shows perhaps a thickened endometrium, and an irregular uterine lining.

But low and behold, when we put a camera inside and we actually look in the endometrial cavity, wow, it’s just loaded with polyps, multiple polyps that this patient would require, a a procedure that’s gonna need to remove all of those polyps and then clean that lining of the uterus, to help control her abnormal uterine bleeding. You can see here that a picture is worth a thousand words.

This was a patient of mine that had a transvaginal ultrasound, and we always do the transvaginal ultrasound at the same time we do the sonohistogram. 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 TVUS, 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 sonohistogram, the saline infused sonogram, there’s definitely the appearance of a structural abnormality that looks like a large solitary polyp. And then the endosy advance is done, and lo and behold, there is that large solitary polyp.

The endosy advance provides the clearest image of the inside of the endometrial cavity. And one can easily see both ostia, the areas of the normal endometrium, and in this case, a large solitary polyp that’s going to require a polypectomy in the future.

In this next slide, it’s talking about postmenopausal bleeding in a patient who has a stenotic cervix.

I I mentioned earlier that we can use hydrodilation as we’re inserting the EndoC device, the EndoC advance into the endometrial cavity. Here we have a sixty one year old, g three p one with postmenopausal spotting, and there’s some questionable echo densities on the transvaginal ultrasound.

So an office hysteroscopy is performed, and we’re trying to get into the endometrial cavity. We’re now injecting a little more fluid, a little more pressure. As we push in, you can see the endometrial canal opening up, and lo and behold, we’re now in the endometrial cavity. And we can see that endometrial cavity is beautiful.

There’s no hyperplasia up. Yes. There’s something there up at the right correction, the left corneal, and there’s a small polyp up there. And so now we have a diagnosis for this patient, who has a polyp, And this polyp can be removed at the point of care when we’re doing this endocele because it’s small enough.

This patient did not require anesthesia.

This is done with a paracervical block.

Once again, the hydrodilatation, injecting fluid while you’re inserting the scope into the cervix, into the endocervical canal, empowers you as 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 in 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 IUD. Now most of the time a patient comes in and is requesting her IUD 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, IUD hook and gently insert that into the endometrial cavity and see if we can feel the IUD. Unfortunately, many times that is unsuccessful.

So here we have another opportunity to use the NDC advance. This is a twenty seven year old, prime Nola Gravita who wants to get pregnant and needs her IUD out, but we can’t find it. So in the office, we go ahead and insert the EndoC advance. We’re now in the endometrial cavity. We see the IUD, and we’re gonna look for the string.

And there is the blue string over there on the right side of the slide. And we’re taking our graspers, and we’re going to try to manipulate them to grab the string, which is inside the endometrial cavity. There’s no way the string is outside of the uterus.

And as we’re manipulating them, we’ll grab the string, and then we can pull the IUD out.

We have saved this patient a bundle of money, saved 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 IUD removed because there’s no pre op planning, is just remarkable.

This patient was able to have a successful IUD removal on the same day she requested it done despite nonvisible strings.

Huge patient satisfier.

Much more comfortable IUD 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 twelve hundred to sixteen hundred dollars when I do a NDC advance in the office and remove tissue or a polyp or an IUD 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 do.

So what are some of the advantages of our endo c advance that we use in the office?

Well, instant endometrial imaging guided by direct visualization.

Once again, we’re gonna take the word blind out of our vocabulary, and everything is now going to be direct visualization.

We can see it, and we can 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 paracervical block because I grab the cervix with a TANAC.

It’s very efficient in terms of the office flow because this can be done in any exam room, and it takes two to five 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 transvaginal ultrasound and an endometrial 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 OR.

In the second part of this slide, you can see now the history and physical and the transvaginal ultrasound and the hysteroscopy 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 can then be set up for treatment. So we’re also minimizing potential multiple visits.

Something that is also important in this time of COVID when patients don’t wanna keep coming to the doctor’s office and when patients don’t wanna 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 are talking to our patients on the phone much more.

We are able to bill for this, which is nice.

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 are 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 explained to my patients that I don’t have to bring you into the hospital to make your diagnosis and in many times to treat your abnormal bleeding.

Thanks to the Endoscopy Advanced, I can do most of it in the office.

So as Stephen 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 endometrial 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 are able to offer our patients now.

So in summary, the EndoC Advance provides direct visualization into the uterine cavity.

So anytime we have something going on in the endometrium and we want to see it, we can easily slide this instrument, which is only four point three millimeters through the cervix into the endometrial cavity and see what’s going on in there, providing us with a high accuracy of diagnosis, a decreased time to treatment, and a tremendous improvement in patient’s care. On a personal note, it maximizes my time and also is 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, doctor Schwartz. I’m now gonna turn over the q and a portion of the program over to Christopher Khan for Cooper Surgical.

Thank you. Excellent talk, doctor Schwartz, and it’s great to speak with you again.

Thank you, Christopher.

Great. And thank you to our audience too for your time this evening. My name is Chris Khan. 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 gonna try to get through as many 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, doctor Schwartz, is what is the most important factor for you in choosing to use Endosy Advance?

I think that the fact that it is so convenient to use and empowers me to perform a high quality of medical care right in my office.

K. Excellent. Thank you.

We’ve had, some questions about, premedication.

When, if ever, do you choose to premedicate your patients before using NOC Advance?

I rarely ever premedicate my patients.

Because the, actual cannula is so narrow and so flexible, it’s extremely easy to insert into the endometrial cavity. I would say of the last hundred patients that I’ve done in the office, I may have premedicated 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 a regular pelvic examination.

But, premedication 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 para cervical block for anything that I’m putting in and out of the uterus.

I even use it for an IUD, 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 as a paracervical block, I use two percent lidocaine. I put about, four cc’s at twelve o’clock, four cc’s at four o’clock, four cc’s at eight o’clock into the cervix.

I have them cough like that as I inject it so they never feel the, actual needle. Then I put an additional eight cc’s between four and eight o’clock a little deeper, and then I’m getting the product set up, so I will, turn on the machine, turn on the camera, turn on the video monitor, hook it up, attach the tubing to it, and input 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 a need for lubrication. I really don’t wanna use I know SurgiLube, or, Vaseline, all those things could be used, but I you’re just gonna be pushing more bacteria into the endometrial cavity. I’ve never had an issue again, with this this cannula because of the size of it. Now another tip and trick is if you inject a little saline, so that’s hydrodilatation, as you’re inserting the cannula in, it kind of gives you your lubrication that you need or even dilates minimally, the, endocervical 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 Osfinder, as part of my setup in the office.

And if there’s difficulty, inserting the cannula, then I will go ahead and use the Osfinder and then insert the cannula.

But, I I I can’t remember the last time I tried to do an endosy. I can’t remember any time I tried to do an endosy 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 distending the uterus.

Do you have a preferred method, and and and why do you choose it as far as using a syringe or an IV bag?

So, my preferred, method is a sixty cc syringe.

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 two sixty cc syringes.

Most of the time, I just use one. Rarely, do I need a second sixty cc syringe.

And then very few times if I’m actually doing a polypectomy and it’s gonna take me longer than a minute or two, I will have a bag of five hundred cc saline and just hang it with gravity, and that’s more than enough to, provide distension and the fluid. But in answer to your question, my preferred method is going to be, just using the sixty cc syringe. It’s just so convenient.

Okay. Great. Thank you. And then there’s been a couple quest questions also about clearing the view, the 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, the endo c all the way up to the fundus, and I’ll push it on the fundus a little bit and and essentially to 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, uploading into an EHR.

Can you speak to your, you know, preferred way of of handling that?

Sure.

One of the beauties of this is that the patient’s awake. The patient gets dressed, and then I go back in the room and I talk 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 thereof.

Then that, the actual video monitor goes to the front desk where it’s downloaded into my EMR, 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 polyp and, how successful you are in doing that? Is there any, you know, criteria you use in terms of size of polyp 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.

Gynecologists in the past have always been operating in a dark space in a closet and doing d and c’s and polypectomies with our really blind. We didn’t see what we were doing. Now we’re able to see exactly what we’re doing. So, diagnostically, we can, sample the endometrial lining in an area that’s hyperplastic.

If there’s a small polyp one or two centimeters, I will go ahead and remove it, at the same time. If it’s a little larger than one and a half to two centimeters, I will then probably reschedule them for, a procedure in which I have some type of morcellation device to, remove it just because it’ll be a lot quicker.

I probably could remove a two or two and a half centimeter polyp. However, I think it would take a long time, and it would be easier, if with a, one of the morseletion 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 end of the advance, do you have a preferred instrument that you use?

Well, the end of the advance has a polyp forcep 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 biopsying 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, I would think that this physician is thinking about retained products of conception. And, anytime you do a hysteroscopy, we want the cervix tight around the hysteroscope.

And so whether it’s a usual, hysteroscope that’s six point, two millimeters or this very tiny, essentially, hystoscope, We have to have the cervix tight around it so we can distend the uterus.

I will many times take a, tenaculum and grab the cervix at twelve, and then again at six and maybe at three and maybe at nine. So that’s four tenaculum or it might be called tenaculae, excuse me if I’m wrong, and that will cause the cervix to tighten around the hysteroscope.

In the OR, I put stitches around the cervix. I put endo loops around the cervix, but it’s just as easy to go ahead and grab, with a TANAC. Another, tip and trick is to go ahead and grab it at twelve o’clock and then regrab where you grabbed it and then regrab it again. And if you just have two TINACs and each time, you’re tightening that cervix around your operating device, the EndoC in this situation, and then you’re gonna distend the 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 laminaria ahead of time for difficult patients?

So problem with the laminaria is it’s gonna dilate the cervix much more than the diameter of the endo c. So you’re gonna have the problem we were just talking about with fluid leaking out.

I always have an os finder available with me, and, usually, I can use the os finder, 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 postmenopausal woman with a very stenotic cervix, I would probably rather than put a laminarion because that’s gonna dilate the cervix too much, is give her some side attack the evening before.

And then I’ve never had difficulty getting the Ospfinder in.

Okay.

Speaking of Ospfinders, where do you order yours? Do you do you order them, in bulk, or do you get them through the convenience kit?

I order them through bulk, I think. I apologize. I’m answering this question, and I’m not a hundred percent sure because my office staff takes care of that for me. I’m sorry.

Okay.

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 in this population. We’re not cutting anything. We’re not, causing any bleeding.

There might be a a little bit of bleeding from dilating the cervix, but it’s never been an issue.

Okay. Can you tell us about your experience removing malpositioned IUDs with the Z Advance?

This is an excellent device for that. Patient comes in, wants her IUD removed, I go ahead and put the speculum in, and lo and behold, I can’t see the IUD string. So the first thing I’ll do is take an IUD hook and see if I can feel for it, twist it around, and pull the IUD out. If that’s not possible, I’ll then and many times, I’ll just do it at the same visit, get the endo c set up, put the endo c in. And then as you saw in my talk today, you can easily see the IUD string, which sometimes is taking a sharp right turn and going back up to the fundus.

And you just go ahead and grab it, and then you pull the whole EndoSee and the, GRASPER 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 in the office?

Especially during the times of COVID, 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 a level of excellence.

We’re able to do these procedures and get appropriate reimbursement. The trick is you bill for the procedure and you bill for the facility. There’s a facility fee. And, Anthem in Southwestern Ohio, many times, will pay sixteen hundred dollars, but even Medicaid will pay six or seven hundred dollars. We have, CareSource here, and, we’ve negotiated with them. And so, if I went into the hospital and did this procedure in the hospital, it would be five or ten thousand dollars, and I might get a hundred and fifty to three hundred. I do it in my office, and, 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 to go ahead and spend time having my staff call the OR, getting the patient to do pre op scheduling, pre op testing, and come into the OR. This is a simple, procedure like putting an IUD and like doing an endometrial biopsy that we can do in the office without any premedication, without any, pre authorizations.

And, 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 EndoC Advance with an EMB, do you use the EndoC Advance first and then EM EMB or vice versa? How do you approach that?

I always do the EndoC Advance first because I wanna see where the abnormal tissue is. If there’s generally no abnormal tissue, I’ll put a pipell in and just get a general sampling just to confirm that there’s no precancerous changes, no hyperplasia, no issues going on, and I can proceed with whatever procedure, we are going to do like an ablation or a hysterectomy.

If there’s a specific area I’m concerned about, I will use the, EndoC biopsy forcep and actually go in and visually biopsy the suspicious area.

And this is now the, standard of care. It should be the standard of care. It’s a state of art with medicine rather than doing line biopsy. So you wanna see first biopsy second.

Thank you. And and thank you for for your time this evening, doctor Schwartz. This last one is is more of a comment. I think doctor Karen Stewart is looking to reconnect with you, re 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 nineteen eighty two, went on the faculty of the university for two years, and I’ve been in private practice ever since.

So, my email is d as in 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, doctor 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 gonna 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.

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