Direct Visualization Can Transform Your Practice – Dr. Michael Stine Jr

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Welcome, and thank you for participating in tonight’s event. My name is Alan Chips, and I will be the meeting manager for this evening’s program. A couple of notes on how the presentation will run. We will have approximately thirty minute time limit for the presentation followed by a question and answer session. To submit questions, please click the ask a question button located underneath the player window and fill out the form.

After the conclusion of the presentation, doctor Stein will participate in a thirty minute q and a session.

If your question is not answered this evening, 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. Michael stein Doctor Stein is in private practice in Tampa, Florida.

Now doctor Stein.

Good evening, and thank you for taking the time out of your evening, and from your lovely families to listen. I’m excited to talk about NDC Advanced and how direct visualization can transform your practice. My name is doctor Michael Stein junior. I am a, board certified OB GYN.

I’m in private practice in Tampa, Florida.

Full disclosure, again, I’m paid as a consultant for Cooper Surgical. I also speak for, Hologic Inc as well as Myriad Genetics.

So the ability to look inside the uterus and diagnose anatomic abnormalities that affect reproductive health and underlying gynecological disorders is truly an invaluable tool for the for the modern gynecologist.

And if you take that another step, you know, further in doing that in the office, not only offers the benefit and convenience for patients and the surgeon, but also has the potential to contribute significantly to overall reductions in health care. You know, when I’m able to tell patients that I can do certain things in the office, Their anxiety level, the the angst that comes with the thought of going to the OR and and in his full general anesthesia and all of the costs that are surrounding that, you you can almost see a sigh of relief, that comes about them. So being able to do things in the office, I think, really resonates with patients, not only from a financial standpoint, but just from a customer service, standpoint, and I love being able to offer it.

So I remember the Palm Cohen coming out when I was in residency, and it really simplified things because you had these crazy words like menarajah and menometarajah and all of these other things. And it was really simplified with this Paul Cohen. And, you know, part of it was structural abnormalities, which is kind of what we’re gonna be talking about tonight and finding. And And if it wasn’t a structural abnormality, you knew that it was the other.

And so abnormal uterine bleeding comprises about thirty percent of all outpatient visits. I definitely see this amount in my GYN only practice in my office almost on a daily basis. And it may account for upwards of seventy percent of consults among peri and postmenopausal women. The primary causes of abnormal uterine bleeding, between the ages of thirty five and menopause, a significant amount, twenty to forty percent is due to structural abnormalities, which again is what we’ll kind of focus on today, and the other sixty to eighty percent are due to nonstructural dysfunctions.

So these are some beautiful pictures, and soon we’ll watch a a little video. So polyps may be the source of the bleeding. Polyps are diagnosed in twenty to forty percent of all women with abnormal bleeding. So blind endometrial biopsy, which is was was the standard of care. You know, it comes with a very high false negative rate, especially in the diagnosis of of polyps.

You know, polyps are a significant cause of abnormal bleeding, and they’re a very common symptom, unfortunately, or fortunately, in that we can kind of find endometrial cancer and be suspicious for it. The prevalence of polyps, and malignancy with abnormal bleeding, almost twenty four percent are shown to have malignant or excuse me, premalignant changes, and one point five percent have malignant degeneration. And just a side note, I just had a patient the other day who, who had had a previous global endometrial biopsy before she presented to me. She was never offered office hysteroscopy.

I did an office hysteroscopy as well as remove a polyp that was found that was missed previously, and in that polyp was, EIN, which is a premalignant condition. So this would have gone by the wayside had she not sought a little bit higher level, of diagnosis.

Show you the video.

So satisfying to see this.

It’s a significant polyp. It’s like it’s arising almost from the from the fundus of the endometrial cavity and coming right up to the endocervical canal.

So sometimes, instead of polyps, fibroids may be the source of the bleeding or leiomyomas. So fibroids occur in twenty five to forty percent of women in reproductive age with a lifetime risk of greater than sixty percent. You know, we don’t really know this exact percentage. There are days in my office where I think the number is almost a hundred percent, especially in African American women as most gynecologists, know.

Submucosal fibroids are diagnosed in five to eleven percent of patients with abnormal bleeding. Blind endometrial biopsy has a significantly high false negative rate, especially in diagnosing a submucosal fibroid. You know, what I always tell patients is that, you know, when I’m when I’m doing that blind or if you’re due you know, a doctor is doing a blind biopsy, it’s gonna bounce off that fibroid. That fibroid is is firm.

It’s really not going to get any of that tissue in, and you’re gonna have a false sense that nothing’s going on in there if nobody took a look. Fibroids have a significant, you know, outcome on having abnormal bleeding, pain, pressure, and infertility.

Hyperplasia or malignancy may be the source of bleeding. As a side note, my wife is an amazing gynecologic oncologist, and I often tell the story that it’s my job to try to keep patients out of my wife’s office or to at least figure out whether they belong in her office or not. They can meet her in a bar. They can meet her in a grocery store. She’s a lovely woman, but I try to stop them from ever meeting her, in life or walking through her office doors. So So endometrial hyperplasia is diagnosed in about three and a half to four percent of women presenting with abnormal bleeding. Some studies have shown up to a seventy five percent false negative rate of blind biopsy, which is just atrocious, for diagnosing hyperplasia.

The risk of progression over the twenty year span of complex hyperplasia without atypia is less than five percent, but with atypia or also known as endometrial intraepithelial neoplasia, it’s upwards of fifteen to twenty eight percent. So it’s really significant and important to try to make that diagnosis.

So office hysteroscopy is proven to be more accurate than biopsy alone. Some beautiful pictures of the different pathology. You know, blind biopsy for polyps is only about eleven percent sensitive, where if you look on hysteroscopy, it jumps up to almost ninety percent.

Myomas or fibroids, only thirteen percent, in diagnosing versus a hysteroscopy.

You basically know that it’s a fibroid. It’s a hundred percent sensitive. And then when it comes to hyperplasia, twenty five percent versus seventy four percent. So big huge differences in in taking a look versus blind biopsy alone. So, you know, those numbers should really resonate.

So ACOG basically confirmed kind of what what we knew that biopsy alone was probably insufficient.

So end endometrial sampling in patients with abnormal bleeding to determine whether carcinoma or premalignant, lesions are present is what, you know, they kind of made a statement on. Endometrial biopsy has a really high accuracy rate if the cancer is everywhere. You know, if if it’s spread throughout the entire endometrial cavity, a blind biopsy is likely going to to to find the diagnosis. So a positive result is way more accurate for ruling in disease than it is for ruling it out. So, you know, I think a blind biopsy with a negative result is kind of gives the patient a false sense of security.

The end point of if it’s truly cancer or complex hyperplasia is great, but the negative results of a blind biopsy, I don’t really hang my my hat on. And oftentimes, if I get referred the patient or I have a patient for a second opinion, if it’s just a blind biopsy, I will go in and and make it a point to take a look, and I explain to the patient why that’s so important. And, I rarely ever get any pushback because the patient really wants to know what’s going on inside of them with my own eyes seeing it. So, again, ACOG supported the advantage of advanced diagnostic imaging.

So, you know, regular ultrasound versus sonohistography, obviously, is superior to just transvaginal ultrasound alone in in detecting intracavitary lesions. Hysteroscopy is able to be performed in the office setting, or in the operating room if needed. Office hysteroscopy is obviously less expensive to the patient. It’s more way more convenient for this sentence, in my opinion, should say the patient first and then the physician second, and it offers a much faster recovery.

The patient is oftentimes not getting general anesthesia.

They have less time off at work because they’re not getting general anesthesia, and they don’t have that recovery.

And then there’s been plenty of meta analysis to evaluate the accuracy, and, you know, its overall success rate. So it it’s it’s pretty significant.

So, again, systematic review of different imaging studies. The objective of of this study was to evaluate the accuracy of, SIS or saline infusion, sonohistogram, and the comparison of transvaginal ultrasound for diagnosing polyps and submucosal fibroids or leiomyomas in women, abnormal bleeding, and it kinda pulled twenty five different studies. And it showed that SIS or saline infusion sonohistogram was definitely superior to transvaginal ultrasound with sensitivities comparison of ninety two percent versus sixty four percent and eighty nine percent of specificity versus, ninety percent respectively with a great p value. So SIS was also compared to hysteroscopy alone, in a bunch of studies, with similar sensitivity, but much different, and inferior specificity.

So transvaginal ultrasound, lacks the sensitivity to be used alone.

Hysteroscopy obviously provides direct visualization of the uterine cavity and combined with pathology, evaluation is, you know, basically the gold standard or the standard of diagnosing intrauterine, abnormalities. And, you you know, I I hope at the end of this, you agree. So another study take home detection of endometrial lesions in symptomatic women. A hundred and five patients were studied with premenopausal abnormal bleeding, postmenopausal abnormal bleeding, or infertility. And you can see that it compared transvaginal ultrasound to saline infusion on our histogram or or SIS versus diagnostic hysteroscopy.

And, again, you know, you’ll see the trend throughout this in diagnosing any uterine abnormality versus a polyp versus a myoma. As you go up, in my opinion, of diagnostic testing from just an ultrasound to an SIS to truly looking live with your own eyes, obviously, your sensitivity and your specificity, increases. So this all completely makes sense.

So why aren’t we we really seeing it?

Traditional hysteroscopy is extremely space and and and time consuming and expensive. You know, I just started my own practice. We actually opened the doors February twenty second, and, we’re doing very well. I’m super happy and excited. But I can tell you from a business owner standpoint, traditional hysteroscopy is crazy expensive.

And so, you know, it’s fairly inconvenient. It’s got a lot more of a diameter when it comes to dilating a woman’s cervix to be able to get inside.

It’s more uncomfortable most of the time. If I have to do that, I do bring in an office anesthesiologist, which obviously increases the expense to the patient. So these are all kind of speed bumps or roadblocks into why, a lot of, providers are not doing traditional hysteroscopy in their office.

So the clinical pathway, I love this slide. So traditional clinical pathway, and I remember this from from the practice that I was previously in, especially for those that did not want to kind of take in hysteroscopy as part of the diagnosis. The patient would be seen on visit one. So the the previous that I know is actually even more visits than what you’re seeing in front of you.

So they would do a history and physical on visit one, then they would bring the patient back for visit two for transvaginal ultrasound. So now we’re at two visits. Transvaginal ultrasound would inevitably be inconclusive or would see a thickened endometrium. And so then they would bring him back from endometrial biopsy, and that was kind of inconclusive.

And so then they may or may not bring them back for a saline infusion sonohistogram. So we’re at almost three to four visits. And then and only then would they decide what to do. And so, you know, patients are are are busy.

Office visits, you know, insurance is not exactly what it used to be. They have co pays. And so to bring a patient back that many times to expect them to take off work, to do whatever it is to come into those visits, it became very time consuming. And inevitably, what would happen is the patients, they sometimes wouldn’t come back. It it wasn’t worth it to them. They would go by the wayside.

And so, you know, this really this slide really resonates to me as to how being able to do quick office, hysteroscopy and diagnostic hysteroscopy in your office, can can significantly change not only the the pathway to diagnosis, the speed to diagnosis, the patient’s overall satisfaction.

It’s it’s it’s huge. So cost effectiveness of office hysteroscopy for for abnormal bleeding. Now I gotta tell you guys a little bit of backstory.

So I went to Florida State University. Go Knowles.

And, we do a lot of drinking and partying there, and maybe I didn’t get quite the same education as some other people. I’m just kidding. But what I can do is math.

And, the cost effectiveness not only to, excuse me, to the patient and also to the physician themselves is huge when you’re able to keep things in your office. So here’s a study, that, looked at a hundred and thirty patients have normal bleeding. It was in an academic setting. So fifty five, went to the OR. Seventy five patients or fifty eight percent, avoided the OR. So avoiding the OR saved the patient, excuse me, saved thirty five hundred dollars per patient with minimal pain, the ability to insert a thin flexible hysteroscope for office diagnostic hysteroscopy.

And it also and and this really, really is important in my practice. It allowed the physician to decide the appropriateness of going to the OR or not. So, you know, those numbers over on the right hand side, no matter what college I went to, they’re pretty clear.

So NOC advanced. That’s why we’re all kind of here tonight, not only to learn about abnormal bleeding, but how can we how can we cost effectively, efficiently, anti anxiety, do office hysteroscopy, and this device is is amazing. So I was able to actually be part of the first generation of this device, and, and the second generation is so much so much better. It’s much clearer picture. It’s more ergonomic, especially so that lower, part right there, that pistol grip was actually created specifically.

My wife is, as you know, as I told you, is a gynecologic oncologist, so women oftentimes have smaller hands.

And it was definitely placed there with, with people with smaller hands in mind for the ergonomic, design of it.

So MDC Advanced used for evaluating abnormal uterine bleeding, menstrual disorders, or pelvic pain. I also as this states, I use it a lot in infertility or recurrent miscarriage patients. I had a patient just the other day who was three months postpartum. She was having significant bleeding, which is kind of outside of the norm.

I did an endo see on her, and lo and behold, she had some retained, placenta. So that had been, ignored basically by her previous physician, just told her it was normal, and nobody evaluated.

And then one simple visit, I was able to look inside and give her the diagnosis. And so we can take care of her. It’s fantastic. So it’s just for identifying polyps and fibroids, retained products of conception, endometrial thickening or atrophy, and definitely tissue, in in need of biopsy. So, you’re able to do a little bit of, procedures with it also, obviously, with a, with a working channel, which was definitely improvement from version one to version two. So you can do a little bit of transsection of the adhesions or septae in a uterus. You can do a small polypectomy, especially if it’s pedunculated, if you have scissors.

Definitely can be used and super easy use, for those retained IUDs to keep them out of the OR. It’s fantastic for that. Directed, visual guided biopsy, and then, obviously, I use it a lot for my presurgical planning to see whether a patient can stay in my office versus pathology is just too complicated and they need to go to the OR. So super, super, fantastic product to be able to do all of these things. So sauna histogram showed some sort of intracavitary lesion. What is that? Is it a polyp?

Is it retained products? Obviously, based on the history, it depends on what that is. Is it a piece of endometrium that’s sloughing off depending on where she is in her endometrial, excuse me, in her, menstrual cycle? So direct visualization actually showed a showed a normal cavity. So it was a false positive with sonohistogram, and that patient without, you know, direct visualization might have been taken to the OR inappropriately.

So super significant when it comes to this kind of pathology.

So, again, kind of case reviews. So two very similar SISs.

You know? Is there something there? Isn’t there something there? On the top picture, you can see where it looks like there’s something at the fundus, and you low and behold, you look in, and it looks like an atrophic normal cavity.

There’s nothing there. The bottom one, again, there looked like there was something there on SIS, and low and behold, there was a polyp there. So, again, two very similar saline sonograms, but two very different, direct visualization outcomes. And this this significantly changes what you’re gonna do with your patient.

So this is one of my pictures that I call the field of polyps.

So you do an s I s. It kind of just looks like some irregularity.

Most physicians may or may not decide to do something with that, irregular lining, but lo and behold, when I took a look, I call it the field of pots.

Not quite as beautiful as a field of flowers, but very significant for the patient to make a diagnosis.

So, three different imaging technologies all on the same patient. So first one, just transvaginal ultrasound alone. Is it just a thick end endometrium? Is there something in there?

We’re not sure. SIS. Okay. So there’s definitely something in there, structure abnormality. Is it a fibroid?

Is it a polyp? Is it retained products of conception? Is it cancer? What is it?

So lo and behold, you look inside and it clearly confirms that it’s a polyp. So, again, hugely, different amounts of information that’s able to be obtained as you go up in in technology and looking live with your own eyes with diagnostic hysteroscopy.

Postmenopausal bleeding. So this is one of my patients. So sixty one year old, gravida three para one with postmenopausal spotting. So she had, some sort of echogenicity on, transvaginal ultrasound. She was referred to me from a family practitioner. So I did, an, endometrial assessment using the, EndoC advanced, and was able to do a polypectomy, pre procedure.

No cytotec, no analgesia was needed, but benign polyp was noted with same day reassurance. So super easy.

I was able to be able to get into her cervix despite being a postmenopausal woman because I was able to just use the fluid to kind of hydrodilate her cervix in order to get in. It was very comfortable for her. So it definitely saves her a lot of angst. Let’s go ahead and watch the video so you can see what I saw.

So here we get into the internal OS by using the fluid to open it.

And looky there.

Super simple, fast, effective.

One of my favorite things, to do for a patient is so gratifying. So the inevitable lost IUD strings, patients freaking out. I have to go to the OR. It’s a twenty seven year old patient who desires pregnancy.

Right? She wants that thing out. She wants to get pregnant, and you can’t find her strings. So what do you do?

You’re able to use NDC advance. You’re able to use the working channel, grab the strings, and remove the IUD within seconds. Huge, huge patient satisfier to keep her out of the OR, much more comfortable. It it’s absolutely fantastic.

So easily able to visualize.

Swing and a miss.

You can do it.

Patient is extremely comfortable during this. Strike two. Come on. You can do it, doctor.

Oh, I have faith.

Yes.

Patients get so excited when you take it out and show it to them.

Here’s a fifty five year old gravida two para two postmenopausal.

She was referred for pelvic pain alone, actually. She had an ultrasound kind of trying to evaluate the the pelvic pain, and lo and behold, it found a a one point two centimeter thickened endometrium. And this is the point in which she was referred, to me. So I was able to do an endo c, a diagnostic hysteroscopy on her and wait till you see this one.

Huge, large endometrial mass, that really wasn’t seen on ultrasound, and that’s it above us. There’s one of the os, tubal ostea, and there it is from the fundus. Keep going. It keeps going.

It keeps going. It keeps going. It keeps going. It keeps going.

When’s it gonna end?

There it is.

So, again, you know, ultrasound alone, we just showed a thickened endometrium, but look at the significance of what what you find when you look inside.

Another patient, who was referred to me with postmenopausal bleeding, but a super stenotic cervix, sixty five year old postmenopausal bleeding. Fibroids were noted on ultrasound, but the endometrium, because of the location of the fibroids, it was not really well seen. So, you know, some doctors may say, oh, well, it’s just fibroids causing the pelvic pain and ignore the rest. Others may say, let’s go straight to the OR.

We just can’t see the endometrial cavities. No big deal. So, you know, I I take the time to look inside and see if there’s any pathology there that we need to find out about before making the next steps. So as you can see in this still shot, multiple endometrial masses noted that weren’t really seen on ultrasound because of the, you know, shadowing that was coming from her fibroids. So proper evaluation of the endometrial cavity, that I’ll then go in and assess those polyps prior to moving on to counseling her on what the next step can be. Here’s a patient, with abnormal bleeding and fibroids and a normal endometrium on ultrasound, fifty one excuse me, fifty four year old, gravida one para one with pelvic pain and normal bleeding. I took her for a diagnostic hysteroscopy with EndoC advanced, and wait till you see this one.

It’s a huge submucosal myoma that basically takes up the entire fundal cavity.

So, again, direct visualization in the, office made the ability for me to decide that this was a little bit too big for me to do in my office, and this patient is gonna go to the OR for for a, hysteroscopic myomectomy. But it also allows me in the OR to make the decision as to which device I’m going to use based on its size. So not only did it allow me to make a decision of office versus OR, but also in planning for the OR itself. So reimbursements. Again, I go back to my Florida State days of numbers speak volumes.

So, you know, reimbursements in the office for office procedures, obviously, insurance companies really want us to try to keep things in the office.

I’m not sure they really care about patient convenience as much as it does saving them and the patient money. So, you know, if you don’t know exactly what your reimbursement is, you can go based on RVUs, and it’s it’s pretty significant. Just the diagnostic hysteroscopy in your r in your office versus the OR is the difference between, you know, just under five RVUs up to just under eleven RVUs, so more than two times.

Five eight five five eight, which is a diagnostic hysteroscopy with sampling, whether that’s a polypectomy, whether that’s endometrial biopsy, it goes from six point seven eight, up to forty two point eight seven. I mean, that’s huge.

And five eight five six two, which is removal of foreign bodies, kind of like that IUD, again, it it it doubles. So it it behooves us not only from a patient’s satisfier standpoint in regards to anxiety and their cost, but it behooves us in regards to our reimbursements. Again, in running a a a new practice, reimbursements make a big difference to me. So if I can give the patient a better quality, less anxiety, and also get myself a better reimbursement, to me, it’s a it’s a it’s a no brainer.

Advantages to end of the advance. So instant instant endometrial imaging, and guided by direct visualization, obviously. Biopsy can be done all during the same session, which I do, almost every single time.

Beautiful clear color display for accurate visualization, across all sorts of conditions.

Patient’s experience is is really, amazing with little to no discomfort without really any analgesia whatsoever.

Efficient workflow. So I often get asked this by other doctors, you know, do you do you schedule them on specific days? Do you do it in your procedure room? Because I do a lot of office procedures and surgeries.

I tell them any day, all day, any room.

Once you get your staff trained on this and you get them experienced and you get them comfortable, the patient will be comfortable.

And this is very similar. I often tell tell providers and tell patients it’s kind of similar to putting in an IUD. It’s It’s very similar in size. It’s essentially, you know, the the, a similar setup. And so it’s it’s it’s super, super easy. Any day, all day, any room.

Convenience of using, again, any exam room, average procedure length is less than three minutes. I challenge you to make it less.

And, obviously, a very low cost, investment compared to the reimbursement, that you get for the procedure itself. Clinical pathway.

Remember that traditional clinical pathway where I told you it was, like, five or six visits.

So, in my practice, you have the first visit that’s the history and physical exam findings. We kind of come up with a plan. And then in in in my practice, we do a transvaginal ultrasound. We do the endo c.

We do the endometrial biopsy. We do it all in one visit. So I basically cut what used to be three visits, or four visits down to two visits. And and in that visit where I do the endocy, especially if I find some sort of pathology, I already have a plan moving forward.

And so it’s it’s it’s a huge patient satisfier in cutting out them taking off of work, the anxiety of having to wait for the next event to come up. It’s it’s fantastic. So it it really does allow you to be efficient.

So, you know, the world, kind of got knocked on its butt, in twenty twenty and something that, I don’t know, some people could have predicted, other people couldn’t have with this pandemic. It really made us think about, how we kind of work up a patient. And, you know, I told you that the first visit of mine is talking about things, getting a history, finding out what the patient’s been going through. And we found out, even though I was very skeptical as a gynecologist, I’m like, patients need to be in front of me.

They have to be undressed. You know, the majority when when the this if anything good came out of this pandemic, I learned that a lot of what I do is getting a history and talking to the patient and counseling the patient and talking to them about their plan. So I think you can really use telemedicine in the, assessment of abnormal bleeding, whether it’s audio, whether it’s vis video. You know, there’s there’s lots of HIPAA compliant platforms now, and you can reduce the patient’s, exposure to your to your office, to the staff, to other patients, in a visit that really probably just needed to to talk to them.

And so telemedicine can really be used in the assessment of abnormal bleeding.

New approach to diagnosis of gynecological disorders, transformative effect on the management of patients with a variety of of gynecologic disorders.

Couldn’t have said it better, doctor Goldstein.

So conclusion, direct visualization of the cavity, super high accuracy of diagnosis. Obviously, I hopefully drove it home that significantly can decrease the time to diagnosis and treatment, which then improves patients’ care. It maximizes my time and efficiency, very cost effective for not only the practice, but more importantly, the patient.

Thank you, doctor Stein.

Just a reminder, you can ask a question by clicking the ask a question button below the webcast screen. If you’re in full screen mode, you will have to leave full screen to see that button. I’m now gonna turn over the q and a portion to the program to Chris Khan from Cooper Surgical.

Thank you, Ellen, and excellent talk, doctor Stein. It’s very good to speak with you again, and thank you very much to our audience for your time this evening. My name is Christopher Khan, and I am the senior global product director at Cooper Surgical, responsible for EndoSee Advance.

And I’m tracking the submitted questions that are still coming in. If you have additional questions, please type them in, and we will try to get to as many of these tonight as possible. And for any additional questions and follow-up, please do check the box for a sales representative follow-up and the polling questions at the end. Okay. Let’s get started with the questions.

Doctor Stein, what is the most important factor in considering EndoSee Advance in your opinion?

I think it’s very important. You know, when when patients come to my office, they they have a problem.

Generally, they have abnormal bleeding. They come with an abnormal ultrasound and they want an answer. They want an answer quickly. They want an answer, immediately. They’re scared.

And I think that choosing EndoSee Advanced to be able to do a quick diagnostic hysteroscopy and potentially even a little bit of an operative hysteroscopy in the office immediately or very quickly with a turnaround time with minimal discomfort, is is is is amazing.

Thank you. And how do you explain this procedure to your patients?

So I I let them know that it is very, similar but different to, hysteroscopy in general where we’re looking inside the uterus, with a camera. I tell them it’s a very, very small camera, comparative to what they may have seen on TV or in the OR or what they’ve had previously.

And that we’re gonna slide it through the cervix. We’re gonna take a quick look inside of the uterus to get an idea of what’s going on and see what’s there and quickly get out.

Okay. Great. And there’s a couple questions here about medications. So, when do you choose to premedicate a patient, before using EndoSee Advance? And what specifically do you use?

There’s a question about Cyto Tech, particularly if you use that, in which method do you deliver that and how long before the procedure do you administer that?

Okay. Great question. I mean, I think every patient should be, individualized.

Although, with that said, I want my patients as comfortable as as possible. So I tend to give, unless there’s a contraindication, Toradol ten milligrams orally, about an hour to an hour and a half before the procedure, just kind of as a standard. And then Synotec, I use, as needed. And the patients that I choose to use it on may be, nulliparous patients, those who have had only C sections and their cervix has never been dilated, or those with a synodic cervix, maybe a postmenopausal patient. I use two hundred micrograms.

And again, I tell them to take it about an hour and a half before. So, on those patients that I choose to use it on, I tell them to take the Toradol about an hour to an hour and a half before. And right after they swallow that pill, they’re going to I use it buccally.

So, I tell them to park it in their cheek about an hour to an hour and a half before, and that works wonders. You know, giving it, in my opinion, the night before, obviously, it works.

But patients often complain about cramping all throughout the night, and they have, you know, dissatisfaction due to that.

And then placing it vaginally. Not every patient has the dexterity to be able to place it in their vagina, especially postmenopausal women and some patients just don’t wanna place it vaginally. And so I find that buccally works very, very well.

Okay. And regarding, do you time your endoc procedures based on the patient’s cycle, or do you have any experience using Provera to to prepare the endometrium beforehand?

So I I don’t, you know, patients being so busy and having their busy lives and schedules.

It would be ideal obviously to to find every single patient and look inside, you know, right after their menstrual cycle or to try to time Prevera with them. I don’t do that in my practice. It’s more than fine to be able to do that. Obviously, patients that are just after their cycle or patients who are on progesterone therapy, you can see a little bit better. But as you get to use this product and you feel comfortable with it, you feel very comfortable being able to globally evaluate, and do a diagnostic hysteroscopy, in my opinion, without any of that.

How common would you find it to to use a a pericervical block?

So I honestly have used the pericervical block maybe less than a handful of times, in the last six or seven years that I’ve been using this product. It, it, it goes in very easily. There’s minimal patient discomfort.

And I, in my practice, don’t find the need to. I play a little bit of, Pink Floyd in the background or some sort of music in the background of their choice in order to get them to relax. And I’m generally in and out, very quickly before they even realize what happened.

That, plays into my next question, which was how what’s the best way to keep patients comfortable during the procedure?

I think you’ve hinted at that, but, maybe, explain how you talk to distract them maybe or, explain the procedure as you’re doing it. What do you typically like to to talk with the patient about?

No, Chris. It’s Pink Floyd. Just only Pink Floyd.

So, you know, I think doing office procedures, takes a certain knack and you kind of learn as you go along. I continue to talk to my patients throughout the entire process.

I talk to them about their day, I talk to them about their kids. Music is going in the background.

My nurses have a distraction technique where they kind of are tapping the patient on the leg and talking to them.

And I think as you feel more comfortable yourself, as your staff feels more comfortable in doing this procedure, the patient really, you will notice the patient relaxes and, and you can get things done a lot quicker and a lot with a lot less discomfort and angst and anxiety.

That’s great. Let’s talk about saline delivery to distend the uterus. What is your preferred method? What do you like your assistant to help out with?

So I’ve, I’ve used both, an IV bag, kind of dropping in on a, on a pressure bag versus what I currently use.

In that I feel like it’s a little bit more cost effective and a little less cumbersome.

Although both methods are great. I use a sixty cc syringe.

I purchased my, sterile saline, from, Henry Schein. You can get it. It comes in these little, hundred and twenty milliliter, containers that have, like a foil top on it. So So it’s exactly two full sixty cc syringes.

I tend to only need one sixty cc syringe but it allows you to in case, there’s a little bit of extra bleeding and you wanna be able to kind of flush out the cavity.

Although both methods are great, I use a short, connection to being of about thirty, I think it’s thirty centimeters along with the sixty cc syringe. And I tell my nurse or my medical assistant who I’ve trained, I said, if you can see, then I can see.

Okay.

And let’s say you find something upon direct visual assessment.

What therapeutic procedures are you comfortable performing in the office with EndoSee Advance?

So, you know, obviously, if it’s a big fibroid, we can’t really do anything with that.

If it’s a larger size polyp, you know, I have, graspers that can go down the working channel that can easily take a biopsy of the polyp.

Although, you know, polyps tend to be abnormal at the base of it. So if you can get to the base of it, fantastic. You can get a better diagnosis.

Small little polyps on stocks or if you happen to have a really, really tiny fibroid on a pedunculated stock, you could go in and grab it. Little, adhesions or synekiae that you may find, you could easily go in during the with the working channel and use a little bit of hysteroscopic scissors, and remove those. Those are are kind of what I would use the working channel for, along with oh, my favorite. My favorite, favorite, favorite as you saw in the video is to remove IUDs with the alligator claims.

That’s great. That’s great. There was a question follow-up a question on a previous, one that we just went through, which was around the distension of the uterus.

What particular fluid do you use?

I just use normal saline.

Normal saline. And what size bag? Or you said you use syringe primarily?

So I generally use, syringes, sixty cc syringe. If you’re gonna use a bag depending on where you purchase yours from, I’ve actually looked into it.

Thousand milliliter bags are actually cheaper than five hundred milliliter bags. I don’t know why. It’s just obviously the way they’re manufactured.

So keep that in mind when it comes to cost effectiveness.

Okay. Great. And, here’s a follow-up question on polypectomies.

And, the gist of this is that there’s really no large studies on tracking polyps and polyp polypectomies over time, and there may be as high as fifty percent regression, maybe possible. But do you use EndoC to follow your patients, that you’ve done these procedures on? And if so, for what time frame?

So I do not tend to follow them with the end of see. I tend to follow them more clinically, based on their bleeding complaints and their bleeding history.

Okay.

Thank you. When you’re doing therapeutic procedures, do you have a preferred instrument or do you go between different ones? Which ones do you like to use with MDC Advanced?

So I have, both a reusable or autoclavable, alligator graspers as well as scissors. And also not to overtly give them a plug, but Cooper Surgical makes an amazing, disposable grasper if you, if you don’t want to spend the I guess, like, eight to eight hundred to a thousand dollars, on the reusable one and you feel like you you remove IUDs or you remove polyps very infrequently. They have an amazing product, that is disposable that is able to be worked down, that is able to be placed down the working channel and can do both, both things.

Okay. Let’s talk about reimbursement.

What has your experience been? Have you generally found procedures to be reimbursed for any watch out areas? And then specifically, if there’s differences with the patient plans, do you vary your patient billing or do you keep it consistent? What do you find works best?

So, I mean, I have negotiated contracts, with all of the major plans, I in con including, Medicare, as obviously I can’t really negotiate that one. I do not my my personal practice, I don’t take Medicaid, so I’m unaware of the reimbursements for Medicaid. But the reimbursements for the major payers are, are phenomenal when it comes to a return on investment.

I think that taking a patient to the OR, is detrimental to our bank accounts. It’s detrimental to the patients in regards to their bank accounts, their ease.

The reimbursements have been phenomenal. So my general practice is I will actually bring a patient in for an office sauna if they need it.

As well as an EndoC and endometrial biopsy, if needed. And I will bill all of that together and get reimbursed without any question.

Okay.

Alright.

Let’s talk about scheduling patients, for appointments when you’re planning multiple procedures back to back. How do you, how often do you schedule those appointments and do you tend to group them together?

So, you know, I used to, as I’ve done hundreds and hundreds now, I do not tend to when I first started.

I definitely tended to keep them in blocks. I would do them about every thirty minutes as I started just for the staff to get more comfortable for me to get more comfortable.

But now as years have gone on, truly what I said in the presentation of anytime, anywhere, any room.

I schedule them every fifteen minutes as needed.

And you know, there’s there’s no there’s no rules. I have about four, rooms in my office and any of those rooms can be used and they’re all set up to be able to do this procedure.

Okay. Thank you. And sometimes doctors we find will, schedule an end of sleep procedure for some of their patients, but maybe not all of them. How do you think about that, and and how do you justify doing routine hysteroscopy, in order to achieve, you know, the like you talked about in in your talk about cost effectiveness and greater efficiency of care?

You know, talk to us about the percentage of the patients that you would, see as viable candidates for endoC.

So in my personal honest opinion, every patient with abnormal bleeding, every patient with an issue is is a viable candidate for an endoC. You know, office hysteroscopy has been proven time and time again, to be, you know, the, the ultimate in diagnosis of, of any sort of endometrial, pathology.

And so, I don’t discriminate.

It is my go to procedure, on nulliparous women, on postmenopausal women, whatever, whatever the case may be, I go straight to that. And patients, you know, I I explain it in a way of, listen, I don’t want to do a procedure that I may or may not know the diagnosis at the end of it and then have to bring you back for something after the fact. I would like to get to the exact diagnosis or get to the facts right off the bat.

Thank you.

How many procedures did it take for you to work up the learning curve?

So, I mean, I think in this case, everybody’s obviously, is, is different. In my personal opinion, it probably took me a good twenty five to thirty cases, to really, really feel, feel comfortable with it. You know, I apologize to you.

You know, not for me to be able to do hysteroscopy. Obviously we’re all trained to do osteoarthritis, but you know, using a device that’s flexible, using a device on an awake patient, You know, you kind of have to get into the flow. I really encourage providers who are, who are starting this procedure or those who have even picked it up and kind of put it down to not give up. This is not the exact same thing as being in the OR and it’s not it’s not meant to be.

Although it can give you almost or just as much information as being in the OR, you just have to remember that your patient is awake. So, you know, repetition, you know, none of us learned after one thing in residency or even in in getting out in the world. And so I really encourage people if they get discouraged, if their patient is a little bit more uncomfortable than they thought or they couldn’t see as much as they thought, to not just give up, to continue because it really is ultimately better for the patient in the long run.

That’s great, Doctor. Stein.

How easy did you find it to train, your office staff to be able to support you in this and be able to, you know, prepare the the reimbursement, billings and all of that?

So that’s that’s a fantastic question. So I started obviously small. So I in my, previous practice is where I started performing end of c and end of c advance.

And we started with the ultrasonographer oddly enough, not the medical assistant, not the nurse, the ultrasonographer because the patients were generally getting ultrasounds, before they were getting this procedure done, to look for other pathology fibroids on the outside, ovarian pathology, whatever it may be. And so I trained an ultrasonographer first and we just went step by step. I taught them what the setup was. I taught them what they were looking for.

And then slowly as the ultrasonographer felt comfortable, I brought in a medical assistant and the ultrasonographer and me helped train the next medical assistant until every single person in my office was able to be able to walk into a room at any point in time and know how to do this procedure. And so I didn’t have to rely on one single person if somebody called out sick or if somebody was in a room with another provider, whatever it was, I was able to train the entire staff.

But I started slowly and then worked each person up.

K. And here’s a question again about patient, preparation before the procedure. Have you ever used a vaginoscopic approach to inserting the cannula or do you always use a speculum and a tenaculum?

I’ve always used the speculum and a tenaculum.

Okay.

Thank you. One last question then. Do you have any final thoughts that you would like to share with the audience tonight?

I just wanna encourage providers, to realize that this technology, can truly be used by, by, by everyone.

It’s a better approach.

It’s keeping patients out of the OR. It’s getting them their diagnosis faster and quicker. The patient’s satisfier when it comes to end of see advanced, is through the roof and patients get excited. I take videos, I take pictures. They’re like, oh my goodness, that’s inside of me. I understand what’s going on now.

And so I really encourage you to consider this this technology.

And then last but not least, if you’re going to consider it, really don’t give up on it. Realize that we all have our own learning curve that we’re you’re going to have to work through some kinks.

Chris has, my permission to share my contact information. You can text me at any point in time if you want to talk through things, if you want to learn how I teach my how I taught my staff. I am here for you at any point in time.

Thank you so much. Again, great talk, very thoughtful answers. Really appreciate your time, and thank everyone’s, time this evening listening to this program. Alan, I will turn this back over to you.

Thank you, everybody.

And that’s gonna conclude the q and a for, this evening’s event. As a reminder, Cooper Surgical will be following up with any questions that the speaker could not get to this evening. Please take a few minutes and, complete the brief survey about tonight’s program by clicking the post program survey button or by scanning the QR code that you see on your screen now. Thank you, and have a great evening.