Laparoscopic Double Discoid Colorectal Resection for the Treatment of Two Distinct Deep Endometriotic Nodules.

OBJECTIVE: To show the surgical steps used to perform a laparoscopic double discoid colorectal resection for the excision of 2 distinct deep endometriotic nodules (DENs). DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: To date there is agreement that discoid resection should be the first choice procedure in patients eligible for surgical treatment with rectal, unifocal DENs measuring ≤ 3 cm [1-3]. For surgical management of lesions of the sigmoid colon, current international guidelines suggest to perform segmental resections [3]. Data on surgical treatment of multiple colorectal DENs separated by a great distance from each other are very limited, mostly owing to the rarity of such a diagnosis. In particular, there is paucity of data concerning the efficacy and safety of a double discoid resection for surgical management of distinct DENs found in the sigmoid colon and rectum [4]. In a context of multiple colorectal DENs, the decision-making process with respect to a double discoid excision must take into consideration both the distance between the 2 nodules and the nodules' distance from anal verge. When technically feasible, such organ-sparing surgery allows preserving the healthy bowel interposed between the endometriotic lesions, seeming to offer advantages in terms of quicker return of bowel function and better rectal functional outcomes than segmental colorectal resection. INTERVENTIONS: The patient was a 36-year-old woman experiencing drug treatment failure and presenting with refractory constipation, dyschezia, dysmenorrhea, dyspareunia, cyclical abdominal bloating, and chronic pelvic pain. Preoperative ultrasonography revealed the presence of an endometriotic nodule of 19 × 6 × 16 mm deeply infiltrating the tunica muscularis of the sigmoid colon. A second DEN was found at the level of the rectum, the latter measuring 19 × 5 × 12 mm and having a distance of 9 cm from the anal verge. Both the intestinal lesions resulted to have a circumferential extent of 30%. The distance between the 2 nodules was 15 cm. A 3-dimensional laparoscopy was performed. Sigmoid colon and rectal mobilization were performed according to our standardized technique [5-7]. A 31-mm circular stapler was used to excise first the nodule of the sigmoid colon. The stapler, in its closed position, was gently introduced into the rectum via the anus and then progressively advanced inside the large bowel up to the level of the sigmoid nodule. After correct positioning, the stapler was completely opened and the nodule was imbricate between the anvil and staple housing of the stapler. Then, the stapler was closed and fired. The procedure was repeated using a second 31 mm circular stapler to resect the rectal endometriotic nodule. The overall operative time was 90 minutes. The estimated blood loss was 5 mL. Neither intra- nor postoperative complications occurred. The patient was discharged 3 days after surgery. The sigmoid colon and rectal endometriotic nodules measured, respectively, 20 × 6 × 15 mm and 20 × 5 × 12 mm on fresh unfixed specimens. Both nodules were found to have endometriosis-free surgical margins on definitive pathology. CONCLUSIONS: The operative technique displayed in this video may contribute to the standardization of a procedure, which could be included among the options available in the surgical armamentarium, to be used in selected cases of multiple colorectal DENs each having 3 cm or less in diameter. Surgeon experience and an adequate preoperative evaluation are of utmost importance to plan the operative strategy and have the best chance of surgical success.

Outcomes of High-Grade Cervical Dysplasia with Positive Margins and HPV Persistence after Cervical Conization.

The objective of this work is to assess the 5-year outcomes of patients undergoing conization for high-grade cervical lesions that simultaneously present as risk factors in the persistence of HPV infection and the positivity of surgical resection margins. This is a retrospective study evaluating patients undergoing conization for high-grade cervical lesions. All patients included had both positive surgical margins and experienced HPV persistence at 6 months. Associations were evaluated with Cox proportional hazard regression and summarized using hazard ratio (HR). The charts of 2966 patients undergoing conization were reviewed. Among the whole population, 163 (5.5%) patients met the inclusion criteria, being at high risk due to the presence of positive surgical margins and experiencing HPV persistence. Of 163 patients included, 17 (10.4%) patients developed a CIN2+ recurrence during the 5-year follow-up. Via univariate analyses, diagnosis of CIN3 instead of CIN2 (HR: 4.88 (95%CI: 1.10, 12.41); p = 0.035) and positive endocervical instead of ectocervical margins (HR: 6.44 (95%CI: 2.80, 9.65); p < 0.001) were associated with increased risk of persistence/recurrence. Via multivariate analyses, only positive endocervical instead of ectocervical margins (HR: 4.56 (95%CI: 1.23, 7.95); p = 0.021) were associated with worse outcomes. In this high-risk group, positive endocervical margins is the main risk factor predicting 5-year recurrence.

Comparison Between Sonography-Based and Surgical Evaluation of Endometriotic Lesions Using the #Enzian Classification - A Retrospective Data Analysis.

PURPOSE: To compare the location and sizes of deep endometriosis (DE) lesions evaluated by preoperative transvaginal sonography (TVS) in different #Enzian compartments with intraoperatively assessed DE location and size. MATERIALS AND METHODS: Retrospective data analysis of 93 women undergoing TVS and surgery for DE in 2019 at a tertiary referral center for endometriosis. RESULTS: #Enzian compartment C (rectum) showed the highest rate of exact concordance with 74% of cases, which increased to 87% when a tolerance margin of a maximum of 3mm for TVS measurements was taken into account. For compartment B (uterosacral ligaments, parametria) and compartment A (vagina, rectovaginal space), the rates of exact concordance were slightly lower. In compartment O (ovary), high exact concordance rates similar to those observed for compartment C were observed. In compartment T (tubo-ovarian unit), most reliable estimations were seen for slight (TVS T1) and severe adhesions (TVS T3). There were only a few cases of missed lesions as well as false positives on TVS: Sensitivity was 100% for all compartments except for A and B left (97%) and FB (urinary bladder, 86%); specificity was 100% for FB, FI (other intestinal locations), FU (ureters) and O right, 86%-98% for A, B right, C, O left and FO (other extragenital lesions) and 70% for B left. CONCLUSION: The preoperative evaluation of the location and size of DE lesions by TVS in different #Enzian compartments is accurate, providing a detailed presurgical description of the extent of ovarian and deep endometriosis and associated minor or severe adhesions.

Comparison of #Enzian classification and revised American Society for Reproductive Medicine stages for the description of disease extent in women with deep endometriosis.

STUDY QUESTION: How is endometriosis extent described by the #Enzian classification compared to the revised American Society for Reproductive Medicine (rASRM) stages in women undergoing radical surgery for deep endometriosis (DE)? SUMMARY ANSWER: The prevalence and severity grade of endometriotic lesions and adhesions as well as the total number of #Enzian compartments affected by DE increase on average with increasing rASRM stage; however, DE lesions are also present in rASRM stages 1 and 2, leading to an underestimation of disease severity when using the rASRM classification. WHAT IS KNOWN ALREADY: Endometriotic lesions can be accurately described regarding their localization and severity by sonography as well as during surgery using the recently updated #Enzian classification for endometriosis. STUDY DESIGN, SIZE, DURATION: This was a prospective multicenter study including a total of 735 women between January 2020 and May 2021. PARTICIPANTS/MATERIALS, SETTING, METHODS: Disease extent in women undergoing radical surgery for DE at tertiary referral centers for endometriosis was intraoperatively described using the #Enzian and the rASRM classification. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 735 women were included in the study. Out of 31 women with rASRM stage 1, which is defined as only minimal disease, 65% (i.e. 20 women) exhibited DE in #Enzian compartment B (uterosacral ligaments/parametria), 45% (14 women) exhibited DE in #Enzian compartment A (vagina/rectovaginal septum) and 26% (8 women) exhibited DE in #Enzian compartment C (rectum). On average, there was a progressive increase from rASRM stages 1-4 in the prevalence and severity grade of DE lesions (i.e. lesions in #Enzian compartments A, B, C, FB (urinary bladder), FU (ureters), FI (other intestinal locations), FO (other extragenital locations)), as well as of endometriotic lesions and adhesions in #Enzian compartments P (peritoneum), O (ovaries) and T (tubo-ovarian unit). In addition, the total number of #Enzian compartments affected by DE lesions on average progressively increased from rASRM stages 1-4, with a maximum of six affected compartments in rASRM stage 4 patients. LIMITATIONS, REASONS FOR CAUTION: Interobserver variability may represent a possible limitation of this study. WIDER IMPLICATIONS OF THE FINDINGS: The #Enzian classification includes the evaluation of DE in addition to the assessment of endometriotic lesions and adhesions of the ovaries and tubes and may therefore provide a comprehensive description of disease localization and extent in women with DE. STUDY FUNDING/COMPETING INTEREST(S): No funding was received for this study. All authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER: N/A.

Ultrasound Evaluation of Retrocervical and Parametrial Deep Endometriosis on the Basis of Surgical Anatomic Landmarks.

STUDY OBJECTIVES: To assess the value of combined transvaginal/transabdominal ultrasonographic evaluation performed by experienced examiners for deep infiltrating endometriosis (DIE) lesions of the retrocervical (torus uterinus and uterosacral ligaments) and parametrial areas and summarize the features and anatomic criteria for identification of these lesions and their extent in the above-mentioned pelvic compartments. DESIGN: Retrospective study. SETTING: A specialized endometriosis center in Avellino, Italy. PATIENTS: A retrospective cohort of patients who underwent laparoscopic surgery for clinically suspected DIE between January 1, 2014, and December 31, 2018, with a dedicated ultrasound (US) evaluation performed no more than 1 month before the intervention. INTERVENTIONS: Preoperative US findings and surgical reports were reviewed. Using the findings of laparoscopic surgery as the gold standard, the sensitivity and specificity of preoperative US evaluation for retrocervical and parametrial endometriotic lesions were calculated with the corresponding 95% confidence intervals. MEASUREMENTS AND MAIN RESULTS: A total of 4983 patients were included. US evaluation showed high diagnostic accuracy for DIE detection in the examined pelvic compartments, with sensitivity and specificity of 97% to 98% and 98% to 100%, respectively, for both retrocervical (torus uterinus and uterosacral ligaments insertion) and parametrial lesions. CONCLUSION: Parametrial extension of DIE indicates major surgical technical difficulties and risk of complications, and urologic and nerve-sparing procedures may be required in such cases. Preoperative evaluation of such scenarios will allow proper counseling of patients and facilitate adequate surgical planning in referral centers; moreover, when necessary, it can guide the constitution of a dedicated multidisciplinary surgical team as an alternative to treatment by a pelvic surgeon alone. Detailed imaging evaluation of DIE lesions and their extension is crucial for clinical management of affected patients. It can facilitate optimization of surgical timing and strategies, thereby potentially preventing ineffective, or even harmful, repeated procedures.

Totally Laparoscopic Resection with Transanal Natural Orifice Specimen Extraction for Deep Endometriosis Infiltrating the Rectum.

OBJECTIVE: To show the surgical steps used to perform a totally laparoscopic segmental rectal resection, with intracorporeal anastomosis and transanal natural orifice specimen extraction (NOSE), in a context of deep endometriosis. DESIGN: Step-by-step video demonstration of the technique. SETTING: Even though the combined use of intracorporeal anastomosis and NOSE has increasingly been investigated during the last decade, there is still lack of defined consensus, both in terms of patient eligibility and operative technique. In particular, experience with intracorporeal anastomosis and NOSE for treatment of deep rectal endometriosis is very limited. Preliminary reports have documented that a totally laparoscopic rectal resection is equally effective and safe compared with the conventional approach using an abdominal minilaparotomy for extracorporeal anastomosis and specimen retrieval. In comparison to the latter, intracorporeal anastomosis with NOSE seems to offer advantages in terms of less postoperative pain, fewer wound-related complications, better cosmetic results, quicker return of bowel function and shorter hospital stay. PATIENT: A 31-year-old woman with a history of constipation, dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain unresponsive to hormonal therapies. Preoperative ultrasonography showed partial obliteration of the Douglas' pouch due to a rectal endometriotic nodule of 42 × 12 × 18 mm in contiguity with a deeply infiltrating retrocervical lesion of 13 × 3 × 17 mm. The rectal nodule resulted in the infiltration of the tunica muscularis with a distance of 12 cm from the anal verge and a circumferential extent of 45%. INTERVENTIONS: A 3-dimensional laparoscopic system was used. Rectal mobilization was performed according to our standardized technique [1]. After determining the proximal and distal resection margins, the rectum was transected using a tissue sealing-device. The resected specimen was placed in a retrieval bag and pulled out through the anus. Proximal and distal resection lines were closed using a 60 mm linear endo-stapler, and a totally intracorporeal, side-to-end anastomosis was performed using a 29 mm circular stapler. MAIN RESULTS: The overall operative time was 85 minutes. The estimated blood loss was 10 mL. Neither intra- nor postoperative complications occurred. The patient was discharged 5 days after surgery. The bowel endometriotic nodule measured 41 × 12 × 18 mm on the fresh unfixed specimen. CONCLUSIONS: Advanced surgical skills are needed to perform an effective and safe, totally laparoscopic rectal resection. The operative technique displayed in this video may contribute to the standardization of such surgical procedure. Accurate patient selection, including adequate preoperative evaluation, is of utmost importance for the best chance of surgical success.

Laparoscopic Technique for Discoid Resection of Rectal Endometriotic Nodules.

OBJECTIVE: To show the surgical steps used to perform a rectal disc excision in the context of deep infiltrating endometriosis characterized by contiguity between an intestinal lesion and the retrocervical region. DESIGN: Step-by-step video demonstration of the technique. SETTING: Although surgical options for the management of rectosigmoid endometriosis have been investigated increasingly, there is no consensus regarding patient eligibility for shaving, discoid resection, or segmental resection. In our practice, women with nodules ≤3 cm in size and >7 mm deep were considered as candidates for rectosigmoid disc excision [1]. Therefore patients' selection, together with the adoption of a standardized surgical technique, has allowed us to maximize the chance of a successful discoid resection, minimizing the complications potentially derivable from this surgical procedure. INTERVENTIONS: The patient was a 30-year-old woman with a history of constipation, dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain unresponsive to hormonal therapies. A preoperative ultrasonography showed complete obliteration of the pouch of Douglas owing to a rectal endometriotic nodule (21 × 7 × 12 mm) in contiguity with a deeply infiltrating retrocervical lesion (28 × 10 × 27 mm). As a result, the rectal nodule infiltrated the tunica muscularis with a distance from the anal verge of 9 cm and an estimated stenosis of 35%. A 3-dimensional laparoscopy was performed. After rectal mobilization and rectovaginal space opening, the intestinal nodule was isolated in its entire circumference (Fig. 1). A 33-mm transanal circular stapler was inserted into the rectum through the anus and used to perform disc excision and suture the rectal wall. The overall operative time was 55 minutes. No intraoperative complication occurred. A complete excision of endometriosis was achieved. The estimated blood loss was 10 mL. An intra-abdominal drain was not placed, and the urinary catheter was removed at the end of the surgery. The patient was discharged 3 days after surgery and did not experience postoperative complications. The diameters of the bowel endometriotic nodule, on measuring fresh specimen, were 20 × 7 × 13 mm. CONCLUSIONS: Advanced laparoscopic surgical skills are needed to perform an effective and safe rectal discoid resection. Subspecialization and an adequate preoperative evaluation are of utmost importance to appropriately plan the treatment strategy against bowel endometriosis.

Preoperative Ultrasound Indications Determine Excision Technique for Bowel Surgery for Deep Infiltrating Endometriosis: A Single, High-Volume Center.

STUDY OBJECTIVE: To identify bowel nodule features of deep infiltrating endometriosis (DIE) measured through preoperative ultrasound scanning that influence laparoscopic surgical strategy. DESIGN: A retrospective study. SETTING: Malzoni Clinic-Endoscopica Malzoni Department, Center for Advanced Endoscopic Gynecological Surgery, Avellino, Italy. PATIENTS: Patients undergoing laparoscopic surgery between January 1, 2014, and December 31, 2018, for clinically suspected DIE with previous ultrasound evaluation ≤1 month before intervention. INTERVENTION: Use of sonographic measurements to determine laparoscopic excision technique (segmental bowel resection, discoid resection, shaving) for DIE with bowel involvement.``` MEASUREMENTS AND MAIN RESULTS: Of 5051 DIE surgeries, 4983 were included; 1494 (29.9%) bowel resections (512 bowel segmental resections and 982 nodulectomies [967 shaving and 15 discoid resections]) were performed, accounting for 34.3% and 65.7% of all bowel procedures, respectively. Preoperative sonographic findings and surgical reports were collected. Sensitivity and specificity of preoperative ultrasound evaluation for all types of DIE lesions were calculated, and sonographic measurements of bowel nodules and different surgical techniques were compared. According to preoperative sonographic measurements, most nodules excised by segmental resection had a longitudinal diameter of 3 to 7 cm, none were <3 cm; all nodules excised by nodulectomy (shaving or discoid resection) had a longitudinal diameter <3 cm. Mean thickness (maximum depth of muscular layer infiltration) of identified bowel nodules estimated through ultrasound scanning was 13.4 mm ± 4.8 mm (mean ± standard deviation) and 5.8 mm ± 2.7 mm for lesions removed by segmental resection and nodulectomy, respectively, and there was a statistically significant difference between them (p <.05). Of the 512 segmental resected bowel nodules, 143 (28%) had a maximum depth ≥9 mm, 354 (69%) had 7 to 9 mm, and 15 (3%) had <7 mm (6 mm, with length >4 cm). All shaved nodules had thickness ≤7 mm. The 15 nodules excised by discoid resection (1.5% of nodulectomies) were <25 mm, but thickness ranged from 7 to 9 mm. CONCLUSION: The need for segmental resection in DIE with bowel-infiltrating nodules depends on the degree of muscular layer infiltration and corresponding thickness (muscularis rule) in addition to nodule length and can be accurately identified by preoperative ultrasound evaluation.

Surgical Principles of Segmental Rectosigmoid Resection and Reanastomosis for Deep Infiltrating Endometriosis.

STUDY OBJECTIVE: To demonstrate the surgical steps involved in segmental rectosigmoid resection and reanastomosis in a deep infiltrating endometriosis (DIE) setting. DESIGN: Step-by-step video demonstration of the technique. SETTING: Despite efforts made to identify criteria able to reliably predict which patients would be more likely to benefit from segmental bowel resection, such predictability remains an area of controversy and ambiguity. Furthermore, a standardized surgical technique has not yet been defined. Based on our experience, patients with DIE and colorectal involvement should be considered for segmental resection followed by anastomosis if they present with lesions not suitable for shaving/nodulectomy (i.e., large, deeply infiltrating nodules with extensive circumferential involvement). In our practice, careful patient selection together with the adoption of a standardized surgical technique allowed us to minimize the potential complications associated with segmental bowel resection. INTERVENTION: The patient was a 27-year-old woman diagnosed by ultrasonography with a bowel endometriotic nodule of 33 × 8 × 14 mm infiltrating the inner layer of the muscularis propria at the rectosigmoid junction, with a distance from the anal verge of approximately 12 cm and an estimated stenosis of 50%. A 3-dimensional laparoscopic segmental rectosigmoid resection was performed, and indocyanine green-enhanced fluorescent angiography was used to assess perfusion of the bowel before completion of the anastomosis. The total operative time was 135 minutes, and no intraoperative complications occurred. Complete excision of endometriosis was achieved. The estimated blood loss was 30 mL. An intra-abdominal drain was not placed, and the urinary catheter was removed at the end of surgery. The patient was discharged at 6 days after surgery and did not experience any postoperative complications. The bowel endometriotic nodule measured 34 × 8 × 13 mm in a fresh specimen. CONCLUSION: Advanced laparoscopic surgical skills are needed to properly perform segmental rectosigmoid resection. Subspecialization and adequate pretreatment evaluation are crucial to ensure the correct decision making process within a complex algorithm for surgical management of bowel endometriosis.

Combined Transvaginal/Transabdominal Pelvic Ultrasonography Accurately Predicts the 3 Dimensions of Deep Infiltrating Bowel Endometriosis Measured after Surgery: A Prospective Study in a Specialized Center.

STUDY OBJECTIVE: To assess the sensitivity and accuracy of combined transvaginal/ transabdominal ultrasonography (TV/TA US) for evaluation of deep infiltrating bowel endometriosis nodules measured after surgery. DESIGN: Prospective study (Canadian Task Force classification II.1). SETTING: A center for advanced endoscopic gynecologic surgery. PATIENTS: All women undergoing laparoscopic surgery and scheduled for segmental resection for clinically suspected bowel endometriosis between January 2014 and December 2016. INTERVENTIONS: In all women with clinically suspected bowel endometriosis, a US scan was performed before surgery to detect and measure the 3 diameters of bowel endometriotic lesions: longitudinal, anteroposterior, and transverse. These diameters were compared with those obtained by direct measurement on a fresh specimen. The sensitivity and specificity values of US evaluation were calculated, with 95% confidence intervals. MEASUREMENTS AND MAIN RESULTS: The sensitivity and specificity of TV/TA US in the 328 patients of this study were 100% when rectal endometriotic lesions were investigated. The specificity was 100%, whereas the sensitivity decreased to 91.4% when sigmoid lesions were investigated. Bowel muscularis infiltration was histologically confirmed in all cases in which endometriotic lesions were detected by US (284 of 284; 100%). All missed sigmoid lesions (12 of 296) were located >25 cm from the anal verge. The mean diameters of endometriotic nodules calculated by US evaluation and by direct measurement on the fresh specimen were 43.19 × 19.87 × 10.79 mm and 42.76 × 19.64 × 10.62 mm, respectively, with no statistically significant differences between the 2 methods. CONCLUSION: We believe that US can be considered an accurate diagnostic technique for the evaluation of deep infiltrating bowel endometriosis when performed by a dedicated experienced sonographer in a specialized center.

Feasibility and Safety of Laparoscopic-Assisted Bowel Segmental Resection for Deep Infiltrating Endometriosis: A Retrospective Cohort Study With Description of Technique.

STUDY OBJECTIVE: To evaluate the feasibility and safety of laparoscopic segmental bowel resection for deep infiltrating endometriosis (DIE). DESIGN: Retrospective clinical study (Canadian Task Force classification II-3). SETTING: Endoscopica Malzoni-Center for Advanced Endoscopic Gynecological Surgery, Avellino, Italy. PATIENTS: A retrospective cohort of 248 patients who underwent laparoscopic segmental bowel resection between January 1, 2011, and December 31, 2014. INTERVENTION: Laparoscopic segmental bowel resection for DIE. MEASUREMENTS AND MAIN RESULTS: Bowel endometriosis was histologically confirmed in all 248 of the 248 patients (100%). The mean length of the resected specimens was 11.83 ± 4.56 cm. In all cases, margins were free of disease. The muscular layer was infiltrated up to the submucosal layer in all 248 patients (100%), whereas the mucosal layer showed signs of infiltration in only 4 patients (1.6%). Two nodules were found in 36 patients (14.5%), and 3 nodules were found in only 8 patients (3.2%). None of the resected bowel segments had nodules shorter than 3 cm, and the majority of lesions had a longitudinal diameter of 3 to 7 cm. In the majority of cases, resected segments involved the mid to low rectum (distance from the lower margin of resected segment from the anal verge of 4 to 12 cm), whereas in 6% of cases, ultra-low resections (≤4 cm) were performed. No intraoperative complications occurred, and conversion to laparotomy was not required for any patient. Major perioperative and early and late postoperative complications occurred in 20 patients (8.06%). Significantly reduced pain associated with disease was observed up to the 1-year follow-up irrespective of postoperative hormonal treatment. Pelvic relapse was found in up to 50% of patients, especially in patients without hormonal suppression, but only in the form of endometriomas or adherences, with no recurrent deep lesions observed. CONCLUSION: This large single-center series demonstrates that laparoscopic bowel resection for DIE is a feasible technique, with low complication rates. In symptomatic patients, treating deep fibrotic endometriosis nodules by laparoscopic segmental resection is very effective in reducing pain and restoring bowel function. This surgical approach is safe but complex, requiring specific skills in laparoscopic urologic and colorectal procedures, and should be performed only in specialized high-volume centers by high-volume surgeons.

Ultrasound mapping system for the surgical management of deep infiltrating endometriosis.

OBJECTIVE: To assess the accuracy of transvaginal sonography (TVS) in defining size and location of deep infiltrating endometriosis (DIE) with laparoscopic/histologic confirmation. DESIGN: Prospective observational study. SETTING: University hospital. PATIENT(S): One hundred four women with suspected DIE on the basis of TVS. INTERVENTION(S): Patients with DIE underwent TVS evaluation before laparoscopic surgery. An accurate mapping of the extent of the disease was recorded during TVS and at laparoscopy. This new mapping system was developed to assess the extent of endometriosis by measuring the size and depth of the lesions at the various pelvic locations. MAIN OUTCOME MEASURE(S): Surgical and histologic confirmation of the ultrasonographic data to evaluate the presence and location of DIE and creation of a new mapping methodology for detecting DIE by TVS. RESULT(S): Depending on the different location of the lesions, the accuracy of TVS ranged from 76%-97%. The lowest sensitivity (59%) and accuracy (76%) were obtained for TVS in the diagnosis of vaginal endometriosis, whereas the greatest accuracy (97%) was shown in detecting bladder lesions and Douglas obliteration. CONCLUSION(S): This new ultrasound mapping system is accurate for detecting the extent of DIE and may be useful for preoperative planning and intraoperative management of symptomatic patients with DIE.

Preoperative and Postoperative Clinical and Transvaginal Ultrasound Findings of Adenomyosis in Patients With Deep Infiltrating Endometriosis.

OBJECTIVES: Deep infiltrating endometriosis (DIE) represents the most complex form of endometriosis and its treatment is still challenging. The coexistence of DIE with other appearances of endometriosis stimulates new studies to improve the preoperative diagnosis. Adenomyosis is a clinical form that shares several symptoms with DIE. The present study investigated the possible presence of adenomyosis in a group of women with DIE and its impact on pre- and postoperative symptoms. MATERIALS AND METHODS: A group of women (n = 121) undergoing laparoscopic treatment for DIE were enrolled. Clinical and ultrasound evaluations were performed as preoperative assessment. The ultrasonographical appearances of DIE and of adenomyosis were recorded by 2-dimensional ultrasound. The following symptoms were considered: dysmenorrhea, dyspareunia, abnormal uterine bleeding, bowel, and urinary symptoms. Pain was evaluated by the visual analog scale system and menstrual bleeding was assessed by the use of the pictorial blood assessment chart. In a subgroup of women (n = 55), a follow-up evaluation (3-6 months after surgery) was done. RESULTS: A relevant number of patients with DIE showed adenomyosis (n = 59; 48.7%); in this group, dysmenorrhea (P = .0019), dyspareunia (P = .0004), and abnormal uterine bleeding (P < .001) were statistically higher than that in the group with only DIE. After surgery, painful symptoms improved in the whole group but remained significantly higher (P < .001) in the group with adenomyosis. CONCLUSIONS: Deep infiltrating endometriosis is frequently associated with adenomyosis, significantly affecting pre- and postoperative symptoms and thus influencing the follow-up management.

Contrast-tuned imaging and second-generation contrast agent SonoVue: a new ultrasound approach to evaluation of tubal patency.

STUDY OBJECTIVE: To determine whether transvaginal hysterosalpingo-contrast sonography (HyCoSy) with a new dedicated contrast-enhanced ultrasound technique, can contribute to accurate diagnosis of tubal occlusion. DESIGN: Prospective observational study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Two-hundred twelve patients with primary or secondary infertility. INTERVENTIONS: All patients underwent transvaginal HyCoSy. If the tubes showed no evidence of patency after injection of air-saline solution, a solution with sulphur hexafluoride bubbles (SonoVue) was injected into the uterine cavity and tubes while contrast-tuned imaging (CnTI) was applied. Patients with tubal occlusion underwent laparoscopic chromoperturbation. MEASUREMENTS AND MAIN RESULTS: Of the 212 patients who underwent tubal insufflation with air-saline solution, 52 demonstrated tubal occlusion, bilateral in 21 patients and unilateral in 31 patients, for a total of 73 suspected occluded tubes. At the HyCoSy test with SonoVue and CnTI, only 47 tubes seemed to be occluded, and in the other 26 tubes, passage of SonoVue was observed. HyCoSy with Sono Vue demonstrated high concordance for tubal obstruction with the laparoscopic dye test (94%). CONCLUSIONS: HyCoSy with SonoVue and CnTi is a low acoustic pressure technique in which bubbles are not immediately destroyed and can be detected for several minutes. This enables the signal sent to the equipment to be filtered from the echoes emanating from other tissues. Therefore, excluding the fundamental image, the bubbles are clearly observed, with no visualization of pelvic tissues and organs. This allows easier evaluation of tubal patency, provides a more accurate assessment of tubal occlusion, and enables better visualization of the tubal course.

Bilateral ovarian pregnancy after intrauterine insemination and controlled ovarian stimulation.

OBJECTIVE: To report a case of bilateral ovarian pregnancy in a young patient who had previously undergone intrauterine insemination (IUI) and controlled ovarian stimulation (COS). DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 34-year-old woman who had previously undergone IUI and COS. INTERVENTION(S): Emergency exploratory laparotomy for circulatory collapse. About 350 mL of bloody fluid was collected in the pelvic cavity. The left ovary was about 6 cm in diameter and was completely involved by a darkish hemorrhagic ovarian mass; the right ovary was involved by a 4-cm mass. A left ovariectomy and a partial resection of the right ovary with preservation of two-thirds of ovarian tissue was performed. MAIN OUTCOME MEASURE(S): IUI and COS outcome. RESULT(S): The pathologic diagnosis was considered, and bilateral ovarian pregnancy was confirmed according to the diagnostic criteria described by Spiegelberg. CONCLUSION(S): Diagnosis of primary ovarian pregnancy is very difficult because of its rarity and asymptomatic state before rupture. However, early diagnosis is fundamental to avoid more serious complications and an emergency invasive procedure.

Feasibility and safety of vaginal myomectomy: a prospective pilot study.

STUDY OBJECTIVE: Classic myomectomy was performed via laparotomy. More recently, laparoscopic myomectomy has become a valuable treatment option. Vaginal myomectomy is a surgical procedure that has recently been evaluated. However, few trials have been reported in past literature. The aim of this study was to evaluate feasibility and complication rate of patients submitted to vaginal myomectomy. DESIGN: Prospective study with review of literature (Canadian Task Force classification II-2). SETTING: Department of Obstetrics and Gynecology, S. Filippo Neri Hospital of Rome, Italy. PATIENTS: Consecutive patients with symptomatic myomas who refused hysterectomy. INTERVENTIONS: After preoperative assessment, patients were submitted to vaginal myomectomy using posterior colpotomy. MEASUREMENTS AND MAIN RESULTS: Operative time, perioperative complications, and hospital stay were prospectively recorded. Follow-up examinations were performed at 1 and 12 months postoperatively. Data on possible symptoms, fertility, and pregnancy outcome during follow-up periods were recorded. Myomectomy was completed vaginally in 17 (94%) of 18 patients. Mean operating time was 48 +/- 22 minutes; mean operative blood loss and hospital stay were 210 +/- 350 mL and 3.5 +/- 2.4 days, respectively. Only 2 (11%) patients required blood transfusion. Three patients have conceived spontaneously. CONCLUSION: Vaginal myomectomy is a feasible and safe surgical procedure, with low morbidity and short hospital stay, and could represent a valid alternative to open or laparoscopic myomectomy in selected cases.