Diaphragm endometriosis: Random localization or extended form of pelvis endometriosis. A large comparative analysis of 202 cases.

OBJECTIVE: The aim of this study was to investigate and present the clinical characteristics of diaphragm endometriosis, to approach the pathogenetic mechanisms, and to answer the question of whether this disease can be considered an extended form of pelvic endometriosis. STUDY DESIGN: It was a retrospective comparative one-to-one analysis of 202 cases. Two groups of patients were compared: Group 1 patients with diaphragm endometriosis vs Group 2 (control group) with pelvis endometriosis, each with 101 patients. RESULTS: Patients with diaphragm endometriosis had extreme significantly higher prevalence of severe pelvis endometriosis included deep infiltrated endometriosis and severe adhesions in term of complete Douglas obliteration (p value = 0.0001). There was neither age nor BMI difference in two groups. Besides of cyclic shoulder or upper abdomen pain there was no difference of symptoms. CONCLUSION: Diaphragm endometriosis is a rare condition with an approximate prevalence of 1.1% of all endometriosis cases. Since the symptoms are very specific and patients do not associate the pain with diaphragmatic endometriosis, the symptoms should be asked about explicitly. If patients with diaphragmatic endometriosis have no symptoms, the lesions do not necessarily need to be removed. The pathogenesis is still unclear. The authors of this study consider this disease to be an extended form of severe pelvic and deep infiltrated endometriosis. However, the right-side dominance still cannot be explained. Further research is needed to fully understand the origin of diaphragmatic endometriosis.

Transcervical radiofrequency ablation of focal adenomyosis: pilot results.

Objective: Adenomyosis is a common gynecological disease, which occurs in women in reproductive age and is characterized by the presence of endometrial glands and stroma within the myometrium. Abnormal uterine bleeding, pelvic pain as well as infertility can be associated with adenomyosis. There are two main types of adenomyosis: diffuse and focal. Previously, adenomyosis was diagnosed only upon histopathological examination after hysterectomy and/or adenomyomectomy. However, the development of imagining techniques such as transvaginal ultrasound and magnetic resonance imaging enables the diagnosis of adenomyosis (diffuse and focal) without any surgical intervention. When medical therapy is contraindicated or ineffective, or if patients have a fertility desire, a surgical treatment may be necessary.Methods: In this study, a total of 13 patients with 16 areas of focal adenomyosis were treated. All patients provided their informed consent to undergo transcervical adenomyosis ablation treatment with the Sonata System, aware that the safety and effectiveness of transcervical radiofrequency (RF) ablation for the treatment of adenomyosis has not been established. Follow-up was performed six months after Sonata treatment.Results: The positive results relating to the improvement of symptoms and reduction of adenomyosis lesion size were observed in our study.Conclusion: Transcervical RF ablation with the Sonata System may be a promising therapeutic alternative method to conventional procedures such as hysterectomy for the treatment of focal adenomyosis, disease which has limited therapeutic approach, and may enable a minimally invasive, uterine preserving option.

Clinical and Surgical Characteristics of Abdominal Wall Endometriosis: A Multicenter Case Series of 80 Women.

BACKGROUND/AIM: Endometriosis of the abdominal wall (AWE) is poorly understood because of its rarity and heterogeneous nature. The aim of this study was to investigate and present the clinical and surgical characteristics of AWE and to propose its classification. PATIENTS AND METHODS: This was a multicentric retrospective study. For this analysis, the data from three endometriosis centers were collected. In total 80 patients were included in this study. The Academic Hospital Cologne Weyertal is a certified, level III endometriosis center in Germany with 750-1,000 endometriosis surgeries being performed annually; Barzilai University Medical Center is a certified endometriosis center in Ashkelon, Israel; and Baku Health Center is an endometriosis Center in Baku, Azerbaijan. RESULTS: The size of nodule (histological specimen) was significant larger in women with than those without adenomyosis (3.34±1.4 vs. 2.55±1.33 cm, p=0.016). The incidence of subfascial involvement was also found to be significantly higher in these women (42% vs. 19%, p=0.03). No significant difference was found in patients with and without obesity. In 78% of cases, the proliferation level (Ki67 marker) was less than 30%. CONCLUSION: AWE has a high prevalence of symptoms such as abdominal wall pain and swelling, as well as bleeding. The strengths of the current study are the investigation of the proliferation marker Ki67 in AWE, the impact of adenomyosis, as well as the suggested classification.

Laparoscopic Approach in Bladder Endometriosis, Intraoperative and Postoperative Outcomes.

BACKGROUND/AIM: Endometriosis is a benign condition affecting 10-20% of women at reproductive age. The urinary tract is affected in 0.3-12.0% of women with endometriosis and in 19.0-53.0% of women with deep infiltrating endometriosis. The bladder is the most commonly affected organ in the urinary tract with a prevalence of up to 80%. Bladder endometriosis is defined as the occurrence of endometrial glands and stroma in the detrusor muscle. The aim of the study was to present the detailed technique and intraoperative and postoperative outcomes of laparoscopic resection of bladder endometriosis. PATIENTS AND METHODS: This was a retrospective study analyzing all surgical procedures, carried out at the Academic Hospital Cologne Weyertal between January 2014 and December 2022. In total 23,862 surgical reports were analyzed, and only patients (n=33 patients) with bladder endometriosis were included in the study. RESULTS: Follow-up was performed in 25 patients by phone contact. Twenty-three patients (92%) reported an improvement of symptoms, especially of dysuria, and an increase of quality of life. Only two patients (8%) reported no change in symptoms (dysmenorrhea and dyspareunia). Two patients (8%) reported bladder dysfunction. Mild postoperative pollakiuria was reported by two patients (8%). Four patients (with mild bladder dysfunction and pollakiuria) were satisfied with postoperative results owing significant improvement of symptoms and increasing the quality of life. CONCLUSION: Surgical treatment of bladder endometriosis can be performed by a gynecologist. In cases where a ureteroneocystostomy is required or the localization of endometriosis nodule is unfavorable, an intervention by a multidisciplinary team is recommended. Laparoscopic partial cystectomy and shaving seem to be an appropriate method for improving urinary symptoms. This surgical approach requires excellent laparoscopic skills.

Delayed expulsion of a large fibroid after transcervical radiofrequency ablation: A case report.

Fibroids are the most common type of benign uterine tumor, which occur up to 68.6% of women. Hypermenorrhea is the most common symptom with a general prevalence of 40%-54%, followed by dysmenorrhea and low abdominal pain. Transcervical fibroids ablation was developed as a minimally invasive, incisionless treatment of fibroids in a short time. This method is safe and effective with an excellent record of safety. We present the case of a 40-year-old woman, who attended in our fibroid excellence center. She reported severe hypermenorrhea and dysmenorrhea. Family planning was definitely completed. Using vaginal ultrasonography a FIGO 2-5 fibroid of 5 cm in diameter was detected. Different treatment options were discussed: medical treatment, laparoscopic fibroidectomy, hysterectomy, and transcervical radiofrequency ablation with Sonata System. Because of advantages of transcervical radiofrequency ablation (minimal invasive treatment without incision, effectivity of method, short surgical time) the patient decided on this method. Three months later, the patient came to the first follow up. She reported a significant improvement of hypermenorrhea. A vaginal ultrasonography was carried out. The fibroid changed its position from FIGO 2-5 to FIGO 2. The patient was very satisfied with the result. After 2 months, she attended in our department again because of severe clear vaginal discharge. She had no bleeding, no pain as well as no fever. We examined her immediately. A fibroid expulsion was detected. The fibroid was removed vaginally. There was no severe bleeding during the operation and the fibroid could be removed completely. The surgery time was 25 minutes.

Are double-J stents in surgery for deep infiltrating endometriosis always necessary? A retrospective analysis.

Introduction: The therapy of deep infiltrating endometriosis places the highest demands. Double-J (DJ) stent insertion is recommended preoperatively. However, we could not find any publication in PubMed that showed the relevant advantages of double-J stent insertion in surgery of deep infiltrating endometriosis (DIE). Aim: To report the advantages and disadvantages of inserting double-J stents in surgery for deep infiltrating endometriosis. Material and methods: All patients who underwent surgery for deep infiltrating endometriosis at Academic Hospital Cologne Weyertal (a level III endometriosis center with up to approximately 900 endometriosis laparoscopic procedures annually) between January 2017 and September 2021 were included in this retrospective analysis. A total of 197 cases were included. The urinary tract complications were analyzed and they were divided into infections, pyelonephritis, urosepsis, intraoperative and postoperative ureteral lesions. Patients were divided into three groups: 1) with DJ stents in whom DJ stents were left in place postoperatively for at least 2 weeks, 2) with DJ stents in whom DJ stents were removed directly at the end of the surgery, 3) without DJ stents. Results: There was a significant difference between all three groups in urinary tract complications: group 1 - 32%, group 2 - 11.6% and group 3 - 7%. The p-value of 0.01 shows statistical significance between group with DJ stents and the group without DJ stents. Urinary tract infection occurred in 25.5% in the first group, 11.6% in the second group and 3.6% in the third group. Here, too, the p-value shows statistical significance between the group with DJ stents and the group without DJ stents. Ureteral injury, on the other hand, occurred rarely and no statistically significant difference was found between group 3 and the total population, 3.6% versus 2.5%. In group 1, the injury rate was minimally higher, 6.4%. After comparing groups 1 and 2 with group 3, there was also no significant difference in ureter injury (6.4% vs. 3.6%, p = 0.42). Conclusions: The authors of this study recommend that DJ stent insertion should not be part of the general preoperative preparation.

Transcervical intrauterine radiofrequency ablation of fibroids in high-risk patients with bleeding disorder.

OBJECTIVES: To show the advantages of transcervical radiofrequency ablation (TRFA) in high-risk patients with bleeding disorder. MATERIAL AND METHODS: It is a retrospective analysis. The study included only patients with known pre-existing conditions (obesity, cardiac and neurological disease, coagulation disorder, anaemia) or post-surgical conditions who were treated with the Sonata® System for fibroid-related bleeding complaints at Academic Hospital Cologne Weyertal between January 2015 and March 2021. These patients were classified as high-risk patients. The fibroids were mostly determined due transvaginal sonography. Thirty patients were included, and 43 fibroids were determined. RESULTS: Therapy with the Sonata® system could be performed without complications in all cases. In our analysis, improvement of fibroid-related symptoms was observed in 89% of cases. CONCLUSIONS: The Sonata® System is on the one hand minimally invasive, uncomplicated and fast and on the other hand a successful method of fibroid therapy, which is particularly suitable for high-risk patients with various pre-existing conditions, for whom a minimally invasive, bloodless and short surgical procedure has great advantages.

Combined procedure of the transcervical radiofrequency ablation (TRFA) system and surgical hysteroscopy. Increased risk or safe procedure?

Introduction: The advantage of transcervical radiofrequency ablation (TRFA) is that it is minimally invasive, incision-free, and treats a wide spectrum of fibroids, including those that are not accessible by surgical hysteroscopy (FIGO 3, 4, 5, 6, and 2-5). However, there are no publications describing a combined procedure of operative hysteroscopy and TRFA yet, so it was still unknown whether a combined procedure is associated with additional risks. Aim: To report the combined technique of transcervical intrauterine radiofrequency ablation of fibroids and surgical hysteroscopy. Material and methods: Our study was designed to show the results of our case series with 21 patients. The retrospective study included only patients who were treated with the combined procedure of surgical hysteroscopy with fibroid and/or endometrial resection and fibroid ablation using the Sonata System. Results: The combined procedure was performed without any complications in all cases. Two days after surgery, no increased morbidity was observed compared to only conventional surgical hysteroscopy and/or therapy with the TRFA. All patients were satisfied with the procedure. No late complications were observed within the first 6 months postoperatively. Seventeen patients with bleeding symptoms were asked about their subjective assessment of improvement. Fifteen patients reported significant improvement in symptoms and 1 patient reported only minimal improvement. Only 1 patient, who underwent TRFA and endometrial resection, did not report any improvement. No increase in symptoms was observed. Conclusions: Although TRFA is an approved method, it is not yet widely used worldwide. The combined procedure has been rarely used. The aim of our work is to show through our case series that transcervical radiofrequency ablation can be combined with surgical hysteroscopy for fibroid and/or endometrial resection without any additional risk.

Ghost Ileostomy: Safe and Cost-effective Alternative to Ileostomy After Rectal Resection for Deep Infiltrating Endometriosis.

BACKGROUND/AIM: Endometriosis infiltrating the rectum often requires resection with a protecting stoma. A ghost ileostomy (GI) is an alternative to prevent the psychological burden for the young women affected. The present study evaluated the safety and cost-effectiveness of the ghost ileostomy (GI) procedure in a group of patients after rectal resection for deep infiltrating endometriosis. PATIENTS AND METHODS: The prospective controlled interventional trial was conducted in 54 consecutive patients with deep infiltrating endometriosis of the rectum. GI was considered after ultra-low resection with primary anastomosis, previous colorectal anastomosis, or pelvic redo surgery. Loop ileostomy (LI) was performed after simultaneous colpotomy with suture, only. Operating time, morbidity according to the Clavien-Dindo classification (CDC), duration of hospital stay, and patient satisfaction were obtained. Individual costs were estimated for the endometriosis procedure with or without a GI or LI, including stoma supply and closure expenses. RESULTS: Of the 54 patients, 27 received GI (50%), whereas 4 underwent LI (7%). The remaining 23 patients received no outlet (NO). The complication rate did not differ among the GI, LI, and NO groups. Two cases were re-operated and required a diverting stoma, one in the GI and the NO group each. The additional healthcare expenses for each patient receiving a LI averaged 6,000 €. The patients were very satisfied with the option of a GI. CONCLUSION: GI is a cost-effective and safe alternative to LI after rectal resection for deep infiltrating endometriosis in cases where it is required. The individual costs per patient were reduced substantially, with a cumulative savings of 160,000 € in healthcare expenditure. Additionally, the method clearly lowers the psychological burden on the young women concerned.

The significance of transcervical ultrasound-guided radiofrequency ablation in the treatment of symptomatic fibroids: results of an expert consensus from German-speaking countries.

Uterine fibroids are one of the most common diseases in female patients, lead mainly to bleeding disorders and lower abdominal pain, and reduce the chance of having children. In recent years we have seen a trend towards more and more pharmacotherapies and minimally invasive organ-preserving treatments. One novel and innovative procedure for an organ-preserving treatment of symptomatic uterine fibroids is the transcervical ultrasound-guided radiofrequency ablation (TRFA). TRFA has been used in Germany since 2013 and later found use in other German-speaking countries as well. There have now been more than 1200 TRFA treatments performed in Germany, Austria, and Switzerland. Experts from these three countries came together for a consensus meeting to analyze the significance of the procedure in the overall concept of the treatment of symptomatic uterine fibroids.

Laparoscopic Isthmocele (Niche) Correction as prevention in patients with fertility desire.

OBJECTIVES: To report the technique of Laparoscopic Isthmocele (Niche) Correction and surgical outcomes. MATERIAL AND METHODS: The retrospective study included only patients with current or potential fertility desire who had laparoscopic surgery for an isthmocele at the Academic Hospital Cologne Weyertal between the beginning of 2014 and the end of 2020. A total of 28 patients were included. Sonographic follow-up of myometrial thickness was performed in 67% cases. RESULTS: In 18% cases myometrial thickness was 5-7 mm, in 11% cases > 7-10 mm and in 39% cases > 10 mm. In the group with postoperative myometrium of 5-7 mm, two patients had preoperative residual myometrium of 2 mm, one patient of 2.5 mm and in one patient residual myometrium was not measurable (< 1 mm). In 11 patients, the postoperative myometrium was either greater than 10 mm and/or no isthmoceles were detectable. There was an increase in mean preoperative myometrial thickness from 2 mm to a mean myometrial thickness of 8.7 mm (myometrial thickness increase to 335%). CONCLUSIONS: In this study, laparoscopic correction of the isthmocele resulted in an increase in myometrial thickness from 2 mm to 8.7 mm (average values). This represents an increase in myometrial thickness of 335%. According to the literature review performed and based on our own results, we recommend prophylactic isthmoceles correction in patients with fertility desire by means of laparoscopic procedure. Laparotomy should be performed only in special cases. Surgical hysteroscopy is not suitable for this purpose, but sufficient studies are still lacking.

Significance of Ki67 expression in endometriosis for infertility.

OBJECTIVE: The aim of the study was to show the significance of Ki67 expression in endometriosis for infertility. STUDY DESIGN: It was a retrospective analysis. 670 cases were analyzed. In 484 cases, immunohistochemical proliferation analysis was performed to determine the expression of Ki67. The indicated percentages of Ki67 expression were divided into three groups. An expression below 10% is considered low, 10-30% intermediate, and over 30% is considered high. RESULTS: There was a significant correlation between Ki67 expression and postoperative pregnancy onset: 66,7% of patients with high proliferation activity became pregnant within one year postoperatively, whereas the 38,7% of patients with moderate and only 17,3% of patients with low Ki67 expression became pregnant. CONCLUSION: In this work, high Ki67 expression was more frequent than low Ki67 expression in women with infertility than in patients without infertility. These results contribute to the importance of endometrial resection in the context of infertility treatment.

Transcervical radiofrequency ablation of fibroids that are 5 cm or larger in women with abnormal uterine bleeding.

INTRODUCTION: Fibroids are the most common benign uterine tumors. Transcervical radiofrequency ablation with the Sonata® System offers a minimally invasive, incisionfree, organ-preserving therapy, with intraoperative visualization of fibroids using intrauterine ultrasound guidance. To demonstrate the effectiveness of transcervical radiofrequency ablation of fibroids that are 5 cm or larger using the Sonata® System, this retrospective analysis was collected. METHOD: 151 patients have been treated with this method in our department up to the time of this analysis. Only patients with at least one fibroid of ≥5 cm and with bleeding symptoms, who were treated with the Sonata® System were included in this retrospective study. A total of 50 patients were included in the study and 57 fibroids were treated. RESULTS: A total of 57 fibroids were detected and treated, however FIGO 1 and 2 fibroids (in total three fibroids were excluded). The smallest fibroid was 4 cm and the largest fibroid was 12 cm. A single ablation was performed in 18 cases, two ablation steps in 16 cases, three ablation steps in 13 cases, and more than three ablation steps in three cases. Depending on ablation steps, the shortest ablation time was 3 min 15 s and the longest ablation time was 25 min 6 s, with an average time of 9 min 12 s. 86% of patients reported an improvement of symptoms Conclusion: Thus, the Sonata® System is a simple, minimally invasive, rapid and successful method that shows significant improvement of symptoms even in large myomas from ≥5 cm.

Transcorporal septal dissection using the balloon technique in complete uterine septums, pre- and postoperative results. A follow up from 2007 to 2020.

OBJECTIVE: The aim of the study is to show the pre- and postoperative results of transcorporal septal dissection using the balloon technique in complete uterine septums, which is a rare pathology. STUDY DESIGN: It is a retrospective analysis. In this study 21 patients with a complete uterine septum were included. All patient underwent the transcorporal septal dissection using the balloon technique. Data analysis was based on patient history, surgical reports and telephone contact with the patients and supervising gynecologists. RESULTS: 73% patients with a current desire to become pregnant managed to do so and 75% of them were able to give birth on time. One patient was pregnant at the time of the analysis. In 17 patients the results of the control hysteroscopy were available. In eight patients (47%) a normal cavity was found. In nine cases (53%) a residual septum of 1-2 cm was found, so that an operative hysteroscopy with a residual septum dissection was performed. The operative time was average 30.6 min in the group without laparoscopy and 56.8 min in the group with laparoscopy. CONCLUSION: The transcorporal septum dissection using the balloon technique is a safe method with a good fertility outcome and requires an experienced surgeon.

Coexistence of endometriomas with extraovarian endometriosis and adhesions.

OBJECTIVE: The aim of the study is to show the coexistence of the endometriomas with peritoneal and deep infiltrating endometriosis, as well as with the adhesions. Study design It's a randomized retrospective study. Patients treated for endometrioma at Academic Hospital Cologne Weyertal from January 2014 to October 2019 were included. In total there were 1054 patients. 310 medical records were chosen at random without a special selection and the data were analysed. RESULTS: In our study, endometriomas were alone, which means without extraovarian endometriosis and/or adhesions, in only 2.3% of the cases. In the total population, 80.6% (250) of the patients had peritoneal endometriosis, 43.2% (134) of the patients had deep infiltrating endometriosis and 38% (118) of the patients had peritoneal and deep infiltrating endometriosis. In our analysis we found that in unilateral endometriomas there is no relationship between endometrioma size and adnexal adhesions. The risk of Douglas obliteration increases with the size of the endometriomas in unilateral endometriomas. In bilateral endometriomas, the risk of a complex adhesions is independent of the size of the endometriomas and relevantly higher than in unilateral endometriomas (Douglas obliteration 31.5% vs 16%, bilateral adnexal adhesions 45.2% vs 21.1%). Unilateral adnexal adhesions occurred in bilateral endometriomas only in 13.7%. CONCLUSION: Endometriomas are the relevant problem in gynaecological practice. It must be taken into account here that endometriomas usually occur with peritoneal endometriosis and that surgical therapy may be useful. However, adhesions and DIE are to be expected with surgical treatment, which could make the operation more difficult. Especially in large and bilateral endometriomas, a high coexistence with extraovarian endometriomas and adhesions is observed. Therefore, surgery should be performed by an experienced surgeon.

Coincidence of uterine malformations and endometriosis: a clinically relevant problem?

INTRODUCTION: It is suspected that uterine malformations and endometriosis have a high coincidence. Furthermore, it is expected that obstructive uterine malformations are significantly higher affected than non-obstructive malformations. The correlation between endometriosis and uterine malformations may be due to increased retrograde menstruation, which would explain a higher coincidence of obstructive malformations and endometriosis [14]. METHODS: This retrospective study investigates whether patients with uterine malformations have a higher prevalence of endometriosis. The study includes patients with uterine malformations who were admitted to our hospital in the period from 01.12.2014 to 30.11.2019. RESULTS: 279 cases were analysed. 263 (94.2%) patients had a non-obstructive uterine malformation, 12 (4.3%) patients had an obstructive uterine malformation and 4 (1.4%) patients had uterine agenesia/hypoplasia. 209 (74.9%) patients had histologically confirmed endometriosis (peritoneal, ovarian or deep infiltrating) and 70 (25.1%) had no endometriosis. In 27 cases, deep infiltrating endometriosis (ENZIAN ABC) was detected additionally to peritoneal and ovarian endometriosis. CONCLUSION: The study shows a high prevalence of endometriosis in women with uterine malformations. For this reason, endometriosis should always be specifically sought in uterine malformations.