Combination of transvaginal sonography and clinical examination for preoperative diagnosis of pelvic endometriosis.

BACKGROUND: The aim of the present study was to evaluate the accuracy of routine clinical examination (per vaginam, PV) combined with transvaginal sonography (TVS) for presurgical, non-invasive diagnosis of endometriosis. METHODS: Two-hundred women with symptoms suggestive of endometriosis were prospectively assessed by PV and TVS prior to laparoscopy and radical resection of disease and histological confirmation. RESULTS: Prevalence of endometriosis on the right/left (r/l) ovary, r/l uterosacral ligament (USL), pouch of Douglas (POD), vagina, bladder, rectovaginal space (RVS) and rectum was 12%, 13%, 12%, 22%, 15%, 11%, 2%, 4% and 24%. Sensitivities, specificities, positive and negative predictive values and positive and negative likelihood ratios for combined use of TVS and PV resulted in 96/100%, 100/99%, 100/93%, 93/100% and -;0.04/87.0;- for the r/l ovarian endometriosis; 67/84%, 97/86%, 73/62%, 96/95% and 19.56;0.35/5.97;0.19 for the r/l USL disease; 87%, 98%, 90%, 98% and 49.11;0.14 for involvement of the POD; 82%, 99%, 95%, 98% and 145.64;0.18 for vaginal endometriosis; 88%, 99%, 78%, 99% and 84.0;0.13 for endometriosis of the RVS; 75%, 98%, 50%, 99% and 49.0;0.25 for bladder involvement and 96%, 98%, 94%, 99% and 48.56;0.04 for rectal endometriosis. CONCLUSIONS: The combination of PV and TVS accurately predicts the presence of endometriosis affecting the ovaries, vagina, rectum, USL, RVS and POD in patients with suspected endometriosis. We suggest the routine combination of PV and TVS as an essential part of the standard primary assessment of pelvic pain patients with suspected endometriosis.

[ENZIAN-score, a classification of deep infiltrating endometriosis]. / ENZIAN-Score, eine Klassifikation der tief infiltrierenden Endometriose.

The ENZIAN-Score is presented as a new instrument to classify the deep infiltrating endometriosis. Especially the retroperitoneal part of the severe endometriosis is focussed on. In analogy to an oncological staging four different stages are pronounced. The localisation and the expansion of the endometriosis nodule was indicated to different subgroups. The still used rAFS-score is of no clinical evidence, as we pointed out in a retrospective study of our patients with severe intestinal endometriosis.

Reduction of postoperative adhesion formation after laparoscopic ovarian cystectomy.

The purpose of this randomized, open-label study was to assess the efficacy of the product Interceed absorbable adhesion barrier in the prevention of adhesion formation on the ovary after laparoscopic ovarian cystectomy. A total of 25 patients requiring laparoscopic bilateral ovarian cystectomy were enrolled into this study. After removal of ovarian cysts, peri-adnexal adhesions, and peritoneal irrigants, and the attainment of meticulous haemostasis, the random assignment of one ovary for wrapping with Interceed was revealed to the surgeon. The other ovary served as the untreated control. A follow-up laparoscopy was performed 8-30 weeks after the initial procedure in 17 patients. Significantly fewer adhesions formed at the Interceed treated ovaries compared with the control (untreated) ovaries (P < 0.05). In terms of adhesion-free outcome, 76% (13/17) of Interceed treated ovaries and 35% (6/17) of control ovaries were free of adhesions. A significant reduction was observed in the area of the sutured ovaries involved with adhesions when Interceed (6%) was used, compared with controls (20%). The reduction of adhesion formation was not related to the size of the cysts at the initial procedure. No adverse events were reported by any patient during the study. In conclusion, Interceed was found to be safe and effective in reducing the incidence of postoperative adhesion formation in patients undergoing laparoscopic ovarian cystectomy.

Laparoscopic creation of a neovagina: modified Vecchietti method.

A new surgical technique for the treatment of vaginal aplasia is described. It consists of a modification of Vecchietti's method, allowing laparoscopic performance of the operation. 9 patients have been treated in this way since January, 1991 with good results. No complications were seen. Being virtually atraumatic, this method requires only brief hospitalisation, which is of vital importance in view of the psychological and physical problems this particular condition entails. Results are identical, so that this technique should always take precedence over the conventional Vecchietti method.

Endoscopic Nd:YAG Laser Coagulation of Intramural Endometriosis of the Bladder

Treatment of intramural endometriosis of the bladder using the Nd:YAG laser is described. An operative cystoscope fitted with a 600 µ fibre is introduced into the bladder. At a power setting of 50 W, superficial coagulation of the visible lesion is performed. The coagulation technique corresponds to that used for the treatment of superficial bladder carcinomas. Three patients were managed in this way. In all patients dysuria and hematuria either significantly decreased or disappeared altogether. No intraoperative complications were observed. This new technique appears to be superior to surgical excision techniques, especially in cases where the lesion is situated on the roof of the bladder. Further studies need to be conducted to compare results obtained from this technique with those of the CO2 laser or excision technique.

Laparoscopic Myomectomy: Sonographic Follow-Up and Second-Look Laparoscopy for the Evaluation of a New Technique

Between 1988 and 1993, 100 women underwent laparoscopic myomectomy in the Department of Obstetrics and Gynecology of the University of Ulm. Indications varied, although most myomectomies were done for fertility enhancement or preservation. Closure of the incision, especially with an open uterine cavity, was done in two or three layers. Several technical limitations specific to laparoscopic surgery impair complete and satisfactory closure of the myomectomy incision. In this study we evaluate the new technique by sonographic control and second-look laparoscopy. In 22 cases second-look laparoscopy was undertaken to assess post-operative adhesion formation and to effect adhesiolysis. The rate of adhesion formation was 28%, depending on site, size, and number of myomas. Adhesion formation was significantly higher (p<0:005) in myomas located on the posterior wall. The density of adhesions did not vary significantly. In 22 cases sonography was done preoperatively, one day after the operation and 6 weeks postoperatively to compare wound healing, depending on myoma site and size. In 74% of cases an intramural hematoma of varying size was observed. By the third control, 6 weeks later, an irregular hypodense area was seen in only 8%. This study demonstrates that laparoscopic myomectomy entails the risks of postoperative adhesion formation and impaired wound healing, including intramural hematoma. So far no data are available showing a correlation between these risks and post-operative infertility or higher incidence of uterine rupture.

Laser techniques in gynaecology.

Lasers have been in use for 15 years in laparoscopic surgery. The CO2-laser in particular has become very popular in the field of gynaecology for the treatment of endometriosis and adhesions. Results achieved with the CO2-laser seem to be superior to those of conventional instruments, although only a small number of randomised prospective studies exist. Fibre lasers, such as the Nd:YAG-, KTP, and Argon-lasers combine vaporisation- and/or coagulation-effects within the same operating instrument. Time-consuming changes of instruments during the procedure are unnecessary. Nevertheless, technical problems and high costs of these laser systems on the one hand, and unfulfilled and unrealistic expectations by physicians and patients alike on the other hand hinder wide-spread use of this technique.

[Experiences with colpocoeliotomia posterior within the scope of surgical laparoscopies]. / Erfahrungen mit der Colpocoeliotomia posterior im Rahmen operativer Laparoskopien.

Laparoscopically performed culdotomy is a safe and easy procedure to remove enucleated myomas or benign ovarian pathological structure. So far, we have not seen any culdotomy-related complications in a group of 19 patients treated in this way. All wounds healed by primary intention. Operating time exceeded the norm by 10 to 30 minutes. The use of an endobag in connection with culdotomy, effectively facilitates removal of dermoids and myomas.

[Linear salpingotomy in the treatment of unruptured tubal pregnancy. Animal experiment study, comparison of 3 laser systems (CO2, Nd:YAG contact, argon)]. / Lineare Salpingotomie zur Therapie der nicht rupturierten Tubargravidität. Tierexperimentelle Untersuchung, Vergleiche von drei verschiedenen Lasersystemen (CO2, Nd:YAG Kontakt, Argon).

The efficacy of three different laser systems for linear salpingotomy was tested in an animal model. For that purpose, the uterus horns of 22 white New Zealand rabbits were incised with the CO2-Laser, the Nd: YAG contact laser and the argon laser using the "bare fiber" technique. The length of uterotomy was between twice and three times of the diameter of the uterine horn. Secondary healing of the incision site was investigated macroscopically (patency, fistulas, formation of adhesions) and microscopically (quantity and quality of the scars) six weeks after the operation. Despite the different primary tissue effect of the laser systems we did not find any significant difference in our postoperative controls.