Robotic-assisted laparoscopy vs conventional laparoscopy for the treatment of advanced stage endometriosis.

STUDY OBJECTIVE: To compare robotic-assisted laparoscopy with conventional laparoscopy for treatment of advanced stage endometriosis insofar as operative time, estimated blood loss, complication rate, and length of hospital stay. STUDY DESIGN: Retrospective cohort study (Canadian Task Force classification II2). All procedures were performed by one surgeon between January 2004 and July 2012. Data was collected via chart review. SETTING: Tertiary referral center for treatment of endometriosis. PATIENTS: Four hundred twenty women with advanced endometriosis. INTERVENTIONS: Fertility-sparing surgery to treat advanced endometriosis, either via conventional or robotic-assisted laparoscopy. MEASUREMENTS AND MAIN RESULTS: Patient demographic data, operative time, estimated blood loss, complication rate, and length of hospital stay were compared between the 2 groups. Two hundred seventy-three patients underwent conventional laparoscopy and 147 patients underwent robotic-assisted laparoscopy for fertility-sparing treatment of advanced stage endometriosis. Patients in both groups had similar characteristics insofar as age, body mass index, and previous abdominal surgeries. There were no significant differences in blood loss or complication rate between the 2 groups. Mean operative time in the conventional laparoscopy group was 135 minutes (range, 115-156 minutes), and in the robotic-assisted laparoscopy group was 196 minutes (range, 185-209 minutes), with a mean difference in operative time of 61 minutes (p < .001). Length of hospital stay was also significantly increased in the robotic-assisted laparoscopy group. Most patients who underwent conventional laparoscopy were discharged to home on the day of surgery. Of 273 patients in the conventional laparoscopy group, only 63 remained in the hospital overnight, and all 147 patients in the robotic-assisted laparoscopy group were discharged on postoperative day 1. CONCLUSION: Conventional laparoscopy and robotic-assisted laparoscopy are excellent methods for treatment of advanced stages of endometriosis. However, use of the robotic platform may increase operative time and might also be associated with longer hospital stay.

The presence of multiple gestational sacs confers a higher live birth rate in women with infertility who achieve a positive pregnancy test after fresh and frozen embryo transfer: a retrospective local cohort.

BACKGROUND: After spontaneous conception, the rate of miscarriage is more common in multiple rather than singleton pregnancies. However, the incidence of miscarriage is lower in in-vitro fertilization twin versus singleton pregnancies. Most patients have little understanding of pregnancy outcomes once they achieve a positive pregnancy test. This study investigated the relationship between multiple pregnancy and miscarriage in women with infertility after fresh and frozen embryo transfer. METHODS: Retrospective local cohort study of all consecutive patients undergoing in-vitro fertilization at our institution (n = 1130), fresh or frozen embryo transfer, between January 1, 2008 and December 31, 2012. Patient characteristics (age, body mass index, initial hCG, maximum follicle stimulating hormone levels) and in-vitro fertilization parameters (estradiol levels, eggs retrieved, and endometrial thickness) were collected and statistically analyzed using T-test and Chi-square test (Stata version 10). Linear and logistic regression were used when appropriate. RESULTS: Overall, live birth rate for all cycles was 30.44% and total pregnancy loss was 6.55% - similar for fresh and frozen cycles despite a higher rate of biochemical pregnancies for frozen cycles. Among all pregnant patients, 62.48% had a live birth. Although clinical pregnancy rate was higher for fresh cycles, live birth rates were similar. In pregnancies where multiple sacs were demonstrated on ultrasound, live birth rates were higher despite 31% of patients losing at least one sac. This finding was comparable between fresh and frozen cycles. However, in patients under age 35 and using donor egg, no live birth advantage was seen in patients with multiple sacs. In fact, transferring more than one embryo did not increase live birth rate either. CONCLUSIONS: Despite the many maternal and fetal risks of multiple pregnancies, patients who achieve a positive pregnancy test with fresh and frozen in-vitro fertilization and who have more than one pregnancy sac are more likely ultimately to deliver at least one baby. This finding is true of both fresh and frozen embryo transfer cycles. This pregnancy advantage is not seen in young patients and in patients using donor egg, and single embryo transfer maximizes birth outcomes.

Strong Association Between Endometriosis and Symptomatic Leiomyomas.

BACKGROUND AND OBJECTIVES: The relationship between leiomyoma and endometriosis is poorly understood. Both contribute to considerable pain and may cause subfertility or infertility in women. We conducted this retrospective study to assess the rate of coexistence of endometriosis in women with symptomatic leiomyoma. The primary outcome measured was the coexistence of histology-proven endometriosis in women with symptomatic leiomyoma. METHODS: This is a retrospective review of a data-based collection of medical records of 244 patients treated at a tertiary medical center, who were evaluated for symptomatic leiomyoma from March 2011 through December 2015. Of those, 208 patients underwent laparoscopic or laparoscopic-assisted myomectomy or hysterectomy. All patients provided consent for possible concomitant diagnosis and treatment of endometriosis. The remaining 36 patients underwent medical therapy and were excluded from the study. All patients who had myomectomy or supracervical hysterectomy underwent minilaparotomy for extracorporeal morcellation and specimen removal beginning in April 2012. RESULTS: Of the 208 patients with the presenting chief concern of symptomatic leiomyoma and who underwent surgical therapy, 181 had concomitant diagnoses of leiomyoma and endometriosis, whereas 27 had leiomyoma. Of the 27 patients, 9 also had adenomyosis. Patients with only fibroid tumors were, on average, 4.0 years older than those with endometriosis and fibroids (mean age, 44 vs 40 ± SD). Patients with both pathologies were also more likely to present with pelvic pain and nulliparity than those with fibroid tumors alone. CONCLUSIONS: In our patient population, 87.1% of patients with a chief concern of symptomatic fibroids also had a diagnosis of histology-proven endometriosis, which affirms the need for concomitant diagnosis and intraoperative treatment of both conditions. Overlooking the coexistence of endometriosis in women with symptomatic leiomyoma may lead to suboptimal treatment of fertility and persistent pelvic pain. It is important for physicians to be aware of the possibility of this association and to thoroughly evaluate the abdomen and pelvis for endometriosis at the time of myomectomy or hysterectomy in an effort to avoid the need for reoperation.