The Prevalence of Endometriosis in Adolescents with Pelvic Pain: A Systematic Review.

STUDY OBJECTIVE: Endometriosis is a recognized cause of pelvic pain in adolescents with menstrual symptoms that significantly affect education, activity, and social interactions. We aim to provide an updated systematic review of the prevalence of endometriosis in adolescents with pelvic pain presenting for gynecological investigation. DATA SOURCES: We searched Medline, Embase, and Cinahl from 2011 to July 2019. METHODS OF STUDY SELECTION: We included cohort studies of adolescents with pelvic pain undergoing gynecological investigation. Two authors independently selected studies and extracted study characteristics and prevalence data. Methodological quality was assessed using the Critical Appraisal Skills Program for cohort studies. RESULTS: This updated systematic review evaluated a total of 19 studies including 1243 symptomatic adolescents. In all, 648 of 1011 (64%) adolescents undergoing laparoscopy were found to have endometriosis. The prevalence ranged from 25% to 100%, with a mean prevalence of 64%. Thirteen studies including 381 participants categorized disease severity using the revised American Society of Reproductive Medicine classification. Among these, 53% of participants (201/381) had stage I, 28% (105/381) had stage II, 20% (76/381) had stage III, and 13% (49/381) had stage IV disease. CONCLUSIONS: The prevalence of endometriosis among adolescents with pelvic pain symptoms is high. Endometriosis is treatable, and prompt recognition will help to ensure that adolescents are signposted earlier to appropriate specialists. The management of adolescents with suspected endometriosis should be consistent with best practice guidance. Despite recommendations to increase the awareness and knowledge of endometriosis in adolescence, minimal research has followed.

Long-term mesh complications and reoperation after laparoscopic mesh sacrohysteropexy: a cross-sectional study.

INTRODUCTION AND HYPOTHESIS: The paucity of long-term safety and efficacy data to support laparoscopic mesh sacrohysteropexy is noteworthy given concerns about the use of polypropylene mesh in pelvic floor surgery. This study is aimed at determining the incidence of mesh-associated complications and reoperation following this procedure. METHODS: This was a cross-sectional postal questionnaire study of women who underwent laparoscopic mesh sacrohysteropexy between 2010 and 2018. Potential participants were identified from surgical databases of five surgeons at two tertiary urogynaecology centres in the UK. The primary outcome was patient-reported mesh complication requiring removal of hysteropexy mesh. Secondary outcomes included other mesh-associated complications, reoperation rates and Patient Global Impression of Improvement (PGI-I) in prolapse symptoms. Descriptive statistics and Kaplan-Meier survival analyses were used. RESULTS: Of 1,766 eligible participants, 1,121 women responded (response proportion 63.5%), at a median follow-up of 46 months. The incidence of mesh complications requiring removal of hysteropexy mesh was 0.4% (4 out of 1,121). The rate of chronic pain service use was 1.8%, and newly diagnosed systemic autoimmune disorders was 5.8%. The rate of reoperation for apical prolapse was 3.7%, and for any form of pelvic organ prolapse it was 13.6%. For PGI-I, 81.4% of patients were "much better" or "very much better". CONCLUSIONS: Laparoscopic mesh sacrohysteropexy has a low incidence of reoperation for mesh complications and apical prolapse, and a high rate of patient-reported improvement in prolapse symptoms. With appropriate clinical governance measures, the procedure offers an alternative to vaginal hysterectomy with apical suspension. However, long-term comparative studies are still required.

Lower urinary tract symptoms in women with vaginal agenesis.

INTRODUCTION AND HYPOTHESIS: Congenital vaginal aplasia is a condition with devastating implications for fertility and sexuality. However, little is known on whether urinary symptomatology is more common prior and following vaginal lengthening procedures in these women. METHODS: We performed a prospective observational study of 19 women with vaginal agenesis before and after vaginal dilation treatment or a laparoscopic Vecchietti procedure. All women completed the ICIQ FLUTS questionnaire before and after treatment in order to assess incidence and changes in urinary symptomatology. RESULTS: Urinary symptoms were present in 53% of women prior to treatment. The majority of bladder symptoms were not significantly altered by treatment, except for incomplete bladder emptying. Women following the Vecchietti procedure had increased urinary hesitancy and a poorer steam compared with those completing dilation treatment. The longer the vaginal length, the greater the urinary frequency. CONCLUSION: Women with vaginal agenesis had significant levels of urinary symptoms and to our knowledge this has not been reported before. The majority of symptoms were not altered by treatment.

Remnant functioning cervical tissue after laparoscopic removal of cavitated noncommunicating rudimentary uterine horn.

Cavitated noncommunicating rudimentary uterine horn is managed via surgical removal. During the past 20 years this has been performed primarily via laparoscopy. At our multidisciplinary specialized center, this condition has been treated in 29 patients over 10 years. Three patients had pelvic pain and recurrent symptoms of menstrual obstruction at 2, 5, and 6 years after the initial operation. Magnetic resonance imaging revealed blood-filled pelvic masses at the site of the previous procedures. After laparoscopic removal of these masses, histologic analysis confirmed the presence of remnant functioning cervical tissue. This is the first report of long-term follow-up of patients with a history of obstructed rudimentary uterine horn to demonstrate that complications can occur several years after such operations. It is essential that any reports of recurrent pain should be considered seriously and investigated.

Short-term outcome of fertility-sparing laparoscopic excision of deeply infiltrating pelvic endometriosis performed in a tertiary referral center.

OBJECTIVE: To examine the short-term surgical outcomes in women undergoing fertility-sparing laparoscopic excision of deeply infiltrating pelvic endometriosis. DESIGN: Retrospective cohort study. SETTING: Tertiary referral center for treatment of endometriosis, a university teaching hospital, London, United Kingdom. PATIENT(S): A total of 177 women who underwent fertility-sparing laparoscopic excision of deeply infiltrating endometriosis between January 1, 2006, and December 31, 2007. INTERVENTION(S): Eligible women were identified from the surgeons' database, and their medical notes were reviewed. Data from preoperative assessment, surgery, and postoperative outcomes were analyzed. MAIN OUTCOME MEASURE(S): Complication rate. RESULT(S): One hundred seventy-seven women underwent fertility-sparing laparoscopic excision of deeply infiltrating endometriosis including excision of uterosacral ligaments (43, 24.3%), excision of rectovaginal septum (56, 31.6%), rectal shave (56, 31.6%), disk excision (7, 4%) or bowel resection (15, 8.5%). The median operative time was 95 minutes with a range of 30 to 270 minutes (interquartile range 75-120 minutes). Overall, complications developed in 18 women (10.2%). In 12 (6.8%) of these only uncomplicated pyrexia developed whereas significant intraoperative and/or postoperative complications developed in the remaining 6 (3.4%). Women spent a median of 2 days recovering in hospital (range 1-7, interquartile range 2-3 days). CONCLUSION(S): Fertility-sparing laparoscopic excision of deeply infiltrating endometriosis appears to be safe with a low short-term complication rate.

Abdominal sacrocolpopexy for vault prolapse without burial of mesh: a case series.

OBJECTIVES: To audit the clinical outcome of abdominal vault suspension (sacrocolpopexy, hysteropexy or cervicopexy) using non-absorbable mesh, without burial by closure of the peritoneum. DESIGN: A case series. SETTING: Urogynaecology units of four hospitals. POPULATION: One hundred and twenty-eight women having open or laparoscopic sacrocolpopexy (121), hysteropexy (6) or cervicopexy (1) using non-absorbable mesh for vault prolapse. METHODS: Patients had suspension of the vault, uterus or cervix from the sacral promontory using a monofilament polypropylene mesh. The pelvic peritoneum was not closed over the mesh. Patients were followed up every six months. MAIN OUTCOME MEASURES: Incidence of bowel complications as a consequence of the mesh; cure rate of prolapse and incidence of other post-operative complications; rate of re-operation for prolapse or incontinence. RESULT: After a median follow up of 19 months (1.5-62), there were no bowel complications as a result of non-burial of mesh. Three patients had asymptomatic vaginal mesh erosion, which required minor surgical intervention. Ninety percent of patients had good resolution of their prolapse symptoms while 10% of patients required further surgery. CONCLUSION: Leaving the mesh uncovered by the pelvic peritoneum was not associated with complications. It appears safe to perform vault suspension without closing the peritoneum.

Laparoscopic ovarian suspension to facilitate surgery for advanced endometriosis.

OBJECTIVE: To describe a new laparoscopic technique that exposes the ovarian fossa and pelvic side wall by suspending the ovaries to the anterior abdominal wall for advanced endometriosis surgery. DESIGN: Report of an operative technique. SETTING: University teaching hospital. PATIENT(S): More than 50 women operated on for endometriosis over the last 2 years. INTERVENTION(S): Laparoscopic suspension of one or both ovaries to the abdominal wall with transabdominal 2-0 polypropylene suture. MAIN OUTCOME MEASURE(S): Technical feasibility. RESULT(S): The technique is easy to perform in a short period of time. CONCLUSION(S): In cases in which a good exposure to the ovarian fossa is needed, this technique can be performed in a short period of time without the need of an assistant.

Ovarian torsion: to pex or not to pex? Case report and review of the literature.

STUDY OBJECTIVE: We report the case of a 7-year-old girl who underwent laparoscopic ovariopexy for a suspected ovarian torsion after a previous oophorectomy. We consider the role of elective ovariopexy of the contralateral ovary in the case of adnexal torsion. DESIGN: Case study and review of the literature. RESULT: There was evidence to suggest a very recent adnexal torsion and an unusually long ovarian pedicle, with a possible familial linkage. The patient underwent laparoscopic ovariopexy for the remaining normal ovary, which was found to be loosely twisted at operation. After detorsion, ovariopexy was performed laparoscopically, by suturing the ovary to the back of uterus. There are no other descriptions in the literature of a familial linkage with ovarian torsion. CONCLUSION: The case presented reminds doctors of the strong possibility of ovarian torsion in young girls presenting with pelvic pain. Laparoscopic ovariopexy for the contralateral ovary should be considered in all women with evidence of torsion, including children and adolescents, as is standard for testicular torsion.

A new technique of laparoscopic ovariopexy before irradiation.

OBJECTIVE: To report a new technique of laparoscopic ovarian transposition to preserve ovarian function in women who require pelvic irradiation for musculoaponeurotic fibromatosis (extra abdominal desmoid). DESIGN: Case report. SETTING: University teaching hospital. PATIENT(S): Two nulliparous women who required adjunctive radiotherapy for musculoaponeurotic fibromatosis where radiotherapy planning indicated that the right ovary could be removed from the field of radiation by anterior transposition. INTERVENTION(S): Laparoscopic suturing of the right ovary to the right round ligament with intracorporeal polypropylene sutures. MAIN OUTCOME MEASURE(S): Technical feasibility, recovery, postoperative adhesions, ease of ovarian repositioning, and evidence of ovulation after completion of radiotherapy. RESULT(S): The technique was easily performed without needing to divide the ligament of the ovary. Recovery was rapid, and there were no postoperative adhesions. The ovary showed evidence of continued function and was easily repositioned by dividing the sutures. CONCLUSION(S): In selected cases, this method of ovarian transposition has the advantages not only of being technically easy but also of allowing for repositioning of the ovary with minimal disruption of its anatomical relationship to the fallopian tube, thereby favoring fertility.

Interstitial laser photocoagulation for uterine myomas.

Thirty myomas in 24 symptomatic patients who refused conventional surgery were treated by interstitial laser photocoagulation, monitored by laparoscopy. The procedure was well tolerated. Magnetic resonance imaging or ultrasound scanning documented shrinkage in 23 lesions (those lesions >6 cm in diameter responded poorly), with clinical benefit in 13 patients.