Combining Sclerotherapy with CO2 Laser Ablation for the Laparoscopic Management of Large Endometrioma: Advantages and Pitfalls.

STUDY OBJECTIVE: To demonstrate the feasibility of management of large endometrioma laparoscopically. DESIGN: Stepwise demonstration with narrated video footage of the laparoscopic 2-step procedure starting with alcohol sclerotherapy of the large endometrioma followed by CO2 laser ablation and 6-month follow-up. SETTING: The debate surrounding the best approach for the management of large endometriomas has been ongoing. Cystectomy especially when treating large endometriomas has been shown to decrease ovarian reserve proportionally to the endometrioma's size.2,4 This is why 2-step approaches have been considered to preserve the ovarian reserve.1,3 We present the case of a 22-year-old nulliparous woman who has primary severe dysmenorrhea resistant to medical treatment. Magnetic resonance imaging shows uterine adenomyosis and a 10 cm large endometrioma of the left ovary and no signs of deep infiltrative endometriosis. She has a desire for pregnancy in the distant future. INTERVENTION: The first step is the laparoscopic ethanol sclerotherapy. After emptying and rinsing the endometrioma's cavity through a 5 mm suction cannula, it is then filled with ethanol through a 14 French Foley catheter to avoid any overflow.5,6 After a time exposure of 10 minutes, the ethanol is withdrawn and the cavity rinsed (Figure 2). The second step of the surgery is performed 12 weeks later (Figure 3). Using CO2 laser, the untreated portion of the inner wall of the remaining endometrioma is vaporized along with remaining superficial endometriosis lesions (Figure 1). CONCLUSION: Laparoscopy sclerotherapy combined to CO2 laser ablation is a feasible technique for the management of a large endometrioma. Further research is still required to evaluate the benefit of a 2-step surgery approach over standard cystectomy and to understand the long-term effects of ethanol-induced ovarian fibrosis.

Surgical Training for Bowel Endometriosis: A New Wet-lab Model.

STUDY OBJECTIVE: To demonstrate a new wet-lab model for training in conservative bowel endometriosis surgery (shaving and discoid resection). DESIGN: Video demonstration. MATERIALS AND METHODS: (1) Modeling deep infiltrating endometriosis using cryopreserved porcine rectum. (2) Conservative resection (shaving and discoid resection) using cold scissor and carbon dioxide laser (free beam and fiber). (3) Discoid resection. RESULTS: In this video, we present a new training model for improving the surgical management of bowel endometriosis. After dissection of the serosa and muscular layers, a modified biological glue is injected into the porcine rectum to accurately simulate an infiltrating bowel endometriosis lesion. Once dried, the simulated lesion can be resected using conventional laparoscopic instruments (cold scissors) or using more advanced techniques such as carbon dioxide laser, free beam and fiber (Storz and Lumenis). In case of bowel perforation during resection, this model enables realistic suturing. CONCLUSION: This new and highly realistic model allows the next generation of endometriosis surgeons to acquire adequate training to make bowel surgery safer and more effective.

Fast-Track in Minimally Invasive Gynecology: A Randomized Trial Comparing Costs and Clinical Outcomes.

Study Objective: Evaluate the effects of a fast-track (FT) protocol on costs and post-operative recovery. Methods: One hundred and seventy women undergoing total laparoscopic hysterectomy for a benign indication were randomized in a FT protocol or a usual care protocol. A FT protocol included the combination of minimally invasive surgery, analgesia optimization, early oral refeeding and rapid mobilization of patients was compared to a usual care protocol. Primary outcome was costs. Secondary outcomes were length of stay, post-operative morbidity and patient satisfaction. Main Results: The mean total cost in the FT group was 13,070 ± 4,321 Euros (EUR) per patient, and that in the usual care group was 3.5% higher at 13,527 ± 3,925 EUR (p = 0.49). The FT group had lower inpatient surgical costs but higher total ambulatory costs during the first post-operative month. The mean hospital stay in the FT group was 52.7 ± 26.8 h, and that in the usual care group was 20% higher at 65.8 ± 33.7 h (p = 0.006). Morbidity during the first post-operative month was not significantly different between the two groups. On their day of discharge, the proportion of patients satisfied with pain management was similar in both groups [83% in FT and 78% in the usual care group (p = 0.57)]. Satisfaction with medical follow-up 1 month after surgery was also similar [91% in FT and 88% in the usual care group (p = 0.69)]. Conclusion: Implementation of a FT protocol in laparoscopic hysterectomy for benign indications has minimal non-significant effects on costs but significantly reduces hospital stay without increasing post-operative morbidity nor decreasing patient satisfaction. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04839263.

Estrogen receptor-α immunoreactivity predicts symptom severity and pain recurrence in deep endometriosis.

OBJECTIVE: To determine the relationship between steroid receptor expression and pain symptoms in endometriosis. DESIGN: Cross-sectional SETTING: University Hospital PATIENT(S): Women with endometriosis (N = 92). INTERVENTION(S): Tissue samples were obtained from patients with surgically diagnosed endometriosis. MAIN OUTCOME MEASURE(S): A tissue microarray (TMA) was generated from patients with endometriosis. Data were collected on the presence and severity of dysmenorrhea, deep dyspareunia, dyschezia, and nonmenstrual pain by use of a numerical rating scale (NRS) at the time of surgery and after 1 year. The intensity of receptor expression was evaluated through immunohistochemistry and measured according to an immunoreactive score (IRS). Clinical variables were correlated to IRS by multivariate logistic regression analysis. RESULTS: Estrogen receptor-α (ER-α), progesterone receptor (PR), androgen receptor (AR), and aromatase expression differed among study participants. ER-α expression was reduced by progestin therapy, whereas of expressions of PR, AR, and aromatase were unchanged. Higher ER-α expression increased the likelihood of moderate to severe dysmenorrhea and deep dyspareunia in women not receiving hormonal treatment. In women receiving progestin therapy, persistently higher ER-α expression was correlated with greater likelihood of deep dyspareunia, severe dyschezia, and endometriosis-associated pain persistence at 1 year. CONCLUSION(S): ER-α, PR, AR, and aromatase were all expressed in deep endometriosis. ER-α levels best correlated with severity of symptoms, which suggests that ER is a key driver of deep endometriosis. Progestin treatment was associated with a reduction of ER-α expression; however, failure of ER suppression by progestins was also a predictor of pain severity and recurrence at 1 year.

Abdominal wall endometriosis: An 11-year retrospective observational cohort study.

OBJECTIVE: The objective of this study was to review the records of patients with excised abdominal wall endometriosis (AWE) to determine patient characteristics, diagnostic methods, presence of concurrent pelvic endometriosis and type of surgery. STUDY DESIGN: Medical records from an 11-year period were searched to identify histologically confirmed AWE cases. Descriptive data were collected and analyzed. Two subgroups were differentiated: isolated AWE and pelvic endometriosis-associated AWE. RESULTS: Thirty-five women with AWE were included. The most common symptom was cyclic abdominal or parietal pain (68.6%); 17.1% of the women had no symptoms. Twenty-nine women (82.8%) had a history of gynecological or obstetrical surgery, most commonly cesarean section (CS). The mean interval between prior surgery and appearance of symptoms was 5.3 years. Six women (17.1%) had no prior surgery; all six presented with umbilical nodules, nulliparity and confirmed mild to severe pelvic endometriosis. Among all patients, 34.3% had concurrent pelvic endometriosis, 40% presented with isolated AWE and 25.7% had no pelvic exploration. Women with concurrent pelvic endometriosis had significantly lower parity, smaller nodule size and a higher likelihood of umbilical location than those with isolated AWE (p < 0.05). A history of CS was more commonly found in women with isolated AWE. The overall recurrence rate over the study period was 11.4%, with a mean follow-up period of 5.2 years. CONCLUSIONS: AWE is an uncommon condition associated with long diagnostic and therapeutic delays. In patients with umbilical AWE and no surgical history, pelvic endometriosis is commonly present and should be highly suspected.

Effect of local aromatase inhibition in endometriosis using a new chick embryo chorioallantoic membrane model.

Endometriosis is an oestrogen-dependent, inflammation-driven gynaecologic disorder causing severe disability. Endometriosis implants are characterized by unbalanced local oestrogen metabolism leading to hyperoestrogenism and aromatase up-regulation is one of main mechanism involved. Aromatase inhibitors such as letrozole or anastrozole use in young women are associated with severely side effects limiting their long-term clinical use. An endometriosis-targeted inhibition of local aromatase could be a viable alternative, although the role of the local inhibition of this enzyme is still unclear. Using a new chick embryo allantoic membrane (CAM) model incorporating xenografted human endometriosis cyst, we showed that topical treatment with anastrozole reduced lesion size, although oestrogens produced by CAM female embryo blunted this effect. Xenografted human endometriosis CAM is a new efficient model for the screening of new drugs targeting endometriosis tissue.

Understanding sexual pain in endometriosis.

Sexual dysfunctions, particularly sexual pain, are common in adult women of all ages. In patients with endometriosis, a chronic gynecological pain condition affecting women of reproductive age, sexual pain is the third most common symptom. Multiple biological factors are involved in endometriosis-related sexual pain including tissue damage, inflammation, hormonal changes, alterations within the peripheral and central nervous system and pelvic floor muscle dysfunctions. Conceptual models of sexual pain espouse a multifactorial view, with empirical evidence suggesting the implication of psychosexual and relationship difficulties in the development and persistence of sexual pain and associated distress. We review literature on the biological, psychological, sexual and interpersonal factors associated with development and persistence of sexual pain in women with endometriosis. In addition, we discuss chronic pain conditions frequently associated with endometriosis (vulvodynia, bladder pain syndrome and inflammatory bowel syndrome) and how they are linked with sexual pain. Finally we discuss the clinical implications and provided suggestions for future research and medical care, focusing on a multidisciplinary and biopsychosocial approach.

Diaphragmatic Endometriosis: Multidisciplinary Treatment.

STUDY OBJECTIVE: To demonstrate a safe laparoscopic procedure for diaphragmatic infiltrative endometriosis. DESIGN: Video case SETTING: Teaching hospital (Canadian Task Force classification III). PATIENTS: One patient presenting deep and severe diaphragmatic endometriosis. INTERVENTION: Laparoscopic cure of diaphragmatic endometriosis. MEASUREMENTS AND MAIN RESULTS: Throughout this video, which was approved by the institutional board review, we demonstrate safe and complete surgical treatment of a patient suffering severe pelvic and diaphragmatic endometriosis. The patient complained of menstrual dyspnea and shoulder pain persisting despite hormonal treatment, associated with persistent dyspareunia and pelvic pain despite a previous laparoscopic surgery. Patient positioning and anesthesia were adapted to the special requirements of the surgical technique and the expected risks. The operation consisted of the exposure of the right diaphragm by mobilization of the liver, CO2 laser vaporization of left and right diaphragmatic lesions, nerve-sparing excision of infiltrating nodules, and pleural exploration. Finally, we performed an excision of pelvic endometriosis. Participation of 3 surgical teams to this procedure allowed a safe and complete laparoscopic treatment with resolution of pain symptoms at a 1- and 3-month follow-up. CONCLUSION: Laparoscopic treatment allows a safe and complete treatment of diaphragmatic endometriosis.

Psychosocial impact of endometriosis: From co-morbidity to intervention.

Endometriosis-associated pelvic pain is a major health concern in women of childbearing age. Controlled studies have shown that endometriosis can adversely affect women and their partners' general psychological well-being, relationship adjustment and overall quality of life. Furthermore, women with endometriosis report significantly more sexual dysfunctions compared to healthy women. Empirical studies indicate that specific psychosocial factors may modulate pain experience, pain-related distress and treatment outcome. Research on psychosexual interventions in endometriosis treatment is limited but shows to be effective in reducing endometriosis-related pain and associated psychosexual outcomes. An individualized, couple-centered, multimodal approach to care, integrating psychosexual and medical management for endometriosis, is thought to be optimal.

Treatment options and reproductive outcome for adenomyosis-associated infertility.

PURPOSE: Adenomyosis is a benign gynecological disease mostly diagnosed in the forth and fifth decades. The recent improvement of the diagnostic tools and a better understanding of the pathology allowed clinicians to postulate a possible relationship between adenomyosis and infertility and to diagnose it in younger asymptomatic women during infertility work-up. Purpose of this article is to review the different theories regarding the possible correlation between adenomyosis and infertility and to discuss the treatment options and the final reproductive outcome after the treatment. MATERIALS AND METHODS: We search Pubmed for articles published in the English language with the use of the following MeSH search terms: "adenomyosis" combined with "treatment" and "fertility outcome" with the restriction to the human species. A manual search of review articles and cross-references completed the search. All selected articles were assessed for study design, patients characteristic, diagnosis of adenomyosis, type of treatment, post-treatment rates of conception, full-term pregnancy and completeness of information of the data sets. RESULTS: Limited data are available concerning the efficacy of the different treatment options of adenomyosis on fertility outcome and the only ones published are retrospective evaluations or small case series. CONCLUSIONS: Adenomyosis represents a common gynecological disorder with a negative impact on fertility. However, it remains challenging to establish if adenomyosis is the only cause of the infertility or not, because patients, in both case and control groups, may be affected by concomitant endometriosis. Further studies are required to determine the reason of implantation failure in women with adenomyosis and the impact of adenomyosis on infertile women with or without endometriosis.

[When sex hurts the couple : the case of endometriosis]. / Quand le sexe fait mal au couple : le cas particulier de l'endométriose.

Sexual health is a critical aspect of quality of life and is also influenced by medical conditions and health care interventions, particularly when gynaecological disorders are involved. Dyspareunia is a common symptom of endometriosis, a cause of personal distress and a main raison for seeking treatment. Endometriosis negatively affects different domains of sexual function and specific biopsychological variables (chronic pain, recurrence, infertility) may further worsen quality of sexual function and relationship. Consequences of endometriosis treatment on global sexual functioning have not been featured prominently in the available literature, assuming wrongly that sexual pain improvement was always translated into a recovered sexual health.

La santé sexuelle est un aspect essentiel de la qualité de vie et est influencée par des conditions et des interventions médicales, en particulier lorsque des pathologies gynécologiques sont en question. La dyspareunie est un symptôme fréquent d'endométriose, une cause de détresse personnelle et un motif important de consultation. L'endométriose affecte négativement différents domaines de la fonction sexuelle et les variables biopsycho-sociales spécifiques (douleur chronique, récurrence, infertilité) peuvent aggraver la fonction sexuelle et la relation dans le couple. Les conséquences du traitement de l'endométriose sur la fonction sexuelle globale n'ont pas été évaluées de manière précise dans la littérature, qui affirme à tort que la diminution de la dyspareunie correspond toujours à l'amélioration de la santé sexuelle.

Sexual function in endometriosis patients and their partners: effect of the disease and consequences of treatment.

BACKGROUND: Sexual function is an important aspect of health and quality of life and is influenced by both medical conditions and health-care interventions, especially when gynecologic disorders are involved. Coital pain is among the main factors that affect sexual functioning, and this symptom is reported by almost half of women suffering from endometriosis. However, sexuality is a complex phenomenon driven by social, psychological and biological/hormonal factors and the presence of endometriosis might further affect domains of sexual function and the quality of a sexual relationship. OBJECTIVE AND RATIONALE: The objective of this report is to review the current state of knowledge on the impact that endometriosis and its treatments have on the sexual function of women and their sexual partners. SEARCH METHODS: A systematic literature search was performed to identify studies evaluating sexual function in endometriosis patients, and a narrative analysis of results is presented. The review discusses relevant quantitative and qualitative studies analyzing the effect of endometriosis and its hormonal and surgical treatments on measures of sexual function and quality of sexual relationship. OUTCOMES: Endometriosis negatively affects different domains of sexual function, and the presence of dyspareunia is not the only determinant of sexual health in these women. Chronic pelvic pain, advanced stages of disease and the presence of physical and mental comorbidities affect sexual function, as well as personality traits and women's expectations. Although a number of studies have evaluated the effect of surgery and hormonal treatment on deep dyspareunia, overall sexual function and quality of the relationship with the partner are often under-investigated. WIDER IMPLICATIONS: Multiple clinical and personal determinants affect sexual function in women with endometriosis, with potentially negative consequences on the sexual function of partners and quality of the relationship. Additional prospective and longitudinal investigations are warranted using specific instruments to analyze biopsychosocial variables of sexual pain in endometriosis patients and the effects that actual treatments have on measures of quality of sexual function and relationship.

Innovations in classical hormonal targets for endometriosis.

Endometriosis is a chronic disease of unknown etiology that affects approximately 10% of women in reproductive age. Several evidences show that endometriosis lesions are associated to hormonal imbalance, including estrogen synthesis, metabolism and responsiveness and progesterone resistance. These hormonal alterations influence the ability of endometrial cells to proliferate, migrate and to infiltrate the mesothelium, causing inflammation, pain and infertility. Hormonal imbalance in endometriosis represents also a target for treatment. We provide an overview on therapeutic strategies based on innovations of classical hormonal mechanisms involved in the development of endometriosis lesions. The development phase of new molecules targeting these pathways is also discussed. Endometriosis is a chronic disease involving young women and additional biological targets of estrogen and progesterone pharmacological manipulation (brain, bone and cardiovascular tissue) need to be carefully considered in order to improve and overcome current limits of long-term medical management of endometriosis.

Endometriosis-Associated Abdominal Wall Cancer: A Poor Prognosis?

OBJECTIVE: Endometriosis-associated abdominal wall cancer (EAAWC) is rare, and few reports are available. This article provides a review of reports in the literature on the pathology, diagnosis, management, and outcome of patients with EAAWC. METHOD: We performed a review of existing reports in the English language literature on cancer arising from abdominal wall endometriosis. MEDLINE and EMBASE searches were conducted for articles published from September 1986 to August 2014 using combinations of medical subject heading terms. RESULTS: We identified 26 articles reporting on EAAWC and added 1 patient who was treated at our institution. In all of these patients, EAAWC was described after uterine surgery (mostly cesarean section). The delay between the first surgery and the diagnosis of malignant disease was more than 20 years. Clear cell carcinoma was the most common histology, followed by endometrioid carcinoma. Death was described in 44% of women within a few months of diagnosis. CONCLUSIONS: Endometriosis-associated abdominal wall cancer is rare and aggressive. It seems to be associated with cesarean section, and it shows poor prognosis. The mainstay of treatment remains extensive surgery and chemotherapy.

Diurnal Variation of Plasma Brain-Derived Neurotrophic Factor Levels in Women with Functional Hypothalamic Amenorrhea.

BACKGROUND: Brain-derived neurotrophic factor (BDNF) is strongly related to hormonal networks and is modulated by hypothalamic activity. OBJECTIVE: To evaluate plasma BDNF concentration in patients with functional hypothalamic amenorrhea (FHA), with reference to the BDNF circadian rhythm and its relation with the cortisol (F) rhythm, and to assess whether the duration of amenorrhea might influence the BDNF:F ratio in FHA. DESIGN: This was an observational study evaluating 36 amenorrheic and 30 eumenorrheic women. SETTING: Basal values of BDNF and hormones were examined in blood samples collected from 7:00 to 9:00 h in all the women. Basal BDNF and F levels were determined in blood samples collected in 12 subjects from each group at 8:00, 12:00, 16:00, 20:00, and 24:00 h. RESULTS: BDNF plasma levels are significantly lower in amenorrheic women (p < 0.001) than in the follicular phase of eumenorrheic women. There are no correlations between BDNF values (p > 0.05), sex steroids, and F in FHA. Low plasma BDNF levels in FHA are not significantly correlated with duration of amenorrhea. The 24-hour variation of BDNF in amenorrheic women is significantly lower when compared to the control group, and normal daily variations of BDNF disappeared in FHA patients. F preserved its circadian rhythm in both groups. CONCLUSIONS: Interactions between BDNF, the hypothalamus-pituitary-adrenal axis, and sex steroids might be critical in clinical conditions of modified homeostasis/adaptation, such as FHA.

Robotic single-site combined cholecystectomy and hysterectomy: Advantages and limits.

INTRODUCTION: Robotic single-site surgery (RSS) represents the latest innovation for clinical use of single incision surgery. Several applications have been reported in urology, general surgery and gynecology with potential application in benign cases as well as in oncology. PRESENTATION OF CASE: To further explore potential applications of RSS, we present the first case reported in the literature of combined cholecystectomy and total hysterectomy using the da Vinci Si single-port platform (Intuitive Surgical Inc., Sunnyvale, CA). DISCUSSION: A critical description of the procedure with potential advantages and limitations of the current platform for combined surgical procedure is provided. CONCLUSION: Robotics may facilitate the widespread diffusion of single incision surgery, overcoming current laparoscopic and LESS limitations. However, the available robotic platform still has technical features that will limit its uptake amongst surgeons and further technological development is needed for a wider diffusion of single incision surgery.

Hormonal causes of recurrent pregnancy loss (RPL).

Endocrine disorders play a major role in approximately 8% to 12% of recurrent pregnancy loss (RPL). Indeed, the local hormonal milieu is crucial in both embryo attachment and early pregnancy. Endocrine abnormalities, including thyroid disorders, luteal phase defects, polycystic ovary syndrome, hyperprolactinaemia and diabetes have to be evaluated in any case of RPL. Moreover, elevated androgen levels and some endocrinological aspects of endometriosis are also factors contributing to RPL. In the present article, we review the significance of endocrine disease on RPL.

Role of imaging in endometriosis.

Endometriosis--the presence of endometrial tissue outside the uterine cavity--is first suspected on the basis of its signs and symptoms. The diagnosis is confirmed by imaging and surgery. Imaging, particularly transvaginal ultrasonography and magnetic resonance imaging, is essential to confirm the diagnosis and guide surgical treatment.