Endometriosis of the appendix: prevalence, associated lesions, and proposal of pathogenetic hypotheses. A retrospective cohort study with prospectively collected data.

OBJECTIVE: To assess the prevalence of endometriosis of the appendix and the association with other pelvic localizations of the disease and to provide pathogenesis hypotheses. METHODS: Monocentric, observational, retrospective, cohort study. Patients undergoing laparoscopic endometriosis surgery in our tertiary referral center were consecutively enrolled. The prevalence of the different localizations of pelvic endometriosis including appendix involvement detected during surgery was collected. Included patients were divided into two groups based on the presence of appendiceal endometriosis. Women with a history of appendectomy were excluded. MEASUREMENTS AND MAIN RESULTS: Four hundred-sixty patients were included for data analysis. The prevalence of appendiceal endometriosis was 2.8%. In patients affected by endometriosis of the appendix, concomitant ovarian and/or bladder endometriosis were more frequently encountered, with prevalence of 53.9% (vs 21.0% in non-appendiceal endometriosis group, p = 0.005) and 38.4% (vs 11.4%, p = 0.003), respectively. Isolated ovarian endometriosis was significantly associated to appendiceal disease compared to isolated uterosacral ligament (USL) endometriosis or USL and ovarian endometriosis combined (46.2% vs 15.4% vs 7.7%, p < 0.001). Poisson regression analysis revealed a 4.1-fold and 4.4-fold higher risk of ovarian and bladder endometriosis, respectively, and a 0.1-fold risk of concomitant USL endometriosis in patients with appendiceal involvement. CONCLUSION: Involvement of the appendix is not uncommon among patients undergoing endometriosis surgery. Significant association was detected between appendiceal, ovarian, and bladder endometriosis that may be explained by disease dissemination coming from endometrioma fluid shedding. Given the prevalence of appendiceal involvement, counseling regarding the potential need for appendectomy during endometriosis surgery should be considered.

The implications of the anatomy of the nerves and vessels in the treatment of rectosigmoid endometriosis.

Endometriosis is a common benign gynecological disease characterized by the presence of endometrial glands and stroma outside the uterus. It can be defined as endometrioma, superficial peritoneal endometriosis or deep infiltrating endometriosis (DIE) depending on the location and the depth of infiltration of the organs. In 5%-12% of cases, DIE affects the digestive tract, frequently involving the distal part of the sigmoid colon and rectum. Surgery is generally recommended in cases of obstructive symptoms and in cases with pain that is non-responsive to medical treatment. Selection of the most optimal surgical technique for the treatment of bowel endometriosis must consider different variables, including the number of lesions, eventual multifocal lesions, as well as length, width and grade of infiltration into the bowel wall. Except for some major and widely accepted indications regarding bowel resection, established international guidelines are not clear on when to employ a more conservative approach like rectal shaving or discoid resection, and when, instead, to opt for bowel resection. Damage to the pelvic autonomic nervous system may be avoided by detection of the middle rectal artery, where its relationship with female pelvic nerve fibers allows its use as an anatomical landmark. To reduce the risk of potential vascular and nervous complications related to bowel resection, a less invasive approach such as shaving or discoid resection can be considered as potential treatment options. Additionally, the middle rectal artery can be used as a reference point in cases of upper bowel resection, where a trans mesorectal technique should be preferred to prevent devascularization and denervation of the bowel segments not affected by the disease.

Systematic use of intraureteral indocyanine green: a game changer in endometriosis surgery. A proof-of-concept study.

BACKGROUND: Endometriosis of the distal segment of the uterosacral ligament may lead to a displaced ureter in the surgical field and must be identified before safe disease excision can be carried out. The aim of this study is to investigate the benefit of the systematic use of preoperative intraureteral indocyanine green (ICG) fluorescence injection in patients undergoing endometriosis surgery. METHOD: In this proof-of-concept, monocentric, observational, cohort study data were prospectively collected and retrospectively analyzed. Patients underwent laparoscopic surgery for deep infiltrating endometriosis with suspected ureteral involvement between January 2022 and December 2023. Using the propensity score matching (PSM) in a 1:1 matching ratio, patients who underwent preoperative ICG injection were compared with those who did not in terms of ureterolysis length and duration, and operative time. RESULTS: The mean length of ureterolysis was shorter in the ICG group compared to the non-ICG group (p < 0.001). The ICG group also had shorter ureterolysis duration (p < 0.001) and operative time (p = 0.02). No complications were reported at mean 6.8-month follow-up visit. CONCLUSIONS: The systematic use of intraureteral ICG prior to uterosacral ligaments endometriosis surgery may be safe and could assist in reducing the length of ureterolysis and operative time. Larger prospective studies are needed to confirm our findings.

How to Manage Endometriosis in Adolescence: The Endometriosis Treatment Italian Club Approach.

The evaluation of endometriosis in an adolescent girl is a challenging topic. The initial stage of the disease and the limited diagnostic instrument appropriate for the youth age and for its typical features can reduce the ability of the gynecologist. At the same time, missing a prompt diagnosis can delay the beginning of specific and punctual management of endometriosis, which could avoid a postponed diagnosis from 6 to 12 years, typical of adolescent girls complaining of dysmenorrhea. This article aimed to answer all the potential questions around the diagnosis and management of endometriosis in adolescents starting from a clinical case looking at the possible solution that is easily reproducible in the clinical practice.

Ultrasound Findings of Adenomyosis in Adolescents: Type and Grade of the Disease.

STUDY OBJECTIVE: To evaluate the ultrasound features, types, and degrees of adenomyosis among adolescents and to correlate these findings with clinical symptoms DESIGN: A retrospective observational study. SETTING: Gynecological ultrasound units from January 2014 to June 2020. PATIENTS: A total of 43 adolescents (aged 12-20 years) who were diagnosed as having adenomyosis at a pelvic ultrasound examination. INTERVENTIONS: Ultrasound features and location and type of adenomyosis within the uterus were evaluated on stored 2-dimensional images and videos and 3-dimensional volumes. Adenomyosis was classified as mild, moderate, and severe according to the extension of the disease in the uterus as described in our previous published classification. MEASUREMENTS AND MAIN RESULTS: Adenomyotic features recorded among our population were myometrial hyperechoic areas, uterine wall asymmetry, intramyometrial cystic areas, and some types of junctional zone alterations. The posterior uterine wall (58%) and the outer myometrial layer (93%) were mostly affected. In 44% of adolescents (19/43) with adenomyosis, at least 1 location of pelvic endometriosis was documented. Dysmenorrhea was the most commonly reported symptoms (88%), and it was associated with adenomyosis of the outer myometrium, myometrial hyperechoic areas, uterine wall asymmetry, and intramyometrial cystic areas. Adolescents with dyspareunia showed diffuse adenomyosis (9/9 patients) including both the inner and outer myometrium (7/9 patients) and in the posterior wall (7/9 patients). Heavy menstrual bleeding was associated with diffuse adenomyosis (18/23 patients) mostly of the outer myometrium (22/23 patients). Scoring system showed predominantly mild disease and no severe adenomyosis was found. Adolescents with diffuse adenomyosis were significantly older and showed a high percentage of heavy menstrual bleeding compared with those with the focal disease of the inner myometrium. CONCLUSION: This study shows that adenomyosis is not only a pathology of adult life, but it involves young patients mostly in a mild-to-moderate form and is associated with typical painful symptoms. In adolescents, the diagnosis of adenomyosis is feasible through a noninvasive way with ultrasound and a proper management can be set.

Urinary Tract Endometriosis: A Multidisciplinary Fight Against a Silent Enemy.

STUDY OBJECTIVE: To demonstrate the safety and feasibility of laparoscopic robotic assisted approach to urinary tract endometriosis. DESIGN: This is an educational video to explain the main steps of robotic assisted ureteroneocystostomy owing to endometriosis. SETTING: Tertiary care university hospital. A patient written consent was obtained on March 9, 2021. The local institutional review board confirmed that the video met the ethical criteria. INTERVENTIONS: Laparoscopic robotic assisted resection of uterosacral ligament endometriotic nodule, left terminal partial ureterectomy, partial cystectomy, and ureteroneocystostomy. CONCLUSION: This video shows a stepwise approach to laparoscopic robotic assisted urinary tract endometriosis management demonstrating its feasibility and safety. Urinary tract endometriosis affect only the 0.3% to 6% of women affected by endometriosis, among which the most common localization is the bladder (84%-90%) [1]. The ureteral compression is rare but can lead to obstruction up to silent loss of renal function [2], which is one of the main factors to take into account in the management of this disease [3].

Adenomyosis and infertility: the role of the junctional zone.

OBJECTIVE: Adenomyosis is a benign uterine disorder characterized by the invasion of the endometrium within the myometrium, starting from the junctional zone (JZ), the inner hormone dependent layer of the myometrium that plays an important role in sperm transport, implantation and placentation. The resulting histological abnormalities and functional defects may represent the pathogenic substrate for infertility and pregnancy complications. The objective of this paper is to review the literature to evaluate the correlation between inner myometrium alterations and infertility and to assess the role of JZ in the origin of adverse obstetric outcomes of both spontaneous and in vitro fertilization (IVF) pregnancies. METHODS: we searched Pubmed for all original and review articles in the English language from January1962 until December 2019, using the MeSH terms of 'adenomyosis', 'junctional zone', combined with 'infertility', 'obstetrical outcomes', 'spontaneous conception', 'in vitro fertilization' and 'classification'. The review was divided into three sections to assess this pathogenic correlation, evaluating also the importance of classification of the disease. RESULTS AND CONCLUSIONS: Absent or incomplete remodeling of the JZ can affect uterine peristalsis, alter vascular plasticity of the spiral arteries and activate inflammatory pathways, all related to adverse obstetric outcomes. Despite these observations, there is still limited evidence whether adenomyosis is a cause of infertility. However, it is reasonable to screen patients for adenomyosis, to consider pregnant women with diffuse adenomyosis at high risk of adverse obstetric outcomes, and to evaluate the importance of a noninvasive validated classification in the management of women with adenomyosis.

Transvaginal Ultrasound Findings After Laparoscopic Rectosigmoid Segmental Resection for Deep Infiltrating Endometriosis.

OBJECTIVES: To evaluate transvaginal ultrasound (TVUS) findings in patients who underwent segmental rectosigmoid resection for deep infiltrating endometriosis (DIE) and to correlate postsurgical ultrasound findings with symptoms. METHODS: A retrospective study including 50 premenopausal women with bowel endometriosis who underwent segmental rectosigmoid resection was conducted. Within 12 months after surgery, a TVUS examination was conducted in all patients to evaluate the presence of postsurgical endometriosis locations and symptoms, including dysmenorrhea, dyspareunia, dysuria, dyschezia, and chronic pelvic pain. Pelvic pain was assessed in all women by a visual analog scale. RESULTS: At the follow-up 32 of 50 patients were receiving medical treatment, whereas 18 women declined postsurgical medical therapy and tried to conceive. A high percentage of adhesions (90%) was found. A negative sliding sign (a simple diagnostic sign that can be performed during a TVUS examination, consisting of gentle pressure applied by both the vaginal transducer and the examiner's hand on the abdomen; if the uterus does not glide freely along with the rectum and posterior fornix, the sign is considered negative, and adhesions can be suspected) was found in 29 (58%) women and was associated with bowel symptoms. Recurrence of posterior DIE was found in 9 cases (18%) and endometriomas in 8 cases (16%). Adenomyosis was observed in 80% of women and was present in all symptomatic patients. CONCLUSIONS: After rectosigmoid segmental resection patients with DIE may continue to be symptomatic, and postoperative TVUS may reveal foci of disease or pelvic adhesions. Moreover, adenomyosis could be linked to symptoms experienced during follow up. Women should be aware that painful symptoms and alterations of pelvic organs could still be present after surgery and be detectable by TVUS.

Medicolegal Issues in Power Morcellation: Cautionary Rules for Gynecologists to Avoid Unfavorable Outcomes.

Power morcellation in laparoscopic surgery enables specialists to carry out minimally invasive procedures such as hysterectomies and myomectomies by cutting specimens into smaller pieces using a rotating blade and removing pieces through a laparoscope. Unexpected uterine sarcoma treated by surgery involving tumor disruption could be associated with poor prognosis. The current study aims to shed light on power morcellation from a medicolegal perspective: the procedure has resulted in adverse outcomes and litigation, and compensation for plaintiffs, as published in various journals cited in PubMed and MEDLINE, Cochrane Library, EMBASE, and GyneWeb. Considering the claims after the US Food and Drug Administration warnings on morcellation, the current study broadens the scope of research by including search engines, legal databases, and court filings (DeJure, Lexis Nexis, Justia, superior court of New Jersey, and US district court of Minnesota) between 1995 and 2019. Legal records show that courts determine professional responsibility regarding complications, making it essential to document adherence to safety protocols and specific guidelines, when available. Sound medical practices and clearly stated institute best practices result in better patient outcomes and are important when unfavorable clinical outcomes occur; adverse legal decisions can be avoided if there are grounds to prove professional conformity with specific guidelines and the unpredictability of an event.

Sacrohysteropexy: A Way to Spare the Uterus.

STUDY OBJECTIVE: To show the safety and feasibility of laparoscopic sacrohysteropexy for treating uterine prolapse. DESIGN: An educational video to explain the laparoscopic steps of this procedure by focusing on the main anatomic landmarks and on tips and tricks to avoid complications. SETTING: A tertiary care university hospital. INTERVENTIONS: Laparoscopic sacropexy with uterus preservation for grade 3 apical defect. CONCLUSION: This video shows a stepwise approach to laparoscopic sacrohysteropexy demonstrating its feasibility and safety. There is a wide choice of surgical procedures and approaches focused on pelvic organ prolapse repair. Since many years, uterine prolapse has been an indication for hysterectomy, regardless of the occurrence of uterine disease and patients' desires. With the introduction of minimally invasive surgery, the uterine-sparing procedures are being increasingly taken into account, especially in young women [1]. Sacrohysteropexy is a uterus-sparing procedure that allows for a reduction in operating time, intraoperative blood loss, mesh-related complications, and surgical costs [2]. Furthermore, this technique has a high success rate with an objective cure rate of 100% for the apical compartment and 80% for all compartments and does not seem to increase the pelvic organ prolapse recurrence rate [3]. Sacropexy is not a life-threatening procedure, but its main objective is to restore functional anatomy with the primary goal of improvement in patient's quality of life. Moreove, no difference has been found with or without uterus preservation in term of postoperative recurrence rate or ent's quality of life [4]. However, high patient satisfaction has been recently reported; therefore, uterine preservation should be considered during patient's counseling.

New Sonographic Classification of Adenomyosis: Do Type and Degree of Adenomyosis Correlate to Severity of Symptoms?

STUDY OBJECTIVE: To correlate the type and degree of adenomyosis, scored through a new system based on the features of transvaginal sonography, to patients' symptoms and fertility. DESIGN: This is a multicenter, observational, prospective study. SETTING: Two endometriosis tertiary referral centers (University of Rome "Tor Vergata" and University of Siena). PATIENTS: A total of 108 patients with ultrasonographic signs of adenomyosis. INTERVENTIONS: A new ultrasonographic scoring system designed to assess the severity and the extent of uterine adenomyosis was used to stage the disease in correlation with the clinical symptoms. Menstrual uterine bleeding was assessed by a pictorial blood loss analysis chart, painful symptoms were evaluated using a visual analog scale, and infertility factors were considered. MEASUREMENTS AND MAIN RESULTS: A total of 108 patients with ultrasonographic signs of adenomyosis (mean age ± standard deviation, 37.7 ± 7.7 years) were classified according to the proposed scoring system. Women with ultrasound diagnosis of diffuse adenomyosis were older (p = .04) and had heavier menstrual bleeding (p = .04) than women with focal disease; however, no statistically significant differences were found regarding the presence and severity of dyspareunia and dysmenorrhea. Higher values of menstrual bleeding were found for severe diffuse adenomyosis, with the highest values being found in those with adenomyomas. In patients trying to conceive, the presence of ultrasound findings of focal disease was associated with a higher percentage of infertility than in those with diffuse disease, and the focal involvement of the junctional zone showed a higher percentage of at least 1 miscarriage than in those with diffuse adenomyosis. CONCLUSION: The ultrasonographic evaluation of the type and extension of adenomyosis in the myometrium seems to be important in correlation to the severity of symptoms and infertility.

Surgical treatment of endometriosis: prognostic factors for better quality of life.

The present study investigated the effect of surgical treatment of endometriosis on physical and mental health. We undertook a prospective survey including 153 premenopausal women with histological diagnosis of endometriosis. The Short Form 12 (SF-12) questionnaire comprising physical and mental component scales was used. Two groups of patients were distinguished: Group A (n = 42) with SF-12 scores above the median in both physical and mental scales; Group B (n = 111) with SF-12 scores below the median in either physical or mental scale. Group A was diagnosed and operated for endometriosis for the first time at an older age (30 vs. 26 years), had undergone more frequently a single surgical intervention (64% vs. 46%), was less affected by symptom or lesion recurrence and had reported less intense current pain symptoms than Group B. Having the first endometriosis surgery at a later age was an independent predictor of better health status (adjusted odds ratio 1.146 per year, 95% confidence interval 1.058-1.242) after accounting for the potential confounding effects of reoperation, pelvic pain and time elapsed since the first surgery. In conclusion, patients with endometriosis who had a single surgery at an older age have good symptom control and better quality of life (QoL).

Isolated Ovarian Endometrioma: A History Between Myth and Reality.

STUDY OBJECTIVE: To assess the association between ovarian endometriomas detectable at transvaginal ultrasound (TVS) and other specific extraovarian lesions including adhesions, deep infiltrating endometriosis (DIE), and adenomyosis. DESIGN: Retrospective observational study (Canadian Task Force classification II-2). SETTING: Two university hospitals. PATIENTS: Two hundred fifty-five symptomatic women with at least 1 ovarian endometrioma found on ultrasound after presentation with pain or irregular menstruation. INTERVENTIONS: Patients underwent TVS followed by either medical or surgical treatment. MEASUREMENTS AND MAIN RESULTS: Two hundred fifty-five women, aged 20 to 40 years, underwent TVS and were found to have at least 1 endometrioma with a diameter > 20 mm. Associated sonographic signs of pelvic endometriosis (adhesions, DIE, and adenomyosis) were recorded, and a subgroup of patients (n = 50) underwent laparoscopic surgery within 3 months of TVS. Mean endometrioma diameter was 40.0 ± 18.1 mm, and bilateral endometriomas were observed in 65 patients (25.5%). TVS showed posterior rectal DIE in 55 patients (21.5%) and a thickening of at least 1 uterosacral ligament in 93 patients (36.4%). One hundred eighty-six patients (73%) had adhesions, and 134 patients (53%) showed signs of myometrial adenomyosis on TVS. Thirty-eight patients (15%) exhibited only a single isolated endometrioma with a mobile ovary and no other signs of pelvic endometriosis/adenomyosis at TVS. CONCLUSION: Ovarian endometriomas are indicators for pelvic endometriosis and are rarely isolated. Particularly, left endometriomas were found to be associated with rectal DIE and left uterosacral ligament localization and bilateral endometriomas correlated with adhesions and pouch of Douglas obliteration, whereas no correlation was found between endometrioma size and DIE. Determining appropriate management, whether clinical or surgical, is critical for ovarian endometriomas and concomitant adhesions, endometriosis, and adenomyosis in patients desiring future fertility.

Three-Dimensional Hysterosalpingo Contrast Sonography with Gel Foam: Methodology and Feasibility to Obtain 3-Dimensional Volumes of Tubal Shape.

OBJECTIVES: To investigate the feasibility of hysterosalpingo foam sonography (HyFoSy) with automated 3-dimensional (3D) software in the evaluation of tubal patency and visualization of the tubal course by obtaining a 3D volume acquisition of tubes. DESIGN: Prospective observational study (Canadian Task Force classification III). SETTING: University hospital. PATIENTS: A total of 132 infertile females evaluated between October 2013 and February 2015. INTERVENTIONS: All patients underwent HyFoSy with the new automated 3D coded contrast imaging (CCI) followed by 2-dimensional (2D) real-time HyFoSy. To evaluate the feasibility of 3D visualization of the tubal course, consecutive volume acquisitions were performed during gel foam contrast agent injection. Conventional 2D real-time hysterosalpingo contrast sonography (HyCoSy) by detection of gel foam moving through the tubes and around the ovaries was finally performed and considered to indicate the final results of tubal status. MEASUREMENTS AND MAIN RESULTS: All the patients underwent 3D CCI HyFoSy, followed by 2D real-time HyFoSy. After both procedures, we observed 108 patients (81.8%) with bilateral tubal patency, 22 patients (16.6%) with unilateral tubal patency, and 2 patients (1.5%) with bilateral tubal occlusion. The concordance rate for tubal status between the first and second 3D volume acquisitions and the final 2D real-time evaluation was 84.8% and 97.0%, respectively. CONCLUSIONS: Transvaginal ultrasound HyFoSy with 3D volume reconstruction of the uterus and tubes is an accurate and safe technique that allows complete visualization of tubal shape and patency with high patient compliance.

Enhanced Endometriosis Archiving Software (ENEAS): An Application for Storing, Retrieving, Comparing, and Sharing Data of Patients Affected by Endometriosis Integrated in the Daily Practice.

Endometriosis is a chronic benign disease affecting women of fertile age, associated with pelvic pain and subfertility, often with negative impacts on quality of life. Meetings involving 5 gynecologists skilled in endometriosis management and 2 informatics technology consultants competent in data management and website administration were enlisted to create an endometriosis databank known as ENEAS (Enhanced Endometriosis Archiving Software). This processing system allows users to store, retrieve, compare, and correlate all data collected in conjunction with different Italian endometriosis centers, with the collective objective of obtaining homogeneous data for a large population sample. ENEAS is a web-oriented application that can be based on any open-source database that can be installed locally on a server, allowing collection of data on approximately 700 items, providing standardized and homogeneous data for comparison and analysis. ENEAS is capable of generating a sheet incorporating all data on the management of endometriosis that is both accurate and suitable for each individual patient. ENEAS is an effective and universal web application that encourages providers in the field of endometriosis to use a common language and share data to standardize medical and surgical treatment, with the main benefits being improved patient satisfaction and quality of life.

Comparison between the stripping technique and the combined excisional/ablative technique for the treatment of bilateral ovarian endometriomas: a multicentre RCT.

STUDY QUESTION: Is the combined excisional/ablative technique for the treatment of ovarian endometriomas better than the traditional stripping technique in terms of recurrence rate? SUMMARY ANSWER: There is no evidence that the combined excisional/ablative technique is better than the traditional stripping technique, as similar recurrence rates were observed for the two techniques. WHAT IS KNOWN ALREADY: The stripping technique is associated with better results compared with ablative, non-excisional techniques for the treatment of ovarian endometriomas. Excisional techniques, such as stripping, have, however, been associated with reduced ovarian reserve as evaluated with anti-Mullerian hormone, and surgical techniques that better preserve the ovarian reserve are needed. STUDY DESIGN, SIZE, DURATION: A prospective, multicentre, randomized blinded clinical trial was carried out on 51 patients with bilateral endometriomas larger than 3 cm. For each patient, serving as her own control, one ovary was randomized to the stripping technique and the contralateral to the combined excisional/ablative technique. Patients were enrolled between January 2013 and April 2014. PARTICIPANTS/MATERIALS, SETTING, METHODS: Patients of reproductive age with pelvic pain and/or infertility affected by bilateral endometriomas larger than 3 cm were included (n = 51). The patients underwent laparoscopic removal of endometriomas with two different surgical techniques performed at either side after random assignment: complete removal by stripping on one side versus the combined technique, consisting of partial excisional cystectomy followed by completion with ablative surgery using bipolar coagulation, on the other side. Post-operative follow-up was performed at 1, 3 and 6 months after surgery for the evaluation of endometrioma recurrence (primary outcome) and of antral follicle count (AFC) and ovarian volumes (OVs) to assess ovarian reserve (secondary outcome). MAIN RESULTS AND THE ROLE OF CHANCE: Recurrence rates were 5.9% for the stripping technique versus 2.0% for the combined technique (odds ratio 3.00; 95% confidence interval: 0.24-157.5; P = 0.62). AFC in the ovaries treated with the stripping technique did not differ significantly from AFC in ovaries treated with the combined technique at all follow-up visits, whereas OV was significantly lower after the combined technique at the 6-month follow-up visit (P = 0.04). LIMITATIONS, REASONS FOR CAUTION: A major limitation of this study is the small sample size and particularly for ovarian reserve, the secondary outcome, for which no formal sample size calculation was performed. The lower-than-expected recurrence rates in the present series may be related to the shorter follow-up in our study compared with most studies in the literature. Further studies with larger sample sizes and longer follow-up are needed to confirm the findings of this study. The combined technique using CO2 laser energy instead of bipolar coagulation should also be evaluated. WIDER IMPLICATIONS OF THE FINDINGS: The traditional excisional technique, i.e. the stripping technique, should still be considered the gold standard approach for the surgical treatment of endometriomas. STUDY FUNDING/COMPETING INTERESTS: No commercial funding was received. The authors report no relevant conflict of interest. TRIAL REGISTRATION NUMBER: ANZCTR number ACTRN12614000653662. TRIAL REGISTRATION DATE: 23 June 2014. DATE OF FIRST PATIENT'S ENROLMENT: 1 January 2013.

Impact of Laparoscopic Surgical Management of Deep Endometriosis on Pregnancy Rate.

STUDY OBJECTIVE: To evaluate the impact of laparoscopic excision of lesions on deep endometriosis-related infertility. DESIGN: Retrospective study. SETTING: Endometriosis tertiary referral center (Canadian Task Force II-2). PATIENTS: A group of 115 patients who had undergone laparoscopic surgery for infertility with histologic confirmation of deep endometriosis. INTERVENTIONS: Patient medical records and operative reports were reviewed. Telephone interviews were conducted for long-term follow-up of fertility outcomes. MEASUREMENTS AND MAIN RESULTS: Evaluation of fertility outcome after laparoscopic treatment of deep endometriosis by spontaneous conception and by assisted reproductive technology (ART) correlated with lesion number, size, and location (anterior, posterolateral, pouch of Douglas, and multiple locations). After a mean follow-up of 22 months the overall pregnancy rate was 54.78% (n = 63) with a live-birth rate of 42.6% (n = 49). Among those patients given the chance to conceive spontaneously (n = 70), the overall pregnancy rate was 60% (n = 42): 38.5% (n = 27) spontaneously and 21.4% (n = 15) by ART. The removal of multiple lesions was associated with a higher pregnancy rate after surgery. When comparing isolated lesion size and disease location, there was no difference in pregnancy rate. Furthermore, those patients who underwent surgical eradication of the disease for the first time had a higher pregnancy rate (odds ratio, 4.18). CONCLUSION: This study demonstrates that laparoscopic excision of deep endometriosis enhances pregnancy rate, by both spontaneous conception and ART. First surgical treatment of multiple lesions was associated with higher pregnancy rates, whereas isolated lesions influenced the pregnancy rate irrespective of their location and size.

Adenomyosis: What the Patient Needs.

A panel of experts in the field of endometriosis expressed their opinions on management options in a 28-year-old patient, attempting pregnancy for 1 year, with severe cyclic pelvic pain and with clinical examination and imaging techniques suggestive of adenomyosis. Many questions this paradigmatic patient may pose to the clinician are addressed, and all clinical scenarios are discussed. A decision algorithm derived from this discussion is also proposed.

Parenterally administered moderate sedation and paracervical block versus general anesthesia for hysteroscopic polypectomy: a pilot study comparing postoperative outcomes.

STUDY OBJECTIVE: To compare parenterally administered moderate sedation and paracervical block versus general anesthesia during day-case operative hysteroscopy for polypectomy in terms of patients' postoperative pain perception, operating time, and postoperative drug administration. DESIGN: A pilot study (Canadian Task Force classification I). SETTING: A university hospital. PATIENTS: Women undergoing hysteroscopic polypectomy procedures (N = 56). INTERVENTIONS: Hysteroscopic polypectomy with general anesthesia or moderate parenteral sedation and paracervical block. MEASUREMENTS AND MAIN RESULTS: The patients were divided into 2 groups: 26 underwent general anesthesia (group 1), and 30 were submitted to moderate parenteral sedation and a paracervical block (group 2). General anesthesia was induced with the laryngeal mask airway with propofol (1% 1-2.5 mg/kg) and fentanyl (1-2 µg/kg) and maintained with an infusion of propofol (2% 3-5 mg/kg/h). After the procedure, patients in the general anesthesia group received postoperative analgesic medication with paracetamol (20 mg/kg) and ketorolac (0.6 mg/kg) or tramadol (2-3 mg/kg). The group receiving moderate parenterally sedation and a paracervical block received a paracervical block with mepivacaine (1% 10 mL) and lidocaine (2% 10 mL) and received fentanyl (1 µg/kg) and propofol (1% 1-3 mg/kg/h) maintaining spontaneous breathing. A blind observer recorded the operative time and the discomfort of patients using a 4-step scale (0-3). The postoperative pain assessment was performed 3 hours after the procedure with a self-administered validated tool, the Brief Pain Inventory. We found that women receiving moderate parenteral sedation and a paracervical block perceived significantly less pain in daily activity (p < .001), walking (p < .001), daily work (p < .001), relations with others (p = .007), sleep (p < .001), and pain contrasting enjoyment of life (p < .001). The total amount of time spent in the operating room in group 2 was significantly lower than in group 1 (p < .014). CONCLUSION: Moderate sedation plus a paracervical block for operative hysteroscopy is associated with reduced pain perception and a shorter operative time.