Laparoscopic treatment of deep endometriosis with a diode laser: our experience.

PURPOSE: To evaluate whether laparoscopic treatment with a diode laser is feasible, safe, and effective in symptomatic patients affected by deep endometriosis (DE). METHODS: This retrospective study was performed using medical record data. The surgical reports, chronic pain scores, and quality of life (QoL) data were evaluated for 50 patients who had undergone laparoscopic surgery between November 2017 and March 2019 at two university hospitals (Monserrato (CA) and Foggia, Italy). Indications for surgery were chronic pelvic pain and/or infertility in patients who wished to conceive spontaneously. Endometriosis lesions/nodules were excised using a diode laser (Leonardo®, Biolitec® DUAL 45) that can combine 980 and 1470 nm wavelengths transmitted through a 1000 µm conical optical fibre. RESULTS: The median patient age was 32 years (range 21-44), with a body mass index (BMI) mean of 21.7  ±  2.9 kg/m2. The mean operation time was 147 min (range 106-190). No intraoperative or early complications (< 30 days) were reported. All patients left the hospital, on average, within 3 days (range 2-9 days) after surgery. A significant improvement in pain was observed at the 3-, 6-, and 12-month follow-up (p < 0.01) in all patients. Moreover, patients reported a significant QoL improvement at the 12-month follow-up. CONCLUSION: The diode laser confirmed its feasibility and safety for treating endometriosis. During the shaving surgical procedure, the diode laser system ensures a safe and effective laparoscopic dissection of deep endometriotic lesions. Further comprehensive randomized trials are necessary to confirm these preliminary data in terms of efficacy, recurrence rates, and pregnancy outcomes.

Is dienogest the best medical treatment for ovarian endometriomas? Results of a multicentric case control study.

Ovarian endometriomas are common manifestations of endometriosis. Surgical excision has been shown to potentially decrease ovarian reserves. In this prospective study, we included 81 patients with ovarian endometriosis. 40 were treated with 2 mg of dienogest daily (DNG) and 41 were treated with cyclic oral estro-progestins (ethinyl estradiol 30 mcg [EE] plus dienogest 2 mg) (DNG + EE). Aim of the study was the effect of the treatment on the size of the endometriotic cysts. Further, in the symptomatic patients, follow-up included an evaluation of chronic pain before and during treatment. Both treatments were able to significantly decrease the pain in symptomatic patients with no statistical differences. The mean visual analog scale score at enrollment was 65 ± 14 and 70 ± 18, and there was significant improvement (19 ± 15, p < .001, DNG; 18 ± 12, p < .001, DNG + EE). The size of the endometrioma cysts were significantly reduced in the DNG group. The mean cyst diameter was 52 ± 22 mm at baseline and 32 ± 12 mm after six months of treatment (p < .001), yielding a 75% volume reduction in DNG group. The decrease in the size of endometrioma cysts observed in the women treated with only progestin could be noteworthy, as it may reduce the negative impacts on the affected ovary and avoid surgery.

Effect of ultramicronized-palmitoylethanolamide and co-micronized palmitoylethanolamide/polydatin on chronic pelvic pain and quality of life in endometriosis patients: An open-label pilot study.

PURPOSE: The aim of the present study was to evaluate the effectiveness of the ultramicronized-palmitoylethanolamide (um-PEA) and co-micronised palmitoylethanolamide/polydatin m(PEA/PLD) in the management of chronic pelvic pain related to endometriosis in patients desiring pregnancy. PATIENTS AND METHODS: Thirty symptomatic women with laparoscopic diagnosis of endometriosis and pregnancy desire were enrolled. Patients were treated with um-PEA twice daily for 10 days followed by m(PEA/PLD) twice daily for 80 days. Intensity of chronic pelvic pain, dyspareunia, dysmenorrhea, dyschezia, and dysuria were evaluated at baseline, after 10, 30, 60, 90 days and after 30 days from the end of treatment, by VAS. Quality of life and women's psychological well-being were evaluated at baseline and at the end of the treatment after 90 days with 36-Item Short Form Health Survey questionnaire and Symptom Check list-90 questionnaire, respectively. All collected data were analyzed with the non-parametric Wilcoxon test. RESULTS: At the end of the treatment, all patients showed a significant improvement in chronic pelvic pain, deep dyspareunia, dysmenorrhea, dyschezia, as well as in quality of life and psychological well-being. CONCLUSION: In spite of the study's limited sample size and the open-label design, this research suggests the efficacy of um-PEA and m(PEA/PLD) in reducing painful symptomatology and improving quality of life as well as psychological well-being in patients suffering from endometriosis. Additionally, this treatment did not show any serious side effect, proving particularly suitable for women with pregnancy desire and without other infertility factors.

Genetics of endometriosis: a comprehensive review.

This review aimed to critically evaluate the review, observational, cohort, and case-control studies performed so far in order to assess the association between endometriosis and genetics. The search strategies used included an online search of the MEDLINE database and a manual search of relevant publications and reviews. Additional reports were collected by systematically reviewing all references from the retrieved papers. Family studies have long suggested that genetic factors play a role in the etiology of endometriosis. Nevertheless, until now, studies on candidate genes have revealed inconsistent and contradictory evidence, leading to more questions rather than clear answers. It is possible that recent technological improvements in genetic evaluation could allow for a better understanding of the pathogenic mechanisms of endometriosis in the near future.

Feasibility of hysteroscopic endometrial polypectomy using a new dual wavelengths laser system (DWLS): preliminary results of a pilot study.

PURPOSE: Currently, endometrial polyps may be successfully treated in an outpatient setting with 5 Fr mechanical and bipolar instruments. Our aim is to evaluate the benefits of minimally invasive techniques in hysteroscopy, focusing on the use of a new dual wavelengths laser system in the treatment of endometrial polyps in an outpatient setting. METHODS: Between September 2012 and December 2014, all consecutive patients of reproductive and menopausal age with ultrasound diagnosis of endometrial polyp with maximum diameter ≤2.5 cm were eligible to participate in a prospective study. They underwent a hysteroscopic procedure with excision of the polyp using a new dual wavelengths laser system. All procedures were performed on an outpatient basis without anesthesia. RESULTS: Laser polypectomy was successfully performed in 219 out of 225 (97.3%). Success of surgery was not influenced by the initial location of polyp. No main complications were reported during or immediately after the procedure. 6 and 12 months follow-up with ultrasound scan did not show any persistence or recurrence of the pathology. CONCLUSIONS: Our preliminary findings seem to support the safety and the effectiveness of the laser hysteroscopic endometrial polypectomy. However, further studies are mandatory to validate its use in daily hysteroscopic practice.

Hysteroscopic metroplasty for the septate uterus with diode laser: a pilot study.

OBJECTIVE: To evaluate the feasibility and safety of office hysteroscopic metroplasty using a 980nm diode laser. STUDY DESIGN: 18 patients were treated for septate uterus between 2013 and 2016. The indications for hysteroscopic metroplasty were recurrent abortion in 11 of the women and primary infertility in the other seven. We used a 5mm-office hysteroscope with a diode laser fibre. After exploration of the cavity, the septum was divided with use of the laser fibre. RESULTS: Operating time was 13,16±1,33min. Intraoperative pain was 3,05±0,72. No intraoperative or postoperative complications were observed. Follow-up performed 2 months after the hysteroscopic metroplasty confirmed the complete removal of the septum and no evidence of intrauterine synechiae. CONCLUSION: Office hysteroscopic metroplasty with use of a diode laser is safe and feasible; we believe that vaporization of the septum with a diode laser could reduce the formation of adhesions and consequently reduce the occurrence of septum persistence.

Leiomyomatosis Peritonealis Disseminata (LPD) ten years after laparoscopic myomectomy associated with ascites and lymph nodes enlargement: a case report.

INTRODUCTION: We report a case of leiomyomatosis peritonealis disseminata (LPD) arising 10 years after a laparoscopic myomectomy that was associated with ascites and lymph nodes enlargement. PRESENTATION OF CASE: The patient presented with small uterine fibroids with a dominant posterior intramural fibroid measuring 9cm in diameter and normal Doppler. Laparotomy revealed a uterus enlarged with fibroids, which was densely adhering to the urinary bladder, greater omentum, and sigmoid colon. Multiple tumors of different size were found attached to the peritoneum, omentum and bowel. The histopathologic examination was consistent with leiomyomatosis peritonealis disseminata. DISCUSSION: Pieces of smooth muscle cell lost in the abdominal cavity during electrical morcellation after laparoscopic myomectomy may progress to leiomyomatosis peritonealis disseminata even after many years (ten in our case) and it can be associated with ascites and lymph nodes enlargement. CONCLUSION: This is the first case reported in literature of leiomyomatosis peritonealis disseminata with these particular features (time of clinical presentation, ascites, lymph nodes enlargement).

Review and meta-analysis of prospective randomized controlled trials (RCTs) comparing laparo-endoscopic single site and multiport laparoscopy in gynecologic operative procedures.

PURPOSE: To critically appraise published randomized controlled trials (RCTs) comparing laparo-endoscopic single site (LESS) and multi-port laparoscopic (MPL) in gynecologic operative surgery; the aim was to assess feasibility, safety, and potential benefits of LESS in comparison to MPL. METHODS: A systematic review and meta-analysis of eleven RCTs. Women undergoing operative LESS and MPL gynecologic procedure (hysterectomy, cystectomy, salpingectomy, salpingo-oophorectomy, myomectomy). Outcomes evaluated were as follows: postoperative overall morbidity, postoperative pain evaluation at 6, 12, 24 and 48 h, cosmetic patient satisfaction, conversion rate, body mass index (BMI), operative time, blood loss, hemoglobin drop, postoperative hospital stay. RESULTS: Eleven RCTs comprising 956 women with gynecologic surgical disease randomized to either LESS (477) or MPL procedures (479) were analyzed systematically. The LESS approach is a surgical procedure with longer operative and better cosmetic results time than MPL but without statistical significance. Operative outcomes, postoperative recovery, postoperative morbidity and patient satisfaction are similar in LESS and MPL. CONCLUSION: LESS may be considered an alternative to MPL with comparable feasibility and safety in gynecologic operative procedures. However, it does not offer the expected advantages in terms of postoperative pain and cosmetic satisfaction.

The use of laser in hysteroscopic surgery.

The term laser, an acronym for light amplification by stimulated emission of radiation, covers a wide range of devices. Lasers are commonly described by the emitted wavelength that covers the entire light spectrum from infrared to ultraviolet and the active lasing medium. Currently, over forty different types of lasers have found application in medicine. Moreover, advances made by gynecologists in the field of operative hysteroscopy have developed a very great interest in the use of surgical lasers. Technical improvements in hysteroscopes and lasers have led several gynecologists to evaluate their use in the surgical treatment of intrauterine pathologies. This narrative review concerns the most common used lasers in hysteroscopic surgery with particular attention to the latest promising results of the laser technology.

Endometrial ablation: first- vs. second-generation techniques.

INTRODUCTION: Endometrial ablation is a procedure that surgically destroys (ablates) the lining of the uterus (endometrium). The goal of endometrial ablation is to reduce menstrual flow. In some women, menstrual flow may stop completely. In some cases, endometrial ablation may be an alternative to hysterectomy. There are several techniques used to perform endometrial ablation, including electrical or electrocautery ablation, in which an electric current travels through a wire loop or rollerball is applied to the endometrial lining to cauterize the tissue; hydrothermal ablation, in which heated fluid is pumped into the uterus and destroys the endometrial lining via high temperatures; balloon therapy ablation, in which a balloon at the end of a catheter is inserted into the uterus and filled with fluid, which is then heated to the point that the endometrial tissues are eroded away; radiofrequency ablation in which a triangular mesh electrode is expanded to fill the uterine cavity, at which point the electrode delivers an electrical current and destroys the endometrial lining; cryoablation (freezing), in which a probe uses extremely low temperatures to freeze and destroy the endometrial tissues; and microwave ablation, in which microwave energy is delivered through a slender probe inserted into the uterus and destroys the endometrial lining. EVIDENCE ACQUISITION: The purpose of this systematic review was to evaluate the feasibility, safety, and efficacy of endometrial ablation performed with first- and second-generation techniques. A literature search in PubMed from January 2000 to September 2015 was performed using the keywords endometrial ablation, menorrhagia, and heavy menstrual bleeding. Results were restricted to systematic reviews, randomized control trials (RCT)/controlled clinical trials, and observational studies written in English from January 2000 to September 2015. EVIDENCE SYNTHESIS: There is no evidence that either broad category is more effective than the other in reducing HMB, and there is no evidence that rates of satisfaction differ significantly. CONCLUSIONS: The overall results of the presented studies suggest that endometrial ablation is an effective therapy for menorrhagia in women with bleeding disorders.

Safe endobag morcellation in a single-port laparoscopy subtotal hysterectomy.

Recently, the American Food and Drug Administration (FDA) published an alert about the risks of uterine tissue morcellation during laparoscopic procedures. In particular, the possible risk of spreading an undiagnosed malignant tumor was emphasized. From then on, a fervent debate in the media has led major scientific societies to express their position on the matter. We present a safe endobag abdominal morcellation in a single port-access laparoscopy subtotal hysterectomy. The endobag abdominal morcellation is feasible and safe; consequently, the development of devices dedicated to intracavitary morcellation in a closed system has been encouraged.

Focusing on surgery results in infertile patients with deep endometriosis.

Infertility is a common problem in patients with endometriosis and the involved mechanisms are still not completely known. The management of infertility in endometriosis patients includes surgery as well as assisted reproductive technology. Laparoscopic surgery has shown better results in infertility patients with endometriosis in comparison to laparotomy procedures. Laparoscopic surgery has proposed benefits in both minimal to moderate diseases. However, while there may be some benefits with severe diseases, there is still not enough evidence to recommend laparoscopic surgery as the recommended surgery when the main goal is to obtain fertility. We performed a MEDLINE search for articles on fertility in women with deep infiltrating endometriosis (DIE) published between 1990 and April 2015 using the following keywords: "endometriosis", "deep infiltrative endometriosis", "infertility", "fertility after surgery", "laparoscopy surgery", "laparotomy", "pregnancy", "fertility outcome", "bladder endometriosis", and "ureteral endometriosis". The aim of this review was to analyze the results of available clinical studies (randomized controlled or not controlled studies; retrospective cohort studies; or case-control and prospective studies) and guidelines on surgical treatment of infertile endometriosis patients, and pregnancy outcomes after surgery.

Surgical technique of endometrioma excision impacts on the ovarian reserve. Single-port access laparoscopy versus multiport access laparoscopy: a case control study.

Several recent studies report the detrimental effect of endometrioma excision on the ovarian reserve. Surgical technique and the excessive use of bipolar coagulation could be the key factors. Single-port access laparoscopy (SPAL) ovarian cystectomy has been reported as a comparable procedure to conventional laparoscopy in terms of operative outcomes. The aim of this study was to evaluate whether the single-port surgery affects the ovarian reserve whilst performing laparoscopic ovarian cystectomy for unilateral endometrioma. This was a prospective, case-control study of 99 women with unilateral endometrioma. Forty-nine women underwent single-port cystectomy and 50 women underwent multiport laparoscopic (MPL) conventional cystectomy. The primary outcome was the assessment of the ovarian reserve. We evaluated the serum anti-Mullerian hormone (AMH) levels before, 4-6 weeks and 3 months after surgery. At T2 we performed an ultrasound assessment of the antral follicular count (AFC). We have drawn attention to a statistically significant decrease of the mean AMH value and AFC in the SPAL group at the 4-6-week and 3-month follow-up compared to the conventional laparoscopy group. In conclusion, our results suggest that SPAL cystectomy should not be recommended to patients undergoing surgery for endometrioma excision who want to preserve their fertility.

Single-port versus conventional multiport access prophylactic laparoscopic bilateral salpingo-oophorectomy in high-risk patients for ovarian cancer: a comparison of surgical outcomes.

Bilateral salpingo-oophorectomy (BSO) in carriers of BRCA1 and BRCA2 mutations is widely recommended as part of a risk-reduction strategy for ovarian or breast cancer due to an underlying genetic predisposition. BSO is also performed as a therapeutic intervention for patients with hormone-positive premenopausal breast cancer. BSO may be performed via a minimally invasive approach with the use of three to four 5 mm and/or 12 mm ports inserted through a skin incision. To further reduce the morbidity associated with the placement of multiple port sites and to improve cosmetic outcomes, single-port laparoscopy has been developed with a single access point from the umbilicus. The purpose of this study was to evaluate the surgical outcomes associated with reducing the risks of salpingo-oophorectomy performed in a single port, while comparing multiport laparoscopy in women with a high risk for ovarian cancer. Single-port laparoscopy-BSO is feasible and safe, with favorable surgical and cosmetic outcomes when compared to conventional laparoscopy.

Single-port Access Subtotal Laparoscopic Hysterectomy: A Prospective Case-Control Study.

STUDY OBJECTIVE: The objective was to evaluate the perioperative outcomes, safety, and patient acceptance of single-port access laparoscopic subtotal hysterectomy (SPAL-SH) in comparison with conventional multiport access laparoscopic subtotal hysterectomy (MPAL-SH). DESIGN: Case-control study. Canadian Task Force Classification II-2. SETTING: The study was conducted at university hospitals in Cagliari, Italy, and Rouen, France. PATIENTS: Sixty-one women with metrorrhagia, abnormal uterine bleeding with uterine myomas, or symptomatic adenomyosis were included in the study. INTERVENTIONS: Thirty-one patients underwent SPAL-SH, and 30 patients underwent conventional MPAL-SH. MEASUREMENTS AND MAIN RESULTS: We analyzed the data to compare the outcomes of SPAL-SH versus MPAL-SH. Patients in the SPAL-SH group had longer operative times than those in the MPAL-SH group (p < .001) but shorter hospital stays (p < .001). Postoperative pain immediately after surgery, after 6 hours, and after 24 hours were lower in the SPAL-SH group (p < .001). The SPAL-SH group reported significantly higher cosmetic satisfaction at 1, 4, and 24 weeks after surgery (p < .01). CONCLUSION: We conclude that SPAL-SH is a feasible and safe alternative to standard MPAL-SH in selected patients. Ongoing refinement of the surgical technique and instrumentation is likely to expand its role in gynecologic surgery in the future. In addition, SPAL-SH has a definite benefit in relation to body image and cosmesis.

Dienogest. A possible conservative approach in bladder endometriosis. Results of a pilot study.

Deep endometriosis involvement of the bladder is uncommon but it is symptomatic in most of the cases. Although laparoscopic excision is very effective, some patients with no pregnancy desire require a medical approach. We performed a pilot study on the effect of a new progestin dienogest on bladder endometriosis. Six patients were treated for 12 months with dienogest 2 mg/daily. Pain, urinary symptoms, quality of life, nodule volume and side effects were recorded. During treatment, symptoms improved very quickly and the nodules exhibit a remarkable reduction in size. Dienogest may be an alternative approach to bladder endometriosis.

New trends of progestins treatment of endometriosis.

The management of endometriosis with OC or progestins is generally safe, effective and well-tolerated and should constitute the first line of medical treatment in symptomatic patients who do not want to have children. Progestins, synthetic progestational agents, have been used in the management of symptomatic endometriosis both as primary therapy and as an adjunct to surgical time. A variety of oral agents have been employed in this regard and investigators have demonstrated differing degrees of benefit. The lack of a standardized instrument to evaluate painful symptoms makes comparative analysis more difficult. Concern about efficacy and side effect has pushed the research on the development of new well-tolerated drugs and to develop new administration routes to minimize general side effects. Aim of the present review is to present the results of clinical studies on new trends of progestins in the treatment of endometriosis.

Three-step model course to teach intracorporeal laparoscopic suturing.

BACKGROUND: Laparoscopy requires a set of skills such as intracorporeal stitching and knotting. The aim of this study is to present an effective specialized training course for the laparoscopic suturing technique. MATERIALS AND METHODS: We designed a specialized 5-day training course for laparoscopic suturing skills with theoretical and practical sessions on inanimate pelvic training. The "gladiator rule" was the method used to teach intracorporeal suturing using the right and left hand from a lateral and suprapubic access. Data on sense of depth, coordination, dexterity, traction power, and posture at the beginning and at the end of the course were compiled. Three practical evaluations were performed by each course participant. Follow-up on subsequent live laparoscopic application of intracorporeal suturing was obtained. RESULTS: We enrolled 44 consecutive trainees: 33 men and 11 women. We found a significant statistical improvement during the course in coordination (P=.001), dexterity (P=.000), traction power (P=.002), and posture (P=.003). Men were better than women in coordination (P=.002), dexterity (P=.000), and traction power (P=.014). No significant statistical difference in suturing skill was found in relation to age, gender, previous courses, surgical training (surgeon or resident), and dominant hand. Twenty-nine of 40 (72.5%) trainees after the course began to apply intracorporeal sutures in vivo. CONCLUSIONS: The present study demonstrates the utility of a 5-day suturing course in teaching laparoscopic suturing technique. The "gladiator rule" is a useful and reproducible theory to teach intracorporeal knotting. The three-step model allows the majority of the trainees to apply laparoscopic suturing in vivo.

Clinical outcomes associated with surgical treatment of endometrioma coupled with resection of the posterior broad ligament.

OBJECTIVE: To evaluate clinical outcomes associated with the resection of both endometrioma and posterior broad ligament (PBL) among women with PBL adhesion associated with endometrioma. METHODS: Between January 2007 and December 2009 at the Villanova Hospital, Florence, Italy, a prospective trial was conducted on 99 consecutive patients with unilateral or bilateral endometrioma who underwent laparoscopic ovarian cystectomy by a stripping technique and homolateral PBL resection where PBL adhesion was associated with endometrioma. The prevalence of PBL adhesion and endometriosis, the association between PBL endometriosis and pain, and the recurrence of endometrioma and pain were evaluated. All data were analyzed with Prism software. RESULTS: Among 124 endometriomas treated by concomitant PBL resection, the PBL was not affected by adhesions in only 2% of patients. PBL endometriosis was superficial in 36 (29.5%) and deep in 86 (70.5%) of the histologic preparations; deep endometriosis correlated with preoperative pain. At 1-year follow-up, endometrioma had recurred in 7 patients; the main symptom reported was mid-cycle pain (24 patients, 24%; P=0.0007). CONCLUSION: Ovarian endometriosis was often (98%) associated with PBL endometriosis; deep endometriosis of PBL correlated with pain symptoms. Although PBL resection increased the incidence of mid-cycle pain, it was associated with low recurrence of endometrioma.