Endometriosis: a rare and interesting cause of recurrent haemorrhagic ascites.

Recurrent haemorrhagic ascites as a cause of endometriosis is rare. We report the case of a 36-year-old woman presenting acutely with abdominal distension, ascites and an elevated CA-125 raising the suspicion of ovarian malignancy. Tissue biopsies retrieved during laparoscopy confirmed the diagnosis of endometriosis associated with haemorrhagic ascites. Gonadotropin-releasing hormone (GnRH) analogues were started to manage symptoms, with good effect. Subsequently, in vitro fertilisation resulted in a successful singleton pregnancy and by the second trimester, there was full resolution in symptoms. During the early puerperal period, the development of massive ascites recurred, requiring symptomatic relief through repeated ascitic drainage and GnRH analogues. Long-term follow-up is planned with the hope of continuing with medical management at least until the patient's family is complete when the surgical option of bilateral salpingo-oophorectomy with or without hysterectomy will be discussed.

Laparoscopic surgery for endometriosis.

BACKGROUND: Endometriosis is the presence of endometrial glands or stroma in sites other than the uterine cavity and is associated with pain and subfertility. Surgical interventions aim to remove visible areas of endometriosis and restore the anatomy. OBJECTIVES: To assess the effectiveness and safety of laparoscopic surgery in the treatment of painful symptoms and subfertility associated with endometriosis. SEARCH METHODS: This review has drawn on the search strategy developed by the Cochrane Menstrual Disorders and Subfertility Group including searching CENTRAL, MEDLINE, EMBASE, PsycINFO, and trial registries from inception to July 2013. SELECTION CRITERIA: Randomised controlled trials (RCTs) were selected in which the effectiveness and safety of laparoscopic surgery used to treat pain or subfertility associated with endometriosis was compared with any other laparoscopic or robotic intervention, holistic or medical treatment or diagnostic laparoscopy only. DATA COLLECTION AND ANALYSIS: Selection of studies, assessment of trial quality and extraction of relevant data were performed independently by two review authors with disagreements resolved by a third review author. The quality of evidence was evaluated using GRADE methods. MAIN RESULTS: Ten RCTs were included in the review. The studies randomised 973 participants experiencing pain or subfertility associated with endometriosis. Five RCTs compared laparoscopic ablation or excision versus diagnostic laparoscopy only. Two RCTs compared laparoscopic excision versus diagnostic laparoscopy only. Two RCTs compared laparoscopic excision versus ablation. One RCT compared laparoscopic ablation versus diagnostic laparoscopy and injectable gonadotropin-releasing hormone analogue (GnRHa) (goserelin) with add-back therapy. Common limitations in the primary studies included lack of clearly-described blinding, failure to fully describe methods of randomisation and allocation concealment, and risk of attrition bias.Laparoscopic surgery was associated with decreased overall pain (measured as 'pain better or improved') compared with diagnostic laparoscopy, both at six months (odds ratio (OR) 6.58, 95% CI 3.31 to 13.10, 3 RCTs, 171 participants, I(2) = 0%, moderate quality evidence) and at 12 months (OR 10.00, 95% CI 3.21 to 31.17, 1 RCT, 69 participants, low quality evidence). Compared with diagnostic laparoscopy, laparoscopic surgery was also associated with an increased live birth or ongoing pregnancy rate (OR 1.94, 95% CI 1.20 to 3.16, P = 0.007, 2 RCTs, 382 participants, I(2) = 0%, moderate quality evidence) and increased clinical pregnancy rate (OR 1.89, 95% CI 1.25 to 2.86, P = 0.003, 3 RCTs, 528 participants, I(2) = 0%, moderate quality evidence). Two studies collected data on adverse events (including infection, vascular and visceral injury and conversion to laparotomy) and reported no events in either arm. Other studies did not report this outcome. The similar effect of laparoscopic surgery and diagnostic laparotomy on the rate of miscarriage per pregnancy was imprecise (OR 0.94, 95% CI 0.35 to 2.54, 2 studies, 112 women, moderate quality evidence).When laparoscopic ablation was compared with diagnostic laparoscopy plus medical therapy (GnRHa plus add-back therapy), more women in the ablation group reported that they were pain free at 12 months (OR 5.63, 95% CI 1.18 to 26.85, 1 RCT, 35 participants, low quality evidence).The difference between laparoscopic ablation and laparoscopic excision in the proportion of women reporting overall pain relief at 12 months on a VAS 0 to 10 pain scale was 0 (95% CI -1.22 to 1.22, P = 1.00, 1 RCT, 103 participants, low quality evidence). AUTHORS' CONCLUSIONS: There is moderate quality evidence that laparoscopic surgery to treat mild and moderate endometriosis reduces overall pain and increases live birth or ongoing pregnancy rates. There is low quality evidence that laparoscopic excision and ablation were similarly effective in relieving pain, although there was only one relevant study. More research is needed considering severe endometriosis, different types of pain associated with endometriosis (for example dysmenorrhoea (pain with menstruation)) and comparing laparoscopic interventions with holistic and medical interventions. There was insufficient evidence on adverse events to allow any conclusions to be drawn regarding safety.

Combined cystoscopic and laparoscopic approach in deep endometriosis of the bladder.

STUDY OBJECTIVE: To report the combined cystoscopic and laparoscopic approach in deep endometriosis with full-thickness infiltration of the bladder. DESIGN: Video (Canadian Task Force classification III). SETTING: University hospital. PATIENT: A 34-year-old nulliparous woman with a large (35-mm) endometriosis nodule infiltrating the bladder and deep endometriosis of the rectum and sigmoid colon. INTERVENTION: The urologic surgeon performed cystoscopy, identified the limits of mucosal involvement, and incised the muscular layer up to fat tissues surrounding the bladder. The gynecologic surgeon identified and followed the circular incision, and completed full-thickness resection of the bladder wall. Surgical technique reports in anonymous patients are exempt from ethical approval by the institutional review board. MEASUREMENTS AND MAIN RESULTS: The patient's functional outcome was uneventful. Laparoscopic resection of large endometriotic nodules of the bladder per se may lead to inadvertent removal of healthy bladder muscle. Thus it increases the risk of postoperative complications and symptoms due to small bladder volume. Conversely, if resection of the nodule is performed only cystoscopically, it probably would not be completely removed. We routinely combine the 2 approaches because this enables complete resection of the endometriotic nodule. It not only averts the risk of excessive removal of healthy bladder muscle but also leaves no disease behind. CONCLUSIONS: On the basis of our experience, we propose the combined cystoscopic and laparoscopic approach in managing large endometriotic nodules with full-thickness infiltration of the bladder.

Deep rectal shaving followed by transanal disc excision in large deep endometriosis of the lower rectum.

STUDY OBJECTIVE: To report an original technique of deep rectal shaving using PlasmaJet (Plasma Surgical, Inc., Roswell, GA) followed by transanal disc excision using the Contour Transtar stapler (Ethicon EndoSurgery Inc., Cincinnati, OH) suitable in large deep endometriosis of the lower rectum. DESIGN: Canadian Task Force III. SETTING: Rouen University Hospital. The procedure was performed in a 30-year-old nullipara referred with a large endometriotic nodule infiltrating the right uterosacral ligament and the anterolateral wall of the lower rectum. Rectal infiltration measured 30 mm in diameter and was responsible for stenosis. The first step of the procedure is represented by laparoscopic deep rectal shaving performed using plasma energy exclusively, combining the detachment of the nodule from the rectum with in situ ablation of residual endometriotic foci of the shaved area. Then, transanal excision is performed by the colorectal surgeon from the rectal approach. Three of 4 traction parachute sutures are placed in the middle and outside the shaved area. Their traction induces the prolapse of the shaved rectal wall that is resected using the Contour Transtar stapler, which is a device originally destined to remove rectal prolapse. The final staple line is inspected for bleeding and secured with an interrupted resorbable suture as required. Surgical technique reports in anonymous patients are exempt from ethical approval by an institutional review board. INTERVENTION: Deep rectal shaving using PlasmaJet followed by transanal disc excision using Contour Transtar stapler. MEASUREMENTS AND MAIN RESULTS: Immediate postoperative outcomes were uneventful, and bowel movements were normal beginning with day 5. To date, this procedure was successfully performed in 17 women with large deep endometriosis of the mid and lower rectum with only favorable rectal functional outcomes. CONCLUSIONS: Based on our experience, we believe that our conservative technique is feasible in large low rectal endometriosis and avoids the risk of unfavorable outcomes related to low colorectal resection.

Wernicke's encephalopathy: a preventable cause of maternal death.

Wernicke's encephalopathy is a rare cause of maternal death. It is a difficult diagnosis to make but prevention and treatment is straightforward. Severe thiamine deficiency causes Wernicke-Korsakoff syndrome. Correct diagnosis and treatment with thiamine will decrease the case fatality rate.

A life threatening uterine inversion and massive post partum hemorrhage caused by placenta accrete during Caesarean section in a primigravida: a case report.

BACKGROUND: A 32-year-old Caucasian primigravida was admitted for elective Caesarean Section at 36 weeks and 6 days with the diagnosis of preeclampsia. CASE PRESENTATION: Traction of the umbilical cord after delivery of a healthy baby resulted in uterine inversion. The placenta was found to be densely adherent to the posterior uterine wall. Piecemeal excision of the placenta as close as possible to the uterine lining was then performed. CONCLUSION: In this way we were able to control a massive post partum hemorrhage and preserve the fertility of the patient.

Serum anti-Müllerian hormone and inhibin B in disorders of spermatogenesis.

This study investigates circulating concentrations of AMH and inhibin B in men with azoospermia. Serum AMH and inhibin B are significantly lower in the men with nonobstructive azoospermia compared to the controls and the men with obstructive azoospermia, suggesting that these hormones could be markers of nonobstructive azoospermia.