Prevalence of occult microscopic endometriosis in clinically negative peritoneum during laparoscopy for chronic pelvic pain.

OBJECTIVE:  To determine the prevalence of occult microscopic endometriosis in patients with chronic pelvic pain and negative laparoscopy. METHODS: A retrospective cross-sectional study included women who underwent laparoscopic evaluation for chronic pelvic pain by three fellowship-trained gynecologic surgeons at a community hospital from January 2011 to December 2016. The aim was to evaluate the prevalence of microscopic endometriosis in this population. RESULTS:  In 142 patients with clinically negative peritoneum on laparoscopy, 39% had occult microscopic endometriosis. Cramping pain score during menses was found to be lower in the positive biopsy group (6.9 vs 8.0, P=0.046). No differences were appreciated in age of menarche, pain during various parts of the menstrual cycle, or duration of symptoms. The biopsy-positive group had a younger age at time of evaluation, although not statistically significant (P=0.179). Current use of hormones affected neither biopsy results nor menstrual or pain characteristics. Detection was similar between robotic and laparoscopic cases and operative morbidity was minimal. CONCLUSION: Occult microscopic endometriosis may be present in approximately 39% of patients with clinically negative appearing peritoneum undergoing laparoscopy for chronic pelvic pain. Given this, biopsies should be performed in patients undergoing laparoscopy who do not have visible lesions.

Evaluating the discordant relationship between Tarlov cysts and symptoms of pudendal neuralgia.

BACKGROUND: Pudendal neuralgia is a painful neuropathic condition involving the pudendal nerve dermatome. Tarlov cysts have been reported in the literature as another potential cause of chronic lumbosacral and pelvic pain. Notably, they are often located in the distribution of the pudendal nerve origin at the S2, S3, and S4 sacral nerve roots and it has been postulated that they may cause similar symptoms to pudendal neuralgia. Literature has been inconsistent on the clinical relevance of the cysts and if they are responsible for symptoms. OBJECTIVE: To evaluate the prevalence of S2-S4 Tarlov cysts at the pudendal nerve origin (S2-S4 sacral nerve roots) in patients specifically diagnosed with pudendal neuralgia, and establish association of patient symptoms with location of Tarlov cyst. STUDY DESIGN: A retrospective study was performed on 242 patients with pudendal neuralgia referred for pelvic magnetic resonance imaging from January 2010 to November 2012. Dedicated magnetic resonance imaging review evaluated for presence, level, site, and size of Tarlov cysts. Among those with demonstrable cysts, subsequent imaging data were collected and correlated with the patients' clinical site of symptoms. Statistical analysis was performed using χ2, Pearson χ2, and Fisher exact tests to assess significance. RESULTS: Thirty-nine (16.1%) patients demonstrated at least 1 sacral Tarlov cyst; and of the 38 patients with complete pain records, 31 (81.6%) had a mismatch in findings. A total of 50 Tarlov cysts were identified in the entire patient cohort. The majority of the Tarlov cysts were found at the S2-S3 level (32/50; 64%). Seventeen patients (44.7%) revealed unilateral discordant findings: unilateral symptoms on the opposite side as the Tarlov cyst. In addition, 14 (36.8%) patients were detected with bilateral discordant findings: 11 (28.9%) had bilateral symptoms with a unilateral Tarlov cyst, and 3 (7.9%) had unilateral symptoms with bilateral cysts. Concordant findings were only demonstrated in 7 patients (18.4%). No significant association was found between cyst size and pain laterality (P = .161), cyst volume and pain location (P = .546), or cyst size and unilateral vs bilateral pain (P = .997). CONCLUSION: The increased prevalence of Tarlov cysts is likely not the etiology of pudendal neuralgia, yet both could be due to similar pathogenesis from part of a focal or generalized condition.

Proteomic analysis of eutopic and ectopic endometriotic tissues based on isobaric peptide tags for relative and absolute quantification (iTRAQ) method.

OBJECTIVE: The present study aimed at performing proteomic analysis of matched eutopic endometrium and ovarian endometrioid cysts from women with endometriosis in order to discover any abnormal protein expression related to the disease. DESIGN AND SETTING: The study included 8 women with stage III/IV endometriosis according to revised American Fertility Society (rAFS) classification and one woman with no signs of the disease as a reference. Proteomic analysis was performed using a novel isobaric tag-based methodology for relative and absolute peptide quantification (iTRAQ) coupled with multidimensional liquid chromatography and tandem mass spectrometry. RESULTS: The selection of 419 proteins was found in all endometriosis specimens. Using normal eutopic endometrium from woman without endometriosis as a reference, some proteins expressions were significantly increased in all endometriosis samples. They included collagen α1(XIV), calmodulin, collagen α(VI), plexin, integrin αVß3, transgelin, desmin, and vimentin. The comparison of these proteins' expression in paired eutopic and ovarian endometriosis samples has revealed that only vimentin was significantly increased in ovarian endometrioma. CONCLUSIONS: It was confirmed that endometriosis is associated with different expression of proteins in endometriotic samples. Nevertheless, further studies seem to be necessary as they may reveal possible markers that would be useful in clinical diagnosis of the disease.

Repeat operation for treatment of persistent pudendal nerve entrapment after pudendal neurolysis.

STUDY OBJECTIVES: To describe a new approach to transgluteal pudendal neurolysis and transposition and to review the outcome in 10 patients who underwent repeat operation because of persistent pudendal neuralgia after failing to improve after initial surgical decompression. DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: Academic chronic pelvic pain practice at St. Joseph's Hospital and Medical Center in Phoenix, Arizona. PATIENTS: Women and men with persistent pudendal neuralgia after undergoing transgluteal pudendal neurolysis and transposition. INTERVENTION: Transgluteal decompression of the pudendal nerve was performed in all 10 patients. In brief, a transgluteal incision was made, and the pudendal nerve was identified via a nerve integrity monitoring system. Adhesiolysis was performed from the piriformis muscle to the distal Alcock canal using a Zeiss NC-4 surgical microscope. The nerve was then enclosed in NeuraWrap Nerve Protector and coated with activated platelet-rich plasma. An ON-Q PainBuster catheter was place along the nerve into the Alcock canal, and 0.5% bupivacaine was infused at 2 mL/hr. The sacrotuberous ligament was repaired using an Achilles or gracillis cadaver ligament. The overlying subcutaneous tissue and skin were then closed. MEASUREMENTS AND MAIN RESULTS: From June 2008 to March 2010, 10 consecutive patients (7 women and 3 men; age range, 29-81 years) underwent repeat operation with transgluteal decompression of the pudendal nerve. Neuropathic pain was unilateral (n = 8) or bilateral (n = 2), in the clitoris or penis (30%), vulva or scrotum (70%), perineum (40%), and rectum (50%). Of the 10 patients, 1 patient was lost to follow-up. Mean follow-up was 23 months. Eight of 9 patients reported global improvement, with 2 patients reporting complete resolution of symptoms. One patient reported no change. Pain, as measured using an 11-point numerical scale, improved from a mean of 7.2 to 4.0 (p = .02), with 5 patients reporting clinically significant improvement (change, ≥2). Comfortable sitting or maximum time that the patient was able to sit without exacerbation of pain improved in 8 patients, with a change in median time of 5 to 45 minutes (p = .008). Change in the ability to sit correlated well with patient-reported global improvement (correlation coefficient, 0.86). No patient experienced worsening of symptoms. CONCLUSION: Patients with persistent pudendal neuralgia after surgical decompression may benefit from repeat operation via our novel approach. Ability to sit correlates well with reported improvement due to surgery.

Side docking: an alternative docking method for gynecologic robotic surgery.

The authors propose an alternative method of robotic docking for gynecologic surgery. In this side-docking method, the robot is docked at an approximately 45° angle to the lower torso, aligned with the outer border of either the left or right stirrup, depending on the surgeon's preference for left or right side-docking. The remainder of the patient and trocar setup is similar to traditional docking. The authors have had an excellent experience with this method as there does not seem to be an increased risk of robotic arm collision as long as the surgeon respects the basic principle of maintaining at least an 8- to 10-cm distance between each of the instrument ports. The significantly improved access to the vagina and perineum may facilitate robotically assisted gynecologic surgical procedures and reduce assistant fatigue and the potential for injury due to a collision with the robotic arms.

Bupivacaine causes cytotoxicity in mouse C2C12 myoblast cells: involvement of ERK and Akt signaling pathways.

AIM: The adverse effects of local anesthetics (LAs) on wound healing at surgical sites have been suggested, and may be related to their cytotoxicity. This study was aimed to compare the cellular toxicity of bupivacaine and lidocaine (two well-known LAs), and to explore the molecular mechanism(s). METHODS: Toxicity of bupivacaine and lidocaine was assessed in cultured mouse C2C12 myoblasts by cell viability and apoptosis assays. Effects of LAs on extracellular signal-regulated kinase (ERK) and protein kinase B (Akt) activation, which are essential for cell proliferation and survival, were evaluated by immunoblotting. RESULTS: Both LAs, especially bupivacaine, prevented cell growth and caused cell death in a dose-dependent manner. The half maximal inhibitory concentrations (IC(50)) for bupivacaine and lidocaine were 0.49+/-0.04 and 3.37+/-0.53 mmol/L, respectively. When applied at the same dilutions of commercially available preparations, the apoptotic effect induced by bupivacaine was more severe than that of lidocaine in C2C12 cells. Furthermore, bupivacaine significantly diminished the ERK activation, which may underlie its anti-proliferative actions. Both LAs suppressed Akt activation, which correlated with their effects on apoptosis. CONCLUSION: Our study demonstrated that, when used at the same dilutions from clinically relevant concentrations, bupivacaine is more cytotoxic than lidocaine in vitro. Anti-proliferation and cell death with concomitant apoptosis mediated by bupivacaine may offer an explanation for its adverse effects in vivo (eg slowing wound healing at the surgical sites). A less toxic, long-acting anesthetic may be needed.

Pudendal neuralgia.

Pudendal neuralgia is a painful, neuropathic condition involving the dermatome of the pudendal nerve. This condition is not widely known and often unrecognized by many practitioners. The International Pudendal Neuropathy Association (tipna.org) estimates the incidence of this condition to be 1/100,000; however, most practitioners treating patients with this condition feel the actual rate of incidence may be significantly higher. Currently, there is fair paucity of medical literature and scientific evidence in the diagnosis and treatment of pudendal neuralgia. Diagnosis of this condition is based on the utilization of Nantes Criteria, in conjunction with clinical history and physical findings. CT-scan guided nerve blocks are also employed, by this author, to provide additional information. Subsequent treatment of pudendal neuralgia is medical and well as surgical, with Physical Therapy a key component to all aspects of treatment. The goal of this paper is to present evidence based information, as well as personal clinical experience, in treating approximately 200 patients with pudendal neuralgia.

Intraabdominal pressure changes associated with lifting: implications for postoperative activity restrictions.

OBJECTIVE: The purpose of this study was to describe the effect of the lifting maneuver and the quantity of weight lifted on the generation of intraabdominal pressure. STUDY DESIGN: Forty-one women who underwent urodynamic evaluation performed 4 lifting maneuvers, each while lifting 0, 2.5, 5, 10, and 15 kg. The lifting maneuvers were routine activities that included squatting with and without assistance, lifting from a counter, and receiving weight. Pressure was recorded with a rectal microtip catheter. Each lift was performed twice, and the average pressure change was analyzed. RESULTS: When controlled for potential confounding variables, repeated-measures analysis of variance revealed a significant interaction between lift weight and lift maneuver (P < .001). Squatting was associated with generation of higher intraabdominal pressure than lifting from a counter or receiving weights into outstretched arms (P < .001). Lifting > or = 2.5 kg resulted in significant changes in intraabdominal pressure, regardless of lift maneuver (P < .001). CONCLUSION: Both the lifting maneuver and the quantity of weight should be considered when counseling patients regarding postoperative lifting.

Ischiorectal abscess after sacrospinous ligament suspension.

An ischiorectal abscess in a 66-year-old patient was determined to be an uncommon complication of sacrospinous fixation. The abscess was diagnosed 9 months after the patient had a sacrospinous ligament suspension. She was treated successfully with perianal incision, drainage, and intravenous antibiotics.

Effects of raloxifene hydrochloride on endometrial cancer cells in vitro.

OBJECTIVE: Determine effects of raloxifene hydrochloride, a selective estrogen receptor modulator (SERM), on growth and proliferation of an estrogen-responsive endometrial cancer cell line in vitro. MATERIALS AND METHODS: Studies were performed with Ishikawa endometrial adenocarcinoma cells, a well-differentiated cancer that expresses estrogen receptors and progesterone receptors. Raloxifene was purified as the hydrochloride salt. The four arms of the study were cells grown (1) without any further addition (control), (2) with estradiol only, (3) with raloxifene only, or (4) with estradiol and raloxifene. Three concentrations of estradiol (10, 100, 1000 pg/ml) and raloxifene (1, 10, 100 ng/ml) were used. After 1 week of culturing, the number of living cells for each experimental group was determined and expressed as a percentage of the control group. RESULTS: Cells treated with raloxifene 10 or 100 ng/ml alone grew significantly faster than control cells: 10 ng/ml [115.25%; SD, 11.05; 95% confidence interval (CI), 107.35-123.16; P = 0.002] and 100 ng/ml (111.14%; SD, 14.19; 95% CI, 100.98-121.29; P = 0.03). Estradiol 10 or 100 pg/ml did not stimulate cell growth, whereas cells treated with 1000 pg/ml grew significantly faster than control cells (114.69%; SD, 16.84; 95% CI, 102.65-126.74; P = 0.02). Raloxifene and estradiol together in any concentration did not affect cell growth. CONCLUSIONS: Raloxifene did not inhibit the growth of endometrial cancer cells in vitro. High concentrations even promoted cell growth. Estradiol in physiologic concentrations did not stimulate the growth of endometrial cancer cells in vitro.

Three-dimensional reconstruction of magnetic resonance images of the anal sphincter and correlation between sphincter volume and pressure.

OBJECTIVE: The purpose of this study was to assess the correlation between internal and external anal sphincter volumes and manometric anal pressures. STUDY DESIGN: Ten healthy nulliparous women underwent anal sphincter magnetic resonance imaging and anal manometry measurement. A 3-dimensional reconstruction of magnetic resonance images was accomplished with the use of 3-dimensional slicer. Sphincter volumes were measured 3 times by the same observer for each of 10 patients. The intrarater reliability was measured with the use of the intraclass correlation coefficient (ICC = sigma (2)(patients)/(sigma (2)(patients) + sigma (2)(error))) from a 2-way analysis of variance model with terms for patient and measurement trial. Measurements that were recorded on anal manometry included squeeze length, length of the high-pressure zone, and maximal resting and squeeze pressures. RESULTS: The mean volumes (+/- SD) were 18.77 +/- 4.64 cm(3), 13.82 +/- 3.8 cm(3), and 32.36 +/- 8.37 cm(3) for internal, external, and combined sphincters, respectively. Intrarater reliability was 98% for external sphincter volume (95% CI, 94%-99%), 98% for internal sphincter volume (95% CI, 94%-99%), and 99% for total volume (95% CI, 97%-100%). On the 3-dimensional images, the internal sphincter was found to be cylindric in shape, with an ellipse as a base. It is elongated in the anterior and posterior direction and flattened on the sides. The external sphincter was found to be funnel-shaped, being narrower caudad and widening in the cephalad direction. Similar to the internal sphincter, the external sphincter is elongated in the anteroposterior diameter. Volumes of the internal, external, and combined sphincters did not correlate with the maximum pressures at rest and squeeze. Correlations higher than r = 0.5 were observed for all 3 sphincter volume measurements versus high pressure zone at squeeze. The highest correlation, r = 0.66, was for internal sphincter volume versus high pressure zone at squeeze CONCLUSION: Three-dimensional reconstruction of the rectal sphincter musculature can be performed easily with 3-dimensional software. Measurements of the sphincter volumes have excellent intrarater reliability. Sphincter volumes do not correlate with pressures at rest or squeeze, but the internal sphincter volume correlates with the length of the high pressure zone at squeeze. Contrary to current generalized concepts, it is possible that the internal sphincter may play some role in generating the squeeze pressure. More research is necessary in applying 3-dimensional magnetic resonance image reconstruction in patients with different parity and continence status. Reconstruction of magnetic resonance images of the rectal sphincter musculature may prove to be beneficial in planning the treatment of patients with fecal incontinence.