Salpingoscopy is an important part of the infertility work-up.

STUDY OBJECTIVES: To assess the efficacy of salpingoscopy as a routine part of the infertility work-up by comparing laparoscopic findings with salpingoscopic findings, and to match the pregnancies achieved by the patients with findings obtained from the endoscopic evaluation. DESIGN: A retrospective study conducted between January 1990 and June 30, 1994. PATIENTS: One hundred twenty-four women undergoing infertility investigations. Two were suspected of having pelvic inflammatory disease, and one had an extrauterine pregnancy. SETTING: The Jan Palfijn General Hospital, Antwerp, Belgium. INTERVENTIONS: Video hysteroscopy, laparoscopy, and salpingoscopy were performed in every patient. Adhesiolysis was done in 46 and neosalpingostomy in 5. Salpingoscopy was performed on 188 fallopian tubes; 60 tubes (24.15%) could not be cannulated. Drilling of polycystic ovaries was done in eight patients, ovarian cystectomy in five, and myomectomy in one. Endometriosis lesions were treated in 38 women. MEASUREMENTS AND MAIN RESULTS: In 3 of 13 women who were diagnosed as having endometritis at hysteroscopy, salpingoscopy revealed severe lesions of the mucosal folds. Of the normal-looking tubes at laparoscopy, 25.8% had mucosal lesions. Of the abnormal looking tubes at laparoscopy, only 13.5% had normal mucosal folds. More than one-fourth (28.5%) of patients with endometriosis AFS I and II had mucosal lesions. The number of pregnancies achieved by these women correlated well with salpingoscopy except in those with class III lesions. CONCLUSION: This study confirms that tubes that look normal externally can have lesions of the endosalpinx. A maximum possibility of spontaneous pregnancy exists when the mucosal folds are normal. Class III lesions are compatible with fertility, although the probability is reduced. With severe mucosal lesions the chances of spontaneous pregnancy are very remote.

Sexuality after laparoscopic-assisted vaginal hysterectomy.

STUDY OBJECTIVE: The aim of the study is to assess the degree of satisfaction of patients with their operation comparing laparoscopic-assisted vaginal hysterectomies (LAVH) with the data available in the literature. DESIGN: A questionnaire was sent to the patients approximately eight months after their operation (a minimum of six and a maximum of 24 months). The questionnaire was conceived to assess conflicting statements and to obtain objective data. SETTING: All the operations were performed at the Jan Palfijin General Hospital, Antwerp, Belgium. INTERVENTIONS: Between January 1991 and December 1993, 116 LAVHs were performed. MEASUREMENTS AND MAIN RESULTS: Fifty-three questionnaires were returned. From the patients returning their questionnaires, 98% prefer LAVH over abdominal hysterectomy because of the cosmetic results. CONCLUSIONS: The psychological and sexual reactions are determined solely by the patients' individual enlightenment.

Management of adnexal masses by operative laparoscopy.

STUDY OBJECTIVE: To assess the efficacy of operative laparoscopy to confirm the diagnosis of benign adnexal masses, and treat the lesions. DESIGN: Consecutive patients evaluated for this indication between January 1989 and December 1993, who met the inclusion criteria. SETTING: The Jan Palfijn General Hospital, Antwerp, Belgium, and the Department of Obstetrics and Gynecology, University of Varese, Varese, Italy. PATIENTS: One hundred twenty-one women with a clinical, biochemical, and ultrasound diagnosis of benign adnexal mass. INTERVENTIONS: Operative videolaparoscopy was carried out in all patients using the carbon dioxide or argon laser, electrical, or mechanical means. MEASUREMENTS AND MAIN RESULTS: Depending on the patient's age and the appearance of the adnexal mass aspirate, biopsy, cystectomy, or adnexectomy was performed. The conversion rate to laparotomy was 2.4%. A pathologic diagnosis was made in all cases. In this series no malignancy was encountered. CONCLUSION: Operative laparoscopy is safe and effective for treating adnexal masses provided that the preoperative diagnosis indicates that the lesions are benign.

Comparison Between Abdominal and Laparoscopic Lymphadenectomy

In cervical cancer the pathologic stage is determined for two reasons: choice of treatment (surgical-radiotherapy-medical) and prognostic evaluation. In early cervical carcinoma the evaluation of pelvic lymph nodes is important. The clinical noninvasive approach using ultrasound, CT, MRI, and lymphography is of limited use because of low accuracy. Therefore, the clinical evaluation has to be performed surgically. This is required in FIGO I and FIGO IIa carcinoma with circumference < 4 cm. If the pelvic nodes are negative a radical hysterectomy is indicated; but if the nodes are positive, this procedure could be avoided and the treatment of choice is pelvic radiotherapy. In some cases radical hysterectomy is performed when the pathology of the lymph nodes is not yet known and subsequent pelvic radiotherapy is performed when the nodes are positive. This sequence of events is a major cause of complications (fistula of the intestinal or the urinary tract, ileus and lymphocysts). Laparoscopic lymphadenectomy may be the method of choice to stage these tumors with minimal discomfort for the patients. This study demonstrates that laparoscopic lymphadenectomy is comparable to open lymphadenectomy in the clinical staging of cervical cancer.

Bag Surgery as Part of a Protocol to Treat Ovarian Masses by Laparoscopy

In a protocol to treat all ovarian masses endoscopically the major objection is that there are reports that even if the preoperative examinations are favorable there is still a chance as high as 2 to 6% of encountering a malignant proliferation within the cyst, necessitating a conversion to laparotomy within the same operating session. Using the following selection criteria: Premenopausal patients less than 45 years; uni-locular cysts on ultrasound or slightly septated; size of the cyst between 4 and 10 cm; benign characteristics on ultrasound; normal biochemistry, including CA 125, ESR, liver enzymes; and cysts resistant to therapy at least for 6 weeks, we have used the bags whenever the macroscopic aspect of the cyst appeared suspicious for malignancy to the surgeon. The tumor was first fully inserted in the Endo pouch (Autosuture-US Surgical) and then transected from its pedicle. We used bipolar coagulation and scissors. The bag was then brought to the abdominal wall and a minilaparotomy of 5 cm on average was performed. The bag was brought into the opening, the sac opened with scissors, the plastic spread on the skin and only then the tumor was treated inside the bag. Using this technique we did not experience any spread in the abdomen as the laparoscope remained in place and the bag prevented the pneumoperitoneum from deflating.

The Role of Hysteroscopy in Missed Abortions

Reviewing the possible causes of missed abortions, it becomes obvious that culturing the tissues is the major difficulty and often a setback for the diagnosis. The reason is the difficulty for the geneticist to obtain a representative sample of fetal tissue. In a multicenter trial in Antwerp, Belgium, we designed a technique to use a hysteroscope equipped with a throughflow system and the possibility to pass instruments through a side channel, to view the fetuses from six weeks onwards. First, the sac is opened and inspected for the presence of a yolk sac. In a second step the fetus is visualized and inspected for gross anatomic malformations. If such malformations exist, biopsies are taken to confirm the visual impressions with the genetic results to make a map to diagnose genetic malformations through direct visualization. If no gross malformations are visible, biopsies are taken at specific sites to facilitate the work in the lab. The first results, including the diagnosis of a 45 X aberration, are discussed.