Sexual Function of Patients with Deep Endometriosis after Surgical Treatment: A Systematic Review.

OBJECTIVE: To review the current state of knowledge on the impact of the surgical treatment on the sexual function and dyspareunia of deep endometriosis patients. DATA SOURCE: A systematic review was conducted in accordance with the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We conducted systematic searches in the PubMed, EMBASE, LILACS, and Web of Science databases from inception until December 2022. The eligibility criteria were studies including: preoperative and postoperative comparative analyses; patients with a diagnosis of deep endometriosis; and questionnaires to measure sexual quality of life. STUDY SELECTION: Two reviewers screened and reviewed 1,100 full-text articles to analyze sexual function after the surgical treatment for deep endometriosis. The risk of bias was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane Collaboration's tool for randomized controlled trials. The present study was registered at the International Prospective Register of Systematic Reviews (PROSPERO; registration CRD42021289742). DATA COLLECTION: General variables about the studies, the surgical technique, complementary treatments, and questionnaires were inserted in an Microsoft Excel 2010 (Microsoft Corp., Redmond, WA, United States) spreadsheet. SYNTHESIS OF DATA: We included 20 studies in which the videolaparoscopy technique was used for the excision of deep infiltrating endometriosis. A meta-analysis could not be performed due to the substantial heterogeneity among the studies. Classes III and IV of the revised American Fertility Society classification were predominant and multiple surgical techniques for the treatment of endometriosis were performed. Standardized and validated questionnaires were applied to evaluate sexual function. CONCLUSION: Laparoscopic surgery is a complex procedure that involves multiple organs, and it has been proved to be effective in improving sexual function and dyspareunia in women with deep infiltrating endometriosis.

OBJETIVO: Revisar a literatura publicada sobre o impacto do tratamento cirúrgico na função sexual e na dispareunia de pacientes com endometriose profunda. FONTE DE DADOS: Uma revisão sistemática foi realizada de acordo com as diretrizes Meta-Analysis of Observational Studies in Epidemiology (MOOSE). Realizamos pesquisas sistemáticas nas bases de dados PubMed, EMBASE, LILACS e Web of Science desde o início até dezembro de 2022. Os critérios de elegibilidade foram estudos que incluíam: análises comparativas pré- e pós-operatórias; pacientes com diagnóstico de endometriose profunda; e a aplicação de questionários para avaliar a função sexual. SELEçãO DOS ESTUDOS: Dois revisores selecionaram e revisaram 1.100 artigos para analisar a da função sexual após o tratamento cirúrgico da endometriose profunda. O risco de viés foi calculado usando-se a escala de Newcastle-Ottawa para estudos observacionais e a ferramenta para ensaios clínicos randomizados da Cochrane Collaboration. O estudo foi cadastrado no International Prospective Register of Systematic Reviews (PROSPERO; cadastro CRD42021289742). COLETA DE DADOS: Variáveis gerais sobre os estudos, a técnica cirúrgica, os tratamentos complementares e os questionários foram inseridas em uma planilha do Microsoft Excel 2010 (Microsoft Corp., Redmond, WA, Estados Unidos). SíNTESE DOS DADOS: Foram incluídos 20 estudos em que se usou a técnica de videolaparoscopia para a excisão da endometriose profunda. Uma meta-análise não pôde ser realizada devido à heterogeneidade substancial entre os estudos incluídos. As classes III e IV da escala revisada da American Fertility Society foram predominantes, e múltiplas técnicas cirúrgicas foram usadas para o tratamento da endometriose. Questionários padronizados e validados foram aplicados para avaliar a função sexual. CONCLUSãO: A cirurgia laparoscópica é um procedimento complexo que envolve múltiplos órgãos, e provou ser eficaz na melhora da função sexual e da dispareunia em mulheres com endometriose profunda.

Three-year Follow-up of a Single Incision Sling Procedure Performed Under Local Anesthesia in an Office Setting.

OBJECTIVE: To assess the 3-year success of placing a single-incision midurethral sling (SIMS) using the Dynamic Intraoperative Standing Sling Technique (DISST) in an office setting under local anesthesia. METHODS: This is a prospective case series of 20 women who underwent in-office SIMS procedure by the DISST from July 2019 to February 2020. This is an extension of our pilot study (11) and all 20 patients were evaluated at a mean follow-up of 34.3months. Success was defined as a composite score of objective success (negative standing cough test at bladder fullness), subjective success based on the modified PGI-I score of "very much better" or "much better," and no retreatment for stress urinary incontinence. Secondary objectives were adverse events, de novo overactivity of the bladder, recurrent urinary tract infections, voiding dysfunction, pain/dyspareunia, and influence on sexual function. RESULTS: The composite success rate was 95% (95% CI [75.1, 99.9]) at the 36-month follow-up. The significant improvement in MESA scores was maintained over the study period. There were no cases of de novo urgency, mesh exposure, postop voiding dysfunction or recurrent urinary tract infections. There were no cases of de novo dyspareunia. CONCLUSION: SIMS placed by the DISST technique under local anesthesia in an office setting has shown sustained efficacy over a 3-year period with no decrease in cure. Subjects remained dry and reported excellent improvement in symptoms and quality of life at the 36-month follow-up visit.

Surgical correction of the genital hiatus at the time of sacrocolpopexy - a 7-year Markov analysis: a cost-effectiveness analysis.

INTRODUCTION AND HYPOTHESIS: To perform a cost-effectiveness analysis of concurrent posterior repair performed at the time of laparoscopic hysterectomy with sacrocolpopexy over a 7-year time period. We hypothesize it is not cost-effective to perform a posterior colporrhaphy. METHODS: We used TreeAge Pro® to construct a decision model with Markov modeling to compare sacrocolpopexy with and without concurrent posterior repair (SCP and SCP+PR) over a time horizon of 7 years. Outcomes included probability and costs associated with prolapse recurrence, prolapse retreatment, and complications including rectal injury, rectovaginal hematoma requiring reoperation, and postoperative dyspareunia. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) calculated as ∆ costs /∆ effectiveness and the willingness to pay (WTP) was set at $100,000/QALY. RESULTS: Our model showed that SCP was the dominant strategy, with lower costs (-$ 2681.06) and higher effectiveness (+0.10) compared to SCP+PR over the 7-year period. In two-way sensitivity analyses, we varied the probability of prolapse recurrence after both strategies. Our conclusions would only change if the probability of recurrence after SCP was at least 29.7% higher than after SCP+PR. When varying the probabilities of dyspareunia for both strategies, SCP+PR only became the dominant strategy if the probability of dyspareunia for SCP+PR was lower than the rate of SCP alone. CONCLUSIONS: In this 7-year Markov cost-effectiveness analysis, SCP without concurrent PR was the dominant strategy. SCP+PR costs more with lower effectiveness than SCP alone, due to higher surgical cost of SCP+PR and higher probability of dyspareunia after SCP+PR.

Long-term mesh exposure after minimally invasive total hysterectomy and sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate total and incident mesh exposure rates at least 2 years after minimally invasive total hysterectomy and sacrocolpopexy. Secondary aims were to evaluate surgical success and late adverse events. METHODS: This extension study included women previously enrolled in the multicenter randomized trial of permanent vs delayed-absorbable suture with lightweight mesh for > stage II uterovaginal prolapse. Owing to COVID-19, women were given the option of an in-person (questionnaires and examination) or telephone visit (questionnaires only). The primary outcome was total and incident suture or mesh exposure, or symptoms suggestive of mesh exposure in women without an examination. Secondary outcomes were surgical success, which was defined as no subjective bulge, no prolapse beyond the hymen, and no pelvic organ prolapse retreatment, and adverse events. RESULTS: A total of 182 out of 200 previously randomized participants were eligible for inclusion, of whom 106 (58%) women (78 in-person and 28 via questionnaire only) agreed to the extension study. At a mean of 3.9 years post-surgery, the rate of mesh or suture exposure was 7.7% (14 out of 182) of whom only 2 were incident cases reported after 1-year follow-up. None reported vaginal bleeding or discharge, dyspareunia, or penile dyspareunia. Surgical success was 93 out of 106 (87.7%): 13 out of 94 (13.8%) failed by bulge symptoms, 2 out of 78 (2.6%) by prolapse beyond the hymen, 1 out of 85 (1.2%) by retreatment with pessary, and 0 by retreatment with surgery. There were no serious adverse events. CONCLUSIONS: The rate of incident mesh exposure between 1 and 3.9 years post-surgery was low, success rates remained high, and there were no delayed serious adverse events.

Pelvic pain after laparoscopic lateral suspension for pelvic organ prolapse: an unrecognized problem?

INTRODUCTION AND HYPOTHESIS: The laparoscopic lateral suspension (LLS) represents an alternative mesh procedure to avoid the dissection at the promontory. However, mesh-related complications such as chronic pelvic pain, dyspareunia, and bladder pain are emerging. The present study is aimed to present a video case report and describe a small case series of patients referred to our center for chronic pelvic pain after LLS. METHODS: A surgical video of the management of a 50-year-old woman with chronic abdominal and pelvic pain, dyspareunia, and recurrent urinary tract infection (UTIs) after uterus sparing LLS is provided. Moreover, we performed a retrospective chart review of similar cases in our institution. RESULTS: The featured procedure was completed without complications and was successful in obtaining symptom relief. Between 2018 and 2022 five patients underwent total or subtotal mesh removal for pain-related symptoms after LLS. At the median follow-up of 24 months, all patients were free from pain, but two (40%) required reoperation for prolapse recurrence CONCLUSIONS: Our experience suggests that LLS involves a certain risk of chronic pelvic pain, which may be challenging to manage and require surgical treatment.

Surgery vs. hormone-based treatment for pain control in deep infiltrating endometriosis: a retrospective cohort study.

OBJECTIVE: To evaluate the outcome of surgical or hormone-based pharmacological treatment for deep infiltrating endometriosis (DIE) in patients with pain symptoms. STUDY DESIGN: A retrospective cohort study of 122 women with DIE of the bowel was conducted: 61 women underwent surgical treatment due to poor pain control and 61 received hormone-based treatment alone for at least six months. Chronic pelvic pain, dysmenorrhea, deep dyspareunia, dyschezia and dysuria were evaluated by a visual analog scale (VAS) to measure pain on a scale from 0 to 10. Dyspareunia was further evaluated using the Deep Dyspareunia Scale (scores of 0-3). RESULTS: Surgery (n = 61 women) was performed at a mean of 3.3 ± 1.6 years previously, while hormone-based treatment alone (n = 61 women) was used for a mean of 3.0 ± 1.41 years. After surgery, women without a desire to procreate received hormone-based treatment. Before treatment, the most intense endometriosis-related pain in the surgical treatment group and hormone-based treatment group alone were chronic pelvic pain (VAS = 9.48 ± 1.49; 8.57 ± 2.22), dysmenorrhea (VAS = 9.61 ± 1.45; 9.02 ± 1.35) and deep dyspareunia (VAS = 8.04 ± 2.82; 7.47 ± 3.21, respectively), all with mean pain scores of around 8 (0-10) in both groups. Both treatments were effective at reducing all symptoms (p < .001). The surgical treatment proved to be more effective and more enduring at improving chronic pelvic pain (p < .001), dyschezia (p = .003) and deep dyspareunia (p < .001). Regarding deep dyspareunia, using the deep dyspareunia scale, ∼70% of surgically treated women scored 0 or 1 (absent or mild deep dyspareunia) after treatment, compared to scores 2 or 3 (intense dyspareunia) in about 70% of the group using hormone-based treatment (p < .001). CONCLUSION: Both types of treatment, surgical and pharmacological, effectively improved pain symptoms associated with DIE. However, improvement in chronic pelvic pain, dyschezia and deep dyspareunia was greater and longer-lasting after surgery.

Urinary and sexual impact of pelvic reconstructive surgery for genital prolapse by surgical route. A randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: The main objective of the study was to evaluate the rates of de novo stress urinary (SUI) and postoperative dyspareunia after both sacrocolpopexy/hysteropexy (SCP) and vaginal mesh surgery. METHODS: A prospective, multicenter, randomized, open-label study with two parallel groups treated by either SCP or Uphold Lite vaginal mesh was carried out. Study participants were ≥ 50 and < 80 years old patients with Pelvic Organ Prolapse Quantification (POP-Q) stage ≥2 who were considered eligible for reconstructive surgery and who were sexually active with no dyspareunia and free from bothersome SUI at presentation. Women were assessed before surgery and at 4-8 weeks and 11-13 months after using validated measures including POP-Q, Pelvic Floor Disability Index (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR), and Patient Global Impression of Improvement (PGI-I). Data were also collected for health economics evaluation. RESULTS: Of the required sample of 156 women, 42 women (19 SCP and 23 vaginal mesh) were only recruited owing to the discontinuation of vaginal mesh worldwide. The median follow-up was 376 days. The rates of bothersome de novo SUI were similar in the SCP and Uphold vaginal mesh groups (15.79 vs 15.00%, OR 0.95 [95% CI 0.22-4.14]). Among 30 sexually active patients at follow-up, the rates of women reporting de novo dyspareunia "usually or always" were 6.7% after SCP vs 13.3% after vaginal mesh (p = 1). Health economics evaluation showed a cost saving of 280€ in favor of the Uphold vaginal mesh technique, but no significant difference in the total cost (2,934.97€ for SCP vs 3,053.26€ for Uphold vaginal mesh). CONCLUSIONS: Bothersome de novo SUI and de novo dyspareunia occurred in approximately 15% and 23% of our study cohorts, with no significant difference between sacrocolpopexy/hysteropexy and anterior/apical vaginal mesh surgery. However, these results should be interpreted with caution owing to the small sample size.

Midurethral Sling Removal or Revision in Women with Chronic Pain.

OBJECTIVES: The objectives of this study are (1) to estimate the incidence of midurethral sling revision/removal in women with preexisting pain diagnoses versus those without these diagnoses and (2) to describe associations between numbers and type of pain diagnoses with revision/removal. METHODS: Women who underwent midurethral sling surgery between 2009 through 2014 were identified in the MarketScan database and tracked and December 31, 2014. Patients with preoperative chronic pain diagnoses (fibromyalgia, endometriosis, irritable bowel, dyspareunia, low back pain, temporomandibular joint syndrome, interstitial cystitis, pelvic/perineal pain) were compared with controls (those without these diagnoses) regarding mesh sling revision/removal. Logistic regression identified variables associated with mesh revision/removal, and survival analysis compared timing of mesh removal/revision. RESULTS: There were 161,459 women who underwent midurethral sling surgery (pain, 83,484; nonpain, 77,975). Pain and nonpain groups differed in age (52.1 vs 53.5 years, P < 0.01) and insurance status (P < 0.01), with the pain group more commonly living in the South or West. Mean follow-up was 42.3 months. Cumulative risk for sling revision/removal was higher in patients with 1 pain diagnosis relative to controls (relative risk, 1.54; 95% confidence interval [CI], 1.41-1.54). Risks increased with increased pain diagnoses (≥4 diagnoses; relative risk, 3.13; 95% CI, 2.81-3.47). Pelvic pain conditions had greatest odds of mesh revision/removal (dyspareunia adjusted odds ratio [aOR], 2.44; 95% CI, 2.23-2.63; interstitial cystitis aOR, 1.46; 95% CI, 1.27-1.66; pelvic/perineal pain aOR, 1.41; 95% CI, 1.33-1.48). Co-occurrence of dyspareunia and interstitial cystitis or pelvic/perineal pain had 12.7% cumulative incidence of sling revision/removal. Cox proportional hazards revealed greatest risk for those with pelvic pain conditions (hazard ratio, 2.40; 95% CI, 2.13-2.70). CONCLUSIONS: Chronic pain diagnoses increased risk of midurethral sling revision/removal; pelvic pain and numbers of diagnoses increased this risk.

Short-term effects of an erbium/neodymium laser combination in superficial dyspareunia: a pilot study.

OBJECTIVE: This prospective pilot study aimed to evaluate the effects of associating a neodymium:yttrium-aluminum-garnet (Nd:YAG) laser with a vaginal erbium laser (VEL), as a non-ablative photothermal therapy for superficial dyspareunia in postmenopausal women (PMW) suffering from genitourinary syndrome of menopause (GSM). METHODS: Two groups of sexually active PMW reporting superficial dyspareunia were selected: one (15 patients, VEL) was treated using an erbium:yttrium-aluminum-garnet laser crystal (XS Fotona SMOOTH; Fotona, Ljubljana, Slovenia) with a wavelength of 2940 nm; in the other group (15 patients, VEL + Nd:YAG) this treatment was followed by Nd:YAG laser (Fotona SP Dynamis, PIANO mode) treatment. Treatment consisted of three laser applications at 30-day intervals. Symptoms were assessed before, after each laser application and after 1 and 3 months from the end of the treatment, using the subjective visual analog scale (VAS) for superficial dyspareunia. RESULTS: Both groups showed a rapid and significant improvement of superficial dyspareunia over time (p < 0.001) independently from age and years since menopause. The VEL + Nd:YAG group showed a greater improvement of superficial dyspareunia (p < 0.001); this difference was evident since the first treatment and remained stable over time. CONCLUSIONS: The addition of Nd:YAG to VEL may induce greater improvement in superficial dyspareunia in PMW with GSM.

Hysteropreservation versus hysterectomy in uterine prolapse surgery: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Hysteropreservation and hysterectomy for uterine prolapse have been compared in several randomized controlled trials (RCTs), as the best treatment has not been definitively determined. This study aimed to summarize the available evidence in RCTs of hysteropreservation versus hysterectomy. METHODS: We performed electronic searches in the PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure databases for eligible RCTs from inception to June 2020. The relative risks (RRs) and weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were calculated for categorical and continuous variables using random-effects models. RESULTS: Twelve RCTs involving 1177 patients were selected for meta-analysis. There were no significant differences between hysteropreservation and hysterectomy for the incidences of recurrence (RR, 0.55; 95% CI, 0.26-1.19; P = 0.130) and reoperation (RR, 1.15; 95% CI, 0.56-2.37; P = 0.705). Moreover, neither hysteropreservation nor hysterectomy had any significant effect on the risk of constipation (RR, 0.72; 95% CI, 0.15-3.46; P = 0.681), voiding dysfunction (RR, 0.99; 95% CI, 0.54-1.84; P = 0.981), intraoperative bleeding (RR, 0.35; 95% CI, 0.05-2.26; P = 0.271), upper leg dullness (RR, 0.70; 95% CI, 0.15-3.17; P = 0.643), dyspareunia (RR, 1.47; 95% CI, 0.69-3.13; P = 0.317), and wound infection (RR, 1.38; 95% CI, 0.24-7.80; P = 0.714). Furthermore, hysteropreservation was associated with less intraoperative blood loss (WMD, -25.68; 95% CI, -44.39 to -6.96; P = 0.007), shorter duration of surgery (WMD, -11.30; 95% CI, -19.04 to -3.55; P = 0.004), and shorter duration of hospitalization (WMD, -0.63; 95% CI, -1.10 to -0.16; P = 0.009) compared with hysterectomy. CONCLUSION: This study found that both hysteropreservation and hysterectomy have similar effects on recurrence and reoperation rates, while hysteropreservation was superior to hysterectomy in reducing intraoperative blood loss and shortening the duration of surgery and hospitalization.

Improvement in dyspareunia after vaginal mesh removal measured by a validated questionnaire.

INTRODUCTION AND HYPOTHESIS: The objective was to examine the effect of the surgical removal of vaginally placed prolapse and incontinence mesh on sexual function. We hypothesize that patients with painful complications of mesh will experience improvement in dyspareunia and sexual function after mesh removal. METHODS: The eligible cohort consisted of 133 women who presented with a new onset of pain attributed to mesh-augmented incontinence or prolapse surgery and who elected to undergo mesh removal between 1 August 2012 and 1 July 2013. Sexual function symptoms were assessed before and after mesh removal surgery using the Pelvic Organ Prolapse and Urinary Incontinence Sexual Function Questionnaire short form (PISQ-12). Multivariate analysis was performed to identify predictors of improvement in dyspareunia. RESULTS: Ninety-four patients undergoing mesh removal completed a pre-operative questionnaire, 63 of whom also completed a post-operative questionnaire. After mesh removal, there was a nearly 50% reduction in the proportion of women reporting always experiencing post-operative pain with intercourse among those experiencing pre-operative pain. There was a statistically significant quantitative improvement in pain with intercourse after mesh removal based on mean change score of PISQ-12 question 5 "How often do you experience pain with intercourse?". In multivariate analysis, only history of vaginal delivery was associated with symptom improvement. CONCLUSION: Removal of transvaginal prolapse mesh is associated with improvement in self-reported dyspareunia based on a standardized question on a validated instrument in a small cohort of women. Although larger studies are needed to confirm the relationship between mesh-augmented surgeries and post-procedural dyspareunia, these data suggest that consideration of mesh removal is a reasonable step for patients with painful intercourse attributed to mesh-augmented prolapse and incontinence surgeries.

Six-month follow-up of minimally invasive nerve-sparing complete excision of endometriosis: What about dyspareunia?

STUDY OBJECTIVE: To assess individual changes of deep dyspareunia (DDyspareunia) six months after laparoscopic nerve-sparing complete excision of endometriosis, with or without robotic assistance. METHODS: This preplanned interdisciplinary observational study with a retrospective analysis of intervention enrolled 126 consecutive women who underwent surgery between January 2018 and September 2019 at a private specialized center. Demographics, medical history and surgery details were recorded systematically. DDyspareunia (primary outcome), dysmenorrhea and acyclic pelvic pain were assessed on self-reported 11-point numeric rating scales both preoperatively and at six-month follow-up. Cases with poor prognosis in relation to dyspareunia were described individually in greater detail. RESULTS: Preoperative DDyspareunia showed weak correlation with dysmenorrhea (rho = .240; P = .014) and pelvic pain (rho = .260; P = .004). Although DDyspareunia improved significantly (P < .001) by 3 points or more in 75.8% (95%CI: 64.7-86.2) and disappeared totally in 59.7% of cases (95%CI:47.8-71.6), individual analysis identified different patterns of response. The probability of a preoperative moderate/severe DDyspareunia worsening more than 2 points was 4.8% (95%CI: 0.0-10.7) and the probability of a woman with no DDyspareunia developing "de novo" moderate or severe DDyspareunia was 7.7% (95%CI: 1.8-15.8) and 5.8% (95%CI: 0.0-13.0), respectively. In a qualitative analysis, several conditions were hypothesized to impact the post-operative DDyspareunia response; these included adenomyosis, mental health disorders, lack of hormone therapy after surgery, colporrhaphy, nodule excision in ENZIAN B compartment (uterosacral ligament/parametrium), the rectovaginal septum or the retrocervical region. CONCLUSION: Endometriosis surgery provides significant improvement in DDyspareunia. However, patients should be alerted about the possibility of unsatisfactory results.

Surgical treatment of deep endometriosis with adenomyosis externa: a challenging case in an infertile woman.

OBJECTIVE: To describe the management and the fertility-enhancing potential of surgery in an infertile patient with deep-infiltrating endometriosis and adenomyosis externa. DESIGN: Video case report. SETTING: Minimally invasive and robotic gynecologic surgery unit of a university hospital. PATIENT(S): A 31-year-old nulliparous patient with dysmenorrhea, dysuria, dyspareunia, and primary infertility. INTERVENTION(S): Bimanual examination, transvaginal ultrasound, and magnetic resonance imaging (MRI) were performed as a comprehensive preoperative workup. The findings were consistent with bladder endometriosis and a 4-cm right pararectal cystic mass suggestive of adenomyosis externa. Laparoscopic excision of all visible endometriosis was performed. A pararectal lesion was found, completely developing in the retroperitoneal spaces, from the right medial pararectal space to the rectovaginal space, reaching the pelvic floor fascia without infiltration of the levator ani muscle. According to Koninckx classification, this kind of lesion corresponds to type III endometriosis or adenomyosis externa. Nerve-sparing eradication of the nodule was performed. The decision to use these techniques was taken with the intention to treat the patient, and not with the aim of testing the procedures performed. Therefore, as a common clinical practice in our institution and for the above reasons, there was no need for consultation of the institutional review board for approval. MAIN OUTCOME MEASURE(S): Improvement of symptoms and spontaneous conception after surgical removal of all endometriotic implants. RESULT(S): There were no intraoperative or postoperative complications, and the patient was discharged after 3 days. She discontinued postoperative hormone therapy with gonadotropin-releasing hormone analogue after 3 months because she desired fertility. She conceived spontaneously after 2 months of attempting. She delivered vaginally and had no complications during pregnancy and labor. Neither recurrence of pain symptoms nor voiding or rectal dysfunctions were reported by the patient. CONCLUSION(S): In the management of a case of deep endometriosis, the preoperative assessment should be carefully carried out to give the surgeon the most accurate information about the extent of the disease and the patient's main objectives. Imaging techniques such as ultrasound and MRI play a fundamental role along with the clinical evaluation in also detecting lesions that are not visible at first laparoscopic inspection. In this case of a young woman without any detectable fertility issues except for endometriosis, the laparoscopic excision of endometriosis was feasible, safe, and effective in improving the patient's fertility and pain symptoms. The fertility-enhancing potential of complete eradication of pelvic endometriosis, including removal of deep posterior localizations such those presented in this case, has been hypothesized by various investigators. It has been suggested that skilled surgical management for symptomatic deep endometriosis may be followed by a high pregnancy rate, with most pregnancies resulting from postoperative natural conception even in patients with primary infertility.

Pelvic venous insufficiency secondary to iliac vein stenosis and ovarian vein reflux treated with iliac vein stenting alone.

BACKGROUND: We have previously reported that in women with a pelvic venous disorder secondary to pelvic venous insufficiency, 56% will present with an iliac vein stenosis (IVS) and ovarian vein reflux (OVR). The purpose of the present investigation was to determine whether women with combined disease can be treated using iliac vein stenting alone. METHODS: A retrospective review of prospectively collected data at the Center for Vascular Medicine was performed. We investigated women with pelvic pain or dyspareunia secondary to combined IVS and OVR who had undergone stenting alone. The patient demographics, pre- and 6-month postoperative visual analog scale (VAS) for pain scores, stent type, stent diameter, stent length, and ovarian vein diameters were assessed. All patients had undergone diagnostic venography of their pelvic veins, left ovarian veins, and pelvic reservoirs and intravascular ultrasonography of their iliac veins. RESULTS: From May 2016 to October 2019, 82 patients with a pelvic venous disorder secondary to IVS and OVR were identified. The present data analysis focused on 38 patients with complete pre- and postoperative VAS scores and duplex scan stent patency data at 6 months. The pelvic and dyspareunia VAS scores at the initial and 6-month follow-up visits were as follows: 6.83 ± 3.19 and 4.24 ± 2.65 and 1.72 ± 2.01 and 0.05 ± 2.0, respectively (P ≤ .001). At 6 months, 29 of the 38 women (76%) reported complete resolution of all symptoms, 26 of 28 (93%) reported complete resolution of their dyspareunia, 5 of 38 (13%) reported significant improvement, and 4 of 38 (10%) reported no improvement. The average ovarian vein diameter was 6.7 ± 2.5 mm. The average stent size and length was 18.20 ± 1.6 mm and 92.41 ± 18.5 mm, with 25 placed in the left common iliac, 2 in the right common iliac vein, and 3 bilaterally. Of the 38 patients, 7 required reintervention (18%). An untreated pelvic reservoir was observed in 17 of the 38 patients (44%). One of the two with no response and six of the patients with improvement had OVR and an untreated pelvic reservoir. The remaining 10 patients with a pelvic reservoir had experienced complete resolution of their symptoms with stenting alone. CONCLUSIONS: Of the 38 women with pelvic pain secondary to combined IVS and OVR, 76% achieved complete symptom resolution with iliac vein stenting alone. Most of the women with a pelvic reservoir were asymptomatic and reported full symptom resolution after stenting alone. However, these data suggest that in some women, a relationship might exist between the presence of a pelvic reservoir and the persistence of symptoms. Therefore, for women with combined IVS and OVR, we recommend iliac vein stenting alone and staged ovarian vein embolization only for women with persistent symptoms.

CO2 laser and the genitourinary syndrome of menopause: a randomized sham-controlled trial.

PURPOSE: This study aimed to clarify the efficacy of intravaginal CO2-laser treatment in postmenopausal women with genitourinary syndrome of menopause (GSM). MATERIALS AND METHODS: This double-blind, randomized, sham-controlled trial included postmenopausal women diagnosed with GSM and bothersome dryness and dyspareunia. Treatment consisted of three sessions. Active CO2-laser treatments (active group) were compared to sham treatments (sham group) with the primary endpoints being changes in dryness and dyspareunia intensity, as assessed by the 10-cm visual analog scale. Secondary endpoints were as follows: changes in Female Sexual Function Index (FSFI; total score and all domains), itching, burning, dysuria, and Urogenital Distress Inventory (UDI-6); incidence of symptoms; and presence of adverse events. All outcomes were evaluated at baseline and 4 months post baseline. RESULTS: Fifty-eight women (28 in the active group and 30 in the sham group) were eligible for inclusion. In the active group, dryness, dyspareunia, FSFI (total score), itching, burning, dysuria, and UDI-6 were significantly improved (mean [standard deviation] -5.6 [2.8], -6 [2.6], 12.3 [8.9], -2.9 [2.8], -2.3 [2.8], -0.9 [2.1], and -8.0 [15.3], respectively). In the sham group, dryness, itching, and burning were significantly improved (-1.9 [2], -1.4 [1.9], and -1 [1.9], respectively). All changes were in favor of the active group. After completion of the protocol, the proportion of participants with dryness, dyspareunia, and sexual dysfunction was significantly lower in the active group compared to those in the sham group (all p < 0.005). CONCLUSIONS: CO2 laser could be proposed as an effective alternative treatment for the management of GSM as it is superior to sham treatments.

Easy way to perform a labia minora reduction.

BACKGROUND: Labia minora reduction is a surgery in the rise. Surgeons are left with a large choice of described techniques yet there is a paucity of visual data to guide surgeons through this procedure. Also, many gynecologic surgeons are reluctant to perform this operation emphasizing potential complications. TECHNIQUE: We present a step by step visual support of a wedge resection technique. EXPERIENCE: This technique of labia minora reduction is safe and carries a great satisfaction rate among patients. CONCLUSION: We believe that a visual description of a simple and quick technique will help standardized patient care and achieve good outcomes.

Pain Resolution and Recurrent Prolapse Rates Following Vaginal Mesh Removal.

OBJECTIVE: To evaluate pain resolution and recurrent prolapse following removal of painful pelvic organ prolapse (POP) mesh. METHODS: This was an IRB-approved retrospective review of patients who underwent POP mesh removal from 2009 to 2018 for the primary indication of pain and/or dyspareunia. Factors of interest included mesh type, complete versus partial removal, presenting symptom(s), and recurrent prolapse. Complete removal was defined as complete excision of all possible mesh, including arms, and partial removal was anything less. Postoperative symptom improvement was categorized as resolved, improved, or unresolved. RESULTS: Ninety-two mesh removal patients were identified, 78 of whom underwent mesh removal for pain or dyspareunia, with mean follow-up of 17.25 months (range: 0.46-60.25). Overall, presenting symptoms resolved or improved in 85.9%. In the 45 complete removal patients, 46.7% resolved, 40.0% improved, and 11.1% unresolved compared to 51.5% resolved, 33.3% improved, and 12.1% unresolved in the 33 partial removal patients (P = .82). Recurrent symptomatic POP developed in 31.1% of patients after complete removal compared to 15.2% after partial removal (P = .12). Overall, 23 (30.3%) patients required additional reconstructive procedures. CONCLUSION: Most patients experienced resolution or improvement in painful symptoms after any degree of mesh removal. Complete removal was not significantly associated with greater symptom improvement compared to partial removal. Complete removal was associated with a higher percentage of recurrent POP, but this association was not statistically significant. Less than one-third of patients required additional surgery.

Peritoneal Retraction Pocket Defects and Their Important Relationship with Pelvic Pain and Endometriosis.

OBJECTIVE: The objective of this video is to demonstrate different clinical presentations of peritoneal defects (peritoneal retraction pockets) and their anatomic relationships with the pelvic innervation, justifying the occurrence of some neurologic symptoms in association with these diseases. DESIGN: Surgical demonstration of complete excision of different types of peritoneal retraction pockets and a comparison with a laparoscopic retroperitoneal cadaveric dissection of the pelvic innervation. SETTING: Private hospital in Curitiba, Paraná, Brazil. INTERVENTIONS: A pelvic peritoneal pocket is a retraction defect in the surface of the peritoneum of variable size and shapes [1]. The origin of defects in the pelvic peritoneum is still unknown [2]. It has been postulated that it is the result of peritoneal irritation or invasion by endometriosis, with resultant scarring and retraction of the peritoneum [3,4]. It has also been suggested that a retraction pocket may be a cause of endometriosis, where the disease presumably settles in a previously altered peritoneal surface [5]. These defects are shown in many studies to be associated with pelvic pain, dyspareunia, and secondary dysmenorrhea [1-4]. Some studies have shown that the excision of these peritoneal defect improves pain symptoms and quality of life [5]. It is important to recognize peritoneal pockets as a potential manifestation of endometriosis because in some cases, the only evidence of endometriosis may be the presence of these peritoneal defects [6]. In this video, we demonstrate different types of peritoneal pockets and their close relationship with pelvic anatomic structures. Case 1 is a 29-year-old woman, gravida 0, with severe dysmenorrhea and catamenial bowel symptoms (bowel distension and diarrhea/constipation) that were unresponsive to medical treatment. Imaging studies were reported as normal, and a laparoscopy showed a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the lateral border of the rectum. Case 2 is a cadaveric dissection of a posterior cul-de-sac peritoneal pocket infiltrating the pararectal fossa, with extension to the pelvic sidewall. After dissection of the obturator fossa, we can observe that the pocket is close to the sacrospinous ligament, pudendal nerve, and some sacral roots. Case 3 is a 31-year-old woman, gravida 1, para 1, with severe dysmenorrhea that was unresponsive to medical treatment and catamenial bowel symptoms (catamenial bowel distention and diarrhea). Imaging studies were reported as normal and a laparoscopy showed left uterosacral peritoneal pocket infiltrating the pararectal fossa in close proximity to the rectal wall. Case 4 is a cadaveric dissection of the ovarian fossa and the obturator fossa showing the proximity between these structures. Case 5 is a 35-year-old woman, gravida 0, with severe dysmenorrhea that was unresponsive to medical treatment, referring difficulty, and pain when walking only during menstruation. A neurologic physical examination revealed weakness in thigh adduction, and the magnetic resonance imaging showed no signs of endometriosis. During laparoscopy, we found a peritoneal pocket infiltrating the ovarian fossa, with involvement in the area between the umbilical ligament and the uterine artery. This type of pocket can easily reach the obturator nerve. Because the obturator nerve and its branches supply the muscle and skin of the medial thigh [7,8], patients may present with thigh adduction weakness or difficulty ambulating [9,10]. Case 6 is a cadaveric dissection of the sacrospinous ligament and the pudendal nerve from a medial approach, between the umbilical artery and the iliac vessels. Case 7 is a 34-year-old woman, gravida 1, para 1, with severe dysmenorrhea and catamenial bowel symptoms as well as deep dyspareunia. The transvaginal ultrasound showed focal adenomyosis and a 2-cm nodule, 9-cm apart from the anal verge, affecting 30% of the bowel circumference. In the laparoscopy, we found a posterior cul-de-sac retraction pocket associated with a large deep endometriosis nodule affecting the vagina and the rectum. In all cases, endometriosis was confirmed by histopathology, and in a 6-month follow-up, all patients showed improvement of bowel, pain, and neurologic symptoms. CONCLUSION: Peritoneal pockets can have different clinical presentations. Depending on the topography and deepness of infiltration, they can be the cause of some neurologic symptoms associated with endometriosis pain. With this video, we try to encourage surgeons to totally excise these lesions and raise awareness about the adjacent key anatomic structures that can be affected.

Patient reported vaginal laxity, sexual function and stress incontinence improvement following vaginal rejuvenation with fractional carbon dioxide laser.

In this study, we have evaluated the efficiency of fractional carbon dioxide laser in the treatment of vaginal laxity and urinary incontinence. Thirty patients with vaginal laxity, sexual dysfunction and urinary incontinence complaints were treated with fractional carbon dioxide laser. Results were evaluated with patient questionnaires relating to comfort during the procedure and general satisfaction following the procedure. In the survey regarding comfort during the procedure, 90% (n:27) of the patients reported that they were comfortable during the procedure. The survey on the level of general satisfaction six months following the procedure revealed high-moderate level of satisfaction in 86% (n:26) of the patients. 66% (n:20) of the patients reported improved vaginal tightness and 63% (n:19) of the patients reported improvement in the quality of their sexual activity. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire(PISQ-12) scores six months following the procedure were not significantly different when compared to the scores prior to the procedure. The average of Questionnaire for Urinary Incontinence Diagnosis(QUID) score prior to the procedure and six months following the procedure was 7.5 and 0.9 respectively (p < 0.05). Fractional carbon dioxide laser treatment results in high level of satisfaction and improvement in vaginal laxity, sexual dysfunction and urinary incontinence symptoms in patients with genitourinary syndrome.

Surgical treatment of vulvar venous malformations without preoperative sclerotherapy: Outcomes of 18 patients.

BACKGROUND: Our aim was to evaluate the benefit of surgical resection of the venous malformations (VMs) of the external female genitalia. METHODS: Over the period of 2009-2019, 18 consecutive females underwent surgical resection for vulvar VM. Evaluations included preoperative Doppler ultrasound, MRI, and pre-and postoperative photographic imaging. The main outcomes were: residual pain, cosmetic distortion, residual VM, and quality of life. RESULTS: Over a 10 year periods, 18 females, mean age 35 years (range 9-71) were included in this study. All patients were symptomatic: 16 had intermittent pain or discomfort, 1 had bleeding and 2 requested cosmetic treatment. Of these cases, there were 5 isolated vulvar VM, 12 associated VM: 3 of the clitoral hood, 3 troncular pelvic vein insufficiency and 12 of the lower limb. Eight patients had undergone previous procedures: 2 sclerotherapy treatments (1-3 sessions), 4 partial surgical resections. There were 18 single resections in the vulva (7 focal, 11 complete), 2 partial resections in clitoral hood and 2 had resection of a VM in the perirtoneovaginal canal at the same time. The mean follow-up was 42. 9 months (range 6-120). Two patients were lost to followup at 6 months. For all patients, elimination of pain and soft tissue redundancy was achieved. Two patients had persistent discomfort and 2 requested cosmetic treatment. CONCLUSION: Surgical resection of vulvar VM can be the best approach with few postoperative complications, good functional and cosmetic results. Appropriate preoperative evaluation is required to identify isolated VM or VM associated with ovarian vein or internal iliac vein insufficiency requiring to be treated before surgery.