Deeply infiltrating endometriosis: evaluation of retro-cervical space on MRI after vaginal opacification.

OBJECTIVES: To prospectively investigate diagnostic value and tolerability of MRI after intra-vaginal gel opacification for diagnosis and preoperative assessment of deeply infiltrating endometriosis. METHODS: Sixty-three women with clinical suspicion of deeply infiltrating endometriosis were previously examined with trans-vaginal ultrasonography and then with MRI pre and post administration of vaginal gel. We evaluated the tolerability of this procedure with a scoring scale from 0 to 3. We also assessed with a score from 1 to 4 the visibility of four regions: Douglas-pouch, utero-sacral-ligaments, posterior-vaginal-fornix and recto-vaginal-septum. All patients underwent laparoscopic surgery after MRI. RESULTS: Five patients considered procedure intolerable. Visibility of utero-sacral-ligaments and posterior-vaginal-fornix showed to be increased with gel (p<0.001). In 57 out of 80 patients the MRI has allowed us to diagnose deeply infiltrating endometriosis. Overall, the percentages of MRI-sensitivity, specificity, positive predictive value and negative predictive value were respectively 67.8%, 95.3%, 89.4 and 83.5% without gel, and 90.8%, 94.6%, 90.8% and 94.6% with gel; trans-vaginal ultrasonography sensitivity, specificity, positive predictive value and negative predictive value were 57.5%, 96.6%, 90.9% and 79.5%. In evaluation of utero-sacral-ligaments trans-vaginal ultrasonography, MRI without gel and with gel sensitivity was respectively 61.9%, 47.6% and 81%; for recto-vaginal-septum these values were 12.5%, 68.7% and 93.7%; for pouch of Douglas 82%, 87% and 97.4%; finally for posterior-vaginal-fornix 27.3%, 36.4% and 81.8%. CONCLUSIONS: MRI with gel opacification of vagina should be recommended for suspicion of deep infiltrating endometriosis, in particular for the added value in evaluation of recto-vaginal septum, utero-sacral ligaments and posterior vaginal fornix.

Recurrence rate of endometrioma after laparoscopic cystectomy: a comparative randomized trial between post-operative hormonal suppression treatment or dietary therapy vs. placebo.

OBJECTIVE(S): To assess the recurrence rate of endometrioma after laparoscopic cystectomy plus hormonal suppression treatment or plus dietary therapy compared to post-operative placebo. STUDY DESIGN: A randomized comparative trial was conducted on 259 consecutive women who underwent laparoscopic unilateral/bilateral cystectomy for endometrioma. Seven days after surgery, the patients were randomly allocated on the basis of a computer-generated randomization sequence, to one of four post-operative management arms as follows: placebo (n=65) or gonadotrophin-releasing hormone analogue (tryptorelin or leuprorelin, 3.75 mg every 28 days) (n=65) or continuous low-dose monophasic oral contraceptives (ethynilestradiol, 0.03 mg plus gestoden, 0.75 mg) (n=64) or dietary therapy (vitamins, minerals salts, lactic ferments, fish oil) (n=65) for 6 months. At 18 months' follow-up after surgery, all patients were monitored with a clinical gynecologic examination, and a transvaginal ultrasonography for possible evidence of endometrioma recurrence. RESULT(S): At 18 months' transvaginal ultrasonographic follow-up after surgery, no significant recurrence rate of endometrioma was detected in women who received a postoperative course of hormonal suppression treatment or dietary therapy when compared with placebo (placebo vs. GnRH-a P=0.316, placebo vs. estroprogestin P=0.803, placebo vs. dietary therapy P=0.544). Second-look laparoscopy was performed on a clinical basis and confirmed the ultrasonographic suspicion of recurrence of endometrioma in all cases: 10 (16.6%) in the post-operative placebo group vs. 6 (10.3%) in the post-operative GnRH-a group vs. 9 (15.0%) in the post-operative continuous estroprogestin group vs. 11 (17.8%) in the post-operative dietary therapy group. Of 36 patients with recurrent ovarian endometriosis, 8 had recurrence on the treated ovary, 20 on the contralateral ovary that appeared to be normal at the time of the first-line surgery, and 8 on both the treated and untreated ovaries. Endometrioma recurrences were associated with moderate-to-severe painful symptoms in 14/36 patients (38.8%), while the remaining 22 (61.1%) patients were asymptomatic. CONCLUSION(S): A 6-month course of hormonal suppression treatment or dietary therapy after laparoscopic cystectomy had no significant effect on the recurrence rate of ovarian endometriosis when compared with surgery plus placebo. So, treatment of endometrioma can be carried out exclusively by laparoscopic cystectomy without post-operative therapy, if a complete excision of ovarian endometriosis has been assured.

Laparoscopic myomectomy for very large myomas using an isobaric (gasless) technique.

OBJECTIVES: Laparoscopic myomectomy using pneumoperitoneum for large myomas (> or = 8 cm) is hindered by several factors, such as the increased operative time, the risk of perioperative bleeding, and the risk of conversion to laparotomy. With the introduction of isobaric laparoscopy using abdominal wall lifting, this procedure can be performed using conventional surgical instruments introduced through small abdominal incisions. The aim of this study was to evaluate the feasibility, reproducibility, and safety of isobaric laparoscopic myomectomy for very large myomas > or = 10 cm using a subcutaneous abdominal wall-lifting device. METHODS: A series of 24 consecutive patients with at least 1 symptomatic myoma > or = 10 cm underwent a gasless laparoscopic myomectomy with the Laparotenser device. Conventional long laparotomy instruments were used. RESULTS: Gasless laparoscopic myomectomy was successful in all 24 consecutive patients. The size of the dominant myoma varied from 10 cm to 20 cm. The median operating time was 93 minutes. The median postoperative drop in hemoglobin was 2.8 g/dL. No surgical complications occurred. The median hospital stay was 2.8 days. CONCLUSION: Gasless laparoscopic myomectomy is feasible, reproducible, and safe for removing very large myomas. Therefore, it can represent an excellent option for the minimally invasive removal of very large myomas.

Isobaric (gasless) laparoscopic myomectomy during pregnancy.

We report on the first case of an isobaric (gasless) laparoscopic myomectomy during the second trimester of pregnancy. Our patient had acute abdominal pain that did not respond to medical management. The procedure was performed under spinal anesthesia with conscious sedation. The remainder of the pregnancy was unremarkable. We believe that surgical management of uterine leiomyoma during pregnancy may be successfully performed in carefully selected patients. Laparotomy can be avoided, and pregnant patients can be managed safely by operative laparoscopy. With isobaric laparoscopy, the adverse effects and potential risks of CO2 insufflation are eliminated. The procedure can be performed under loco-regional anesthesia. The uterine closure can be performed safely and quickly as in laparotomy.

Office hysteroscopy: comparison of 2.7- and 4-mm hysteroscopes for acceptability, feasibility and diagnostic accuracy.

OBJECTIVE: To compare 2.7- and 4-mm rigid optics, with 3- and 5-mm outer sheaths, respectively, in office diagnostic hysteroscopy by evaluating pain, patient tolerability, optical view and diagnostic accuracy of the procedure. STUDY DESIGN: Three hundred seventy-one consecutive patients undergoing hysteroscopy were included in a prospective, randomized clinical trial, and the outcomes were analyzed. A saline solution was used as the distension medium. The t test for unpaired samples, chi2 tables of contingency and ANOVA 2 x 3 were used where appropriate. The study took place at Tor Vergata University Hospital of Rome, Rome, Italy. The 371 women were referred consecutively for suspected endometrial pathologies and were separated into 2 groups. Diagnostic accuracy of the hysteroscopic procedure, pain experienced by the 2 groups (as assessed by a visual analogue score) and patient acceptability were assessed with a questionnaire. RESULTS: Satisfactory hysteroscopy was achieved in 253 of 310 patients with a 2.7-mm hysteroscope and in 47 of 61 patients with a 4-mm hysteroscope. This difference was not significant. Menopausal status was the most important factor influencing the practicability of the hysteroscopic procedure (p < 0.001). CONCLUSION: The narrower-diameter hysteroscopes tended to lower the incidence of pain associated with office hysteroscopy, but this was not significant. Parity did not show any influence on hysteroscopic practicability. Menopausal status was the most important factor influencing the feasibility of the hysteroscopic procedure.

Gasless laparoscopic myomectomy. Indications, surgical technique and advantages of a new procedure for removing uterine leiomyomas.

OBJECTIVE: To evaluate the feasibility, safety and reliability of gasless laparoscopic myomectomy (GLM) using a new subcutaneous lifting system (Laparotenser, Lucini L&T, Milan, Italy) for removing subserosal and intramural leiomyomas. STUDY DESIGN: A total of 279 women with at least 1 symptomatic subserosal or intramural myoma measuring > 30 mm underwent GLM between April 1997 and July 2001. All procedures were performed by the same surgeons using the same technique. RESULTS: GLM was successful in all 279 patients. The mean size of the myomas were 5.9 cm. Their average number per patient was 3.1. The mean operating time was 73 minutes. Forty-eight patients subsequently carried a pregnancy to term. No cases of uterine rupture during pregnancy or labor were observed. CONCLUSION: GLM is a feasible, reliable and safe procedure for removing intramural and subserosal myomas. It appears to offer several advantages over laparoscopy with pneumoperitoneum. In addition, the largest and multiple medium-sized myomas can be removed rapidly and safely.

Transvaginal hydrolaparoscopic ovarian drilling using bipolar electrosurgery to treat anovulatory women with polycystic ovary syndrome.

STUDY OBJECTIVE: To verify the value, feasibility, and reliability of transvaginal hydrolaparoscopic ovarian drilling using the bipolar VersaPoint system to treat clomiphene-resistant, anovulatory women with polycystic ovary syndrome. DESIGN: Prospective clinical study (Canadian Task Force classification II-2). SETTING: University teaching hospital. PATIENTS: Twenty-eight women. INTERVENTION: Transvaginal hydrolaparoscopic ovarian drilling using the bipolar VersaPoint spring electrode. MEASUREMENTS AND MAIN RESULTS: After the surgical procedure, ovulation occurred spontaneously in 66.7% of women. Thirteen pregnancies occurred; eight were spontaneous, and four were achieved after induction of ovulation with clomiphene citrate and one after stimulation with gonadotropins. In 21 women whose infertility was due exclusively to anovulation, the cumulative pregnancy rate was 38% at 3 months and 76% at 6 months. No ovarian hyperstimulation or abortion occurred. The single complication was bleeding from an ovary that required conversion to laparoscopy. CONCLUSION: Transvaginal hydrolaparoscopic ovarian drilling with the bipolar VersaPoint system is a useful therapeutic option in these women.

Transvaginal hydrolaparoscopy vs. conventional laparoscopy for evaluating unexplained primary infertility in women.

OBJECTIVE: To verify the usefulness and reliability of transvaginal hydrolaparoscopy (THL) as a screening tool for evaluating infertility in women in comparison with conventional diagnostic laparoscopy. STUDY DESIGN: Sixty consecutive women with unexplained primary infertility were prospectively enrolled into the study. After examination of the whole pelvic cavity, tubal patency was evaluated and the uterine cavity studied by hysteroscopy. Immediately after THL, conventional laparoscopy was performed. Main outcome measures were the success rate of accessing the pouch of Douglas, rate of complete examinations, rate of complications and accuracy of THL in comparison with laparoscopy. RESULTS: Success rate of accessing the pouch of Douglas and performing THL was 93.3%. The rate of complete evaluation of all the pelvic structures was 76.8%. In studying tubal pathology, 77.8% agreement was found between the two techniques. Diagnosis of endometriosis was correct in 55.5% of patients. Overall, THL results correlated closely with conventional laparoscopic results in 92.86%, but the diagnostic accuracy of THL was 100% in cases of complete pelvic evaluation. CONCLUSION: THL is a feasible, reliable and safe procedure and can be considered an alternative procedure for evaluating infertility in women. In cases of incomplete pelvic evaluation or abnormal findings, conventional laparoscopy is indicated as the second step in the evaluation.