Should a detailed ultrasound examination of the complete urinary tract be routinely performed in women with suspected pelvic endometriosis?

STUDY QUESTION: Is there any benefit to including the routine examination by ultrasound of the bladder, ureters and kidneys of women with endometriosis? SUMMARY ANSWER: The benefit of examination of the complete urinary tract of women with suspected endometriosis is that ureteric endometriosis, with or without hydronephrosis, can be detected which facilitates early intervention to prevent nephropathy. WHAT IS ALREADY KNOWN: Women with endometriosis can get ureteric obstruction but there is no clear consensus on the correct diagnostic technique. Ultrasound is accurate at detecting women with bladder endometriosis but ureteric involvement has not been assessed previously. STUDY DESIGN, SIZE, DURATION: This was a prospective observational study, conducted at a teaching hospital over a period of 14 months. A total of 848 women presenting with chronic pelvic pain were included into the study. PARTICIPANTS/MATERIALS, SETTING, METHODS: All women with chronic pelvic pain underwent a detailed transvaginal and transabdominal pelvic ultrasound examination to investigate possible causes of their symptoms. This included a systematic assessment of the urinary bladder, pelvic sections of the ureters and kidneys. The ultrasound findings were compared with findings at surgery and the results of targeted urological imaging and interventions. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 848 women presenting with chronic pelvic pain were included into the study. 28/848 women (3.3% 95% CI 2.1-4.5) had evidence of urinary tract abnormalities on initial ultrasound scan. Among these 17/848 (2.0% 95% CI 1.06-2.94) had evidence of urinary tract endometriosis, whilst 11/848 (1.3% 95% CI 0.54-2.06) women had other urinary tract abnormalities. Among women with urinary tract endometriosis 11/17 (65%) had evidence of ureteric involvement, 3/17 (18%) had both ureteric and bladder disease and 3/17 (18%) had bladder disease only. 12/17 (59%) women with urinary tract endometriosis also had evidence of hydronephrosis. The diagnosis of ureteral endometriosis had a sensitivity of 12/13 (92%) (95% CI 63.9-99.8), specificity 151/151 100% (95% CI 97.6-100), PPV 100% (95% CI 73.5-100), NPV 99.3% (95% CI 96.3-99.9%) LR- 0.08 (95% CI 0.01-0.39). LIMITATIONS, REASONS FOR CAUTION: The routine examination of the complete urinary tract including the distal ureters is a novel technique that should be evaluated in different populations. WIDER IMPLICATIONS OF THE FINDINGS: Ultrasound is an accurate test to diagnose urinary tract involvement in women with suspected pelvic endometriosis and examination of the complete urinary tract should become an integral part of ultrasound assessment of women with suspected endometriosis.

ß-hCG resolution times during expectant management of tubal ectopic pregnancies.

BACKGROUND: A subset of women with a tubal ectopic pregnancy can be safely managed expectantly. Expectant management involves a degree of disruption with hospital visits to determine serum ß-hCG (ß-human chorionic gonadotrophin) concentration until the pregnancy test becomes negative and expectant management is considered complete. The length of time required for the pregnancy test to become negative and the parameters that influence this interval have not been described. Information on the likely length of follow up would be useful for women considering expectant management of their tubal ectopic pregnancy. METHODS: This was a retrospective study at a tertiary referral center in an inner city London Hospital. We included women who were diagnosed with a tubal ectopic pregnancy by transvaginal ultrasound between March 2009 and March 2014. During the study period 474 women were diagnosed with a tubal ectopic pregnancy and 256 (54 %) of them fulfilled our management criteria for expectant management. A total of 158 (33 %) women had successful expectant management and in those cases we recorded the diameter of the ectopic pregnancy (mm), the maximum serum ß-hCG (IU/L) and levels during follow up until resolution as well as the interval to resolution (days). RESULTS: The median interval from maximum serum ß-hCG concentration to resolution was 18.0 days (IQR 11.0-28.0). The maximum serum ß-hCG concentration and the rate of decline of ß-hCG were independently associated with the length of follow up. Women's age and size of ectopic pregnancy did not have significant effects on the length of follow up. CONCLUSION: Women undergoing expectant management of ectopic pregnancy can be informed that the likely length of follow up is under 3 weeks and that it positively correlates with initial ß-hCG level at the time of diagnosis.

Angiokeratoma of the vulva.

Angiokeratoma of the vulva is relatively uncommon in the general population. We present two cases of angiokeratoma of the vulva and review the literature. The two patients presented with the complaint of vulvar pruritus. They underwent wide local excision of the lesions. Histopathology revealed angiokeratoma of the vulva. The women remain well with no evidence of recurrence 48 and 32 months after initial surgery. Although it is a rare disease, angiokeratoma of the vulva should be included in the differential diagnosis of a vulvar tumor.

Primary ovarian non-Hodgkin's lymphoma.

BACKGROUND: Primary ovarian non Hodgkin's lymphoma (PONHL) is a very rare disease. We present a case of PONHL and review the literature. CASE: The patient, a 24-year-old nulliparous Greek woman, presented with the complaint of abdominal pain. She underwent left salpingo-oophorectomy, multiple biopsies from the right ovary, total omentectomy, pelvic and paraortic lymphadenectomy, appendectomy and curettage. The histopathology revealed diffuse large B-cell non-Hodgkin's lymphoma of the left ovary. She underwent postoperative chemotherapy. She remains well without evidence of disease, 15 months after initial surgery. CONCLUSION: The use of chemotherapy is based on the principle that PONHL must be considered a localized manifestation of systemic disease. Patients with PONHL have a similar outcome compared to patients with other NHL.

Loop electrosurgical excision procedure in Greek patients with vaginal intraepithelial neoplasia.

OBJECTIVE: The aim of our study was to evaluate the therapeutic effectiveness of the loop electrosurgical excision procedure (LEEP) in Greek patients with vaginal intraepithelial neoplasia (VAIN). MATERIALS AND METHODS: Between January 2002 and January 2009, 23 women with histologically confirmed VAIN were included in our study. For the LEEP procedure we used a high frequency electrosurgery unit with at least 80 W output. RESULTS: Complete response rate at 12 months of follow-up was 86.96%. Recurrence rate at 12 months of follow-up was 13.04%. Complete response rate at 24 months of follow-up was 75%. Recurrence rate at 24 months of follow-up was 25%. CONCLUSION: LEEP may constitute a valuable excisional method for the treatment of VAIN. It provides an interpretable specimen of the whole lesion within a few minutes. It needs a short period of training and has low cost.

Synchronous primary endometrial and fallopian tube cancers.

BACKGROUND: Synchronous primary cancers are relatively uncommon in the general population. We present a case of synchronous primary endometrial and fallopian tube cancers and review the literature. CASE: The patient, a 54-year-old, gravida 2, para 2 postmenopausal Greek woman presented with a complaint of abnormal vaginal bleeding. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and total omentectomy. The histopathology revealed synchronous primary cancers of the endometrium and right fallopian tube. The patient underwent postoperative chemotherapy and postoperative radiotherapy. She remains well without evidence of disease, 65 months after initial surgery. CONCLUSION: The reason for the better median overall survival of patients with synchronous primary endometrial and fallopian tube cancers is not intuitively obvious. Perhaps it is due to the detection of patients at earlier clinical stage and lower grade disease state.

Loop electrosurgical excision procedure in Greek patients with vulvar intraepithelial neoplasia.

OBJECTIVE: The aim of our study was to evaluate the therapeutic effectiveness of loop electrosurgical excision procedure (LEEP) in Greek patients with vulvar intraepithelial neoplasia (VIN). MATERIALS AND METHODS: Between January 2002 and January 2009, 55 women with histologically confirmed VIN usual type were included in our study. For the LEEP procedure we used a high frequency electrosurgical unit with at least 80 W output. The tissue was removed to the second surgical plane. Statistical analyses were performed using the SPSS-13 for Windows. RESULTS: Complete response rate at 12-month follow-up was 100%. Complete response rate at 48 months of follow-up was 80%. Recurrence rate at 48 months of follow-up was 20%. CONCLUSION: LEEP may constitute a valuable excisional method for the treatment of VIN. It provides an interpretable specimen of the whole lesion within a few minutes. It needs a short period of training and has low cost.