How to minimize bleeding in laparoscopic myomectomy.

PURPOSE OF REVIEW: Laparoscopic myomectomy is a common surgical procedure for symptomatic myomas. However, bleeding control during surgery may pose a challenge. Therefore, the aim of this study was to review recent evidence regarding interventions to control bleeding during laparoscopic myomectomy. RECENT FINDINGS: The use of vasopressin resulted in less blood loss compared to placebo. Barbed sutures reduced blood loss compared to conventional sutures. Intravenous infusion of tranexamic acid (TXA) in the intraoperative period of large myomectomies showed no significant difference compared to placebo. Uterine artery occlusion (UAO) and emergency uterine artery embolization were reported to be feasible and may reduce and treat bleeding before conversion to laparotomy. SUMMARY: Several methods can control bleeding during laparoscopic myomectomy. Vasopressin and barbed sutures resulted in decreased blood loss, and TXA did not have an impact on bleeding control. The use of UAO and emergency embolization techniques can contribute to the control of bleeding; however, further studies are needed to prove the efficacy of these and other agents.

Bilateral ureteral endometriosis-an indolent, aggressive, and dangerous condition.

OBJECTIVE: To describe an unusual bilateral ureteral reimplantation due to endometriosis and to provide a flowchart of conservative decision making. DESIGN: Video description of a case, demonstrating a step-by-step explanation of the decision planning and description of the surgical steps in a female patient with bilateral ureteral endometriosis who had previously undergone operation for bowel endometriosis, and who presented with extensive disease in the posterior compartment with no symptoms besides bilateral renal function disruption. The study was reviewed and approved by the Hospital Beneficência Portuguesa de São Paulo Institutional Review Board. SETTING: Tertiary referral center. PATIENTS: Deep infiltrating endometriosis involving the ureter has an incidence of 0.1% to 1%, normally affecting the lower one-third of its segment, up to 4 cm above the vesicoureteric junction. Bilateral ureteral involvement occurs in 9% of cases. The absence of specific symptoms makes the diagnosis of this condition challenging. Lumbar pain develops when its involvement is complicated by marked obstruction with impaired renal function. Decompressive surgery is mandatory. The necessity of ureteroneocystostomy increases along with the severity of hydronephrosis, accounting for 62% of ureteral decompressive procedures. However, bilateral ureteroneocystostomy is a rare procedure, not exceeding 6% of ureteral reimplantations. This case illustrates a situation in which a patient with a previous bowel segmental resection presented with an advanced bilateral posterior deep infiltrating endometriosis, compromising the lower rectum below the previous anastomosis, vagina, posterior, and lateral parametrium bilaterally and both inferior hypogastric plexi. Hormonal therapy improved endometriosis symptoms but did not control the urinary tract involvement. Along with the patient, considering a high probability of intestinal, urinary, and sexual impairment, a conservative approach was chosen. INTERVENTION: The procedure started with adesiolysis, accessing the retroperitoneum and identifying both dilated ureters (Figs. 1 and 2). They were dissected as caudally as possible, until endometriosis fibrosis was reached, to have a bigger length of proximal ureter to allow a tension-free ureteroneocystostomy. The Retzius space was developed, and the bladder was freed and mobilized (Fig. 3). After cutting the ureter, the proximal end was spatulated. The bladder dome was approximated to the psoas muscle with an interrupted suture to permit a tension-free ureteroneocystostomy. The detrusor muscle was opened for approximately 2 to 3 cm, exposing the vesical mucosa, which was subsequently opened. The posterior ureterovesical anastomosis was performed with running monofilament absorbable 4-0 sutures. A double-J stent was placed, and the anterior ureterovesical anastomosis was completed. The detrusor muscle was loosely closed over the ureter with interrupted absorbable sutures to avoid urinary reflux. A Maryland clamp was used to ensure sufficient entry of the tunnel. All these steps were repeated in the contralateral side. MAIN OUTCOME MEASURE(S): Successful performance of a bilateral laparoscopy tension-free ureteroneocystostomy with bilateral psoas hitch. RESULTS: The postoperative course was uneventful. Renal function was restored. One year after surgery, the patient remained asymptomatic, and endometriotic lesions showed no increase, thus remaining stable. CONCLUSION: Ureteral endometriosis can be aggressive and indolent. Decompressive procedures must be performed. The decision-making process must take into consideration the patient's characteristics and expectations. In selected cases, a conservative approach may be required, when future possible functional disfunctions can be worse than the actual symptoms. In those situations, close surveillance is necessary.

Caracterização morfológica da endometriose ovariana / Morphologic characterization of ovarian endometriosis

Introdução: De origem controversa e repercussões imprevisíveis, o acometimento ovariano pela endometriose é considerado importante marcador de extensão da doença, pois pode se associar a endometriose profunda. Inúmeras teorias etiopatogênicas tentam explicar a gênese da endometriose ovariana e, duas delas recentemente tem sido reativadas, como a da metaplasia celômica que justificaria o conceito atual de endometriose intra-ovariana profunda e a da menstruação retrógrada, que explica a origem tubárea dos endometriomas. Estima-se em 5% a 10% de câncer ovariano em lesões de endometriose de ovário; enquanto, a frequência total de transformação maligna foi estimada entre 0,3 a 2,5%. Objetivo: Avaliar as formas de apresentação da endometriose ovariana e possíveis associações com o quadro clínico, com outros locais de doença, com os marcadores de atividade proliferativa (Ki-67), com a expressão de alterações moleculares dos mecanismos apoptóticos consideradas importantes no processo de carcinogênese das lesões de endometriose (p53 e Bcl-2) e com os receptores de estrogênio (dependência hormonal). Métodos: Estudo de coorte retrospectivo exploratório, com 63 pacientes operadas entre 2002 a 2012, com diagnóstico de endometriose ovariana preenchendo os critérios de inclusão e exclusão. Os preparados histológicos foram reavaliados e reclassificados de acordo com o tipo histológico, com a forma de apresentação e com a presença de infiltração do parênquima ovariano, sendo divididas em endometriose ovariana peritoneal, cistica e intraparenquimatosa. Foram avaliados a expressão do Ki-67, do p53, do Bcl- 2 e dos receptores de estrogênio no epitélio e no estroma tecidual. As pacientes ainda foram avaliadas de acordo com os sintomas clínicos e locais concomitantes de doença. Resultados: A forma de apresentação da endometriose ovariana mais frequente foi a cística (72,2%), seguida pela intraparenquimatosa (22,2%) e pela forma peritoneal (5,6%). Todas podem...

Introduction: Of controversial origin and unpredictable repercussions, ovarian endometriosis is an important marker of disease extensiveness, as it may be related to deep infiltrating endometriosis. Numerous theories try to explain its origin, but two of them have been recently reactivated, such as celomic metaplasia, which would justify the concept of deep ovarian endometriosis, and retrograde menstruation, which can explain the tubal origin of ovarian endometriosis. It is estimated 5% to 10% of ovarian cancer in ovarian endometriosis, but malignant transformation may occur in 0.3 to 2.5% of the cases. Objective: Identify the presenting forms of ovarian endometrisosis and its possible relations to clinical symptoms, to other sites of disease, to proliferative activity markers (Ki-67), to the molecular expression of apoptotic mechanisms, considered important to the process of malignant transformation (p53 and Bcl-2) and to estrogen receptors (hormonal dependency). Methods: This is a retrospective exploratory cohort study, done between 2002 and 2012, including 63 women with laparoscopic diagnosis of ovarian endometriosis which fullfilled inclusion and exclusion criteria. The histologic specimens were reanalysed and reclassified according to the histologic pattern, to its presenting form and to the presence of parenchyma infiltration. The expression of Ki-67, p53, Bcl-2 and estrogen receptors were evaluated in the tissue epithelium and stroma. Clinical symptoms and concomitant sites of disease were also evaluated. Results: The most frequent form of ovarian endometriosis was cystic (72.2%), followed by intra-parenchymatous (22.2%) and peritoneal (5.6%). All of them can be infiltrative. The prevalence of infiltrative ovarian endometriosis was 30.5%. No association were found between symptoms, anatomical distribution of disease, markers expression and the presenting forms of ovarian endometriosis as well as adjacent parenchymal infiltration. Conclusion:...

CD4(+) CD25(high) Foxp3(+) cells increased in the peritoneal fluid of patients with endometriosis.

PROBLEM: To evaluate CD4(+) CD25(high) Foxp3(+) cells and IL-6, IL-10, IL-17, and TGF-ß in the peritoneal fluid of women with endometriosis. METHOD OF STUDY: A total of ninety-eight patients were studied: endometriosis (n = 70) and control (n = 28). First, peritoneal fluid lymphocytes were isolated, and CD4(+) CD25(high) cells were identified using flow cytometry. Then, RT-PCR was performed to verify Foxp3 expression in these cells. Also, IL-6, IL-10, IL-17, and TGF-ß concentration was determined. RESULTS: Of all the lymphocytes in the peritoneal fluid of women with endometriosis, 36.5% (median) were CD4(+) CD25(high) compared to only 1.15% (median) in the control group (P < 0.001). Foxp3 expression was similarly elevated in patients with the disease compared to those without (median, 50 versus 5; P < 0.001). IL-6 and TGF-ß were higher in endometriosis group (IL-6: 327.5 pg/mL versus 195.5 pg/mL; TGF-ß: 340 pg/mL versus 171.5 pg/mL; both P < 0.001). IL-10 and IL-17 showed no significant differences between the two groups. CONCLUSION: The peritoneal fluid of patients with endometriosis had a higher percentage of CD4(+) CD25(high) Foxp3(+) cells and also higher levels of IL-6 and TGF-ß compared to women without the disease. These findings suggest that CD4(+) CD25(high) Foxp3(+) cells may play a role in the pathogenesis of endometriosis.