A 24-months Follow-up Study of Individuals with Endometriosis using Transvaginal Ultrasound.

STUDY OBJECTIVE: To investigate the progression of deep infiltrating endometriosis using transvaginal ultrasound surveillance of patients undergoing conservative management. DESIGN: Retrospective single cohort. SETTING: Australian tertiary university hospital PATIENTS: One hundred twenty two women with endometriosis proven on transvaginal ultrasound who had not undergone surgical management. INTERVENTIONS: The progression of endometriosis lesions demonstrated on transvaginal ultrasound in women receiving conservative management over the course of 24 months. MEASUREMENTS AND MAIN RESULTS: A total of 122 patients fulfilled the inclusion criteria. All women had 2 ultrasounds that were performed at least 6 months apart. The median follow-up time was 490.5 days (255.4-725.6). At second scan, 22% (95% CI: 15-30%) of cohort experienced an increase in the number of endometriosis nodules compared to first scan, with 51% (95% CI: 42-60%) remaining static while 27% (95% CI: 19-35%) experienced a decrease. While there was no statistically significant difference in the volumes of uterosacral ligament, retro cervical, and bowel endometriosis, endometrioma volumes were significantly lower at second scan (Median = 3.24 mL, IQR = 0.6-16.87) as compared to the first scan (Median = 7.41 mL, IQR = 2.04-28.95), p <.001. CONCLUSION: Individuals with deep infiltrating endometriosis are unlikely to see significant disease progression over time. Both surgical and nonsurgical interventions are effective in managing endometriosis in terms of endometriotic nodule size and number, as measured by ultrasound.

Yoga, cognitive-behavioural therapy versus education to improve quality of life and reduce healthcare costs in people with endometriosis: a randomised controlled trial.

INTRODUCTION: Endometriosis is a debilitating chronic inflammatory condition highly burdensome to the healthcare system. The present trial will establish the efficacy of (1) yoga and (2) cognitive-behavioural therapy (CBT), above (3) education, on quality of life, biopsychosocial outcomes and cost-effectiveness. METHODS AND ANALYSIS: This study is a parallel randomised controlled trial. Participants will be randomly allocated to yoga, CBT or education. Participants will be English-speaking adults, have a diagnosis of endometriosis by a qualified physician, with pain for at least 6 months, and access to internet. Participants will attend 8 weekly group CBT sessions of 120 min; or 8 weekly group yoga sessions of 60 min; or receive weekly educational handouts on endometriosis. The primary outcome measure is quality of life. The analysis will include mixed-effects analysis of variance and linear models, cost-utility analysis from a societal and health system perspective and qualitative thematic analysis. ETHICS AND DISSEMINATION: Enrolment in the study is voluntary and participants can withdraw at any time. Participants will be given the option to discuss the study with their next of kin/treating physician. Findings will be disseminated via publications, conferences and briefs to professional organisations. The University's media team will also be used to further disseminate via lay person articles and media releases. TRIAL REGISTRATION NUMBER: ACTRN12620000756921p; Pre-results.

Recent advances in benign gynecological laparoscopic surgery.

Minimally invasive surgery continues to transform the field of gynecological surgery and is now the standard of care for the surgical treatment of many diseases in gynecology. Owing to minimally invasive surgery's clear advantages, new advances in technology are being employed rapidly and enabling even the most complicated procedures to be performed less invasively. We examine recent literature on minimally invasive surgical innovations, advances, and common practices in benign gynecology that, from our point of view, made an impact on the way laparoscopic surgery is performed and managed in the last decade.

Endometrial stem/progenitor cells in menstrual blood and peritoneal fluid of women with and without endometriosis.

RESEARCH QUESTION: Are endometrial stem/progenitor cells shed into uterine menstrual blood (UMB) and the peritoneal cavity in women with and without endometriosis during menstruation? DESIGN: Women with (n = 32) and without endometriosis (n = 29) at laparoscopy (total 61), carried out during the menstrual (n = 41) and non-menstrual phase (n = 20) were recruited. The UMB, peritoneal fluid and peripheral blood were analysed by clonogenicity assay and flow cytometry to quantify the concentrations of endometrial clonogenic cells, SUSD2+ mesenchymal stem cells (eMSC) and N-cadherin+ epithelial progenitor cells (eEPC). RESULTS: Clonogenic endometrial cells, eMSC and eEPC were found in most UMB samples at similar concentrations in women with and without endometriosis. In contrast, 62.5% of women with endometriosis and 75.0% without (controls) had clonogenic cells in peritoneal fluid samples during menses. The eMSC were present in the peritoneal fluid of 76.9% of women with endometriosis and 44.4% without, and eEPC were found in the peritoneal fluid of 60.0% of women with and 25.0% without endometriosis during menses. Median clonogenic, eMSC and eEPC concentrations in peritoneal fluid were not significantly different between groups. More clonogenic cells persisted beyond the menstrual phase in the peritoneal fluid of women with endometriosis (menstrual 119/ml [0-1360/ml] versus non-menstrual 8.5/ml [0-387/ml]; P = 0.277) compared with controls (menstrual 76.5/ml [1-1378/ml] versus non-menstrual 0/ml [0-14/ml]; P = 0.0362). No clonogenic endometrial cells were found in peripheral blood. CONCLUSIONS: Clonogenic endometrial cells, SUSD2+ eMSC and N-cadherin+ eEPC are present in UMB and the peritoneal fluid of women with and without endometriosis. Further study of the function of these cells may shed light on the cellular origins of endometriosis.

Can anyone screen for deep infiltrating endometriosis with transvaginal ultrasound?

BACKGROUND: Surgical treatment of deep infiltrating endometriosis (DIE) is complex, and preoperative diagnosis benefits both surgeon and patient. Studies in expert centres have reported high accuracy for transvaginal ultrasound (TVUS) diagnosis of DIE. External validation of these findings has been limited, and no information is available on how quickly these skills can be acquired. The aim of this study was to measure the learning curve of DIE-TVUS and to identify the causes for inaccuracies in the diagnosis of bowel lesions and Pouch of Douglas (POD) obliteration. METHODS: Following one week of training at the University of São Paulo (Brazil), 205 consecutive women with a history of endometriosis symptoms were prospectively assessed by TVUS after minimal bowel preparation. TVUS findings were correlated with laparoscopic findings in eighty-five cases to assess the accuracy. The LC-CUSUM and CUSUM were used to assess the learning curve and maintenance of competency, respectively. RESULTS: The sensitivity and specificity for DIE of the bladder, vagina and bowel were 33% and 100%, 80% and 100%, and 88% and 93%, respectively. The sensitivity and specificity for the presence of POD obliteration were 88% and 90%, respectively. LC-CUSUM analysis confirmed that competency for DIE-TVUS was achieved within 38 scans for the detection of POD obliteration and within 36 scans for the detection of bowel nodules. Competency was maintained for the remainder of the scans as assessed by the CUSUM. CONCLUSIONS: After one week of DIE-TVUS training, competency can be achieved within forty procedures, allowing diagnosis of DIE with similar diagnostic accuracy as reported by centres of excellence.

Reliability of visual diagnosis of endometriosis.

OBJECTIVE: To determine whether accuracy of visual diagnosis of endometriosis at laparoscopy is determined by stage of disease. DESIGN: Prospective longitudinal cohort study (Canadian Task Force classification II-2). SETTING: Tertiary referral centers in three Australian states. PATIENTS: Of 1439 biopsy specimens, endometriosis was proved in at least one specimen in 431 patients. INTERVENTIONS: Laparoscopy with visual diagnosis and staging of endometriosis followed by histopathologic analysis and confirmation. Operations were performed by five experienced laparoscopic gynecologists. MEASUREMENTS AND MAIN RESULTS: Histopathologic confirmation of visual diagnosis of endometriosis adjusted for significant covariates. Endometriosis was accurately diagnosed in 49.7% of American Society for Reproductive Medicine (ASRM) stage I, which was significantly less accurate than for other stages of endometriosis. Deep endometriosis was more likely to be diagnosed accurately than superficial endometriosis (adjusted odds ratio, 2.51; 95% confidence interval, 1.50-4.18; p < .01). Lesion volume was also predictive, with larger lesions diagnosed more accurately than smaller lesions. In general, lesion site did not greatly influence accuracy except for superficial ovarian lesions, which were more likely to be incorrectly diagnosed visually as endometriosis (adjusted odds ratio, 0.16; 95% confidence interval, 0.06-0.41; p < .01). There was no statistically significant difference in accuracy between the gynecologic surgeons. CONCLUSION: The accuracy of visual diagnosis of endometriosis was substantially influenced by American Society of Reproductive Medicine stage, the depth and volume of the lesion, and to a lesser extent the location of the lesion.

Comparison of ultrasonic shears and traditional suture ligature for vaginal hysterectomy: randomized controlled trial.

STUDY OBJECTIVE: To compare operating time, intraoperative blood loss, postoperative analgesia, and length of hospital stay using ultrasonic shears vs traditional suture ligature in vaginal hysterectomy. DESIGN: Randomized controlled trial (Canadian Task Force classification I). SETTING: Gynecology units within a single health network, university hospital. PATIENTS: Forty women requiring vaginal hysterectomy because of benign disease. INTERVENTIONS: Vaginal hysterectomy performed using either ultrasonically activated shears (USS) or traditional suture ligatures. MEASUREMENTS AND MAIN RESULTS: Twenty-one patients were randomized to the USS arm, and 19 patients to the traditional suture ligature arm. Patient characteristics were comparable. Mean (SD) hysterectomy time and was similar in both the USS and traditional arms, 28.66 (4.0) minutes vs 32.37 (3.18) minutes (p = .47), as was total operating time, 97.38 (8.9) minutes vs 91.63 (7.69) minutes (p = .63). Operative blood loss was significantly decreased in the USS group: 62.63 (12.46) mL vs 136.05 (21.54) mL (p = .006). There was, however, no significant change in hemoglobin concentration between the 2 groups: 19.53 (1.79) g/L vs -16.72 (2.5) g/L. There was no significant difference in mean oxycodone use: 9.29 (2.66) mg vs 8.06 (3.19) mg (p = .77). Length of hospital stay was similar in both groups: 58.98 (3.27) hours vs 60.05 (6.48) hours (p = .88). There was no significant difference in overall complication rates between the groups. CONCLUSION: Although the Harmonic scalpel system, compared with the traditional suture ligation method, seems to be a safe alternative for securing the pedicles in vaginal hysterectomy, it offers no benefit insofar as operative time, reduction in clinically significant blood loss, and analgesic requirements.

Bowel resection for severe endometriosis: an Australian series of 177 cases.

BACKGROUND: Colorectal resection for severe endometriosis has been increasingly described in the literature over the last 20 years. AIMS: To describe the experiences of three gynaecological surgeons who perform radical surgery for colorectal endometriosis. METHODS: The records of three surgeons were reviewed. Relevant information was extracted and complied into a database. RESULTS: One hundred and seventy-seven women were identified as having undergone surgery between February 1997 and October 2007. The primary reason for presentation was pain in the majority of women (79%). Eighty-one segmental resections were performed, 71 disc excisions, ten appendicectomies and multiple procedures in ten women. The majority of procedures (81.4%) were performed laparoscopically. Histology confirmed the presence of disease in 98.3% of cases. A further 124 procedures to remove other sites of endometriosis were conducted, along with an additional 44 procedures not primarily for endometriosis. A total of 16 unintended events occurred. CONCLUSIONS: Our study adds to the growing body of literature describing colorectal resection for severe endometriosis. Overall, the surgery appeared to be well tolerated, demonstrating the role for this surgery.

Evolution of the complications of laparoscopic hysterectomy after a decade: a follow up of the Monash experience.

A retrospective review of medical records was performed to assess the incidence and types of significant complications encountered during laparoscopic hysterectomy which would affect the use of a laparoscopic approach versus other routes of hysterectomy. A total of 526 consecutive patients' medical data between January 1994 and August 2007 were reviewed. Two hundred and thirty-two laparoscopic-assisted vaginal hysterectomies and 294 total laparoscopic hysterectomies were performed at Monash Medical Centre, a Melbourne tertiary public hospital, and three Melbourne private hospitals, by or under the supervision of three surgeons. Sixteen significant complications occurred. There were two cases of ureteric fistula, two bladder injuries, two bowel obstructions, four postoperative haematomas, one case of a bladder fistula, four conversions to laparotomy and one superficial epigastric artery injury. Inpatient stay ranged from two to six days. Our complication and inpatient stay rates are consistent with the previously reported rates, although there has been a reduction of incidence of visceral injuries with experience and introduction of new equipment.

Reliability and validity of an objective assessment instrument of laparoscopic skill.

A novel objective assessment method in reproductive endoscopic surgery could advance surgical education.

Safer laparoscopic trocar entry: it's all about pressure.

This prospective observational study aimed to assess the feasibility of adapting peritoneal hyperdistention to 25 mmHg during laparoscopy in an Australian hospital environment. A total of 1150 consecutive diagnostic or operative laparoscopies were performed. All cases were monitored for early detection of untoward physiological changes. All patients had Veress needle insufflation with distension to 25 mmHg prior to insertion of the primary trocar. No patients experienced any surgical entry complications or adverse clinical effects noted during anaesthetic. The aim of the current study is to assess the feasibility and safety of increasing the peritoneal insufflation pressure to 25 mmHg for primary trocar insertion.

Ignorance of electrosurgery among obstetricians and gynaecologists.

OBJECTIVE: The purpose of this study was to assess the level of skill of laparoscopic surgeons in electrosurgery. DESIGN: Subjects were asked to complete a practical diathermy station and a written test of electrosurgical knowledge. SETTING: Tests were held in teaching and non-teaching hospitals. SAMPLE: Twenty specialists in obstetrics and gynaecology were randomly selected and tested on the Monash University gynaecological laparoscopic pelvi-trainer. Twelve candidates were consultants with 9-28 years of practice in operative laparoscopy, and 8 were registrars with up to six years of practice in operative laparoscopy. Seven consultants and one registrar were from rural Australia, and three consultants were from New Zealand. METHODS: Candidates were marked with checklist criteria resulting in a pass/fail score, as well as a weighted scoring system. We retested 11 candidates one year later with the same stations. MAIN OUTCOME MEASURES: No improvement in electrosurgery skill in one year of obstetric and gynaecological practice. RESULTS: No candidate successfully completed the written electrosurgery station in the initial test. A slight improvement in the pass rate to 18% was observed in the second test. The pass rate of the diathermy station dropped from 50% to 36% in the second test. CONCLUSION: The study found ignorance of electrosurgery/diathermy among gynaecological surgeons. One year later, skills were no better.

Rectal surgery for endometriosis--should we be aggressive?

STUDY OBJECTIVE: To assess the outcome of aggressive but conservative laparoscopic surgery in the treatment of severe endometriosis involving the rectum. DESIGN: Retrospective study (Canadian Task Force classification III). SETTING: Endosurgery unit of a tertiary referral center. PATIENTS: One hundred sixty-nine women. INTERVENTION: Laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS: The procedure was completed successfully laparoscopically in 145 (86%) and by laparotomy in 24 women (14%). The rate of preoperative symptoms was higher in 25 women who underwent bowel resection compared with those who had other bowel surgery. In addition to bowel surgery, excision of uterosacral ligaments, adhesiolysis, excision of endometrioma, and oophorectomy were the four most commonly performed procedures. At 35-month follow-up 61 patients (36%) required further surgery for pain. The average time between primary and repeat surgery was 16 months. This second operation was performed by laparoscopy in over three-fourths of the women. Overall recurrent endometriosis was found in 26 patients (15%). Overall morbidity associated with all surgery was 12.4%. CONCLUSION: Surgery for endometriosis of the cul-de-sac and bowel involves some of the most difficult dissections encountered, but it can be accomplished successfully with the low postoperative morbidity typical of laparoscopy.

Laparoscopic diagnosis of endometriosis.

OBJECTIVE: To consider and explain the possibility of difficulties in diagnosis of endometriosis at previous laparoscopy DESIGN: Retrospective patient record review. SETTING: The Endometriosis Care Centre of Australia and the private practices of authors. SAMPLE: Two hundred and fifteen patients with clinical evidence of endometriosis examined laparoscopically between March 1999 and May 2001. MAIN OUTCOME MEASURES: Confirmation of endometriosis by histological biopsy. RESULTS: Endometriosis was confirmed in 168 of the 215 women. Of these women 38 had a previous negative laparoscopy within 12 months of the current laparoscopy. CONCLUSIONS: It is possible that in some of the patients, who previously had a negative laparoscopy, endometriosis was not recognised. Possible reasons for difficulty in diagnosis have been identified and techniques to improve diagnosis suggested. This retrospective study was performed to consider and explain the possibility of difficulties in diagnosis of endometriosis at previous laparoscopy.