Rare case of giant cystic adenomyoma mimicking a uterine malformation, diagnosed and treated by hysteroscopy.

We describe a case of giant cystic uterine adenomyoma that was diagnosed and treated by hysteroscopy. In a 27-year-old woman with menometrorrhagia, severe dysmenorrhea, and chronic pelvic pain, pelvic ultrasonography revealed an enlarged uterine cavity filled with homogeneous low echogenic fluid content. A large cornual hematometra of 8.0 cm in diameter in a bicornuate uterus was suspected, and this hypothesis was also supported by magnetic resonance imaging findings. On the contrary, hysteroscopy revealed a bilocular huge cystic lesion of the posterior uterine wall that was removed by means of monopolar loop resection. The operative finding and the histopathologic examination confirmed the diagnosis of cystic adenomyoma of the uterus. Hysteroscopy may represent a valid tool for diagnosis and minimally invasive treatment of cystic adenomyoma, including those of large volume. Its use is helpful in differential diagnosis between cystic adenomyoma and uterine malformations as a possible cause of pelvic pain.

Laparoscopic surgical treatment of diaphragmatic endometriosis: a 7-year single-institution retrospective review.

BACKGROUND: Diaphragmatic endometriosis is a rare condition that may cause invalidating epigastric or thoracic pain and catamenial pneumothorax. During the past decades, laparoscopy has been proposed as an optimal tool for diagnosis and surgical eradication of the disease. METHODS: We present a retrospective series of consecutive patients affected by diaphragmatic endometriosis, treated by laparoscopy at our institution, during a period of 7 years. RESULTS: Among 3,008 patients with pelvic endometriosis, 46 cases with intraoperative diagnosis of diaphragmatic endometriosis were identified. Operative findings showed multiple diaphragmatic lesions in 32 (69.5 %) patients and single lesions in 14 (30.4 %). Diaphragmatic implants were distributed on the right side in 40 (86.9 %) patients; in 5 patients (10.8 %) they were bilateral and 1 patient had a single lesion on the left hemidiaphragm. Most of the symptomatic patients were treated by complete excision of the nodules, whereas only three patients referring right upper-quadrant abdominal pain and right shoulder catamenial pain had superficial diaphragmatic endometriosis and were treated by diathermocoagulation. CONCLUSION: Diaphragmatic endometriosis should be included in the concept of complete eradication of endometriosis. This kind of surgery has been shown to be feasible and cost-effective; however, it should be managed in a referral center, by an expert laparoscopic gynecologist with knowledge of oncological surgical techniques, with the support of a general surgeon and a trained anesthesiologist.

Transvaginal sonography for preoperative assessment of deep endometriosis.

PURPOSE: To determinate transvaginal scan (TVS) accuracy in the preoperative evaluation of deep endometriosis in a large cohort of patients with subsequent laparoscopic assessment. METHODS: A retrospective study was performed in a tertiary referral center for endometriosis. Transvaginal scan reports were retrieved from an electronic database of all patients who underwent laparoscopy for pelvic pain or infertility in 2009. The accuracy of TVS was assessed for 10 different sites of pelvic endometriosis. RESULTS: Four hundred twenty women were included in the study. Sensitivity and specificity of TVS were 61% and 99%, respectively, for bladder endometriosis, 52% and 96% for endometriosis of rectovaginal septum, 65% and 99% for rectum endometriosis, and 69% and 98% for endometriosis of the sigmoid colon. CONCLUSIONS: TVS appears to be useful for the detection of endometriosis located in the bladder and involving the sigmoid colon, the rectovaginal septum, and the rectum.

Nerve-sparing laparoscopic eradication of deep endometriosis with segmental rectal and parametrial resection: the Negrar method. A single-center, prospective, clinical trial.

BACKGROUND: The weight of surgical radicality, together with a lack of anatomical theoretical basis for surgery and inappropriate practical skills, can lead to serious impairments to bladder, rectal, and sexual functions after laparoscopic excision of deep infiltrating endometriosis. Although the "classical" laparoscopic technique for endometriosis excision involving segmental bowel resection has proven to relieve symptoms successfully, it is hampered by several postoperative long-term and/or definitive pelvic dysfunctions. METHODS: In this prospective cohort study, we compare the laparoscopic nerve-sparing approach to the classical laparoscopic procedure in a series of 126 cases. Satisfactory data for bowel, bladder, and sexual function were considered as primary endpoints. RESULTS: A total of 126 patients were considered for analysis: 61 treated with nerve-sparing radical excision of pelvic endometriosis with segmental bowel resection (group B), and 65 treated with the classical technique (group A). Intraoperative, perioperative, and postoperative complications were similar between the two groups. Mean days of self-catheterization were significantly lower in the nerve-sparing group (39.8 days) compared with the non-nerve-sparing group (121.1 days; p < 0.001). The relapse rate within 12 months after surgery was comparable between the two groups. Patients of group A suffered from urinary retention more frequently between 1 and 6 months (p = 0.035) compared with group B and did not experience any improvement between 6 months and 1 year (p = 0.018). Overall detection of severe bladder/rectal/sexual dysfunctions was significantly different between the two groups, and 56 patients of group A (86.2%) reported a significantly higher rate of severe neurologic pelvic dysfunctions vs. 1 patient (1.6%) of group B (p < 0.001). CONCLUSIONS: Our technique appears to be feasible and offers good results in terms of reduced bladder morbidity and apparently higher satisfaction than the classical technique. Considering that this kind of surgery requires uncommon surgical skills and anatomical knowledge, we believe that it should be performed only in selected reference centers.

Laparoscopic rectal resection for severe endometriosis of the mid and low rectum: technique and operative results.

BACKGROUND: Although several studies have shown that laparoscopic resection is safe and feasible in bowel endometriosis, limited data are available on the specific treatment for endometriosis of the rectum. The aim of this study is to describe operative and postoperative outcomes after laparoscopic resection of the mid/low rectum for endometriosis. METHODS: Between 2002 and 2010, 750 patients (median age 33 years) underwent laparoscopic resection of the mid/low rectum for deep infiltrating endometriosis at a single institution. All operations were performed with a standardized technique by a single surgeon. RESULTS: Median operative time was 255 min, and median blood loss 150 ml. Of patients, 7% required blood transfusions. Laparotomic conversion rate was 1.6%. Mechanical low and very low colorectal anastomoses were carried out in 92.5 and 7.5% of patients, respectively. Temporary ileostomy rate was 14.5%. Median length of stay was 8 days. Overall surgical morbidity was 9% with no mortality. Rates of anastomotic leak, rectovaginal fistula, and intraabdominal bleeding were 3, 2, and 1.2%. Forty patients (5.5%) required reoperation. CONCLUSIONS: Laparoscopic resection of the mid/low rectum for endometriosis can be performed safely with acceptable rates of morbidity/reoperation and with low rates of specific complications, including anastomotic leak and rectovaginal fistula. The very high surgical volume of the operating surgeon is probably one of the most important factors in order to maximize postoperative outcomes.

Ureteral endometriosis: clinical and radiological follow-up after laparoscopic ureterocystoneostomy.

BACKGROUND: Ureteral endometriosis is a rare entity that may lead to progressive hydroureteronephrosis and renal loss. When the localization of ureteral stenosis is close to the ureterovesical junction, ureterocystoneostomy may be required. The aim of the present study was to evaluate post-operative complication rates and clinical outcomes at 1- and 6-month follow-up after laparoscopic ureterocystoneostomy. METHOD: Twenty patients who underwent ureterocystoneostomy for pelvic endometriosis in our tertiary referral centre for endoscopic surgery during 1 year were studied. A cystography was performed on Day 7 after surgery to verify the integrity of anastomosis and a satisfactory bladder capacity. Follow-up consisted of gynaecological examination and transvaginal ultrasound at 1 and 6 months after surgery. At 6 months, urography and cystography were also performed. Measurements included results of a pre-operative clinical and instrumental assessment, intra- and post-operative complications, post-operative bladder capacity at cystography and improvement of pain, using a visual analogue scale for the main symptoms related to endometriosis and uro-specific pain. RESULTS: Neither a case of ureteral fistula nor other complications requiring re-intervention were reported. Post-operative transient deficit of bladder voiding occurred in five cases (25%), urinary infection in one and post-operative pyrexia in four (20%) patients. The median time to resuming voiding function was 3 days (range 1-20 days). In six cases, a mild vesico-ureteral reflux at the operated side was observed at 7-day cystography. Post-operative symptomatology was improved significantly (P<0.05) for all symptoms. Urography and cystography performed at 6 months confirmed good post-operative reconstructions in all cases. CONCLUSIONS: The objective of surgical treatment of ureteral endometriosis is to remove the stenotic tract and to preserve renal function. In cases of intrinsic ureteral endometriosis, the procedure of laparoscopic ureterocystoneostomy is feasible and has good outcomes at short- and medium-term follow-up.

Laparoscopic ileocecal resection for bowel endometriosis.

BACKGROUND: Ileocecal endometriosis is a very rare entity, and its diagnosis is usually made during surgery for other endometriosis sites or, rarely, because of direct complications of ileal involvement. This study was designed to analyze perioperative and long-term outcomes after bowel resection for ileocecal endometriosis. METHODS: All patients who underwent surgery for ileocecal endometriosis between October 2004 and January 2008 were prospectively collected and analyzed. RESULTS: Thirty-one women (median age, 34 (range, 25-40) years) were identified. Ileocecal endometriosis was diagnosed during surgery in all patients, and it was associated with colorectal endometriosis in 29 patients (94%). All patients underwent laparoscopic ileocecal resection with no laparotomic conversion. Rectosigmoid or rectal resections was associated in 28 patients (90%) and nodulectomy for sigmoid endometriosis in 1 patient. Median duration of surgery was 301 (range, 90-480) min. Other associated surgical procedures included total hysterectomy (n = 3, 14%), ureterolysis (n = 7, 23%), excision of vesical (n = 4, 13%), vaginal (n = 8, 26%), and parametrial (n = 3, 14%) nodules. There was no mortality. Four patients (13%) required blood transfusions and one a reoperation for bleeding. In a patient who performed ureterolysis, a ureteral fistula occurred. The median hospital stay was 7 (range, 5-18) days. Long-term (>12 months) follow-up data were available for 18 patients. After a median follow-up of 27 months, in 12 of 18 patients (67%) defecation after surgery was normal. Only one patient developed recurrence, which is under medical treatment. CONCLUSIONS: Laparoscopic ileocecal resection is safe and feasible and should be considered as part of surgery for endometriosis with radical intent.

Distribution of endometriotic lesions in endometriosis stage IV supports the menstrual reflux theory and requires specific preoperative assessment and therapy.

A detailed picture of the prevalence and distribution of abdomino-pelvic endometriosis in more that 1,500 cases of endometriosis stage IV is presented. A great prevalence of endometriotic localizations in the posterior pelvic compartment compared to the other quadrants with more frequently observed lesions on the left part of the pelvis supports the menstrual reflux theory. The extent of anatomical sites suggests the opportunity to plan a proper preoperative instrumental study for patients with clinical suspect of severe endometriosis possibly to set a multidisciplinary clinical or surgical management.

Cyclic sciatica in a patient with deep monolateral endometriosis infiltrating the right sciatic nerve.

STUDY DESIGN: Case report. OBJECTIVE: To show by case presentation, the potential for endometriosis to infiltrate the somatic nerves causing lower extremity neuropathic pain and to discuss possible surgical remedy and the effectiveness of laparoscopic neurolysis. SUMMARY OF BACKGROUND DATA: Pelvic endometriosis may infiltrate the pelvic wall and somatic nerves causing severe neuropathic symptoms. METHODS: We report a case of a 41-year-old woman with a history of severe dysmenorrhea, dyspareunia, and chronic pelvic pain with concomitant monolateral right sciatica because of deep infiltrating pelvic endometriosis involving the sciatic nerve and pelvic wall. RESULTS: The patient was treated by laparoscopic neurolysis of the involved somatic nerves according to the Possover operation. CONCLUSIONS: Endometriosis is a chronic inflammatory disease, potentially infiltrating the somatic nerves. Laparoscopic neurolysis is a therapeutic aetiological therapy, which can relieve neurological symptoms deriving from nerve infiltration/compression.

Fertility and clinical outcome after bowel resection in infertile women with endometriosis.

Bowel resection for endometriosis improves pain symptoms and quality of life in symptomatic women. However, little is known about fertility after surgery, particularly after such treatment in women suffering from infertility. The aim of the present study was to evaluate post-operative fertility and long-term clinical outcome after laparoscopic colorectal resection for endometriosis in infertile women. This study reports clinical outcomes in 62 infertile women who underwent laparoscopic excision of endometriosis with segmental bowel resection performed for severe intestinal symptoms. Among women younger than 30 years trying to conceive spontaneously, the cumulative pregnancy rate was 58% and the cumulative pregnancy rate was 45% in those aged 30-34 years. The total pain recurrence was 9.7% (six cases) and endometriosis recurrence was diagnosed by ultrasound in 14.5% (nine cases) during the follow-up period. Four of these patients needed further surgery because of severe symptoms. The surgical treatment of bowel endometriosis seems to improve pain symptoms and patients' satisfaction rates, and it could also be indicated in infertile women.

Laparoscopic colorectal resection for deep infiltrating endometriosis: analysis of 436 cases.

BACKGROUND: Complete removal of all visible lesions is considered the adequate treatment of pelvic endometriosis in order to reduce recurrence. Laparoscopic colorectal resection of bowel endometriosis is still challenging. A large series is reported. METHODS: A longitudinal evaluation of surgical and clinical complications of 436 cases of severe endometriosis with colorectal resection was carried out. All procedures were performed laparoscopically in a single center and short-term complications were surveyed. RESULTS: The overall complication rate was 8.3% with need for laparoconversion in 3.2%. Sixty patients required blood transfusion (13.7%), and rectovaginal fistulae were the most frequent postoperative complication (3.2%). CONCLUSION: Laparoscopic colorectal resection for endometriosis is a relatively safe procedure in a context of close collaboration between gynecologists and surgeons, although it requires adequate training.

Two case reports of bowel leiomyomas and review of literature.

We report two cases of two women underwent laparoscopic hysterectomy and myomectomy. During surgery, three myomas were identified as completely detached from the uterus, and attached to the bowel. Patients's history revealed a laparoscopic myomectomy. Our first hypothesis therefore was that these were lost myomas of the first surgery. However, only one leyomyoma was removed in both patients. Therefore, we can assume that these myomas were not certainly not lost-myomas and we may conclude that it could be either as residues of previous morcellation or they were pedunculated-myomas that have been spontaneously detached from the uterus and re-implanted onto the bowel.

Symptomatic vaginal bleeding in a postmenopausal woman revealing colon adenocarcinoma metastasizing exclusively to the vagina.

Vaginal carcinomas are rare entities, accounting for 2% of all malignant cancers of the female genital tract, and the vast majority are metastatic. Adenocarcinoma of the colon metastasizing to the vagina is extremely rare, only 5 cases have been reported. We present the case of a woman who experienced vaginal bleeding as an isolated symptom of vaginal metastasis of colorectal adenocarcinoma. Vaginal localization of metastasis from colorectal cancer significantly worsens the survival prognosis, and a standard treatment has not yet been proposed. Potential mechanisms of spread of colorectal cancer to the vagina and therapeutic approaches are discussed. In this case, treatment included surgery and chemotherapy.

Laparoscopic nerve-sparing transperitoneal approach for endometriosis infiltrating the pelvic wall and somatic nerves: anatomical considerations and surgical technique.

PURPOSE: Endometriotic or fibrotic involvement of sacral plexus and pudendal and sciatic nerves may be quite frequently the endopelvic cause of ano-genital and pelvic pain. Feasibility of a laparoscopic transperitoneal approach to the somatic nerves of the pelvis was determined and showed by Possover et al. for diagnosis and treatment of ano-genital pain caused by pudendal and/or sacral nerve roots lesions and adopted at our institution. In this paper we report our experience and anatomo-surgical consideration regarding this technique. METHODS: Confidence with this technique was obtained after several laparoscopic and laparotomic dissections on fresh, embalmed and formalin-fixed female cadavers and is now routinely performed at our institution in all cases of extensive endometriosis of the pelvic wall, involving the somatic nerves. RESULTS: We describe two different laparoscopic transperitoneal approaches to the lateral pelvic wall in case of: (A) deep pelvic endometriosis with rectal and/or parametrial involvement extending to pelvic wall and somatic nerves; (B) isolated endometriosis of pelvic wall and somatic nerves. CONCLUSIONS: Laparoscopic transperitoneal retroperitoneal nerve-sparing approach to the pelvic wall proved to be a feasible and useful procedure even if limited to referred laparoscopic centers and anatomically experienced and skilled surgeons.

Laparoscopic management of ureteral endometriosis.

PURPOSE OF REVIEW: Severe endometriosis is a leading cause of infertility and pelvic pain and represents one of the most challenging cases in gynecology. Ureteral endometriosis is a rare entity that can lead to ureteral obstruction with subsequent hydroureter, dilatation of the renal pelvis till kidney failure. Laparoscopic management of these lesions is considered the treatment of choice. RECENT FINDINGS: A few studies offer new insights into the laparoscopic management of ureteral endometriosis and the most common surgical procedures are described. SUMMARY: In cases of moderate-severe hydronephrosis due to ureteral endometriosis, laparoscopic ureteral transection (ureterostomy or ureterocystoneostomy) provides good results with low recurrence rates.

Total laparoscopic hysterectomy of an uterus of 1840 grams: a case report.

This case report describes a total laparoscopic hysterectomy of a large uterus of a woman who recently underwent neurosurgery for a grade IV glioblastoma. Because of a severe anaemia due to chronic vaginal haemorrhage for a fibromatosis uterus, she was not able to start a chemotherapic oncological protocol. We thus decided to perform a total hysterectomy through a laparoscopic approach in order to reduce the hospital stay and to ensure a quick recovery. We studied a surgical but also anaesthesiological strategy in order to obtain a good result with no or as few as possible complications.

Barium enema evaluation of colonic involvement in endometriosis.

OBJECTIVE: The purpose of our study was to define the role of double-contrast barium enema (DCBE) compared with laparoscopy in the diagnosis and local staging of intestinal endometriosis. MATERIALS AND METHODS: A search of our radiology database revealed the cases of 234 women who underwent surgical resection for pelvic endometriosis with associated intestinal surgery for intestinal endometriosis. We retrospectively evaluated all preoperative DCBE images for the presence of bowel endometriosis and the number, site (rectum, sigmoid, cecum), and size of the lesions. The radiographic findings at DCBE were retrospectively correlated with those at surgical pathologic examination. RESULTS: DCBE revealed 211 intestinal lesions of bowel endometriosis in 168 (71.8%) of 234 patients with pelvic endometriosis clinically enrolled. Forty (23.8%) of the 168 women had more than one endometriotic bowel nodule (two nodules in 37 cases, three in three cases). Laparoscopy revealed 233 intestinal lesions in 174 (74.3%) of the patients. Fifty-four (31.0%) of 174 women had more than one endometriotic bowel nodule (two nodules in 49 cases, three in five cases). There was 100% correlation between the DCBE and histologic findings as far as site and size of the lesions were concerned. DCBE had a sensitivity of 88.4%, specificity of 93.0%, positive predictive value of 97.5%, negative predictive of 71.0%, and accuracy of 89.5% in the identification of bowel endometriosis. CONCLUSION: DCBE is helpful in discerning bowel wall involvement in endometriosis, enabling proper surgical planning. DCBE also appears to have a role in the management of endometriosis.