Thai Interest Group for Endometriosis (TIGE) consensus statement on endometriosis-associated pain.

This consensus statement has been developed by the Thai Interest Group for Endometriosis (TIGE) for use by Thai clinicians in the diagnosis and management of endometriosis. TIGE is a group of clinical and academic gynaecologists with a particular interest in endometriosis. Endometriosis is an oestrogen-dependent inflammatory disease which causes chronic symptoms such as dysmenorrhoea, chronic pelvic pain, dyspareunia and subfertility, and it is common in reproductive-age women. There is limited overall data on its prevalence in different clinical settings in Thailand, but it is clear that the disease causes significant problems for patients in terms of their working lives, fertility, and quality of life, as well as placing a great burden on national healthcare resources. Decisions about selecting the appropriate treatment for women with endometriosis depend on many factors including the age of the patient, the extent and severity of disease, concomitant conditions, economic status, patient preference, access to medication, and fertility need. Several hormonal treatments are available but no consensus has been reached about the best option for long-term prevention of recurrence. Bearing in mind differences in environment, genetics, and access to the healthcare system, this treatment guideline has been tailored to the particular circumstances of Thai women.

A randomized, double-blind, placebo-controlled trial of oral pregabalin for relief of shoulder pain after laparoscopic gynecologic surgery.

STUDY OBJECTIVE: To investigate the efficacy of pregabalin for the relief of postoperative shoulder pain after laparoscopic gynecologic surgery. DESIGN: Prospective, randomized, double-blind, placebo-controlled trial (Canadian Task Force classification I). SETTING: Tertiary referral center, university hospital. PATIENTS: Fifty-six women undergoing elective laparoscopic gynecologic surgery between June 2012 and March 2013. INTERVENTIONS: Women in the study group received 75 mg pregabalin 2 hours before surgery and then every 12 hours for 2 doses, and women in the control group received an identical capsule and the same dosage of placebo. MEASUREMENTS AND MAIN RESULTS: Visual analog scale (VAS) scores for shoulder pain and surgical pain at 24 and 48 hours after surgery were evaluated as primary outcome. Postoperative analgesics used and drug-related adverse events were also monitored. Patients in the pregabalin group had significantly lower postoperative VAS scores for shoulder pain at 24 hours, compared with the placebo group (median, 23.14 [range, 13.67-32.61] vs. 37.22 [27.75-46.64]; p = .04), and required less analgesic (p = .01). There were no significant differences in VAS scores for surgical pain and adverse events between the 2 groups (p = .56). CONCLUSIONS: Perioperative administration of 75 mg pregabalin significantly reduced postoperative laparoscopic shoulder pain and amount of analgesic used.

A randomized, prospective study comparing the use of the missile trocar and the pyramidal trocar for laparoscopy access.

BACKGROUND: The missile trocar was developed for smooth abdominal penetration of the primary port. It contains a longitudinal tunnel connecting the abdominal cavity with the outside. OBJECTIVE: To evaluate the efficacy of the missile trocar compared with the traditional method using the Veress needle. MATERIAL AND METHOD: The times required to enter the abdominal cavity and the difficulty of the procedure were compared with the traditional Veress needle. A blind technique was used on 100 consecutive patients in a randomized fashion. RESULTS: The missile trocar technique took 2.7 +/- 1.6 minutes to perform compared with 3.9 +/- 1.3 min in the Veress needle group (p = 0.001), and the difficulty of the procedure was 2.1 +/- 1.9 cm (p = 0.433) rated from 10-cm scale. No carbon dioxide leakage or serious complications occurred in any patient. CONCLUSION: The results of the present study indicate that a long-tip missile trocar technique may be used safely when the technique is fully understood. This procedure is a relatively quick alternative approach for laparoscopy.

Diagnostic accuracy of 3D-transvaginal ultrasound in detecting uterine cavity abnormalities in infertile patients as compared with hysteroscopy.

OBJECTIVE: To assess diagnostic accuracy of 3D transvaginal ultrasound (3D-TVS) compared with hysteroscopy in detecting uterine cavity abnormalities in infertile women. STUDY DESIGN: This prospective observational cross-sectional study was conducted during the July 2013 to December 2013 study period. Sixty-nine women with infertility were enrolled. In the mid to late follicular phase of each subject's menstrual cycle, 3D transvaginal ultrasound and hysteroscopy were performed on the same day in each patient. Hysteroscopy is widely considered to be the gold standard method for investigation of the uterine cavity. Uterine cavity characteristics and abnormalities were recorded. Diagnostic accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios were evaluated. RESULTS: Hysteroscopy was successfully performed in all subjects. Hysteroscopy diagnosed pathological findings in 22 of 69 cases (31.8%). There were 18 endometrial polyps, 3 submucous myomas, and 1 septate uterus. Three-dimensional transvaginal ultrasound in comparison with hysteroscopy had 84.1% diagnostic accuracy, 68.2% sensitivity, 91.5% specificity, 79% positive predictive value, and 86% negative predictive value. The positive and negative likelihood ratios were 8.01 and 0.3, respectively. 3D-TVS successfully detected every case of submucous myoma and uterine anomaly. For detection of endometrial polyps, 3D-TVS had 61.1% sensitivity, 91.5% specificity, and 83.1% diagnostic accuracy. CONCLUSION: 3D-TVS demonstrated 84.1% diagnostic accuracy for detecting uterine cavity abnormalities in infertile women. A significant percentage of infertile patients had evidence of uterine cavity pathology. Hysteroscopy is, therefore, recommended for accurate detection and diagnosis of uterine cavity lesion.

Five years follow up of laparoscopic burch colposuspension for stress urinary incontinence in Thai women.

OBJECTIVES: To study the cure rate and 5 year results of laparoscopic burch colposuspension for stress urinary incontinence in Thai women. MATERIAL AND METHOD: Twenty one Thai women with stress urinary incontinence attending the gynecology clinic at King Chulalongkorn Memorial hospital were recruited. Pre operative clinical and urodynamic evaluation were done. They underwent Laparoscopic burch colposuspension between January - December 1998. The cure rate was evaluated by clinical and urodynamic examination. RESULTS: The mean +/- SD of operative time, blood loss and hospital stay were 70 +/- 20 min, 140 +/- 30 ml and 1.6 +/- 0.5 days respectively. The complication rate was 19.1% (Bladder injuries 2 cases, voiding difficulties 1 case and de novo detrusor overactivity 1 case). The objective cure rate at 5 years was 76.2%. CONCLUSION: The authors found that the cure rate was rather low in laparoscopic burch colposuspension. Due to the long operative time, the requirement of complicated instruments and well trained physicians, the authors suggested that this technique should be selected only in cases of women with concomitant gynecologic disease that required lapascopic surgery.

The three years results of tension free vaginal tape (TVT) for the treatment of stress urinary incontinence in Thai women.

OBJECTIVE: To evaluate the three years result of TVT procedure in Thai women with genuine stress urinary incontinence (SUI). MATERIAL AND METHOD: Sixty three women, aged 35 - 71 years attending the gynecology clinic at King Chulalongkorn Hospital from February 2000 to May 2001 were recruited in the present study. Pre-operative evaluation included history taking and physical examination. All had stress urinary incontinence urodynamically confirmed genuine stress urinary incontinence and were treated with TVT Follow up at 3, 6, 12, 18, 24, 30 and 36 months were scheduled after surgery. RESULTS: The mean +/- SD of operative time for TVT was 32.3 +/- 10.0 min the mean +/- SD of hospitalization was 1.8 +/- 2.0 days. Two patients had bladder perforations by the trocar without severe bleeding and needed no reparation. No healing defect or rejection of the prolene mesh was found. The cure rate and improved rate were 95.2% and 4.8% respectively (60 from 63 cases) at 3 years follow up. CONCLUSION: The three years results revealed that TVT was effective and safe in the treatment of SUI in Thai women.

Prevalence of genital prolapse in Thai menopausal women (using new standardization classification).

BACKGROUND: There is an increasing number of menopausal women in Thailand (estimation of 5 million women). There is no published data on the prevalence of genital prolapse among Thai menopausal woman. So the authors created this hospital based study to identify the magnitude of this problem in Thai menopausal women. OBJECTIVE: To study the prevalence and symptoms of genital prolapse in Thai menopausal women attending the menopausal clinic in King Chulalongkorn Memorial Hospital. STUDY DESIGN: Descriptive study (Cross-sectional study). MATERIAL AND METHOD: Two hundred and fifteen Thai menopausal women attending the menopause clinic at King Chulalongkorn Memorial Hospital from the 1st of January to the 28th of February 2004 were recruited. Urinary symptoms history taking and pelvic examination were done. The severity of any prolapse was classified using International Continence Society classification. RESULTS: Prevalance of Thai menopausal women having any type of genital prolapse was 43.3%. Anterior vaginal wall prolapse and superior vaginal prolapse were the two highest prevalences of genital prolapse (29.3% and 14.9%). The prevalence of genital prolapse increased by the menopausal age. The two leading symptoms were stress incontinence and vaginal outlet relaxation (89.3% and 51.6%). CONCLUSION: From the present study, the authors found the prevalence of any genital prolapse (43.3%) and stress incontinence(89.3%) among Thai women attending menopausal clinic in King Chulalongkorn Memorial Hospital. The authors strongly recommend pelvic examination and urinary-symptoms history taking to evaluate the severity of genital prolapse.

Laparoscopic enucleation of an endometriotic cyst in a renal transplant patient. A case report.

BACKGROUND: Laparoscopic enucleation of an endometriotic cyst in a renal transplant patient has not been reported before. CASE: An endometriotic cyst was found in the same side as a transplanted kidney. Laparoscopic enucleation of the cyst was performed. CONCLUSION: A renal transplant patient with an endometriotic cyst can be treated successfully with laparoscopic enucleation.

Risk factors of ectopic pregnancy.

OBJECTIVES: To assess the risk factors of ectopic pregnancy in Thai women. SETTING: Department of Obstetrics and Gynaecology, Faculty of Medicine, Chulalongkorn University. DESIGN: Case controlled study. MATERIAL AND METHOD: From 1999 to 2000, 208 cases of ectopic pregnancy and 781 controls (postpartum women) were included in the study. The women were interviewed by trained research interviewers using a standardized questionnaire. Detailed information regarding age at first intercourse, number of sexual partners, history of changing partners within 6 months, previous obstetric history, history of spontaneous and criminal abortion, history of pelvic inflammatory disease, smoking, history of endometriosis and history of previous ectopic pregnancy was collected. RESULTS: By multivariate analysis, 5 variables remained as strong and independent risk factors for ectopic pregnancy: the number of sexual partners > or = 2 (OR = 3.02, 95% CI (1.75-5.23), vaginal delivery > or = 1 (OR = 0.005, 95% CI (0.002-0.0015), history of pelvic inflamatory disease (OR = 3.17, 95% CI (1.40-7.19), smoking (OR = 2.49, 95% CI (1.36-4.55), infertility (OR = 2.74, 95% CI (1.35-5.54)). CONCLUSION: Problems of multiple sexual partners, pelvic inflammatory disease, smoking and infertility were the main risk factors of ectopic pregnancy in Thai women.

The preemptive analgesic effect of celecoxib for day-case diagnostic laparoscopy.

In a randomized trial, the preemptive analgesic effect of celecoxib in 110 infertile women undergoing day-case diagnostic laparoscopy was studied at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. The patients randomly received either 200 mg celecoxib or placebo orally 2 hours before diagnostic laparoscopy. The post-operative shoulder pain and wound pain were self assessed and recorded, using Visual Analogue Scores (VAS) at 1, 2, 4, 12, and 24 hours. Total post-operative analgesic requirements were recorded at 24 hours. The mean Visual Analogue Scores (VAS) of shoulder pain in celecoxib group was statistically lower than those of the placebo group (p = 0.04). Nevertheless, the mean VAS of wound pain and the total post-operative analgesic requirements were not significantly different. It was concluded that the preemptive celecoxib in day-case diagnostic laparoscopy might have the advantage of decreasing post laparoscopic shoulder pain.

Long term results of anterior colporrhaphy with Kelly plication for the treatment of stress urinary incontinence.

OBJECTIVE: To study the five years' outcome of anterior colporrhaphy with Kelly plication for the treatment of stress urinary incontinence MATERIAL AND METHOD: Fifty two patients who underwent anterior colporrhaphy with Kelly plication with or without posterior colpoperineorrhapy for the treatment of stress urinary incontinence between January 1997 and February 1998 in King Chulalongkorn Memorial hospital were included in the study. All patients were contacted by phone, forty seven patients (90.38%) responded and were willing to participate in the present study. The patients' characteristics, operative data and outcome were reviewed. Questionnaires designed to assess the outcomes of the procedure and incontinence symptoms were given to each patient at the appointment date. Pelvic examination was performed using the Baden halfway classification for genital prolapse grading. Cough test was performed during pelvic examination for the objective demonstration of stress incontinence. RESULTS: The mean +/- SD of age was 46.68 +/- 8.78 yrs. The authors found that the incidence of post operative urinary retention was 43.3%. Incontinence rates at 1, 2, 3, 4 and 5 years were 0, 8.51%, 21.28%, 29.79% and 46.81% respectively. CONCLUSION: The present results show the high recurrence rate at the five-year follow up. The authors emphasized the need of long term follow up and pre-operative counseling about the high chance of having recurrence by this operative technique.

Location of quinacrine pellets in different positions of non-surgical female sterilization.

OBJECTIVE: To compare quinacrine pellets distribution in the uterine cavity between women standing up promptly after insertion and those lying down for a further 30-minutes. DESIGNS: Randomized controlled trial MATERIAL AND METHOD: Twenty women who, desired interval female sterilization, were equally randomized into 2 groups. Quinacrine pellets were inserted twice, one month apart in both groups. Transvaginal ultrasonography (TVS) was performed after insertion in order to locate the position of the quinacrine pellets. In group I, the TVS was performed after the women stood up promptly. In group II, the TVS was performed after the women lay down for 30-minute. The distribution of quinacrine pellets, measured from the uterine fundus to the lowest pellet, were compared. RESULTS: There was no difference at the baseline and 30 minutes measurement of both groups. In the first insertion, there was statistical difference of the distance of the quinacrine pellets when compared in the same group immediately and the 30-minute measurement (Gr 1: 19.10+/-3.28 mm vs 22.30+/-3.50 mm); (Gr 2: 18.70+/-3.40 mm vs 24.40+/-5.95 mm). In the same manner, the authors found statistical difference in the same group of the second insertion (Gr 1: 21.80+/-5.39 mm vs 24.70+/-7.24 mm); (Gr 2 : 20.89+/-4.78 mm vs 28.30+/-7.59 mm) CONCLUSIONS: There was statistical difference of quinacrine pellet distribution in uterine cavity after time. However, body movement did not effect the position of the pellets. The failure rate of quinacrine pellet insertion for non-surgical female sterilization may not be explained by the changes of position after insertion.

Serum beta-hCG regression after laparoscopic salpingostomy in the treatment of ectopic pregnancy in Thai women.

This is a descriptive study which reviewed the regression pattern of serum beta hCG in Thai women with ectopic pregnancy after laparoscopic salpingostomy. The study group included the medical records of 21 patients who underwent laparoscopic salpingostomy between January 1991 and August 2001. The results revealed that the regression of serum beta hCG in patients with ectopic pregnancy after laparoscopic salpingostomy was about 10, 100, 1,000 times at day 6, 20 and 35 after operation. The correlation between days after operation and serum beta hCG was in the equation of log (beta hCG difference) = -0.0671 (days after operation) - 0.6187. This estimation curve can probably be used to predict the normal serum beta-hCG regression after laparoscopic salpingostomy.

Laparoscopic finding in Thai women with chronic pelvic pain.

OBJECTIVE: To study the laparoscopic findings in Thai women with chronic pelvic pain. SETTING: The Gynecology Endoscopy unit, Department of Obstetrics and Gynecology, Faculty of Medicine, King Chulalongkorn Memorial hospital. DESIGN: Descriptive study. MATERIAL AND METHOD: The medical records of Thai women with chronic pelvic pain undergoing laparoscopic diagnosis from January 1996 to December 2001 at King Chulalongkorn Hospital were reviewed. Patients' characteristics and laparoscopic findings were reviewed and analyzed. RESULTS: One hundred and ten eligible women were enrolled in this study. The mean age was 33.9 +/- 7.2 years old (16-54 years old). Sixty-seven (60.90%) women had endometriosis, 14 (12.73%) women had pelvic adhesion, 4 (3.64%) women had myoma uteri, 4 (3.64%) women had tubal occlusion and 13 (11.81%) women had normal findings. The majority (38.15%) of endometriosis findings were in minimal stage of American Fertility Society (AFS) scores. CONCLUSIONS: The vast majority of causes of chronic pelvic pain in women in this study was pelvic endometriosis. Laparoscopic diagnosis was an important tool for identifying the causes in Thai patients.

Rectus sheath hooking: alternative method of abdominal wall lifting and fixing for laparoscopy: a pilot cadaver bio-mechanical study.

Four bio-mechanical tests were used to study properties of the rectus sheath for laparoscopic abdominal access procedure and to provide surgical exposure by the ChulaLift gasless retractor. The profile of forces and displacement showed how some patients were good candidates for the gasless operation. The lifting weight should not excess 10 kg for minimal harm and optimal exposure. The rectus hooking could be an alternative choice for abdominal wall fixing during the first trocar entry. One-cm width hooking, the rectus sheath could withstand 18-20 kg lifting force. The exposure provided by the gasless technique was narrow between the lateral ports compared to the conventional technique. The rectus sheath could be hooked to provide effective fixing of the area to be penetrated by the first trocar, and this fascial layer could be lifted to produce exposure in the gasless technique.

Dilating missile trocar for primary port establishment: a cadaver study.

The missile trocar was developed for controllable entry force, smaller fascial defects and post-operative pain improvement. The trocar was composed of a fascial-dilating long-conical head and a handle. Accompanied with this trocar, the authors designed a rectus sheath-hooking instrument to promote negative intra-abdominal pressure during the trocar puncture. The hooking procedure allowed room air to pass through the central canal of the trocar and fill the space between the intestinal loops and the trocar tip. The abdominal access procedure succeeded in forty-five attempts in fresh cadavers. No second attempt was done. The trocar accessed into the peritoneal cavity at every attempt without intestinal penetration. The missile trocar may be an alternative device for establishment of the primary port. Its efficacy and safety still has to be proved.

Feasibility and safety of robotic surgery for gynecologic cancers.

BACKGROUND: To determine surgical outcomes, perioperative complications, and patient outcomes in gynecologic cancer patients undergoing robotic surgery. MATERIALS AND METHODS: Surgical outcomes, including docking time, total operative time, console time, estimated blood loss (EBL), conversion rate and perioperative complications were retrospectively reviewed in 30 gynecologic cancer patients undergoing robotic surgery. Patient outcomes included recovery time and patient satisfaction, as scored by a visual analogue scale (VAS) from 0-10. RESULTS: The operations included 24 hysterectomies with pelvic lymphadenectomy (PLD) and/or para-aortic lymphadenectomy, four radical hysterectomies with PLD, and two radical trachelectomies with PLD. Mean docking time was 12.8 ± 9.7 min, total operative time was 345.5 ± 85.0 min, and console time was 281.9 ± 78.6 min. These times were decreased in the second half of the cases. There was no conversion rate. Three intraoperative complications, including one external iliac artery injury, one bladder injury, and one massive bleeding requiring blood transfusion were reported. Postoperative complications occurred in eight patients, most were minor. Only one patient had port herniation that required reoperation. Mean hospital stay was 3.5 ± 1.7 days, and recovery time was 14.2 ± 8.1 days. Two-thirds of patients felt very satisfied and one-third felt satisfied; the mean satisfaction score was 9.4 +0.9. Two patients with stage III endometrial cancer developed isolated port site metastasis at five and 13 months postoperatively. CONCLUSIONS: Robotic surgery for gynecologic cancer appears to be feasible, with acceptable perioperative complication rate, fast recovery time and high patient satisfaction.

Disseminated gonococcal infection during pregnancy.

BACKGROUND: Disseminated gonococcal infection in pregnancy is rare with the incidence of 0.04-0.09% in pregnant women. Its most common manifestation is arthritis. CASE: A 38-year-old woman, G1P0, 36+ weeks pregnancy came to hospital with decreased fetal movement. She had purulent vaginal discharge and history of self treatment 1 month earlier. She had a fever with arthritis for 3 days. Purulent joint fluid from arthrocentesis of her right wrist demonstrated intracellular Gram negative diplococcal bacteria. The diagnosis was disseminated gonococcal infection. She was successfully treated with parenteral ceftriaxone followed by oral cefixime. Cesarean section was performed due to preterm premature rupture of the membranes. The maternal and neonatal outcomes were uneventful. CONCLUSION: Disseminated gonococcal infections are not rare, however, disseminated gonococcal infection in pregnancy is a rare condition. Clinicians should be suspicious of the disease when a pregnant patient presents with arthritic symptoms.