Painful sexual intercourse, quality of life and sexual function in patients with endometriosis: not just deep dyspareunia.

PURPOSE: To evaluate the prevalence of deep and superficial dyspareunia in women with diagnosis of endometriosis. Secondly, to assess the temporal relation between deep and superficial dyspareunia in women reporting both symptoms (concomitant dyspareunia) and the impact on quality of life (QoL) and sexual function. METHODS: This is a cross-sectional cohort study that included fertile women with diagnosis of endometriosis. Enrolled subjects reported pain symptoms including dyspareunia and its temporal onset and completed two one-time validated questionnaires regarding sexual function (Female Sexual Function Index) and QoL (International QoL Assessment SF-36). RESULTS: Among the 334 enrolled patients, 75.7% (95%) reported dyspareunia. Women were divided into four groups according to the presence and type of dyspareunia: isolated superficial dyspareunia (6.3%), isolated deep dyspareunia (26.0%), concomitant dyspareunia (43.4%) and no dyspareunia (24.3%). Women with concomitant dyspareunia reported higher NRS scores than women with isolated dyspareunia or no dyspareunia (P ≤ 0.001). The majority of women with concomitant dyspareunia (56.6%) reported that deep dyspareunia developed before superficial dyspareunia. Women with concomitant dyspareunia reported worse QoL and worse sexual function than women with isolated dyspareunia or without dyspareunia (P ≤ 0.001). CONCLUSION: Dyspareunia is a common symptom in women with endometriosis, with many reporting concomitant deep and superficial dyspareunia. Concomitant dyspareunia can significantly impact sexual function and quality of life (QoL). Therefore, it is crucial to investigate dyspareunia thoroughly and differentiate between its types to tailor effective therapeutic strategies.

Dienogest alone or dienogest combined with estrogens in the treatment of ovarian endometriomas, that is the question. A retrospective cohort study.

PURPOSE: to compare the effects of Dienogest 2 mg (D) alone or combined with estrogens (D + ethinylestradiol 0.03 mg, D + EE; D + estradiol valerate 1-3 mg, D + EV) in terms of symptoms and endometriotic lesions variations. METHODS: This retrospective study included symptomatic patients in reproductive age with ultrasound diagnosis of ovarian endometriomas. Medical therapy for at least 12 months with D, D + EE or D + EV was required. Women were evaluated at baseline visit (V1) and after 6 (V2) and 12 months (V3) of therapy. RESULTS: 297 patients were enrolled (156 in the D group, 58 in the D + EE group, 83 in the D + EV group). Medical treatment leaded to a significant reduction in size of endometriomas after 12 months, with no differences between the three groups. When comparing D and D + EE/D + EV groups, a significant decrease of dysmenorrhea was detected in the D group than in D + EE/D + EV group. Conversely, the reduction of dysuria was more significative in the D + EE/D + EV groups rather than in the D group. Regarding tolerability, treatment associated side effects were reported by 16.2% patients. The most frequent one was uterine bleeding/spotting, significantly higher in the D + EV group. CONCLUSION: Dienogest alone or associated with estrogens (EE/EV) seems to be equally effective in reducing endometriotic lesions mean diameter. The reduction of dysmenorrhea was more significative when D was administered alone, while dysuria seems to improve more when D is associated with estrogens.

Effects of Pelvic Floor Muscle Physiotherapy on Urinary, Bowel, and Sexual Functions in Women with Deep Infiltrating Endometriosis: A Randomized Controlled Trial.

Background and Objectives: Endometriosis is a chronic and recurrent disease defined as the presence and proliferation of endometrial glands and stroma outside the uterine cavity. It affects up to 6-10% of women of reproductive age and can be classified into superficial, ovarian, and deep infiltrating endometriosis (DIE). Deep infiltrating endometriosis can be associated with pain symptoms and pelvic floor muscle hypertone. Moreover, it may be responsible of bowel, urinary, and sexual dysfunctions with impairment of women's quality of life. Few studies have investigated the role of physiotherapy in women with DIE. Here, we aimed first to evaluate the effects of pelvic floor physiotherapy (PFP) on urinary, bowel, and sexual functions. Secondly, we aimed to evaluate the effects of ultrasound visual feedback during PFP on pelvic floor and subjective modifications in the frequency of sexual intercourse. Materials and Methods: This randomized controlled trial was conducted between June 2018 and December 2019 at our tertiary center. Nulliparous women with DIE and superficial dyspareunia were enrolled. At first examination, levator hiatal area (LHA) assessed with 3D/4D transperineal ultrasound, pain symptoms, urinary, bowel, and sexual functions were evaluated. Then, women were randomly assigned to no intervention (control group) or treatment with five individual sessions of PFP (experimental group), and after four months women underwent a second examination. Urinary, bowel, and sexual functions were assessed with validated questionnaires at first and second examinations. In particular, the Bristol Female Lower Urinary Tract Symptoms questionnaire was used to evaluate urinary symptoms, the Knowles-Eccersley-Scott-Symptom questionnaire to assess the presence of constipation, and the Female Sexual Function Index to investigate sexual function. Study outcomes were the comparisons among groups in terms of differences in actual changes in median of questionnaire scores between first and second examinations. Results: Thirty women (17 in the experimental group and 13 in the control group) completed the study. No significant differences were found between the two groups regarding urinary, bowel, and sexual functions, although women in the experimental group showed a tendency towards an improvement in constipation symptoms. Conclusion: In women with DIE, PFP does not appear to affect urinary, bowel, and sexual functions. Therefore, despite the improvement in superficial dyspareunia, chronic pelvic pain, and PFM relaxation with high treatment satisfaction, women should be informed about the unclear impact of PFP on urinary, bowel, and sexual functions. Larger studies are necessary to further investigate the impact of PFP on these functions.

Three-Dimensional Ultrasound Evaluation of Pelvic Floor Muscle Contraction in Women Affected by Deep Infiltrating Endometriosis: Application of a Quick Contraction Scale.

OBJECTIVES: Using transperineal 3D/4D ultrasound, we evaluated the prevalence of the various categories of a 4-point pelvic contraction scale among women affected by ovarian endometriosis (OE), deep infiltrating endometriosis (DIE), and healthy controls. METHODS: This prospective study was conducted on nulliparous women scheduled for surgery to remove endometriosis, and nulliparous healthy volunteers who did not show any clinical or sonographic signs of endometriosis, who served as controls. Patients were subjected to 3D/4D transperineal ultrasound obtaining measurements of the antero-posterior diameter (APD), both at rest and during maximal pelvic floor muscle (PFM) contraction (PFMC). The difference of APD from rest to maximal PFMC was then calculated as percent change from baseline (ΔAPD) and patients were thus categorized using the 4-point pelvic contraction scale. RESULTS: One hundred sixty-four patients were considered for the study. Mean difference in APD between relaxed state and maximal PFMC was 23.3 ± 7.9% (range 2.4-40.0) in controls, 20.5 ± 9.0% (range 0.0-37.3) in patients with OE, and 14.6 ± 10.4% (range 0.0-37.1) in patients with DIE (F-test = 19.5, P-value < .001). A significant negative correlation was found between the contraction scale and dyspareunia (rs = -0.17, P = .032), and it appeared to be stronger among patients with DIE (rs = -0.20, P = .076). CONCLUSIONS: PFM function in endometriotic patients could be assessed reliably through this 4-point scale. The rapid identification of women suffering from PFM dysfunction, along with deep dyspareunia, could enable gynecologists to offer them additional therapies, such as PFM rehabilitation.

Comparison of perioperative outcomes between standard laparoscopic and robot-assisted approach in patients with rectosigmoid endometriosis.

INTRODUCTION: Robot-assisted laparoscopic surgery (RALS) has gained widespread application in several surgical specialties. Previous studies on the feasibility and safety of RALS vs standard laparoscopy (S-LPS) for rectosigmoid endometriosis are limited and reported conflicting data. This study aims to compare S-LPS and RALS in patients with rectosigmoid endometriosis in terms of perioperative surgical and clinical data. MATERIAL AND METHODS: This is a multicentric, observational, prospective cohort study including 44 patients affected by rectosigmoid endometriosis referred to two tertiary referral centers for endometriosis from September 2018 to September 2019. Patients were divided into two groups: 22 patients underwent S-LPS, and 22 underwent RALS. Our primary outcome was to compare operative time (from skin incision to suture) between the two groups. Secondary outcomes included: operative room time (patient entry into operative room and patient out), estimated blood loss, laparotomic conversion rate, length of hospital stay, perioperative complications, and evaluation of endometriosis-related symptoms at 12-month follow up. RESULTS: The two groups were comparable regarding preoperative and surgical data, except for higher rates of hysterectomies and bilateral uterosacral ligament removal procedures in the RALS group. Also after adjusting for these discrepancies, operative time was similar between S-LPS and RALS. Operative room time was statistically longer in the RALS group compared with that of S-LPS. No statistically significant difference was found concerning other study outcomes. Pain and bowel symptoms improved in both groups at 12-month follow up. CONCLUSIONS: If performed by expert teams, RALS provides similar perioperative outcomes compared with S-LPS in rectosigmoid endometriosis surgical treatment, except for longer operative room time.

Indocyanine Green Fluorescence Angiography after Full-thickness Bowel Resection for Rectosigmoid Endometriosis-A Feasibility Study.

STUDY OBJECTIVE: To evaluate feasibility of near-infrared (NIR)-indocyanine green (ICG) imaging for bowel vascularization assessment after full-thickness bowel resection for rectosigmoid endometriosis (RSE). DESIGN: This is a prospective, single-center, preliminary study on consecutive patients who were symptomatic submitted to discoid or segmental resection for RSE and NIR-ICG evaluation for vascular assessment of the anastomotic line from May 2018 to January 2020. SETTING: Tertiary university hospital. PATIENTS: Thirty-two women with RSE meeting eligibility criteria were included for study analysis. INTERVENTIONS: NIR-ICG evaluation of anastomotic line vascularization after RSE removal. MEASUREMENTS AND MAIN RESULTS: Fluorescence degree of the anastomotic line was assessed with a 0 to 2 Likert scale, as follows: 0 or "absent" (no fluorescence observed), 1 or "irregular" (not uniform distribution or weak fluorescence), and 2 or "regular" (uniform distribution of fluorescence and similar to the proximal colon). In all the patients included in the study (100%), NIR-ICG imaging allowed the evaluation of fluorescence degree of the anastomotic line. No adverse reaction related to ICG use was recorded. The protocol did not greatly lengthen operating time (median, 4 [range, 3-5] minutes). Excellent interoperator agreement was observed. Most of the patients (31 of 32, 96.9%) showed regular fluorescence on the anastomotic line; in 1 patient with irregular fluorescence at NIR-ICG after discoid excision, the anastomotic suture was reinforced through interrupted stitches. We had 1 case of anastomotic leakage after segmental resection with intraoperative good fluorescence at NIR-ICG evaluation. CONCLUSION: NIR-ICG imaging for anastomotic perfusion assessment after discoid or segmental resection for RSE seems to be a feasible, safe, and reproducible method.

Use of Indocyanine Green for Intraoperative Perfusion Assessment in Women with Ureteral Endometriosis: A Preliminary Study.

STUDY OBJECTIVE: To evaluate the feasibility, safety, and potential usefulness of near-infrared imaging (NIR) with indocyanine green (ICG) to assess ureteral perfusion after conservative surgery (ureterolysis or nodule removal) for ureteral endometriosis. Any changes to the surgical plan regarding intraoperative ureteral stent placement after NIR-ICG evaluation and early postoperative outcomes were recorded. DESIGN: Prospective case series study. SETTING: Tertiary level referral center for endometriosis and minimally invasive gynecology. PATIENTS: Consecutive symptomatic women scheduled for laparoscopic conservative ureteral surgery for ureteral endometriosis. INTERVENTIONS: After ureterolysis or nodule removal, residual perfusion of the ureters with regular caliber and peristalsis was evaluated through NIR-ICG imaging. Ureteral perfusion grade was defined as absent, irregular, or regular. Time required for NIR-ICG assessment, interoperator agreement regarding ureteral perfusion grade, any changes to the surgical plan after NIR-ICG evaluation, perioperative complications, and clinical-radiologic outcomes at early follow-up were recorded. MEASUREMENTS AND MAIN RESULTS: A total of 31 ureters were examined with NIR-ICG imaging after conservative ureteral procedures. ICG assessment required 5.4 + 2.3 minutes. No complications related to fluorescence imaging were observed. Local ischemia supporting ureteral stent placement was suspected in 5 ureters (16.1%) at white light. Of these, 2 (40.0%) presented regular fluorescence; thus, ureteral stent placement was avoided. In the remaining 3 (60.0%), NIR-ICG confirmed irregular or absent fluorescence, requiring ureteral stent placement. Interoperator agreement regarding NIR-ICG evaluation was high. At a 3-month follow-up, all procedures were clinically and radiologically successful. CONCLUSION: NIR-ICG imaging after conservative surgery for ureteral endometriosis seems to be a feasible, safe, and useful tool to assess ureteral perfusion and guide surgical decision, together with other visual cues at white light. However, this approach needs to be validated by further larger and controlled studies.

Long-Term Medical Therapy after Laparoscopic Excision of Ovarian Endometriomas: Can We Reduce and Predict the Risk of Recurrence?

OBJECTIVES: Up to 32% of women experience anatomic recurrence after conservative surgery for endometriomas, while pain recurs in 10-40% of cases. Long-term postoperative hormonal therapy is recommended to prevent disease recurrence. We evaluated the efficacy of long-term therapy with estroprogestins (EPs) or progestins (Ps) in preventing endometrioma recurrence, as identifiable cysts and subjective symptoms, after laparoscopic excision. DESIGN: This retrospective cohort study included 375 women submitted to laparoscopic endometrioma excision. Women were followed up at 6 and 12 months and then yearly after surgery. Based on postoperative medical therapy, women were divided into 4 groups: nonusers, cyclic EP users, continuous EP users, and progestogen users. Materials, Setting, Methods: Anamnestic and anthropometric characteristics were collected as well as clinical and surgical data. Gynecological examination, and transvaginal and transabdominal ultrasound scans were performed. Pain (numerical rating score >5) and endometrioma recurrence at ultrasound (ovarian cyst with typical sonographic features ≥10 mm in mean diameter) were recorded at each examination. The reoperation rate in women with recurrence was investigated. RESULTS: The median follow-up was 3.7 years with a maximum of 16.7 years. Most patients used EPs (119 cyclic and 61 continuous users), 95 used P, and 100 were nonusers. In 135 women (36%), endometriotic cyst recurrence was diagnosed, with a mean diameter of 18.7 ± 10.8 mm (range 10-55 mm). The median recurrent cyst-free time was 7.9 years (95% CI 5.8-10.8). Dysmenorrhea was the first symptom to reappear, affecting 162 patients (43.2%). Upon multivariable regression analysis, continuous users had a lower risk of relapse (OR 0.56, 95% CI 0.32-0.99), in terms of both cysts and symptom recurrence, than patients who received no medications. The reoperation rate was 16.2%. LIMITATIONS: The main limitation of this study is its retrospective design. Also, women switching therapies throughout the follow-up period were sorted into one of the study groups based on the longest treatment taken, without considering the discontinuation rates. CONCLUSIONS: Long-term EPs, administered in a continuous regimen and starting immediately after conservative surgery for endometriomas, seem to reduce the disease recurrence risk.

Transperineal Ultrasound Visual Feedback Assisted Pelvic Floor Muscle Physiotherapy in Women With Deep Infiltrating Endometriosis and Dyspareunia: A Pilot Study.

A prospective study with the aim to evaluate the effects of pelvic floor physiotherapy was conducted among women with deep infiltrating endometriosis (DIE) and associated dyspareunia. At initial evaluation superficial and deep dyspareunia were assessed using a numerical rating scale, and levator hiatus area (LHA) was assessed with 3-D/4-D transperineal ultrasound. Women underwent five individual sessions of ultrasound visual feedback assisted pelvic floor physiotherapy. One month after the therapy, dyspareunia and LHA were reassessed and compared with pre-therapy data. Pelvic floor physiotherapy seems to improve both superficial and deep dyspareunia and pelvic floor muscle relaxation in women with DIE.

Painful Love: Superficial Dyspareunia and Three Dimensional Transperineal Ultrasound Evaluation of Pelvic Floor Muscle in Women with Endometriosis.

We conducted an observational study between March 2015 and March 2018 in our academic center. Symptomatic, sexually active women with clinical and sonographic diagnosis of deep infiltrating endometriosis (DIE) or isolated ovarian endometriosis were enrolled. Women were asked to rank endometriosis-related symptoms, especially superficial and deep dyspareunia. Moreover, 3D transperineal ultrasound was performed to assess the levator hiatus area (LHA) evaluating pelvic floor muscle (PFM) morphometry. Women with endometriosis seem to have a high prevalence of superficial dyspareunia and three-dimensional transperineal ultrasound seems to be a viable technique to assess PFM morphometry in these women.

Liver function, tolerability and satisfaction during treatment with ulipristal acetate in women with fibroids: a single center experience.

The aim of the study was to evaluate liver function in women treated with ulipristal acetate (UPA) and to assess the tolerability and satisfaction during treatment. This Cross-sectional study included women with symptomatic uterine fibroids subjected to one or more 3-month treatment courses of 5 mg UPA daily. Following European Medical Agency's prescriptions, women were asked about symptoms potentially related to liver damage and had blood tests done, to assess serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Data on side effects, tolerability and satisfaction with the therapy were obtained during a phone interview. A total of 162 women completed the study with a mean treatment duration of 1.8 ± 0.9 cycles. No increased AST and ALT serum levels were detected and no woman reported symptoms suggestive of liver injury. The majority of women reported improvement of fibroids-related symptoms and a high degree of satisfaction with treatment. More than half of women had side effects, in most cases not as severe as to discontinue therapy. Ulipristal acetate did not worsen liver function or cause severe organ injury and showed high tolerability and satisfaction profiles. Therefore, we believe that it can still be considered a valuable option in the treatment of uterine fibroids.

First Impressions Can Be Deceiving: Surgical Outcomes of Laparoscopic Myomectomy in Patients Pretreated with Ulipristal Acetate.

STUDY OBJECTIVE: To compare enucleation time, total operative time, and perioperative complications during laparoscopic myomectomy in patients pretreated with ulipristal acetate (UPA) compared with untreated patients. DESIGN: Prospective, observational pilot study. SETTING: Tertiary referral center of minimally invasive gynecologic surgery, Sant'Orsola Academic Hospital, Bologna, Italy. PATIENTS: Seventy-four of 108 patients scheduled for laparoscopic myomectomy from January to November 2017 were enrolled. INTERVENTIONS: Laparoscopic myomectomy following pretreatment with UPA or no hormonal pretreatment therapy. MEASUREMENTS AND MAIN RESULTS: Of the 74 patients who were enrolled, 29 were pretreated with UPA (UPA group), and 45 did not receive any hormonal therapy before surgery (control group). Surgeons, blinded to patient pre-operative treatment, completed a 3-item questionnaire after each procedure to evaluate surgical difficulty. Based on surgeon response, myomas in the UPA group appeared softer and more difficult to enucleate because of less clear cleavage planes than the control group. The overall difficulty of myoma detachment from the myometrium was judged considerably higher in the UPA group. Despite this, enucleation time, total operative time, and perioperative complications were not statistically different in the 2 groups. CONCLUSION: Myomas in patients pretreated with UPA are subjectively less easy to enucleate; however, surgical times and perioperative outcomes are not affected by pretreatment with UPA.

Impact of Temporary Protective Ileostomy on Intestinal Function and Quality of Life after a 2-Year Follow-up in Patients Who Underwent Colorectal Segmental Resection for Endometriosis.

STUDY OBJECTIVE: To compare 2-year follow-up intestinal function and quality of life (QoL) between women with temporary protective ileostomy (PI) and recanalization and women without PI after colorectal segmental resection for deep infiltrating endometriosis (DIE). DESIGN: Prospective observational exploratory study. SETTING: Tertiary level referral center for minimally invasive gynecologic surgery. PATIENTS: Consecutive patients who underwent laparoscopic colorectal resection and PI because of DIE between January 2015 and January 2018; an equal number of women without PI were matched according to age and anamnestic findings to serve as controls. INTERVENTIONS: Realization of a PI or immediate recanalization in patients who underwent laparoscopic colorectal resection. MEASUREMENTS AND MAIN RESULTS: Thirty-six patients were considered for the analyses: 18 in the PI group and 18 in the non-PI group. Baseline intestinal function and QoL were evaluated using 2 validated questionnaires. The main reasons for ileostomy were colpotomy (66.7%), ultralow bowel anastomosis (27.8%), concomitant ureteroneocystostomy, and positive Michelin test result (5.6%). The mean interval between first and second surgery in the PI group was 3.7 ± 1.7 months. Perioperative severe complications included 1 stenosis of colorectal anastomosis in 1 woman in the PI group and 1 perianastomotic abscess in the non-PI group; overall the complications were comparable between the 2 groups. At the 2-year follow-up from recanalization, bowel function and QoL improved from baseline, with no statistical differences between the groups (Knowles-Eccersley-Scott-Symptom delta: 5.9 ± 9.3 in the PI group vs 7.7 ± 10.2 in the non-PI group, p = .6; Gastrointestinal Quality of Life Index delta: 16.0 ± 27.5 vs 19.2 ± 24.7, p = .7). CONCLUSION: Temporary PI after colorectal resection for DIE does not seem to influence patients' bowel function and QoL at a median follow-up from recanalization at 2 years.

Endometriosis of the Appendix: When to Predict and How to Manage-A Multivariate Analysis of 1935 Endometriosis Cases.

STUDY OBJECTIVE: To evaluate appendiceal endometriosis (AE) prevalence and risk factors in endometriotic patients submitted to surgery. DESIGN: A retrospective cohort study. SETTING: A tertiary level referral center, university hospital. PATIENTS: One thousand nine hundred thirty-five consecutive patients who underwent surgical removal for symptomatic endometriosis. INTERVENTIONS: Electronic medical records of patients submitted to surgery over a 12-year period were reviewed. We assessed any correlation between demographic, clinical, and surgical variables and AE. In our center, appendectomy was performed using a selective approach. Appendix removal was performed in case of gross abnormalities of the organ, such as enlargement, dilation, tortuosity, or discoloration of the organ or the presence of suspected endometriotic implants. MEASUREMENTS AND MAIN RESULTS: AE prevalence was 2.6% (50/1935), with only 1 false-positive case at gross intraoperative evaluation. In multivariate analysis using a stepwise logistic regression model, independent risk factors for AE were adenomyosis (adjusted odds ratio [aOR] = 2.48; 95% confidence interval [CI], 1.32-4.68), right endometrioma (aOR = 8.03; 95% CI, 4.08-15.80), right endometrioma ≥5 cm (aOR = 13.90; 95% CI, 6.63-29.15), bladder endometriosis (aOR = 2.05; 95% CI, 1.05-3.99), deep posterior pelvic endometriosis (aOR = 5.79; 95% CI, 2.82-11.90), left deep lateral pelvic endometriosis (aOR = 2.11; 95% CI, 1.10-4.02), and ileocecal involvement (aOR = 12.51; 95% CI, 2.07-75.75). CONCLUSION: Among patients with endometriosis submitted to surgery, AE was observed in 2.6%, and it was associated with adenomyosis, large right endometrioma, bladder endometriosis, deep posterior pelvic endometriosis, left deep lateral pelvic endometriosis, and ileocecal involvement.

Question Mark Sign and Transvaginal Ultrasound Uterine Tenderness for the Diagnosis of Adenomyosis: A Prospective Validation.

OBJECTIVES: To evaluate the diagnostic accuracy of the classic ultrasound (US) signs of adenomyosis, the question mark sign and transvaginal ultrasound (TVUS) uterine tenderness, in the diagnosis of adenomyosis. METHODS: This was a prospective study including 78 patients waiting for hysterectomy for uterine benign diseases and undergoing preoperative US examinations to evaluate all criteria for US diagnosis of adenomyosis as reported by the consensus statement of the Morphological Uterus Sonographic Assessment group. A US diagnosis of adenomyosis was made in the presence of 2 or more Morphological Uterus Sonographic Assessment features. Moreover, the question mark sign and TVUS uterine tenderness were evaluated. Ultrasound features were compared with the histologic examination, which was considered the reference standard for the diagnosis of adenomyosis. The Cohen κ coefficient was used to measure the accordance between US and histologic results. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of each US feature were calculated. RESULTS: The prevalence of adenomyosis in the sample was 33.3%. The sensitivity, specificity, PPV, NPV, and accuracy of TVUS in the diagnosis of adenomyosis were 77%, 96%, 91%, 89%, and 90%, respectively. Myometrial heterogeneity was the most frequently encountered feature (100%) but showed low specificity (7%). The question mark sign and TVUS uterine tenderness showed sensitivity, specificity, PPV, NPV, and accuracy of 41%, 96%, 83%, 77%, and 69% and 69%, 65%, 66%, 81%, and 67%. CONCLUSIONS: The question mark sign and TVUS uterine tenderness are useful tools for the diagnosis of adenomyosis.

Feasibility and safety of laparoscopic approach in obese patients with endometriosis: a multivariable regression analysis.

PURPOSE: To evaluate the feasibility and safety of laparoscopic excision of endometriotic lesions in obese women. METHODS: Retrospective analysis of prospectively collected data involving consecutive women scheduled for complete laparoscopic removal of macroscopic endometriotic lesions between January 2012 and November 2018. Operative time, laparotomic conversion rates, complication rates, and length of hospital stay were recorded. RESULTS: One thousand two hundred thirty women were enrolled and divided into two main groups, according to the World Health Organization classification of obesity, obese (body mass index ≥ 30 kg/m2) and non-obese (body mass index < 30 kg/m2). During the study period, 91 (7.4% of overall study cohort) obese women underwent surgery. At univariate analyses, significant differences between the two groups were found in terms of age, rates of severe endometriosis, American Society of Anesthesiologists physical status classification ≥ III, and different surgical procedures. Significant differences in terms of median operative time [125 (interquartile range (IQR) 85-165) in obese group vs 110 min (IQR 75-155) in non-obese group, P = 0.04] were observed. There were no significant differences between the obese and non-obese groups with respect to the other variables of interest. After adjusted multivariable regression models for potential confounders, difference in operating time (coefficient of 13.389; 95% CI 1.716, 25.060) was still found to be significant. CONCLUSION: In our tertiary care referral center, laparoscopic removal of endometriosis is feasible and safe, except for a slight increase of operative time and conversion rate.

Rectosigmoid Endometriosis Vascular Patterns at Intraoperative Indocyanine Green Angiography and their Correlation with Clinicopathological Data.

Introduction. The objective of the study was to evaluate the presence of different rectosigmoid endometriosis (RSE) vascular patterns using intraoperative indocyanine green (ICG) angiography and their correlation with clinicopathological data. Material and Methods. A prospective pilot study on 30 consecutive symptomatic women affected by RSE and scheduled for minimally invasive surgery between May 2018 and January 2019. ICG was used for the intraoperative evaluation of RSE vascularization. Perfusion grade was classified as follows: 0-1 = no or low fluorescence (hypovascular pattern); 2 = regular fluorescence, similar to healthy surrounding rectosigmoid tract (isovascular pattern); and 3-4 = diffuse or abundant fluorescence (hypervascular pattern). Results. Thirty women were intravenously injected with ICG after nodule exposure. No adverse effects related to ICG use were noted. After a 5- to 50-s latency from ICG injection, the real-time direct visualization of RSE perfusion showed diffuse or abundant fluorescence in 12/30 (40%) women, while in the remaining 18/30 (60%), fluorescence was poor or absent. No statistical differences were observed between the 2 groups regarding preoperative, intraoperative, and histological variables analyzed, except for a maximum diameter of bowel lesions and microvessel density (MVD). Hypovascular nodules had a larger maximum diameter (39.5 ± 15.6 mm vs 30.3 ± 11.4 mm, P < .05) and lower MVD (154.6+/43.6 vs 281.1+/-77.4, P < .05) than hypervascular ones. Conclusions. ICG angiography is a feasible and safe technique to intraoperatively assess RSE vascularization. The majority (60%) of endometriotic nodule presented a hypovascular pattern. The hypovascular pattern seems to be associated with a larger nodule size and lower MVD.

Adenomyosis and endometriosis in adolescents and young women with pelvic pain: prevalence and risk factors.

AIM: To evaluate the prevalence of ultrasound diagnosis of adenomyosis and endometriosis in young women complaining of pelvic pain and to find the symptoms and clinical characteristics associated with these diseases in young women. METHODS: Cross-sectional study, including 100 young women (14-24 years) with a history of chronic pelvic pain. Women were asked detailed medical hystory and pain symptoms scores (Visual Analogue Scale) and underwent gynecological examination and ultrasound evaluation. RESULTS: The prevalence of endometriosis and adenomyosis in young women amounted to 25.0% and 46.0%, respectively. A significant correlation was found between ovarian endometriosis and adenomyosis. Dysmenorrhea and dyspareunia were risk factors for adenomyosis. Dyschezia, dyspareunia, chronic pelvic pain, presence of sonographic soft markers suggestive of pelvic adhesions, being a worker and having a previous surgery were risk factors for endometriosis. Young women (20-24 years) had a higher incidence of both adenomyosis and endometriosis than adolescents (14-19 years). CONCLUSIONS: Our outcomes strengthen the hypothesis of a progressive and common course of the natural history of endometriosis, which initially may manifest with symptoms, then with signs of pelvic adhesions and finally as adenomyosis, ovarian endometriomas or deep infiltrating endometriosis.

Pelvic floor dysfunction at transperineal ultrasound and voiding alteration in women with posterior deep endometriosis.

INTRODUCTION AND HYPOTHESIS: Posterior deep infiltrating endometriosis (DIE) has been associated with pelvic floor muscle (PFM) alteration and voiding dysfunction (VD). The aim of this study is to evaluate the correlation between the presence of VD and altered PFM morphometry, objectively evaluated using 3D/4D transperineal ultrasound at rest and during dynamic maneuvers, in patients with posterior DIE. METHODS: A prospective study was conducted on 108 symptomatic women scheduled for surgical removal of posterior DIE. The study population was divided in two groups according to presence or absence of VD on the Bristol Female Lower Urinary Tract Symptoms (BFLUTS). A 3D/4D transperineal ultrasound was performed to compare the following PFM morphometric parameters: levator hiatus area (LHA), antero-posterior (AP) and left-right (LR) diameters and levator ani muscle (LAM) coactivation. LAM coactivation was defined as the paradoxical contraction of the pelvic floor muscle during the Valsalva maneuver causing a smaller LHA than in the resting state. RESULTS: Forty-eight (45.2%) women presented VD, while 60 (54.8%) women did not report any voiding complaints. Baseline characteristics did not significantly differ between the two groups. We did not find any significant statistical differences in PFM parameters between the two groups, except for a higher rate of levator ani muscle coactivation in women with VD compared with women without VD [64.6% (31/48) versus 31.7% (19/60), respectively; p = < 0.001]. CONCLUSIONS: In women affected by posterior DIE, LAM coactivation at 3D/4D transperineal ultrasound seems to be more frequent in patients with than without VD.

Surgical, Clinical, and Functional Outcomes in Patients with Rectosigmoid Endometriosis in the Gray Zone: 13-Year Long-Term Follow-up.

STUDY OBJECTIVE: To compare long-term surgical, clinical, and functional outcomes between conservative and radical surgery in patients with rectosigmoid endometriosis (RSE) and preoperative intermediate risk of segmental resection. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Endometriosis tertiary level referral center, St. Orsola Academic Hospital, Bologna, Italy. PATIENTS: Three hundred and ninety-two patients with RSE presented for complete macroscopic surgical excision between January 2004 and January 2017. INTERVENTION: Assessment of laparoscopic bowel shaving, discoid excision, or segmental resection for the treatment of RSE. MEASUREMENTS AND MAIN RESULTS: The 392 patients were divided into 3 groups according to surgical technique: shaving (n = 297; 75.8%), discoid excision (n = 33; 8.4%), and segmental resection (n = 62; 15.8%). Preoperative characteristics, surgical data, short- and long-term complications, and rates of proven and suspected recurrence were assessed. The segmental resection group had a higher rate of short-term complications compared with the discoid and shaving groups (17.7% vs 9.1% vs 5.4%, respectively; p = .004). The median follow-up time was 43 months (range, 12-163 months). Suspected and proven RSE recurrence rates showed no statistically significant differences among the 3 groups. There also were no significant differences concerning the rate of de novo chronic constipation and urinary retention. CONCLUSION: To date, there is no consensus regarding the choice between radical (segmental resection) or conservative (shaving, discoid excision) surgical management for RSE, particularly for patients with preoperative intermediate risk of bowel segmental resection (the gray zone). Our data suggest that conservative surgery is preferred over radical surgery in patients with RSE in the gray zone risk category, resulting in similar suspected and proven RSE recurrence rates and associated with fewer short-term complications.