Diameter of dominant leiomyoma is a possible determinant to predict coexistent endometriosis

Objective

To identify the frequency and assess risk factors for unexpected discovery of peritoneal endometriotic implants in patients who underwent myomectomy or hysterectomy for symptomatic uterine leiomyomas.

Study design

We retrospectively collected medical records of 829 patients with symptomatic leiomyomas in The University of Tokyo Hospital. All the patients underwent abdominal or laparoscopic surgeries between January 2001 and December 2010 and the presence or absence of endometriosis during surgery was analyzed. Possible determinant to predict coexistent endometriosis was statistically investigated.

Results

In total, 105 leiomyoma cases (12.7% in 829 patients) were diagnosed with endometriosis. Patients with small dominant leiomyomas were significantly complicated by peritoneal endometriotic implants (small leiomyomas were classified as <8 cm). The patients with both diagnoses were more likely to be infertile and at age 39 years or younger than those with leiomyoma alone.

Conclusions

Women undergoing myomectomy or hysterectomy with both endometriosis and leiomyomas have several different clinical features compared with women with only leiomyomas. The size of largest leiomyoma may provide an important clue for coexistent endometriosis. Women with substantial infertility despite a smaller leiomyomas burden may be more likely to have a surgical indication for concomitant endometriosis.     

Resultados de un programa de cirugía mayor ambulatoria en ginecología

Objective

To evaluate the outcomes of an ambulatory surgery program in gynecological diseases.

Material and methods

We performed a retrospective study of patients who underwent surgical hysteroscopy or laparoscopic tubal sterilization from January 2002 to December 2006. Several quality indicators (substitution, cancellation, admission and readmission rates) and the systemic and surgical complications appearing in the first week after surgery were analyzed.

Results

During the study period, 1,214 patients underwent surgery in the gynecology service, with a global substitution rate of 90%. The admission rate after surgery was 1.15%. Severe complications occurred in 10 patients, representing a proportional risk of 1:121. Less severe complications requiring hospital admission occurred in 35 patients. Severe gynecological complications occurred in 2 patients.

Conclusions

Despite compliance with optimal requirements, there was a low rate of postoperative complications of variable severity.     

Ovarian carcinoma associated with endometriosis

Objectives

Previous studies have suggested an association between endometriosis and development of ovarian cancer. A study was performed to evaluate the cases of ovarian carcinoma associated with endometriosis.

Study design

The study includes patients with ovarian carcinoma associated with endometriosis diagnosed between 2000 and 2010 at Hacettepe University Hospital, Ankara, Turkey. A total of 1086 patients who underwent surgical staging for ovarian carcinoma were analyzed retrospectively for the presence of histologically documented endometriosis. The clinical and pathological characteristics of 45 ovarian carcinoma patients associated with endometriosis were evaluated including histologic subtype, stage and grade.

Results

Ovarian carcinoma was found to be associated with endometriosis in 4.1% (45/1086) of the cases. Of them, 17 patients (37.8%) had clear cell, 15 (33.3%) had endometrioid, 6 (13.3%) had serous papillary, 4 (8.9%) had mucinous and the remaining 3 patients had an undifferentiated subtype of ovarian carcinoma. Twenty-three (51.1%) patients had stage I, 4 (8.9%) had stage II and 18 (40.0%) had stage III disease. The frequency of coexistence of endometriosis was 20.4% (17/83) for clear cell carcinoma and 9.3% (15/161) for endometrioid cell carcinoma.

Conclusions

Only a small proportion of ovarian cancer cases were found to be associated with endometriosis. Endometriosis was most frequently associated with clear cell and endometrioid types of ovarian carcinoma. Ovarian carcinoma associated with endometriosis seems to represent a distinct disease entity with different histological subtypes, early presentation and a relatively favorable outcome.     

Tratamiento de la endometriosis con 5 mg o 25 mg diarios de mifepristona durante 6 meses. Ensayo clínico aleatorizado,doble ciego

Objectives

To evaluate the safety and efficacy of 5 mg and 25 mg doses of mifepristone for the treatment of endometriosis.

Design

Randomized double-blind study.

Setting

Eusebio Hernández Hospital, Havana, Cuba.

Subjects

Twenty-six women laparoscopically diagnosed with endometriosis were included.

Treatment

Group I received one tablet of 25 mg mifepristone daily and group II received one tablet of 5 mg mifepristone daily for 6 months. Laparoscopy and endometrial biopsy were performed before and after treatment.

Variable to evaluate efficacy

Reduction in the intensity of dysmenorrhea measured by a visual analogue scale.

Results

In both groups reductions in the intensity of dysmenorrhea and dyspareunia were highly significant compared with initial values (P <.001). All the women were amenorrheic after 45 days of treatment.

Conclusions

At doses of 5 mg or 25 mg, mifepristone could be an alternative for the treatment of endometriosis.     

Long-term follow-up and recurrence rate after mesorectum-sparing bowel resection among women with rectovaginal endometriosis

Objective

To demonstrate the quality of a combined vaginal–abdominal surgical approach to rectovaginal endometriosis by analyzing long-term outcome and recurrence rates.

Methods

In a prospective cohort study in Berlin, Germany, women with endometriosis of the rectovaginal septum were enrolled between September 2004 and December 2012. Bowel infiltration was verified intraoperatively and treated by a nerve-sparing, mesentery-preserving vaginal–abdominal operative approach. Operative results were evaluated by assessing short- and long-term complications and recurrence rates.

Results

During the study period, 110 women underwent surgery. For 71 (64.5%) patients, bowel infiltration was confirmed intraoperatively. Overall, 15% of the patients had peri- or postoperative complications. No long-term complications occurred. After a median follow-up of 64 months, no recurrence in the rectovaginal septum was observed among the study patients. The recurrence of pelvic endometriosis was 15%.

Conclusion

The surgical nerve-sparing approach to rectovaginal endometriosis was confirmed to facilitate precise diagnosis and treatment with minimal morbidity and a long-term complication rate of 0%.     

Abordaje laparoscópico del dolor abdominal agudo en mujeres en edad fértil

Objectives

To assess the effectiveness of the laparoscopic approach in acute abdominal pain in women of reproductive age presenting to the Emergency Department.

Material and methods

We performed an observational, prospective study of acute abdominal pain treated by gynecological laparoscopic procedures. The main variables evaluated were the cause of pain, type of surgery, complications, and conversions to open surgery.

Results

Between January 2009 and December 2011, we performed 110 urgent laparoscopic interventions. The reasons for surgery were rupture of an ovarian cyst in 40 interventions (36.7%), an ectopic pregnancy in 24 (21.8%), a pelvic inflammatory disease in 23 (20.9%), adnexal torsion in 12 (10.9%), and other reasons in 11 (10%). In these 110 interventions, there was one case of postoperative bleeding requiring reintervention and one case of conversion.

Conclusions

The laparoscopic approach is safe and effective in urgent gynecological surgery.     

Regression of the inflammatory microenvironment of the peritoneal cavity in women with endometriosis by GnRHa treatment

Objective

To investigate the effect of gonadotropin-releasing hormone analogues (GnRHa) on the peritoneal fluid microenvironment in women with endometriosis.

Study design

Peritoneal fluid was collected from 85 women with severe endometriosis (rAFS stage III and IV) during laparoscopic surgery during the proliferative phase. Prior to surgery clinical data were collected. The concentrations of specific markers for endometriosis in the peritoneal fluid were determined using an ELISA and a comparison between peritoneal fluid markers in women using GnRHa and no hormonal treatment was performed using a non-parametric Mann–Whitney U test.

Results

The study included peritoneal fluid from 39 patients who had been administered GnRHa (Zoladex^®) in the three months prior to surgery and 46 from women with no hormonal treatment in this period. Concentrations of IL-8, PAPP-A, glycodelin-A and midkine were significantly reduced in the GnRHa treatment group compared to women receiving no hormonal treatment. RANTES, MCP-1, ENA-78, TNF-α, OPG, IP-10 and defensin showed no significant change between the two groups.

Conclusions

GnRHa mediate a significant regression in the inflammatory nature of the peritoneal microenvironment in women with endometriosis.     

Estudio descriptivo del nuevo sistema morcelador de histeroscopia diagnóstica-terapéutica

Hypothesis

The new morcellation system is a safe and effective diagnostic-therapeutic technique for the outpatient management of endometrial polyps.

Objective

To describe our inicial experience with the new mechanical Truclear System (Smith&Nephew) hysteroscope in a number of polypectomies performed in the outpatient setting without the need for surgical referral.

Patients and methods

An observational prospective non-randomized study was performed in 100 patients who underwent hysteroscopy between June 2011 and January 2012 at the Igualada Hospital. There were two patient groups: group 1 included the first 55 patients who met the inclusion criteria for hysteroscopy and group 2 included 45 patients with endometrial polyps suspected on ultrasound.

Results

We performed 41 and 40 uneventful hysteroscopies in groups 1 and 2, respectively, 56 and 82.5% were suspected endometrial polyps, respectively. Polypectomy was 100% successful in all patients. None of the patients were referred for surgery. Tolerance was moderate to good in 91.3% of the patients.

Conclusion

The new morcellator system allows polypectomies to be conducted in outpatients with an ultrasound diagnosis of polyps, without the need to refer the patient for surgery.     

Pronóstico y resultados en pacientes diagnosticadas de endometriosis a las que se les ha realizado por primera vez una cirugía conservadora por dolor o esterilidad

Objective

To analyze clinical outcomes in patients with suspected endometriosis undergoing conservative surgery. Pain reduction, pregnancy rates, and reinterventions were analyzed.

Material and methods

Patients with suspected endometriosis and symptoms of pain or infertility undergoing conservative surgery for the first time were included (n = 128). Exclusion criteria consisted of incomplete medical histories and interventions indicated for reasons other than pain or infertility.

Results

Surgery was indicated for pain in 70.3% and for infertility in 29.7%. A total of 32.5% of the patients had pain at the first postsurgical visit, 42.5% at 6 months and 58.3% at 1 year. Reintervention was performed in 11.29%. Among reinterventions for pain, there was a higher percentage of intestinal symptoms before surgery (P=.07), as well as episodes of abdominal pain requiring hospital care (P=.08); a higher proportion of these patients had pain in the first visit (P=.05) and at 1 year (P=.03) than patients not undergoing reintervention. Postsurgical medical treatment was less frequent in patients undergoing reintervention (P=.11). Among patients undergoing surgery for infertility, pregnancy was achieved in 65.8%.

Conclusions

Pain was less frequent in the first postsurgical visit than in subsequent visits. Among patients undergoing reintervention for pain, there was a higher percentage of intestinal symptoms and episodes of abdominal pain requiring hospital care prior to the intervention. Pain at the first visit and at 1 year are factors of poor prognosis for reintervention. Patients undergoing reintervention for pain less frequently required postsurgical medical treatment. More than half of patients with interfertility and endometriosis achieved spontaneous pregnancy after surgery.     

Biopsychosocial correlates of persistent postsurgical pain in women with endometriosis

Objective

To examine pain and biopsychosocial correlates over time for women with persistent postsurgical pain after surgery for endometriosis.

Methods

Cross-sectional study of women who underwent any endometriosis surgery between 2003 and 2006. Following surgery, patients completed validated questionnaires (Short-Form McGill Pain Questionnaire, 12-item Short-Form Health Survey, Beck Depression Inventory, Coping Strategies Questionnaire catastrophizing subscale). The primary outcome was pelvic pain intensity, measured by the McGill total pain score. Bivariate comparisons between each potential predictor and pain intensity were performed using the χ² and t tests, 1-way analysis of variance, and simple linear regression.

Results

In total, 79 completed the questionnaires and were included in the present analysis. The McGill affective pain score was negatively correlated with age (β-coefficient –0.12, P = 0.002) and positively correlated with catastrophization (β-coefficient 0.66, P = 0.01). Women with a history of dyspareunia scored significantly higher on the McGill total pain score (P < 0.001); there was no association between pain intensity and endometriosis severity.

Conclusion

Younger age and catastrophization are correlated with persistent pain following surgery for endometriosis. The severity of endometriosis does not predict persistent pain. Further evaluation of psychosocial factors may identify patients who are least likely to benefit from surgeries for endometriosis-associated pelvic pain.     

Long-term follow-up after ureteral reimplantation in patients with severe deep infiltrating endometriosis

Objective

To investigate the intraoperative features and long-term postoperative results of patients with ureteral endometriosis who underwent ureteral reimplantation.

Study design

In this retrospective study, we reviewed records of all patients with ureteral endometriosis treated by ureteral reimplantation. Pre-, intra- and post-operative information was collected.

Results

Of patients operated for endometriosis, seven were diagnosed with severe ureteral endometriosis and underwent ureteral reimplantation. Psoas hitch was the preferred technique for the ureteral reimplantation. During a mean postoperative follow up of 42.3 ± 20.0 months, all but one patient reported significant symptomatic improvement. None of the patients needed additional medical or surgical treatment and no recurrence was noted.

Conclusion

Ureteral reimplantation performed by a multidisciplinary surgical team is a suitable technique in selected cases, gives good long-term results and has no need for repeated surgical treatment.     

Src as a novel therapeutic target for endometriosis

Background

Endometriosis is a common condition that is associated with an increased risk of developing ovarian carcinoma. Improved in vitro models of this disease are needed to better understand how endometriosis, a benign disease, can undergo neoplastic transformation, and for the development of novel treatment strategies to prevent this progression.

Methods

We describe the generation and in vitro characterization of novel TERT immortalized ovarian endometriosis epithelial cell lines (EEC16-TERT).

Results

Expression of TERT alone was sufficient to immortalize endometriosis epithelial cells. TERT immortalization induces an epithelial-to-mesenchymal transition and perturbation in the expression of genes involved in the development of ovarian cancer. EEC16-TERT was non-tumorigenic when xenografted into immunocompromised mice but grew in anchorage-independent growth assays in an epidermal growth factor and hydrocortisone dependent manner. Colony formation in agar was abolished by inhibition of Src, and the Src pathway was found to be activated in human endometriosis lesions.

Conclusions

This new in vitro model system mimics endometriosis and the early stages of neoplastic transformation in the development of endometriosis associated ovarian cancer. We demonstrate the potential clinical relevance of this model by identifying Src activation as a novel pathway in endometriosis that could be targeted therapeutically, perhaps as a novel strategy to manage endometriosis clinically, or to prevent the development of endometriosis-associated ovarian cancer.     

Increased levels of oxidative stress markers in the peritoneal fluid of women with endometriosis

Objective

To evaluate 8-hydroxy-2-deoxyguanosine (8-OHdG) and 8-isoprostane levels in the peritoneal fluid (PF) of women with endometriosis.

Study design

One hundred and ten women with laparoscopically and histopathologically confirmed endometriosis and, as reference groups, 119 patients with simple serous (n = 78) and dermoid (n = 41) ovarian cysts were studied. Peritoneal fluid 8-OHdG and 8-isoprostane concentrations were evaluated by enzyme-linked immunosorbent assays.

Results

8-OHdG and 8-isoprostane levels in peritoneal fluid were significantly higher in patients with endometriosis compared with the reference groups. Higher PF 8-OHdG and 8-isoprostane concentrations were observed in patients with advanced stages of endometriosis. A statistically significant positive correlation was found between 8-OHdG and 8-isoprostane levels in peritoneal fluid.

Conclusion

Endometriosis induces greater oxidative stress and frequent DNA mutations in peritoneal fluid than nonendometriotic ovarian cysts. The most severe oxidative stress occurs in the peritoneal cavity of women with more advanced stages of the disease.     

Inducción de endometriosis en rata Wistar,mediante autotransplante de fragmento uterino,sobre cicatriz previamente producida en el cuerno uterino izquierdo

Objective

To study the possibility of inducing internal or external endometriosis in Wistar rats through a new microsurgical model known as PGR 1.

Subjects and methods

Eleven Wistar rats underwent autologous transplantation of a uterine fragment over a deliberately created scar. After 8 weeks, a further intervention was carried out to inspect the abdominal cavity and take samples for pathological analysis.

Results

Macroscopic results consisted of adhesions mainly affecting the implant and yellow vesicles. Microscopic findings consisted of vesicles/cysts, inflammatory phenomena, neovascularization, and internal endometriosis in one animal

Conclusions

This new implant model could enhance our understanding of the mechanisms involved in the development of endometriosis, both internal and external.     

Tratamiento quirúrgico de los quistes dermoides de ovario: laparoscopia frente a laparotomía

Objective

To compare the results of laparoscopy and laparotomy in teh treatment of ovarian dermoid cysts (cystectomy, oophorectomy and adenectomy, mainly those related with complications (intraoperative spillage).

Subjects and methods

We analize retrospectively a case series of 91 patients with dermoid cysts treated al Hospital Severo Ochoa in Madrid, from January 2001 to Decembre 2004. Data were obtained from the pathology register and from the hospital charts, and were analized with the software EpiInfo 6.0 version.

Results

79% laparoscopic approaches, same complications rate, same intraoperative spillage risk, lower hospital stay in laparoscopic group, lower operating time in case of oophorectomy/anexectomy by laparotomy.

Conclusions

Laparoscopic management of ovarian teratomas is as safe as laparotomic one. The same complications rate is observed in both groups, and lower hospital stay is achieved in laparoscopic surgery. If cystectomy is recommended intraoperative spillage risk should not contraindicate laparoscopy.     

Resultados de 1.000 cirugías ginecológicas laparoscópicas sucesivas

Objectives

To review the indications and outcomes of 1,000 consecutive laparoscopic surgeries.

Material and methods

We carried out an observational, retrospective study of the first 1,000 gynecological laparoscopic procedures performed in our hospital. Data on complications and conversions were recorded.

Results

Between January 2005 and November 2011, we performed 1000 laparoscopic surgeries: 452 (45.2%) ovarian procedures, 200 (20%) hysterectomies for benign causes, 105 (10.5%) gynecological neoplasms, 88 (8.8%) tubal ligations, 75 (7.5%) diagnostic laparoscopies, 56 (5.6%) myomectomies, 19 (1.9%) sacropexies and 5 (0.5%) appendectomies. There were 22 major complications (2.2%) and 32 conversions to open surgery (3.2%).

Conclusion

The laparoscopic approach to gynecological surgery is safe and effective.     

The influence of endometriosis-related symptoms on work life and work ability: a study of Danish endometriosis patients in employment

Objective

Little is known about the implications of endometriosis on women's work life. This study aimed at examining the relation between endometriosis-related symptoms and work ability in employed women with endometriosis.

Study design

In a cohort study, 610 patients with diagnosed endometriosis and 751 reference women completed an electronic survey based on the Endometriosis Health Profile 30-questionnaire and the Work Ability Index (short form). Percentages were reported for all data. Binary and multivariate logistic regression analyses were used to assess risk factors for low work ability. The level of statistical significance was set at p < 0.025 in all analyses.

Results

In binary analyses a diagnosis of endometriosis was associated with more sick days, work disturbances due to symptoms, lower work ability and a wide number of other implications on work life in employed women. Moreover, a higher pain level and degree of symptoms were associated with low work ability. Full regression analysis indicated that tiredness, frequent pain, a higher daily pain level, a higher number of sick days and feeling depressed at work were associated with low work ability. A long delay from symptom onset to diagnosis was associated with low work ability.

Conclusions

These data indicate a severe impact of endometriosis on the work ability of employed women with endometriosis and add to the evidence that this disease represents a significant socio-economic burden.