Coagulation-Induced Diaphragm Fenestrations after Laparoscopic Excision of Diaphragmatic Endometriosis

Study Objective

To present an unusual consequence of laparoscopic treatment of diaphragmatic endometriosis, to discuss the possible etiologies, and to propose proper management.

Long-term Follow-up of Sexual Quality of Life after Laparoscopic Surgery in Patients with Deep Infiltrating Endometriosis

Study ObjectiveWe performed a long-term follow-up to quantify the impairment of sexual quality of life (SQL) and health-related QL (HRQL) in sexually active women after laparoscopic excision of deep infiltrating endometriosis (DIE).DesignProspective case-control study.SettingHospital Clinic of Barcelona.PatientsA total of 193 patients (after dropout and exclusions) were divided into 2 groups: one hundred twenty-nine premenopausal women with DIE (DIE group) and 64 healthy women who underwent tubal ligation (C group).InterventionsAll patients underwent laparoscopic surgery: laparoscopic endometriosis surgery in the DIE group and laparoscopic tubal ligation in the C group. All women were followed for at least 36 months, and they completed the Medical Outcomes Study 36-item short form questionnaire to assess their HRQL and 3 self-administered questionnaires that evaluate different aspects of SQL: the generic Sexual Quality of Life–Female questionnaire, the Female Sexual Distress Scale to evaluate “sexually related distress,” and the Brief Profile of Female Sexual Function to screen hypoactive sexual desire disorder. The patients with DIE as well as the controls completed the 4 questionnaires before surgery, and the patients with DIE also completed the questionnaires at 6 and 36 months after surgery.Measurements and Main ResultsA comparison of the patients and controls before surgery showed a statistically significant impairment in SQL and HRQL among the patients with DIE. A statistically significant improvement in SQL and HRQL was observed in the DIE group 6 months after surgery, with scores being similar to those of the C group. An evaluation 36 months after surgery showed that SQL and HRQL were better than presurgical SQL and HRQL in the DIE group, with a slight reduction compared with the 6-month evaluation.ConclusionSQL and HRQL improved in patients with DIE undergoing complete laparoscopic endometriosis resection and were comparable to those of healthy women at 6 months after surgery, showing a slight reduction at 36 months of follow-up.     

Quality of Life after Laparoscopic and Open Abdominal Myomectomy

Study ObjectiveTo evaluate the baseline and postoperative changes in quality of life and symptom-severity scores in women undergoing laparoscopic or open abdominal myomectomy for symptomatic myomas.DesignProspective cohort study of patients choosing myomectomy for symptomatic uterine myomas.SettingAcademic medical center.PatientsA total of 143 women enrolled in the study. Of these, 80 women completed both a preoperative questionnaire and at least 1 postoperative questionnaire between 6 and 27 months after surgery.InterventionsA total of 52 women had open abdominal myomectomy, and 28 had laparoscopic myomectomy between October 2014 and September 2017.Measurements and Main ResultsThe results of the Uterine Fibroid Symptom and Health-Related Quality-of-Life Questionnaire were compared before and after laparoscopic or open myomectomy. Women undergoing open abdominal myomectomy had larger and more numerous myomas than women undergoing laparoscopic myomectomy. Baseline quality-of-life scores were less adversely affected for women having laparoscopic myomectomy (mean [standard deviation], 57 [24] laparoscopic vs 43 [19] open abdominal, p = .01). However, baseline symptom-severity scores were statistically similar (49 [22] for laparoscopic and 57 [20] for open abdominal, p = .08) approaches. Six to 12 months after surgery, both open abdominal and laparoscopic surgeries provided excellent and similar improvements in symptom-severity and quality of life (postoperative symptoms severity scores, mean [standard deviation], 20 [14] laparoscopic vs 13 [11] open abdominal, p = .24 and quality-of-life scores, mean [standard deviation], 91 [16] laparoscopic vs 88 [17] open abdominal, p = .49). These improvements were sustained for women who returned questionnaires up to 27 months of follow-up.ConclusionWomen with symptomatic myomas have a compromised quality of life, and they experience a similarly dramatic improvement in quality of life and decrease in symptom-severity after both laparoscopic and open abdominal myomectomies.     

Patient Quality of Life and Symptoms after Surgical Treatment for Endometriosis

Study Objective

To assess the impact of surgical treatment of endometriosis on quality of life and pain over a 3-year period of postoperative follow-up.

Opioid Use After Laparoscopic Surgery for Endometriosis and Pelvic Pain

Study ObjectiveThe primary objective was to quantify postoperative opioid use after laparoscopic surgery for endometriosis or pelvic pain. The secondary objective was to identify patient characteristics associated with greater postoperative opioid requirements.DesignProspective, survey-based study in which subjects completed 1 preoperative and 7 postoperative surveys within 28 days of surgery regarding medication usage and pain control.SettingTertiary care, academic center.PatientsA total of 100 women with endometriosis or pelvic pain.InterventionsLaparoscopic same-day discharge surgery by fellowship-trained minimally invasive gynecologists.Measurements and Main ResultsA total of 100 patients were recruited and 8 excluded, for a final sample size of 92 patients. All patients completed the preoperative survey. Postoperative response rates ranged from 70.7% to 80%. The mean number of pills (5 mg oxycodone tablets) taken by day 28 was 6.8. The average number of pills prescribed was 10.2, with a minimum of 4 (n = 1) and maximum of 20 (n = 3). Previous laparoscopy for pelvic pain was associated with a significant increase in postoperative narcotic use (8.2 vs 5.6; p = .044). Hysterectomy was the only surgical procedure associated with a significant increase in postoperative narcotic use (9.7 vs 5.4; p = .013). There were no difference in number of pills taken by presence of deep endometriosis or pathology-confirmed endometriosis (all p >.36). There was a trend of greater opioid use in patients with diagnoses of self-reported chronic pelvic pain, anxiety, and depression (7.9 vs 5.7, p = .051; 7.7 vs 5.2, p = .155; 8.1 vs 5.6, p = .118).ConclusionMost patients undergoing laparoscopic surgery for endometriosis and pelvic pain had a lower postoperative opioid requirement than prescribed, suggesting surgeons can prescribe fewer postoperative narcotics in this population. Patients with a previous surgery for pelvic pain, self-reported chronic pelvic pain syndrome, anxiety, and depression may represent a subset of patients with increased postoperative opioid requirements.     

Laparoscopic Posthysterectomy Vaginal Vault Excision for Chronic Pelvic Pain and Deep Dyspareunia

Study ObjectiveTo evaluate the outcome of posthysterectomy laparoscopic vaginal vault excision and its long-term effects on chronic pelvic pain, dyspareunia, quality of life, and patient satisfaction.Materials and MethodsThis is a retrospective cohort study (Canadian task force classification II–3) incorporating case note review and a postal questionnaire. It describes 22 consecutive patients who underwent laparoscopic vaginal vault excision for posthysterectomy dyspareunia and chronic pelvic pain. At laparoscopy, full thickness vaginal vault was excised along with scar tissue or any cyst. The vaginal cuff was closed laparoscopically. The patients were sent a validated questionnaire to assess their pain scores, general health, quality of life, and satisfaction with the surgery. The mean interval from vaginal vault excision and to questionnaire distribution was 1.8 years. The statistical analysis was performed with SPSS 15.ResultsThe mean age of the women was 40 years. All women had vaginal vault tenderness on examination and underwent laparoscopic vaginal vault excision. The only intraoperative complication was 1 puncture injury of the bladder, which was produced by 10-Veres needle during manipulation. A single or a combination of additional procedures was performed at the same time. The patient satisfaction questionnaires were received from 16 (72.7%) women. Of the 16 (72.7%) respondents, 13 (81.25%) confirmed improvement in dyspareunia. The mean pain scores decreased, and quality of life and general health improved significantly after vaginal vault excision (p <.05, t test).ConclusionLaparoscopic vaginal apex excision is a safe and effective management option after carefully excluding other causes of deep dyspareunia and chronic pelvic pain. It also provides an opportunity to detect and surgically excise previously undiagnosed endometriosis and other disease.     

Long-Term Outcomes on Quality of Life in Women Submitted to Laparoscopic Treatment for Bowel Endometriosis

Study ObjectiveTo evaluate the long-term effects of laparoscopic surgery on quality of life in women with bowel endometriosis.DesignObservational prospective cohort study (Canadian Task Force classification II).SettingCentral Hospital of Santa Casa, Sao Paulo, Brazil.PatientsForty-five patients answered a short-form, 36-item, quality-of-life questionnaire (SF-36) at 3 different times.InterventionsBetween June 2007 and September 2008, patients underwent laparoscopic surgery to treat deep infiltrative endometriosis, with colorectal resection.Measurements and Main ResultsForty-five patients with bowel endometriosis were followed up from 2007 to 2012. Before surgery, all patients exhibited signs suggestive of bowel endometriosis at magnetic resonance imaging and transrectal ultrasound. The patients underwent laparoscopic surgery for resection of the endometriosis lesions, including colorectal resection. The patients completed the questionnaire before surgery (T0), at 12 (T12) and 48 (T48) months after surgery. The 8 items of the SF-36 questionnaire at the different time points of application were compared. For each domain attribute, a score of 0 to 100 was assigned, where 0 signified the worst quality of life, and 100 the best. Statistical analysis was performed using analysis of variance. If differences were detected, multiple comparisons were performed using the Tukey test. Analysis of each domain revealed improved quality of life when comparing the period before surgery with 12 and 48 months after surgery. There was a significant increase (p < .001) in the scores in all of the SF-36 domains when comparing T0 vs T12 and T0 vs T48, with higher average scores at T48 corresponding to the domains of physical functioning, role physical, and social functioning (scores of 85.56, 75.69, and 73.61, respectively).ConclusionLaparoscopic treatment of bowel endometriosis improved the long-term quality of life of patients.     

Endometriosis of Bladder: Outcomes after Laparoscopic Surgery

Study ObjectiveTo describe outcomes after laparoscopic excision of deep bladder endometriosis.DesignRetrospective study (Canadian Task Force classification II-3).SettingUniversity hospitals.PatientsTwenty-one consecutive patients with endometriotic nodule on the bladder (infiltrating detrusor muscle) from a series of 169 patients were included in the study. The primary outcome studied was resolution of bladder symptoms. Secondary outcomes included complication rates, recurrence rates, and pregnancy rates after laparoscopic surgery.InterventionsLaparoscopic excision of bladder endometriosis.Measurements and Main ResultsLaparoscopy was feasible in all cases without the need for conversion. Median follow-up was 20 months. Ten patients (47.6%) underwent partial cystectomy, and the remaining patients underwent partial-thickness excision of the detrusor muscle. Sixteen patients (76%) had associated deep lesions in the pelvis. The most common associated lesions were rectovaginal nodules (38%) and ureteric lesions (14%), with signs of obstruction. Major complications developed in 3 patients (14%), primarily related to bowel resection. Six patients became pregnant (60%). No patients experienced disease recurrence.ConclusionLaparoscopic excision is feasible in all types of bladder endometriosis but often involves multiple procedures to manage associated lesions, especially rectovaginal nodules and ureteric lesions. Previous reports have suggested that ureteric lesions are not associated with bladder endometriosis; however, this was not true in our series. Complications are primarily related to severity of the disease and associated procedures. Partial cystectomy is not required in all cases to achieve adequate clearance. Complete excision of the disease is associated with resolution of bladder symptoms and low recurrence rates.     

Evaluation of Quality of Life and Sexual Satisfaction in Women Suffering from Chronic Pelvic Pain With or Without Endometriosis

IntroductionChronic pelvic pain (CPP) is one of the most frequent symptoms in women of reproductive age. This is an enigmatic clinical condition that results from the complex interactions of physiological and psychological factors with direct impact on the social, marital, and professional lives of women.AimTo evaluate the quality of life and sexual satisfaction of women who suffer from CPP with or without endometriosis.MethodForty‐nine patients who had been diagnosed with endometriosis and 35 patients with CPP diagnosed with another gynecological condition, all 84 of whom were treated at the Chronic Pelvic Pain and Endometriosis Clinic at Universidade Federal de São Paulo (UNIFESP) from January to July of 2008. The controls were 50 healthy women from the Family Planning Clinic at UNIFESP.Main Outcome MeasuresWorld Health Organization Quality of Life Assessment‐Bref (WHOQOL‐BREF) quality of life questionnaire and the Golombok‐Rust Inventory of Sexual Satisfaction (GRISS).ResultsNo statistically significant differences were observed between the groups with CPP symptoms, in either the results from the WHOQOL‐BREF or in the GRISS questionnaire. In both questionnaires, differences were observed when the two groups of symptomatic women were compared with the group of healthy women.ConclusionCPP caused by endometriosis or other gynecological conditions leads to a significant reduction of quality of life and sexual satisfaction. Tripoli TM, Sato H, Sartori MG, de Araujo FF, Girão MJBC, and Schor E. Evaluation of quality of life and sexual satisfaction in women suffering from chronic pelvic pain with or without endometriosis. J Sex Med 2011;8:497–503.     

Robotic Excision of Full-thickness Diaphragmatic Endometriosis

Study ObjectiveTo describe a robotic approach to excision of full-thickness diaphragmatic endometriosis.DesignSurgical technique demonstration.SettingSymptomatic diaphragmatic endometriosis is commonly associated with lesions that are deeply invasive. In the presence of symptomatic diaphragmatic endometriosis, the posterior diaphragm should be explored.InterventionsThis video presents a systematic robotic approach to the excision of diaphragmatic endometriosis, highlighting key anatomic landmarks and technical considerations to complete the procedure safely and effectively. Resection of hepatic ligaments, use of a 30° endoscope, and right lateral access can be used to visualize this anatomic area [1]. The phrenic nerve is rarely identified during laparoscopy, if at all, and an inability to identify this structure during hemidiaphragm resection does not seem to result in significant patient morbidity. After diaphragm resection, the pleural cavity and lung should be systematically inspected to rule out the presence of additional endometriotic lesions. If the long axis of the diaphragmatic defect is parallel to the posterior chest wall and can be closed tension-free, then mesh is not necessary [1]. Insertion of a red rubber catheter into the thorax along with the use of negative pressure suction at the end of closure of the diaphragmatic defect may avoid use of a postoperative chest tube.ConclusionThe use of robotic assistance for resection of diaphragmatic endometriosis makes this procedure easy and safe to perform. Compared with ablative procedures, complete surgical excision offers higher rates of symptom improvement and resolution in patients with diaphragmatic endometriosis.     

Dienogest Versus Leuprolide Acetate for Recurrent Pelvic Pain Following Laparoscopic Treatment of Endometriosis

Objective

To compare the efficacy and safety of dienogest (DNG) with depot leuprolide acetate (LA) in patients with recurrent pelvic pain following laparoscopic surgery for endometriosis.

Design

Prospective randomized trial.

Setting

Zagazig University hospitals, Egypt.

Patients

Two hundred and forty-two patients with recurrent pelvic pain following laparoscopic surgery for endometriosis.

Intervention

Dienogest (2 mg/day, orally) or depot LA (3.75 mg/4 weeks, intramuscularly) for 12 weeks.

Main Outcome Measures

A visual analogue scale was used to test the intensity of pain before and after the end of treatment.

Results

There was highly significant reduction in pelvic pain, back pain and dyspareunia in both groups with mean of difference in dienogest group (28.7?±?5.3, 19.0?±?4.3 and 20.0?±?3.08 mm, respectively) and in LA group (26.2?±?3.01, 19.5?±?3.01 and 17.9?±?2.9 mm, respectively). The most frequent drug-related adverse effects in dienogest group were vaginal bleeding and weight gain (64.5 and 10.8%, respectively) which were significantly higher than LA group (21.5 and 3.3%, respectively). While the most frequent drug-related adverse effects in LA group were hot flushes and vaginal dryness (46.3 and 15.7%, respectively) which were significantly higher than dienogest group (15.7 and 3.3%, respectively).

Conclusion

Daily dienogest is as effective as depot LA for relieving endometriosis-associated pelvic pain, low back pain and dyspareunia. In addition, dienogest has acceptable safety, tolerability and lower incidence of hot flushes. Thus, it may offer an effective and well-tolerated treatment in endometriosis.

     

Outcomes after Laparoscopic Excision of Bladder Endometriosis Using a CO2 Laser: A Review of 207 Cases in a Single Center

Study ObjectiveAssess efficacy, safety, fertility outcomes and recurrence after laparoscopic resection of bladder endometriosis (BE) using a CO₂ laser.DesignRetrospective cohort study.SettingsUniversity gynecologic surgery unit, referral center for endometriosis.PatientsA total of 207 women having undergone laparoscopic BE excision between January 1998 and January 2019.InterventionsNone.Main Outcome MeasuresIntra- and postoperative complication rates. Disease recurrence and fertility outcomes in patients with a minimum 1-year follow-up (n = 176) for “isolated” and “non-isolated” BE groups.ResultsForty-three patients presented with isolated BE. Bladder “shaving” without mucosae opening was performed in 50.7% cases. No intraoperative complications were noted. One postoperative grade 3 complication was related to BE excision: a bladder breach requiring closure by repeat laparoscopy. Mean (± SD) follow-up was 7.05 (± 4.65) years. In patients wishing to conceive (n = 132), the total pregnancy rate (PR) was 75% (48.5% spontaneous), 76.19% in the isolated BE group (56.3% spontaneous). Among the 94 patients with previous infertility, 74.5% conceived, 50% spontaneously. No statistical difference was found in PR and need for in vitro fertilization between isolated and nonisolated BE groups. BE recurrence rate was 3.4%. No difference was observed between groups with full-thickness bladder resection (4/88) and shaving (2/88) (p = .406). Age at surgery (hazard ratio 0.91 [0.84–0.98], p = .016) and postoperative pregnancy (hazard ratio 0.07 [0.01–0.91], p = .042) showed influence on disease recurrence.ConclusionsThe study demonstrates that laparoscopic BE removal is feasible with very low complications rates and was associated with high PR (both spontaneous and in vitro fertilization), even in patients with previous infertility. BE recurrence is lower than for other endometriosis locations. Bladder endometriosis; Laparoscopy; Deep infiltrating endometriosis; Fertility; Partial bladder resection     

Vaginally Assisted Laparoscopic Urethrolysis and Mesh Excision after Tension-free Vaginal Tape

Study ObjectiveTo present technique of vaginally assisted laparoscopic urethrolysis and mesh excision after tension-free vaginal tape.DesignDemonstration video.SettingDespite the Food and Drug Administration's warning to limit the use of mesh, midurethral sling surgery (MUS) has not significantly decreased, but operations for complications have increased 3 times [1]. Urethral obstruction after MUS has an incidence of 2.7% to 11% [2] that requires resurgery, which ranges from pull-down, mesh excision to urethrolysis and is chosen by the surgeon's experience. Retropubic urethrolysis and mesh excision are reported to be more successful [3]. Urethrolysis can be performed by a retropubic, transvaginal, or suprameatal approach. Transvaginal mesh excision and urethrolysis are not satisfactory in all cases, and it might be difficult to identify the mesh if it is dislocated proximally or buried in dense fibrosis, which may increase urethral/bladder injuries. Although vaginal urethrolysis and mesh removal are usually preferred as the primary approach, there is no randomized controlled trial comparing retropubic and vaginal urethrolysis with/without mesh removal. Gynecologists should master each technique to provide individualized treatment. Laparoscopic urethrolysis has the advantage of the identification of neighboring structures and provides a safer operation (Fig. 1). Combined vaginal and laparoscopic approaches can be used to totally remove the mesh and for difficult surgeries at the junction of the retropubic urethra and the midurethra (Fig. 2).Interventions(1) Timing of urethrolysis is controversial. Although urethral loosening or pulling down in the first few days and mesh excision in the first 15 days can be useful, urethrolysis can be chosen for delayed cases with marked fibrosis. Preoperative diagnostic cystoscopy to exclude urethral mesh erosion is essential. Intermittent catheterization until surgery should be done. (2) The technique is described in 5 steps. The arcus tendineus is an important landmark [4] (Fig. 3).ConclusionLaparoscopic urethrolysis for urinary obstruction after MUS can be a safe and successful procedure after failed vaginal approach or can be considered as a primary approach in select cases.     

Endometriosis and Mechanisms of Pelvic Pain

Endometriosis remains an enigmatic disorder in that the cause, the natural history, and the precise mechanisms by which it causes pain are not completely understood. The pain symptoms most commonly attributed to endometriosis are dysmenorrhea, dyspareunia, and chronic pelvic pain. Pain may be due to nociceptive, inflammatory, or neuropathic mechanisms, and there is evidence that all 3 of these mechanisms are relevant to endometriosis-associated pelvic pain. It is proposed that the clinically observed inconsistencies of the relationships of endometriosis severity and the presence or severity of pain are likely due to variable roles of different pain mechanisms in endometriosis. A better understanding of the roles of nociceptive, inflammatory, and neuropathic pain in endometriosis is likely to improve the treatment of women with endometriosis-associated pelvic pain.     

Laparoscopic Excision of Sacrocolpopexy Mesh

Study ObjectiveTo demonstrate surgical maneuvers to facilitate laparoscopic excision of sacrocolpopexy mesh and prevent potential complications.DesignStep-by-step illustration of various surgical techniques using a video compiled from 3 laparoscopic sacrocolpopexy mesh excision procedures performed at Magee–Womens Hospital for various indications (Canadian Task Force classification xx-xx).SettingMesh complications such as infection and erosion are frequently managed conservatively but often necessitate mesh excision for symptom relief. Laparoscopic excision of sacrocolpopexy mesh procedures is typically challenging, even in the hands of experienced surgeons. Synthetic mesh, being a foreign body, activates an inflammatory process that leads to surrounding tissue fibrosis and scar tissue formation that can distort the pelvic anatomy, thereby putting vital organs at risk of injury. Such organs include the bladder, rectum, and vagina caudally; the left common iliac vein and middle sacral vessels cephalad; and the ureters at the level of the vaginal cuff angles.InterventionLaparoscopic excision of sacrocolpopexy mesh.ConclusionWhen planning laparoscopic sacrocolpopexy mesh excision, complications can be prevented with use of proper surgical technique. It is important to identify vital structures because they may be displaced due to tissue fibrosis. When developing various surgical planes, surgeons should first operate in areas that are free of adhesions. This will enhance exposure when dissecting the mesh in proximity of scarred tissue and vital organs. Use of vaginal and rectal probes helps to delineate the vesicovaginal and rectovaginal spaces to prevent bladder and bowel injury.     

Urinary Tract Endometriosis: How to Predict and Prevent Recurrence after Primary Surgical Excision

Study ObjectiveTo investigate the clinical and surgical predictors of urinary tract endometriosis (UTE) relapse.DesignRetrospective single institutional study.SettingItalian multidisciplinary referral center for endometriosis.PatientsConsecutive patients affected by UTE and surgically treated between January 2016 and March 2020.InterventionSurgical excision for UTE. Uni- and multivariate logistic regression analyses were fitted to evaluate clinical and surgical predictors of recurrence.Measurements and Main ResultsA total of 105 female age-reproductive patients were enrolled. Median age was 32 years (interquartile range, 24–37). Ureteral involvement was recorded in 53 patients (50.5%), being unilateral and bilateral in 46 patients (43.8%) and 7 patients (6.7%), respectively. Bladder involvement occurred in 52 patients (49.5%). Open surgical approach was performed in 24 cases (22.9%), whereas 30 patients (28.5%) and 51 patients (48.6%) were treated with laparoscopic and robot-assisted approach, respectively. Overall, 53 patients (50.5%) received adjuvant hormonal therapy. At a median follow-up of 39 months (interquartile range, 22–51), 30 patients (28.6%) experienced disease relapse, with 14 recurrences (13.3%) recorded at the level of the urinary tract. At multivariable analysis, age at first surgery <25 years (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.10–1.84; p = .02) and the presence of a concomitant autoimmune disease (OR, 1.45; 95% CI, 1.24–2.17; p = .02) were found as predictors of deep infiltrating endometriosis recurrence, whereas adjuvant postsurgical therapy showed a protective role (OR, 0.83; 95% CI, 0.53–0.98; p = .01).ConclusionsYoung age (<25 years) and the presence of autoimmune diseases were significant predictors for the development of disease recurrence, whereas adjuvant hormonal therapy showed a protective role.