Robotic technology for pelvic exenteration in cases of cervical cancer

Background

Cervical cancer represents one of the most common types of neoplasia among women; the use of minimally invasive techniques in the treatment of cervical cancer is a challenge.

Objectives

To present evidence regarding robotic technology in the performance of pelvic exenteration in cases of cervical cancer.

Search strategy

PubMed and Scopus databases were searched.

Selection criteria

Articles examining the use of robotic technology for pelvic exenteration in cases of cervical cancer were included.

Data collection and analysis

Four studies were included.

Main results

Most cancers treated with robotic-assisted pelvic exenteration were squamous cell carcinomas of the cervix. The stage of primary cancer ranged from IB2 to IVA. In 7 of the 8 patients, anterior pelvic exenteration was performed; the other patient underwent total pelvic exenteration. Procedure duration ranged from 375 to 600 minutes; blood loss was 200–550 mL. Postoperative complications occurred in 2 of the 8 patients and included perineal abscess, Miami pouch fistula, and ureteral stenosis. Postoperative hospital stay ranged from 3 to 53 days, and postoperative follow-up ranged from 2 to 31 months.

Conclusions

The gold standard for pelvic exenteration remains the open surgical approach; however, the application of robotic technology could be an alternate choice associated with excellent results.     

Overall survival after pelvic exenteration for gynecologic malignancy

Background

Five-Year survival after pelvic exenteration for gynecologic malignancies has been reported as high as 60%. The objective of this study was to determine overall survival (OS) after pelvic exenteration and evaluate factors impacting outcome.

Methods

A retrospective review of all women who underwent pelvic exenteration at our institution between February 1993 and December 2010 was performed. OS was defined as time from exenteration to date of death or last contact. Survival analysis was performed using the Kaplan Meyer method. Multivariate analysis was performed to determine the impact of clinical and pathologic factors on survival outcomes.

Results

One hundred sixty patients with gynecologic malignancy underwent pelvic exenteration. Five-year recurrence free survival (RFS) was 33% (95%CI 0.25–0.40). Factors which negatively impacted RFS included shorter treatment-free interval (p = .050), vulvar primary (p = .032), positive margins (p < .001), lymphovascular space invasion (LVSI, p < .001), positive lymph nodes (p < .001) and perineural invasion (p = 0.030). In multivariate analysis, positive margins (p = .040), positive nodes (p < .001) and lymphovascular space invasion (LVSI, p = .003) retained a significant impact on RFS.Five-year OS was 40% (95% CI 0.32–0.48). Factors which negatively impacted OS included vulvar primary (p = .04), positive margins (p < .001), LVSI (p < .001), positive lymph nodes (p < .001) and perineural invasion (p = .008). In multivariate analysis, positive nodes (p = .001) and LVSI (p = .001) retained a significant impact on OS.

Conclusion

Five-year OS after pelvic exenteration was 40%. Survival outcomes have not significantly improved despite improvements in technique and patient selection. Multiple non-modifiable factors at the time of exenteration are associated with poor survival.     

Pelvic exenteration: Impact of age on surgical and oncologic outcomes

Objective

To evaluate whether preoperative age impacts surgical outcomes, complication rates, and/or recurrence in women undergoing pelvic exenteration.

Methods

All women who underwent a pelvic exenteration for any gynecologic indication at our institution from 1993 to 2010 were included. Women were stratified into groups based on age in years (young: ≤ 50, middle: 51–64, and senior: ≥ 65). Baseline characteristics, surgical outcomes, early (< 60 days) and late (≥ 60 days) postoperative complications, and recurrence/survival outcomes were ascertained. Fisher's exact test or Kruskal–Wallis test was performed. Kaplan–Meier survival curves were compared.

Results

161 patients were included (58 young, 62 in the middle, and 41 senior). Women in the young group predominately had a diagnosis of cervical cancer (82.8%) while women in the senior group primarily had a diagnosis of vulvar or vaginal cancer (70.7%). Senior women were also more likely to have hypertension (p < 0.0001) and pulmonary disease (p = 0.040). Operative time was significantly shorter for women in the senior group (8.5 h) compared with the middle (9.5 h) and young group (10.1 h) (p = 0.0089). There were no significant differences in early or late complications when stratified by age. The overall survival did not differ between age groups (p = 0.3760).

Conclusion

Although hypertension and pulmonary disease were more frequent in the senior age group, duration of surgery, blood loss, length of hospital stay and complication rates did not increase with age. Advanced chronological age should not be considered a contraindication to a potentially curative surgical procedure.     

Indications and long-term clinical outcomes in 282 patients with pelvic exenteration for advanced or recurrent cervical cancer

Objective

The aim of this study was to summarize the clinical experience at our clinic with pelvic exenteration as a treatment for cervical cancer with special regard to the indications and outcomes of specific patient groups.

Methods

Medical records of 282 women who underwent pelvic exenteration to treat cervical cancer were analyzed.

Results

In total, 70 patients (25%) underwent primary exenteration, and 212 (75%) underwent secondary exenteration. Exenteration was anterior for 14 (5%) patients, posterior for 6 (2%) and total for 262 (93%). The overall survival (OS) of the 282 patients was 41% at 5 years and 37% at 10 years. The disease-free survival at 5 years was 61%. For 133 patients for whom pelvic exenteration was a curative procedure, the OS was 64% at 5 years and 57% at 10 years. For cases of pelvic exenteration as a palliative intervention, the OS was 19% at 5 years and 18% at 10 years. No difference was seen in the OS at 5 years between patients who received primary and secondary operations. No significant difference in the OS was found regardless of whether the patients had positive pelvic lymph nodes, whereas in cases of paraaortic lymph node metastasis, the OS was significantly lower. Out of all of the procedures, 139 (49%) involved no perioperative or postoperative complications. One major complication was reported for 72 (26%) patients, two complications occurred for 42 patients (15%) and more than three complications were noted for 29 (10%) patients.

Conclusion

Pelvic exenteration is an effective technique with a high percentage of long-term survivors. To the best of our knowledge, our study involves the largest published number of patients treated with pelvic exenteration for a single gynecological cancer and shows that previous contraindications for pelvic exenteration, such as lymph node metastasis (especially when confined to the pelvic lymph nodes), older age or palliative intent, should be reconsidered.     

Pelvic exenteration in the age of modern chemoradiation

Background

To examine outcomes after pelvic exenteration in women treated with modern chemoradiation and surgical techniques.

Methods

All patients at our institution with a diagnosis of gynecologic malignancy who underwent pelvic exenteration after treatment with chemoradiation between 1/90 and 6/08 were evaluated with a retrospective chart review.

Results

44 women were identified, of whom 29 (66%) had cervical, 6 (14%) had uterine, 5 (11%) had vaginal, and 4 (9%) had vulvar cancer. The majority of patients (82%) were initially treated with external beam whole-pelvic radiation with concurrent cisplatin. 38 patients (86%) underwent exenteration for a central pelvic recurrence, and the remaining 6 patients (14%) for radiation necrosis. The most common surgical complication was transfusion requirement in 36 patients (82%), followed by wound infection in 15 (34%), small bowel obstruction in 8 (18%), and sepsis in 6 (14%). The median time spent in the ICU post-operatively was 2 days. One patient (2%) died during her post-operative hospital stay. The mean EBL overall was 2497 cc and the mean operative time was 544 min. Use of electrothermal bipolar coagulation, which was used in 64% of the exenterations, significantly reduced blood loss (3679 cc vs. 1836 cc, p = 0.014). After exenteration, 21 patients (48%) were diagnosed with a recurrence of cancer, and the mean progression free survival was 31 months. Patients who received exenteration less than 2 years after their initial chemoradiation had a significantly shorter overall survival time (8 months vs. 33 months, p = 0.016).

Conclusions

Approximately 50% of women develop recurrence following exenterations done after chemoradiation. Survival is significantly longer in patients who necessitate exenteration greater than 2 years out from initial treatment. Electrothermal bipolar coagulation appears to significantly reduce blood loss during these surgeries.     

Comparison study of single-port (Octoport™) and four-port total laparoscopic hysterectomy

Objective

To compare the perioperative surgical outcomes and complication rates between single-port total laparoscopic hysterectomy and conventional four-port total laparoscopic hysterectomy.

Study design

Between June 2009 and April 2011, 56 patients underwent total laparoscopic hysterectomy. Of these 56 patients, 28 underwent single-port (Octoport™) total laparoscopic hysterectomy and 28 underwent conventional four-port total laparoscopic hysterectomy. We analyzed the following parameters for all the patients: age, body mass index, operative time, blood loss, change in hemoglobin level, vaginal stump suture time and length of hospital stay.

Results

The general characteristics of the patients were similar in both groups. There were no statistically significant differences in blood loss, hemoglobin change, length of postoperative hospital stay and complication rate. However, the mean operative time of the single-port group was significantly longer than that of the four-port group (93.5 ± 24.0 min vs. 78.7 ± 17.4 min; P = 0.011). The operative time for vaginal stump suture was profoundly decreased with experience in the single-port group.

Conclusion

With the exception of operative time, the surgical outcomes and incidence of complications of the single-port group were comparable to those of the four-port group. However, the operative time decreased in the single-port group with increasing experience.     

Radiation therapy for pelvic lymph node metastasis from uterine cervical cancer

Objectives

This study aimed to evaluate the efficacy of radiation therapy for pelvic lymph node metastasis from uterine cervical cancer and identify an optimal radiation regimen.

Methods

A total of 111 metastatic pelvic lymph nodes, ranging from 11 to 56 mm (median, 25 mm) on CT/MRI, in 62 patients with uterine cervical cancer were treated initially with curative radiation therapy, with 46 patients receiving concurrent chemotherapy. Total radiation doses ranged from 45 to 61.2 Gy (median, 50.4 Gy) in 1.8–2 Gy (median, 1.8 Gy) fractions.

Results

At a median follow-up of 33 months, 46 of the 62 patients survived. Only 2 irradiated lymph nodes, 24 and 28 mm in diameter, in 1 patient progressed after irradiation alone with 50.4 Gy in 1.8 Gy fractions. All 33 metastatic lymph nodes ≥ 30 mm in diameter were controlled by irradiation at a median dose of 55.8 Gy. The 3-year lymph node-progression free rates were 98.2% in all 62 patients and 98.0% in all 111 metastatic lymph nodes. Except for transient hematologic reactions, 2 patients developed grade ≥ 3 therapy-related toxicities, 1 with an ulcer and the other with perforation of the sigmoid colon. In addition, 2 patients experienced ileus after irradiation.

Conclusions

Radiation therapy effectively controlled pelvic lymph node metastases in patients with uterine cervical cancer, with most nodes < 24 mm in diameter controlled by total doses of 50.4 Gy in 1.8 Gy fractions and larger nodes controlled by 55.8 Gy, particularly with concurrent chemotherapy. Higher doses to metastatic lymph nodes may increase intestinal toxicities.     

The effect of body mass index on surgical outcomes and survival following pelvic exenteration

Objective

We sought to evaluate whether preoperative body mass index (BMI) impacts surgical outcomes, complication rates, and/or recurrence rates in women undergoing pelvic exenteration.

Methods

All women who underwent pelvic exenteration for gynecologic indications at our institution from 1993 through 2010 were included. Women were stratified into 3 groups based on BMI. Baseline characteristics, surgical outcomes, early (< 60 days) and late (≥ 60 days) postoperative complications, and recurrence/survival outcomes were collected. Multivariate logistic regression analyses were performed. Kaplan-Meier survival curves were compared using log-rank test.

Results

161 patients were included (59 normal weight, 44 overweight, 58 obese). Median follow-up times were 22, 29, and 25 months. Most patients underwent total pelvic exenteration (68%); 64.6% had a vaginal reconstruction. On multivariate analysis, both overweight and obese patients had a higher risk of early superficial wound separation compared to normal weight patients — OR 10.74 (3.33-34.62, p < 0.001) and OR 4.35 (1.40-13.52, p = 0.011), respectively. Length of surgery was significantly longer for overweight (9.6 h, OR 1.26, 1.02-1.55, p = 0.032) and obese (10.1 h, OR 1.24, 1.04-1.47, p = 0.014) patients than for normal weight patients (8.7 h). Late postoperative complications for patients in the normal weight, overweight, and obese groups were 47.5%, 45.5%, and 43.1% (p = 0.144). There were no differences in time to recurrence (p = 0.752) or overall survival (p = 0.103) between groups.

Conclusion

Although operative times were longer and risk for superficial wound separation was significantly higher, pelvic exenteration appears to be feasible and safe in overweight and obese women with overall complication rates and survival outcomes comparable to normal weight women.     

Synthetic cyanoacrylic glue in the prevention of post-operative lymphocele after pelvic lymphadenectomy in patients with uterine malignancies: A prospective,single-blind,preliminary study

Objectives

Lymphoceles are among the most common post-operative complications of pelvic lymphadenectomy, with a reported incidence of 1% to 29% in gynecology oncology. Several studies evaluated the effectiveness of biological glues on reducing lymphoceles, but no data on gynecological patients are available. We evaluated the effectiveness of cyanoacrylic glues (n-butyl cyanoacrylate) (Glubran 2 — GEM s.r.l., Italy) in preventing lymphocele on 30 patients who underwent pelvic lymphadenectomy for endometrial or cervical cancer.

Methods

Single-blind prospective randomized study. Patients were divided into 2 groups: pelvic lymphadenectomy plus n-butyl cyanoacrylate (treatment group: 44 patients) and pelvic lymphadenectomy without n-butyl cyanoacrylate (control group: 44 patients). Primary endpoint was incidence of pelvic lymphocele in the two groups 30 days after surgery, and evaluated with pelvic ultrasound and RMI examination. Secondary endpoints evaluated drainage volume of lymphorrhea 36, 48, 72 and 96 h after surgery.

Results

15% in the treatment group and 36.6% in the control group had lymphocele 1 month after the procedure (p < 0.03; RR 0.4 [95% CI 0.152–0.999]). Concerning the secondary outcome in group A the amount of lymphorrhea presented a constant significant decrease during evaluation; on the contrary, in group B, after an initial decrease at 48 h, the amount of lymphorrhea remained unchanged; at all considered times the amount of lymphorrhea resulted significantly greater in controls.

Conclusion

Intraoperative application of n-butyl cyanoacrylate seems to reduce lymph production after pelvic lymphadenectomy, providing a useful additional treatment option for reducing drainage volume and preventing lymphocele development after pelvic lymphadenectomy.     

Neoadjuvant chemotherapy followed by robotic radical hysterectomy in locally advanced cervical cancer: A multi-institution study

Objective

Minimally invasive surgery has been performed in locally advanced cervical cancer (LACC) without adverse effect in patient's overall prognosis and survival. The aim of this report is to evaluate the feasibility and morbidity of total robotic radical hysterectomy (TRRH) with pelvic lymphadenectomy in patients with LACC after neo-adjuvant chemotherapy (NACT).

Methods

From February 2008 to April 2013 a retrospective data collection of women undergoing TRRH for cervical cancer stage FIGO IB2 to IIB, after neo-adjuvant chemotherapy, was conducted at “Regina Elena” National Cancer Institute of Rome and European Institute of Oncology of Milan. All patients deemed operable underwent TRRH with pelvic lymphadenectomy within 4 weeks from the last chemotherapy cycle.

Results

Median operative time was 225 min (range, 105–387 min). The median blood loss was 150 mL (range, 30–700 mL). The median number of removed pelvic lymph nodes was 23 (range, 8–69). Sixteen patients had an optimal response (12 PCR, 4 pPR1) to chemotherapy, 33 patients had a pPR2 and 11 patient showed stable disease. Adjuvant therapy was administrated in 36 patients (60%). We experienced one intra-operative complication and 19 post-operative complications, but no conversions to laparotomy were necessary to manage these complications. Six patients received a blood transfusion. At the time of this report, with a median follow-up of 28.9 months, 50 patients (83%) are free from recurrence.

Conclusion

This experience demonstrates the feasibility of TRRH pelvic lymphadenectomy after NACT in LACC with good accuracy and safety.     

Exenteration in the treatment of Stage III/IV vulvar cancer

Objectives and methods

Vulvar carcinomas are rare genital malignancies. While advanced primary cancer chemoradiation is often preferred over pelvic exenteration (PE), PE is often the only therapy available in cases of recurrence. In a retrospective study, we analyzed predictive factors and outcomes of patients who underwent exenteration for vulvar cancer in our department during the past 10 years.

Results

We identified 27 patients; 9 of them suffered from primary disease, and 18 had experienced a recurrence. A total of 18 patients presented with stage FIGO III, and 9 patients presented with stage IV. In 10 patients, the disease had spread to the inguinal lymph nodes, and in 3 patients, it had also spread to the pelvic nodes. At the end of surgery, all patients were macroscopically tumor free, which was confirmed microscopically in 20 patients (74%, R0), with the other 7 patients having microscopic tumor remnants. For all patients, median time of survival was 37 months, the five-year survival rate (5YSR) was 62%, and the overall survival (OS) was 59%. Patients with tumor-free lymph nodes had an OS of 76% and a 5YSR of 83% vs. 40% and 36%, respectively, for patients with tumorous spread to the nodes (p = 0.03). The 5YSR correlated to the degree of resection (R0 vs. R1, 74% vs. 21%, p = 0.01).

Conclusion

PE is a therapeutic option in advanced primary or relapsed vulvar carcinoma, offering median- to long-term survival for many patients. Carcinomatous spread to regional lymph nodes and complete resection are the most important prognostic factors.     

Histerectomía radical laparoscópica total en el cáncer de cérvix. Factibilidad,morbilidad y supervivencia

Objective

To assess feasibility, perioperative morbidity and medium term survival of total laparoscopic radical hysterectomy in cervical cancer.

Material and methods

A total of 31 consecutive patients diagnosed FIGO clinical stage IA2 (n = 4), IB1 (n = 22), IIA (n = 2) and IB2 (n = 3) in Son Llàtzer hospital (Palma de Mallorca) that were programmed for a total laparoscopic radical hysterectomy were studied. We analyzed tumor histological characteristics, surgical technique, perioperative variables, postoperative complications and mid-term survival results.

Results

Feasibility rate was 96%. The most frequently operative complication was accidental bladder incision (3 cases). Postoperative complications rate was 20% (6 cases) which includes one surgical reintervention. Average operative time was 258 minutes (range: 180-360). Blood transfusion rate was 17% (n = 5) and mean hospital stay was 7.8 days (range: 2-29). After one month after surgery 72% of patients had a normal miccional function. Mean tumoral size was 26.5 mm and lymphatic positive nodes rate was 17% (n = 5). Mean follow-up time was 26 months. Tumor relapse rate was 17% (n = 5) and survival-free disease of 100% for IA2 stage, 82.6% of IB1/IIA stages and 66.7% for IB2 stage.

Conclusions

Total laparoscopic radical hysterectomy is a feasible technique in most of the patients with cervical cancer. It needs more operative time than abdominal route but it presents less perioperative morbidity, less blood transfusion and less ospitalization days. The medium term survival is comparable with conventional abdominal route.     

Assessment of female sexual function among women with pelvic organ prolapse or urinary incontinence via an Arabic validated short-form sexual questionnaire

Objective

To assess female sexual function among women with pelvic organ prolapse or urinary incontinence via an Arabic, validated, short-form sexual questionnaire (PISQ-12).

Methods

The present study was conducted among women attending Suez Canal University Hospital, Ismailia, Egypt, between September 2009 and August 2011. In the pilot study, 42 women completed the final version of the Arabic PISQ-12 at recruitment and then 2 weeks later, and the data were compared to evaluate reliability and internal consistency. The formal comparative study included 154 premenopausal sexually active women: 80 control women, and 74 women with some degree of pelvic prolapse with or without stress incontinence. All participants had a vaginal examination and completed the questionnaire. The main outcome measures were the mean questionnaire scores within its 3 domains (behavioral, physical, and partner-related).

Results

The test–retest reliability and internal consistency of the Arabic PISQ-12 were excellent. Validity was approved by an expert panel. The case group had a significantly lower mean total questionnaire score (31.07 ± 4.2 vs 34.7 ± 6.2; P < 0.05) but a higher partner-related score (9.0 ± 2.4 vs 8.4 ± 2.5; P < 0.05).

Conclusion

The Arabic version of PISQ-12 was shown to be an effective and objective method of evaluating sexual function among patients with pelvic organ prolapse.     

Robotic nerve-sparing radical hysterectomy: feasibility and technique

Objective

To describe the anatomy of pelvic autonomic nerves as it applies to nerve-sparing radical hysterectomy, and the technique, feasibility, and results of robotic nerve-sparing radical hysterectomy.

Methods

Prospective evaluation of 6 patients undergoing robotic nerve-sparing radical hysterectomy (type C1) for cervical cancer Stage IB (1B1 in 3 and 1B2 in 3 patients). Pelvic lymphadenectomy was performed in 3 patients and pelvic and aortic in the remaining 3 patients.

Results

The operation was completed in all patients. The mean age of the patients was 51.0 (range 33-73) and mean BMI 27.8 (range 23.2-35.1). The mean operating time was 238.6 min (range 207-256), mean blood loss 135 ml (range 100-150), mean number of lymph nodes was 23.6 (range 19-29), mean hospital stay was 2 days (range 1-4). There were no intraoperative complications. Postoperative complications occurred in 1 patient with an ileus who required an extended hospital stay. One patient did not regain normal urinary voidings until the fourth week after surgery. All patients remain free of disease.

Conclusion

Robotic nerve-sparing radical hysterectomy is safe and feasible. Urinary dysfunction may occur.     

Prognostic factors of primary fallopian tube cancer in a single institute in Taiwan

Objective

To improve the understanding of primary fallopian tube carcinoma (PFTC) through an analysis of possible clinical and pathologic determinants of prognosis.

Methods

A retrospective review of the database of a tertiary hospital in Taiwan for 1978–2007 was conducted to identify patients with a diagnosis of PFTC and to evaluate the clinicopathologic features associated with PFTC outcome.

Results

Fifty-eight patients (mean age 62.5 years) had a diagnosis of PFTC. Stage III/IV disease (55%) and poorly differentiated tumors (52%) were most common. The median follow-up was 93 months (range, 11–333 months). The 5-year disease-free survival rate was 59%, and the overall survival rate was 64%. Factors important in disease-free and overall survival in univariate analysis included the presence of pelvic and/or para-aortic lymph node metastases, International Federation of Gynecology and Obstetrics stage, high preoperative carbohydrate antigen 125 serum level, completion of optimal debulking surgery, and the use of paclitaxel-based chemotherapy; however, only patients with optimal cytoreduction had a decreased hazard of recurrence (hazard ratio [HR] 0.06; 95% confidence interval [CI] 0.01–0.23) and mortality (HR 0.08; 95% CI, 0.02–0.31) in multivariate analysis.

Conclusion

Advanced tumor stage, in particular the presence of lymph node metastases, worsened the prognosis of patients with PFTC. However, optimal debulking surgery significantly improved the prognosis, emphasizing the importance of the treatment strategy.     

Selective salpingography: preliminary experience of an office operative option for proximal tubal recanalization

Objective

To evaluate treatment efficacy and patient acceptability of the new Radiographic Tubal Assessment Set (RTAS) (Cook Ireland Ltd., Limerick, Ireland) for selective salpingography (SSG).

Study design

33 women, between 23 and 38 years old, referred to the Fertility Centre of the Department of Obstetrics, Gynecology and Reproductive Science, Second University of Naples, for sterility problems, underwent an office operative SSG with the RTAS. Of the 33 women, 12 had bilateral tubal obstruction (Group A) and 21 had unilateral tubal obstruction (Group B). Patients who did not regain tubal patency were referred for laparoscopic surgery. To verify patient acceptability, a visual analogue score (VAS 1-10) of pain was completed immediately after the procedure.

Results

From a total of 45 obstructed fallopian tubes, 34 were recanalized, giving a success rate for the procedure of 75.6% (p < 0.001). Nine patients with bilateral tubal obstruction (Group A) had the tubes recanalized and five obtained a spontaneous pregnancy. Sixteen patients with monolateral tubal obstruction (Group B) had the tubes recanalized and nine obtained a spontaneous pregnancy. A total of seven patients were sent for operative laparoscopy: four of them had the tubes recanalized and two obtained a spontaneous pregnancy. One patient was lost to follow-up. The evaluation of the level of pain felt during the procedure on the 10 cm VAS showed mean pelvic pain 2.9 ± 2.2, and an incidence of no discomfort ± low pain significantly higher than moderate ± severe pain (p < 0.0001).

Conclusion

The RTAS can be considered a safe and effective tool to perform this office operative procedure for tubal recanalization, with a high acceptability for the patient. The “see and treat” approach in patients with proximal tubal obstruction (PTO) suggests for the future the use of this device under sonographic guidance, taking into account accurate patient selection.     

Successful treatment of refractory endometriosis-related chronic pelvic pain with aromatase inhibitors in premenopausal patients

Objective

Not every patient with endometriosis responds to currently recommended conventional medical treatment regimens. The objective of this study was to determine the efficacy and side effects of aromatase inhibitors in the treatment of premenopausal patients with endometriosis associated with chronic pelvic pain refractory to conventional treatment.

Study design

Four premenopausal patients with documented refractory endometriosis and chronic pelvic pain were treated with aromatase inhibitors, either anastrazole (3) or letrozole (1), for 6 months. The treatment was combined with calcium 1.5 g per day and vitamin D 800 U per day. The main outcome measure was reduction in pelvic pain assessed by visual analogue scale. Side effects were documented and changes in serum LH, FSH and 17-β estradiol and bone density (Dexa scan) were measured before, during and after treatment.

Results

There was marked improvement in pelvic pain in the four patients. Their mean pain score fell from 9 prior to treatment to 4.5 at the end of treatment. One patient with infertility conceived immediately after completing the treatment. There were no changes in the hormone levels and bone scan scores. The most common side effect was irregular bleeding with anastrazole and joint pains with letrozole.

Conclusions

Aromatase inhibitors are beneficial in premenopausal women with chronic pelvic pain secondary to refractory endometriosis without compromising fertility and with minimal side effects. Further cohort and comparative studies are needed to confirm these observations.