Laparoscopic Diagnosis and Treatment of Obturator Nerve Entrapment Because of a Deep Infiltrating Endometriotic Nodule: A Case Report

Deep infiltrating endometriosis (DIE) is a particular form of endometriosis causing a variety of severe pelvic pain in women. The involvement of peripheral nerves by DIE implants is very rare. The most common involved site is the sacral plexus. There are few reported cases of involvement of the obturator nerve by DIE. To our knowledge, only 6 cases of symptomatic obturator nerve involvement by DIE have been described (according to PubMed database search in July 2018), and 3 of them were treated laparoscopically. We report a rare case of a deep infiltrating endometriotic nodule entrapping the right obturator nerve. Unlike the previously reported cases, patient history, clinical and laboratory data, and missed findings in previous imaging studies made our case difficult to diagnose. We successfully diagnosed the case and treated the patient with laparoscopic surgery. A video showing the surgery is also included. The recent follow-up in July 2018 (18 months after the operation was performed in January 2017) showed no signs or symptoms of recurrence or any other new complaints. The 18-month follow-up for this case is the longest follow-up data reported in the literature.     

Surgical Management of Superficial Peritoneal Adolescent Endometriosis

BackgroundAdolescent endometriosis typically presents as stage I with superficial peritoneal disease and less commonly as stage III or IV with deeply infiltrative disease. Endometriosis lesions can be destroyed (cautery or laser), cutting out the discrete lesion with excision and destroyed, or radically excised with removal of the lesion and surrounding tissue. It has been shown to be beneficial to excise deeply infiltrative disease to improve pain. Radical excision has been promoted by a subset of surgeons and involves removal of large areas of peritoneum with the promise/proposal of a cure and suggestion of no need for medical suppression of endometriosis. The best technique to manage superficial peritoneal disease has not yet been defined.CaseA 15-year-old young woman with a history of 2 previous laparoscopies for pain and an ovarian cyst who underwent removal of a mucinous cystadenoma, presented to a local gynecologist with chronic pelvic pain. She underwent a third laparoscopy and was found to have superficial peritoneal endometriosis and filmy adhesions believed to be due to the previous ovarian surgery. The endometriosis was surgically destroyed with the use of cautery and the filmy adhesions were lysed. Months later she had a return of pain and was advised to have a fourth laparoscopy with radical excision by an “excisionalist” gynecologist. She was found to have superficial peritoneal disease with ASRM-defined stage I endometriosis and underwent radical excision of the peritoneum of the anterior cul de sac, posterior cul de sac, and both pelvic side walls. She was informed that she had been cured of her endometriosis and was thus not treated with postoperative hormonal suppression. Her pain did not improve and in fact worsened after the radical excisional surgery. She self-referred for care. She started menstrual suppression treatment with continuous estrogen/progestin therapy for medical treatment of endometriosis but after 6 months she was still having severe pain without bleeding. Eight months after the radical excisional surgery she elected to have a fifth laparoscopy to address potential adhesions. At that time she was found to have extensive pelvic adhesions with the uterus adherent to the anterior cul de sac, and adhesions in the posterior cul de sac. In addition, both ovaries were involved with adhesions and adherent to the pelvic side walls. She was found to have clear and red lesions of superficial peritoneal endometriosis. She underwent a lysis of adhesions, and excision of lesions, and destruction of endometriosis. Her pain improved postoperatively; menstrual suppression was continued and she has remained with a continued excellent quality of life with over 2 years of follow-up.Summary and ConclusionFor this patient, radical excisional surgery resulted in increased pain and extensive adhesion formation. It was not curative because endometriosis was documented on follow-up surgery. In a previously published long-term follow-up report of adolescents with recurrent pain 2-10 years after destruction of superficial peritoneal disease, it was reported that there were no increased adhesions and no trend toward disease progression. Excisional gynecologists who perform this procedure should not suggest that radical excisional surgery is helpful and without increased risk, until studies have shown long-term benefit in the surgical management of superficial peritoneal endometriosis.     

Obturator hernia

Obturator hernias are relatively rare. In the past 15 years at the Mayo Clinic, eight patients underwent nine operations for repair of 11 obturator hernias, which represented 0.073 per cent (11 of 15,098) of all hernias repaired at this institution. Elderly women with chronic disease were most frequently affected. Symptoms were usually intermittent; mechanical small intestinal obstruction was the most common presenting condition, followed by pain in the thigh or groin area. The Howship-Romberg sign was found in only two patients, and a correct preoperative diagnosis was made in only one patient. Midline abdominal incisions were made in all patients. Incarcerated ileum was the most frequently encountered organ in the hernia sac. Surprisingly, foci of endometriosis in the obturator defect accounted for symptoms in two patients with three obturator hernias. Right-sided obturator hernias outnumbered left, and bilateral obturator hernias were found synchronously in two instances and metachronously in one instance. The often debilitated state of the patients with obturator hernia and the frequent delay of diagnosis combined to produce significant operative morbidity and mortality rates.     

Ovarian vein incompetence: a potential cause of chronic pelvic pain in women

OBJECTIVE(S): To evaluate whether ovarian vein incompetence may be a source of chronic pelvic pain (CPP) in women. STUDY DESIGN: Twenty-two women, aged 19-50 years, with chronic pelvic pain, no laparoscopically detected pelvic pathology, and evidence of reflux in dilated pelvic veins on transvaginal color Doppler ultrasound underwent retrograde ovarian venography and sclerotherapy of the ovarian vein(s) if incompetent. The primary outcome was symptom change as assessed by a symptom questionnaire and visual analog pain scales (VAS) at 3, 6, and 12 months of follow-up. Changes in pelvic circulations after sclerotherapy procedure were also evaluated by serial ultrasound examinations. Differences between baseline and post-procedural VAS scores were analysed using the Wilcoxon signed-rank test. RESULTS: Twenty (91%) of the 22 women had venographic evidence of incompetent ovarian vein(s) and received sclerotherapy. There were no immediate or late complications. Variable symptom relief was observed in 17 (85%) of the 20 treated women, with follow-up at 12 months showing marked-to-complete relief in 15 patients and mild-to-moderate relief in the remaining 2 patients. Three (15%) women had no improvement in symptoms. Median VAS scores at 3 (2.0), 6 (2.5), and 12 months (3.0) were significantly lower than at baseline (8.0) (P<.001). Follow-up ultrasound examinations showed absence of pelvic venous reflux in all but 3 patients, in whom recurrence of reflux was seen at 3 months. CONCLUSION(S): Ovarian vein sclerotherapy provided symptomatic relief and improved pelvic circulation in most patients. These findings suggest that ovarian vein incompetence was the likely source of chronic pain in these women, and that sclerotherapy was a safe and effective treatment for this condition. CONDENSATION: Ovarian vein incompetence leading to pelvic circulatory changes may be a cause of chronic pelvic pain in women.     

Endometriosis with massive hemorrhagic ascites: a case report and review of the literature

Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity. It generally involves the peritoneum, ovaries and rectovaginal septum. Its characteristic symptoms include dysmenorrhea, pelvic pain, deep dyspareunia and infertility. It may also involve the gastrointestinal tract, urinary tract or extra abdominal sites, giving rise to a wide variety of clinical symptoms such as bloody stools, renal haemorrhage, hemoptysis and pleural effusion during menstruation. Recurrent hemorrhagic ascites secondary to endometriosis is an unusual occurrence, 41 cases have been reported since 1954. Here we report an additional case, in order to draw attention to this condition. A 28 years-old black nulligravida woman was seen for the first time in april 2000 with a chief complaint of infertility. Her past medical history was unremarkable. She had regular menses but associated with severe dysmenorrhea. She also recalled abdominal and pelvic pain for several years. She underwent an ovulation induction with gonadotrophin, which resulted in a progressive increase of pelvic pain. A first laparoscopy was performed, revealing voluminous ascites (10 I). Two years later the ascites recurred spontaneously. Ultrasound examination revealed suspect "para uterine masses". A second exploratory laparoscopy showed a voluminous bloody ascites (71), and extensive adhesions. On histologic examination all specimens (peritoneal biopsies) were compatible with endometriosis and ruled out malignancy. Treatment with Gn RH analog was performed and full remission was obtained after 6 months. One year later the ascites recurred again spontaneously, leading to a third laparoscopy in an other medical institution. Histologic examination showed endometrial stromal tissue and fibrous proliferation. Later she became pregnant after in vitro fertilization. In the first trimester of pregnancy, the pelvic ultrasound showed only a small effusion in the pouch of Douglas. Still, the ascites did not progress during pregnancy. The patient was hospitalized from 27 to 33 weeks of gestational age for threatened labor, but she finally had a normal vaginal delivery at 36 weeks of gestational age. Four months later, she had no complaint, but the pelvic ultrasound showed the recurrence of the ascites. She will have a drainage. The future treatement will consists of GnRH analog for about six months, which will be relayed by a long term progestative therapy. A diagnosis of endometriosis should always be considered in middle-age women who presents with bloody ascites. Long follow-up is advisable for patients who undergo conservative treatment because of thehigh risk of recurrence.     

Endometriosis entrapment of the obturator nerve after previous cervical cancer surgery

A 26-year-old patient underwent pelvic lymphadenectomy and trachelectomy because of cervical cancer stage IB. Later she developed symptoms from obturator nerve entrapment. Examinations could not reveal metastatic cancer disease, but endometriosis surrounding the obturator nerve was discovered. Laparoscopic removal of the endometriotic tissue surrounding the nerve was performed and the patient's symptoms then disappeared.     

Obturator Internus Muscle Endometriosis with Nerve Involvement: a Rare Clinical Presentation

Study Objective

To describe our surgical approach in a rare case of deep infiltrating endometriosis of the obturator internus muscle with obturator nerve involvement.

Intestinal surgery and surgery of urinary tract in treatment of recurrent cervical cancer--case report

A case of a 31-year-old patient admitted to the Institute with a diagnosis of recurrent cervical cancer after radical hysterectomy and radiation therapy 12 months before. The patient had intestinal and urinary obstruction and also the tumor compressed the iliac blood vessels superficially. She underwent clinical examination, pelvic and abdominal ultrasound and multislice CT scan. A recurring tumor with a diameter of 7 cm was diagnosed. It was localized in the left parailiac and obturator region and infiltrated the left ureter, left bladder side wall, sigmoid colon and iliac blood vessels superficially. The patient had left pelvic sidewall relapse, so she underwent a palliative surgical procedure. We evacuated the complete tumor together with the infiltrated parts of the left ureter, sigmoid colon and bladder. At the end of operation left ureterocystoneostomy was performed as well as the Hartmann procedure with anus praeter insertion. There were no significant postoperative complications. After the surgical treatment of the recurrence, we suggested that the patient continue treatment of her disease with chemotherapy.     

Dyspareunia, back pain and chronic pelvic pain: the importance of this pain complex in gynecological practice and its relation with grandmultiparity and pelvic relaxation.

The aim of this study was to evaluate the correlation between severe dyspareunia, back pain, dysmenorrhea and chronic pelvic pain (CPP), and the relationship of each pain type with various sociodemographic factors, pelvic relaxation and high parity. Two hundred thirty-five premenstrual individuals were included. The prevalences of CPP, deep dyspareunia, dysmenorrhea and back pain were found to be 80.4, 30.6, 57.0 and 57.4%, respectively. Marriage duration was longer (p < 0. 01) and also parity was higher (p < 0.0001) in CPP cases than controls. However, none of the demographic factors had a significant correlation with dyspareunia, back pain and dysmenorrhea. CPP was correlated with both back pain (r = 0.18, p < 0.005) and dyspareunia (r = 0.19, p < 0.004). However, there was no correlation between back pain and dyspareunia. On the other hand, dysmenorrhea did not show a correlation with any pain types. While grandmultiparity had a significant effect on CPP (p < 0.0001), it did not have a significant effect on other pain types in a MANOVA model. CPP is very often seen in our population and it often makes a pain complex with dyspareunia and back pain. The prevention of grandmultiparity is important to decrease the incidence of CPP.     

Return of chronic pelvic pain from endometriosis after raloxifene treatment: a randomized controlled trial

OBJECTIVE: To evaluate whether 6 months of raloxifene was effective in treatment of chronic pelvic pain in women with endometriosis. METHODS: Women with chronic pelvic pain and no endometriosis treatment for 6 months underwent laparoscopy for excision of all lesions. Those with biopsy-proven endometriosis were randomly allocated to raloxifene (180 mg) or placebo daily. A second laparoscopy was performed at 2 years, or earlier, if pain returned. Return of pain was defined as 2 months of pain equal to or more severe than that at study entry. Menstrual cycles and adverse events were recorded. The log rank test was used to compare the time to return of pain by drug group. Analyses were done as intent-to-treat. RESULTS: A total of 127 of 158 women underwent surgery. Of these, 93 had biopsy-confirmed endometriosis and were randomly assigned to study treatment. Menstrual cycle length, pelvic pain severity, quality of life, bone mineral density, and adverse events did not differ between treatment groups. The Data Safety Monitoring Committee terminated the study early when the raloxifene group experienced pain (P=.03) and had second surgery (P=.016) significantly sooner than the placebo group. Interestingly, biopsy-proven endometriosis was not associated with return of pain (P=.6). CONCLUSION: Raloxifene significantly shortened the time to return of chronic pelvic pain. Because recurrence of endometriosis lesions did not correlate with return of pain, other factors are implicated in pelvic pain. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.cliicaltrials.gov, NCT00001848 LEVEL OF EVIDENCE: I.     

Laparoscopic removal of an intraperitoneal translocated intrauterine contraceptive device

The use of an intrauterine contraceptive device (IUD) is often accompanied by various complications, the perforation of the uterus constituting the most dangerous. Here we report the case of a patient who complained of abdominal pains. She had had an IUD inserted 15 months previously. Three months later, as she could no longer see the IUD strings at the external os of the cervix, she underwent pelvic ultrasonography, which did not show the IUD in the uterine cavity. A diagnosis of expulsion of the IUD was made. A few months later, the patient accidentally became pregnant, and decided to have an abortion. From that time on, she started to complain of the above-mentioned symptoms. She had an abdominal X-ray which revealed the IUD in the abdominal cavity. She then underwent a laparoscopic removal of the translocated IUD.     

Laparoscopic excision of endometriosis of the obturator nerve: a case report

Endometriosis, a common cause of cyclic and chronic pelvic pain in women, can present with a multitude of symptoms. Numerous case reports exist describing the involvement of the sciatic nerve with endometriosis; however, there are few reported cases of infiltration of the other pelvic nerves such as the obturator nerve. To our knowledge, this is the first case of laparoscopic management of symptomatic endometriosis of the obturator nerve.     

Laparoscopic removal of an intraperitoneal translocated intrauterine contraceptive device.

The use of an intrauterine contraceptive device (IUD) is often accompanied by various complications, the perforation of the uterus constituting the most dangerous. Here we report the case of a patient who complained of abdominal pains. She had had an IUD inserted 15 months previously. Three months later, as she could no longer see the IUD strings at the external os of the cervix, she underwent pelvic ultrasonography, which did not show the IUD in the uterine cavity. A diagnosis of expulsion of the IUD was made. A few months later, the patient accidentally became pregnant, and decided to have an abortion. From that time on, she started to complain of the above-mentioned symptoms. She had an abdominal X-ray which revealed the IUD in the abdominal cavity. She then underwent a laparoscopic removal of the translocated IUD.     

Laparoscopic plication and suspension of the round ligament for chronic pelvic pain and dyspareunia

STUDY OBJECTIVE: To describe a technique of uterine suspension using round ligaments to relieve pain in selected patients with various degrees of uterine retroversion. DESIGN: Prospective clinical study (Canadian Task Force classification II-2). SETTING: University-based center for reproductive medicine. PATIENTS: Thirty women who underwent laparoscopy for investigation of chronic pelvic pain (CPP) and dyspareunia. INTERVENTION: Round ligaments were plicated using a modification of intracorporeal knot tying during laparoscopy. MEASUREMENTS AND MAIN RESULTS: The extent of plication was planned to elevate the uterus and bring it minimally forward. Mean +/- SD operating time was 14+/-4 minutes. Pain scores before and after surgery were 4.5+/-1.0 and 1.6+/-0.6, respectively (p<0.001). There were no complications during or after surgery. Only three women had minimal dyspareunia postoperatively, although they had anteverted uteri. One patient had severe dyspareunia that developed 7 months after surgery and continued through the second year of follow-up. Nineteen women with anteverted uteri were free of dyspareunia after 2 years. CONCLUSION: Round ligament plication is safe and effective in patients with retroverted uteri and dyspareunia or CPP.     

不同糖耐量状态肥胖儿童血清脂联素的变化及其临床意义

目的了解不同葡萄糖耐量状态的肥胖儿童血清脂联素水平，探讨其与年 龄、体重指数(BMI)、血脂、血糖及胰岛素水平的关系。 方法选择2002~2004年于广州市儿童医院初诊并住院诊治的肥胖儿童52例，分为36例糖耐量正常(NGT)肥胖组和16例糖耐量受损(IGT)肥胖组。测定两组肥胖儿童和41例年龄、性别匹配的正常儿童空腹血清脂联素、胆固醇(CHO)、甘油三酯(TG)、低密度脂蛋白胆固醇(LDL C)、血糖和胰岛素(FINS)，计算胰岛素抵抗指数(HOMA IR)。肥胖组儿童均做口服葡萄糖耐量试验(OGTT)，测定OGTT 2h血糖和胰岛素。 结果正常对照组、NGT肥胖组及IGT肥胖组血清脂联素水平依次降低，HOMA IR依次升高，且均有统计学意义；相关性分析显示肥胖儿童血清脂联素与TG、LDL C、FINS呈显著负相关(P<005)。 结论肥胖儿童血清脂联素水平降低，并与血脂、胰岛素抵抗密切相关；与NGT肥胖组相比，IGT肥胖组儿童的血清脂联素水平进一步降低。     

Intravaginal electrical stimulation for the treatment of chronic pelvic pain

OBJECTIVE: To evaluate the efficacy of intravaginal electrical stimulation in women with chronic pelvic pain (CPP). STUDY DESIGN: Between May 2002 and February 2004, 24 women with CPP with no apparent cause were evaluated. They underwent 10 sessions of intravaginal electrical stimulation. A program for measuring chronic diffuse pain, with a frequency of 8 Hz, variation in intensity and frequency, pulse length of 1 msec, and adjustment to the bearable intensity of each individual patient (in milliamps) was utilized. Treatment consisted of 30-minute applications, 2 or 3 times per week, and the pain was evaluated using a visual analog scale before and after each session and immediately after completion of the total treatment. The women were asked to evaluate the pain 2 weeks, 4 weeks and 7 months following the end of treatment. RESULTS: Intravaginal electrical stimulation was effective in alleviating pain in women with CPP, as evaluated at the end of treatment and 2 weeks, 4 weeks and 7 months after completion of treatment (p<0.05). There were significantly fewer complaints of dyspareunia following treatment (p = 0.0005). CONCLUSION: Intravaginal electrical stimulation is effective in the alleviation of pain in women with CPP.     

子宫神经去除术治疗子宫腺肌症疼痛的临床观察

目的探讨子宫神经去除术（LUNA）治疗子宫腺肌症痛经及慢性盆腔痛的临床效果。方法对患有痛经、非经期盆腔痛或性交痛的子宫腺肌症患者进行LUNA手术。采用视觉模拟评分法对痛经、非经期盆腔痛及性交痛量化评分。结果对60例子宫腺肌症患者术后随访6～24个月，其痛经、非经期盆腔痛或性交痛的症状均有明显改善，手术前后三者的评分变化差异均有显著性（P〈0．01），但术后各阶段之间的比较差异无显著性（P〉0．05）。患者满意率术后3个月为76．92％，术后24个月为69．23％。结论LUNA对缓解子宫腺肌症引起的痛经及慢性盆腔痛具有一定的疗效。     

Intractable recurrent cervical cancer with pelvic bone involvement successfully treated with external hemipelvectomy

The indication of external hemipelvectomy for lateral recurrent cervical cancer involving the pelvic bone is controversial. We report the second longest surviving patient of recurrent cervical cancer successfully treated by external hemipelvectomy. A 38-year-old woman who had undergone conization for stage Ia1 cervical cancer six years earlier had severe right inguinal pain. A large multicystic recurrent tumor was identified in the right obturator region. After chemotherapy and chemoradiation, the tumor regressed, but soon relapsed. The patient's symptoms flared and the tumor was enlarged involving the right iliac bone. We performed right external hemipelvectomy with amputation of the right lower extremity, right iliac wing and ischiopubic bone. There was no major complication after the operation and the patient was discharged on postoperative day 48. After 27 months of follow-up, she has no complaints and is without evidence of recurrence. In selected cases of intractable lateral recurrent cervical cancer with pelvic bone involvement, relief from tumor-related pain and a possibility of prolonged survival can be expected by external hemipelvectomy.     

Synchronous primary endometrial and ovarian cancers: a case report

Synchronous primary cancers of the endometrium and ovary are relatively uncommon in the general population. The patient, a 49-year-old postmenopausal Greek woman, presented with abdominal pain and a pelvic mass. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, total omentectomy, appendectomy and pelvic lymph node dissection. The histopathology revealed synchronous primary cancers of the endometrium and right ovary. She underwent postoperative chemotherapy. Thirty-nine months after surgery, she remains well without evidence of recurrence.     

Interstitial Cystitis Is an Etiology of Chronic Pelvic Pain in Young Women

Study ObjectiveThe prevalence of interstitial cystitis (IC) in young women, especially in those 18 years old or younger, is not well defined. This case series was performed to investigate IC as a cause of chronic pelvic pain (CPP) in young women.DesignCase series.SettingUniversity medical center.ParticipantsTwenty-eight women with CPP, ages 13 to 25, who underwent concomitant laparoscopy and cystoscopy.InterventionsAll subjects underwent concomitant diagnostic laparoscopy and cystoscopy with hydrodistension for evaluation of CPP. Charts were reviewed to discern preoperative symptoms, operative findings, and postoperative diagnoses.Main Outcome MeasureDiagnosis of IC based on symptoms and cystoscopic findings.ResultsAll 28 women had CPP, 23 (82%) had dysmenorrhea, and 12 of 25 (48%) sexually active subjects had dyspareunia. Twenty-six subjects (93%) had urinary symptoms including frequency (75%), nocturia (32%), urgency (25%), and dysuria (18%). Eleven (39%) subjects were diagnosed with IC and 18 (64%) with endometriosis, including 7 (25%) subjects with both IC and endometriosis. Laparoscopic findings were normal in 6 (21%) subjects. Of the 26 subjects with urinary symptoms, 21 (81%) had findings on laparoscopy or cystoscopy. In this cohort of young women with chronic pelvic pain, urinary frequency and dyspareunia were significantly associated with the diagnosis of IC.ConclusionsThe results of this study suggest that interstitial cystitis is an etiology of CPP in young women. Evaluation of the bladder as an origin of pelvic pain is warranted in young women with CPP and urinary frequency or dyspareunia.