The feasibility and efficacy of laparoscopic oophorectomy in the management of pelvic pain after hysterectomy.

We aim to assess the feasibility and efficacy of laparoscopic oophorectomy in women with pelvic pain after hysterectomy in this retrospective review of 35 consecutive women presenting with pelvic pain who had had their ovaries conserved at the time of hysterectomy. Pain was attributed to the presence of these residual ovaries if there was an adnexal mass--or the pain improved following ovarian suppression with a GnRH analogue. The procedure was completed laparoscopically in 32 (91%) women. Overall, 27 (77%) women reported symptomatic relief following surgery. We conclude that laparoscopic oophorectomy is safe and provides symptomatic relief in this group of women.     

Conscious pain mapping by laparoscopy in women with chronic pelvic pain

OBJECTIVE: To evaluate the findings and outcomes of laparoscopic conscious pain mapping in women with unsuccessfully treated chronic pelvic pain. METHODS: Fifty consecutive women with at least one prior procedure for chronic pelvic pain had conscious pain mapping. Operative findings and clinical outcomes were documented. Preoperative and postoperative pain levels were evaluated using visual analog scales. RESULTS: Conscious pain mapping was successful in 35 cases (70%). Twenty-nine patients had 42 specific positive sites, and six patients had diffuse visceroperitoneal pelvic tenderness. Adhesions and endometriosis accounted for 45% of positive lesions or sites. About half of women with endometriosis or adhesions mapped pain specifically to those lesions. For endometriosis, histologic but not visual diagnosis predicted positive mapping. Specific viscera accounted for 36% of positively mapped sites. Diagnoses of chronic visceral pain syndrome were suggested by the findings in 16 (46%) patients whose mapping was successful. Mean +/- standard deviation visual analog scale pain levels were 8.7 +/- 1.2 preoperatively and 5.5 +/- 3.7 postoperatively. Twenty-two women (44%) had decreased pain postoperatively and eight (16%) were pain-free. CONCLUSION: Conscious pain mapping can be done with reasonable success in women with prior surgical evaluations and treatments for chronic pelvic pain. Chronic visceral pain syndrome, adhesions, and endometriosis were the most common diagnoses.     

Pain and Quality of Life after Laparoscopic Excision of Endometriosis

Study ObjectiveTo evaluate the long-term impact of laparoscopic excision of endometriosis on quality of life through pain reduction as measured by the Endometriosis Health Profile-30 (EHP-30) in uterine-sparing (preservation of the uterus and at least 1 ovary) and nonuterine-sparing (removal of the uterus) surgery.DesignCohort study.SettingAcademic medical center.PatientsSixty-one women who had undergone laparoscopic excision of endometriosis for pelvic pain were enrolled in a tissue-procurement study.InterventionsPatients who had previously completed an EHP-30 preoperatively and at 4 weeks postoperatively were mailed a copy of the EHP-30 2.6 to 6.8 years after their index surgery.Measurements and Main ResultsThe primary outcome was quality of life as measured by changes in the EHP-30 scores before their index surgery and those measured weeks and years later. The secondary outcome was a comparison of the EHP-30 scores between patients who underwent excision of endometriosis alone and those who underwent excision of endometriosis with hysterectomy +/– oophorectomy. From 2011 to 2015, 61 women underwent laparoscopic excision of endometriosis for pelvic pain. Forty-six of the 61 patients completed the EHP-30 for a response rate of 75%. The patients demonstrated significant improvement in all 5 scales of the EHP-30 (pain, control and powerlessness, emotional well-being, social support, and self-image) at 4 weeks postoperatively (p <.001), which persisted for up to 6.8 years in follow-up (p <.001) when compared with their baseline scores. The improvement in EHP-30 scores did not differ by American Society for Reproductive Medicine staging or index surgery. Definitive surgery (total laparoscopic hysterectomy/bilateral salpingo-oophorectomy) was not associated with improved outcomes when compared with uterine-sparing surgery.ConclusionLaparoscopic excision of endometriosis offers improvement in all quality-of-life domains as measured by the EHP-30, including a reduction in pain, an effect that may persist for up to 6.8 years. These findings suggest that laparoscopic excision of endometriosis with uterine preservation can be considered as an option for discussion during counseling for treatment of endometriosis.     

Extraovarian Endometrioid Carcinoma Associated with Unopposed Oestrogen Replacement Therapy

EDITORIAL COMMENT: We accepted this case report for publication because, apart from being interesting, it raises the question of the appropriate hormone replacement therapy after bilateral oophorectomy (usually with hysterectomy) has been performed when there is evidence of endometriosis. Menopausal symptoms in these women can be relieved by oestrogen therapy without return of pelvic pain or dyspareunia. The authors report a case of endometrial-like carcinoma in a woman with known endometriosis after a hysterectomy and prolonged unopposed oestrogen therapy. Although this is a solitary case report, the authors explain that there are 8 others in the literature where malignancy occurred in extraovarian endometriosis after bilateral oophorectomy associated with unopposed oestrogen. One of our reviewers commented that a combination of oestrogen and progestogen should always be considered when prescribing hormone replacement therapy in women with a known history of endometriosis, following total hysterectomy and bilateral oophorectomy.     

Extraovarian Endometrioid Carcinoma Associated with Unopposed Oestrogen Replacement Therapy

EDITORIAL COMMENT: We accepted this case report for publication because, apart from being interesting, it raises the question of the appropriate hormone replacement therapy after bilateral oophorectomy (usually with hysterectomy) has been performed when there is evidence of endometriosis. Menopausal symptoms in these women can be relieved by oestrogen therapy without return of pelvic pain or dyspareunia. The authors report a case of endometrial-like carcinoma in a woman with known endometriosis after a hysterectomy and prolonged unopposed oestrogen therapy. Although this is a solitary case report, the authors explain that there are 8 others in the literature where malignancy occurred in extraovarian endometriosis after bilateral oophorectomy associated with unopposed oestrogen. One of our reviewers commented that a combination of oestrogen and progestogen should always be considered when prescribing hormone replacement therapy in women with a known history of endometriosis, following total hysterectomy and bilateral oophorectomy.     

GnRH analogue in assessing chronic pelvic pain in women with residual ovaries

Objective To assess whether suppression of ovarian function by a gonadotrophin releasing hormone (GnRH) analogue could assist in the diagnosis of chronic pelvic pain in women with residual ovaries.
Design Uncontrolled, observational study.
Setting District general hospital (seven women) and teaching hospital (one woman).
Participants Eight women with residual ovaries and chronic pelvic pain.
Interventions Goserelin 3.6 mg every 28 days was used followed by surgery to remove residual ovaries.
Main outcome measures The women's response to goserelin and surgery (12 months or more post-operatively) was assessed clinically.
Results Goserelin was associated with resolution of pelvic pain in the six women who obtained relief of pain with oophorectomy. The only woman who did not respond to goserelin also failed to gain relief with surgery. One woman who responded to goserelin declined surgery.
Conclusions Suppression of ovarian function by GnRH analogues may allow differentiation of pelvic pain caused by the residual ovary syndrome from other causes. This would enable selection of cases likely to benefit from surgery, avoiding potentially difficult surgery in women who will gain little or no relief of symptoms with surgery. Only eight cases are reported and a randomised controlled trial would be required to determine the place of GnRH agonists in the treatment of the residual ovary syndrome.     

Uterine size and endometrial thickness and the significance of cystic ovaries in women with pelvic pain due to congestion

In a group of 55 women with chronic pain due to pelvic congestion measurement by ultrasound revealed they had a larger uterus and thicker endometrium as compared with a group of normal women matched for age, parity and the presence of polycystic ovaries found on ultrasound scanning. Many women with pelvic congestion (56%) were found on ultrasound to have cystic changes in their ovaries which ranged from a classic polycystic pattern to the appearance of clusters of 4-6 cysts in bilaterally enlarged ovaries. It is suggested that uterine enlargement and thickening of the endometrium are caused by oestrogen, either from the effects on the target organs of an increased concentration or of hypersensitivity to oestrogen.     

Clinical features of women with chronic lower abdominal pain and pelvic congestion

Summary. The clinical features of 35 women with pelvic pain and demonstrable congestion on pelvic venography have been characterized by comparing their symptoms and signs with those of 22 women with pelvic pain due to classical pathology. Women with pelvic pain and congestion had a mean age of 32·4 years, were more often multiparous and had had symptoms for 6 months to 20 years. The pain was dull and aching with sharp exacerbations. In individual women it commonly occurred on one side of the abdomen but unlike the pain due to'classical pathology', it could occur on the other side. The pain was exacerbated by postural changes, and walking. Congestive dysmenorrhoea, deep dyspareunia and postcoital ache were common findings in women with pelvic congestion and 60% had evidence of significant emotional disturbance. The combination of tenderness on abdominal palpation over the ovarian point and a history of postcoital ache was 94% sensitive and 77% specific for discriminating pelvic congestion from other causes of pelvic pain.     

Clinical features of women with chronic lower abdominal pain and pelvic congestion

The clinical features of 35 women with pelvic pain and demonstrable congestion on pelvic venography have been characterized by comparing their symptoms and signs with those of 22 women with pelvic pain due to classical pathology. Women with pelvic pain and congestion had a mean age of 32.4 years, were more often multiparous and had had symptoms for 6 months to 20 years. The pain was dull and aching with sharp exacerbations. In individual women it commonly occurred on one side of the abdomen but unlike the pain due to 'classical pathology', it could occur on the other side. The pain was exacerbated by postural changes, and walking. Congestive dysmenorrhoea, deep dyspareunia and postcoital ache were common findings in women with pelvic congestion and 60% had evidence of significant emotional disturbance. The combination of tenderness on abdominal palpation over the ovarian point and a history of postcoital ache was 94% sensitive and 77% specific for discriminating pelvic congestion from other causes of pelvic pain.     

Uterine size and endometrial thickness and the significance of cystic ovaries in women with pelvic pain due to congestion

Summary. In a group of 55 women with chronic pain due to pelvic congestion measurement by ultrasound revealed they had a larger uterus and thicker endometrium as compared with a group of normal women matched for age, parity and the presence of polycystic ovaries found on ultrasound scanning. Many women with pelvic congestion (56%) were found on ultrasound to have cystic changes in their ovaries which ranged from a classic polycystic pattern to the appearance of clusters of 4–6 cysts in bilaterally enlarged ovaries. It is suggested that uterine enlargement and thickening of the endometrium are caused by oestrogen, either from the effects on the target organs of an increased concentration or of hypersensitivity to oestrogen.     

Frequency and laparoscopic management of ovarian remnant syndrome

STUDY OBJECTIVE: To report the frequency and outcome of laparoscopy in women with chronic pelvic pain and/or pelvic mass who were found to have ovarian remnants. DESIGN: Cohort study. (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: One hundred nineteen women who had had hysterectomy and oophorectomy. INTERVENTION: Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: Ovarian remnants were known in 5 and were found intraoperatively in 21 patients (18%). These 26 women had undergone at least one laparoscopy in an attempt to remove the remnants. After the ureter was identified, ovarian remnants were dissected and removed from the retroperitoneum laparoscopically with minimal risk of vessel or visceral injury. There were no intraoperative or postoperative complications and no conversions to laparotomy. In addition to ovarian remnants, adhesions were found in 19 women, endometriosis in 4, and no other pathology in 3. Twenty women had complete relief of symptoms. At follow-up of 1 to 8 years (mean 5 yrs), six underwent repeat laparoscopy for persistent pain; one had recurrent ovarian remnant. CONCLUSIONS: Ovarian remnant syndrome is not an infrequent complication after hysterectomy and oophorectomy in women with endometriosis.     

Laparoscopic Removal of Endometriosis in the Pouch of Douglas

EDITORIAL COMMENT": This paper provides important data on dealing, via the laparoscope, with endometriosis involving the uterosacral ligaments and peritoneum of the pouch of Douglas in patients with pelvic pain and/or infertility. None of the 26 women in this study had had a hysterectomy, although this procedure usually relieves pain associated with endometriosis involving the pouch of Douglas and uterosacral ligaments. Perhaps we require more data regarding symptoms from residual endometriosis in patients having hysterectomy and uterosacral endometriosis; relevant considerations include whether bilateral oophorectomy is also performed or whether the patient receives postoperative hormone replacement therapy in this circumstance. It seems to the editor that the uterosacral ligaments and pouch of Douglas are seldom removed when hysterectomy is performed in the type of cases reported in this paper; one achieves mobility of the uterus before its removal by cutting the uterosacral ligaments, not removing them; in these cases we are concerned about the keeping away from the ureters and rectum rather than excising scarring due to endometriosis - yet the authors note that 'biopsy of scarred lesions often shows active endometriosis!
Summary: Twenty-six patients with endometriosis in the pouch of Douglas were treated by laparoscopic excisional surgery; previous medical and surgical therapy had failed in 24 of them. Endometriosis in the pouch of Douglas occurred infrequently in association with bladder or ovarian endometriosis. Coital and rectal pain were markedly reduced or cured 6 months after surgery in all except 2 patients. Laparoscopic surgical excision of endometriosis is indicated when drug or other surgical treatments fail and may avoid the need for hysterectomy in some patients.     

Laparoscopic treatment of infiltrative rectosigmoid colon and rectovaginal septum endometriosis by the technique of videolaparoscopy and the CO2 laser.

OBJECTIVE: To present the technique and results of videolaparoscopy and the CO2 laser as a treatment for deep, infiltrative endometriosis of the rectovaginal septum, uterosacral ligaments, pouch of Douglas and anterior wall of the rectosigmoid colon. DESIGN: Observational study with 1-5 year follow up. SETTING: Sub-specialty practice: Endometriosis clinic and centre for special pelvic surgery. SUBJECTS: 185 women, aged 25-41 years. All had pelvic endometriosis and were referred because of the failure of previous medical and/or surgical treatment. INTERVENTIONS: Vaporization and excision of endometriotic implants and nodules, ureterolysis, ureteric stents, laparoscopic anterior rectal wall resection and reanastomosis, presacral neurectomy, laparoscopic hysterectomy, salpingo-oophorectomy and appendicectomy using the CO2 laser. MAIN OUTCOME MEASURES: 174 patients were followed for 1-5 years after surgery by office visit questionnaire or telephone interview. Eleven were lost to follow-up. RESULTS: 175 patients were discharged within 24 h. Nine with bowel perforations and one with a partial bowel resection were discharged 2-4 days postoperatively. Two patients required ureteric stents, which were removed 6 weeks postoperatively without sequelae. 162 women reported moderate to complete pain relief (145 after one procedure, 13 after two and four after three). 12 reported persistent or worse pain following the surgery. Seven eventually underwent total hysterectomy, four had bowel resections and one had a salpingo-oophorectomy. Of 61 with infertility, 25 achieved pregnancy. Postoperative complications included shoulder pain, anterior abdominal wall ecchymosis, urine retention and dyschezia for one to two weeks. CONCLUSIONS: Our experience suggests that rectosigmoid colon and infiltrative rectovaginal septum endometriosis can be effectively treated via videolaparoscopy in the hands of experienced endoscopic gynaecologists.     

Accuracy of ultrasound measurements of female pelvic organs

Uterine size, endometrial thickness and ovarian volume were measured ultrasonically and the results compared with caliper measurements made shortly afterwards at the time of total hysterectomy and bilateral salpingo-oophorectomy. The results establish the validity of ultrasound measurements. Histological studies also confirmed the diagnosis made with ultrasound of polycystic ovaries in women complaining of pain due to pelvic congestion.     

Accuracy of ultrasound measurements of female pelvic organs

Summary. Uterine size, endometrial thickness and ovarian volume were measured ultrasonically and the results compared with caliper measurements made shortly afterwards at the time of total hysterectomy and bilateral salpingo-oophorectomy. The results establish the validity of ultrasound measurements. Histological studies also confirmed the diagnosis made with ultrasound of polycystic ovaries in women complaining of pain due to pelvic congestion.     

A prospective study to evaluate oophorectomy at the time of vaginal hysterectomy

Objective To assess the feasibility and safety of vaginal removal of ovaries at the time of vaginal hysterectomy.
Design Prospective study.
Setting London teaching hospital.
Population Between March 1993 and March 1995, 40 women were admitted under the care of one consultant for vaginal hysterectomy and bilateral oophorectomy.
Methods The success rate of removing the ovaries vaginally was calculated and the operative time, blood loss, intra- and post-operative complications and patient recovery were analysed and compared with 48 patients who had a vaginal hysterectomy but retained their ovaries during the same time period.
Results Thirty-nine (97.5%) of the 40 women due to undergo removal of the ovaries were managed successfully via the vaginal route; one woman required laparoscopic removal of one of her ovaries containing an ovarian cyst which was not diagnosed pre-operatively. A variety of techniques were used for vaginal oophorectomy which included salpingo-oophorectomy, oophorectomy without salpingectomy, and transvaginal endoscopic oophorectomy utilising endoloop sutures or bipolar electrosurgery. Oophorectomy added a mean of 23.4 min (88.3 vs 64.9 min, 95% CI 10.2–36.7,   P < 0.001  ) to the total operating time compared with vaginal hysterectomy alone. No laparotomies were required, and both the complication rate and post-operative inpatient stay were similar for the two groups.
Conclusion The need to perform oophorectomy should not be considered a contraindication to vaginal hysterectomy.     

Open laparoscopy simplifies instrumentation required for laparoscopic oophorectomy and salpingo-oophorectomy.

Eight consecutive cases of open laparoscopic oophorectomy and salpingo-oophorectomy are reported. A modified technique that requires fewer specialized instruments and includes removal of the intact adnexa is demonstrated. Patients were not included if there was any suspicion of malignancy. Indications for surgery included chronic pelvic pain after hysterectomy (N = 5), endometriosis (N = 1), estrogen receptor-positive metastatic breast carcinoma that had not responded to chemotherapy (N = 1), and tuboovarian ectopic pregnancy (N = 1). No intraoperative or postoperative complications occurred. The average hospital stay was 1.1 days, and patients were released 3-14 days postoperatively. Five of the six patients with chronic pelvic pain had prompt resolution of their symptoms. In one patient who had a unilateral salpingo-oophorectomy, a contralateral procedure was required 3 months later because of continued chronic pelvic pain; her pain subsequently resolved. Laparoscopic salpingo-oophorectomy has the potential to decrease morbidity as compared with laparotomy in appropriately selected cases.     

Bilateral Ureteric Obstruction Due to Recurrent Endometriosis Associated with Hormone Replacement Therapy

EDITORIAL COMMENT : We accepted this case report for publication since it addresses the important problem of whether hormone replacement therapy should be withheld after bilateral oophorectomy (usually associated with hysterectomy) in the premenopausal woman who had extensive endometriosis. Our endocrinologist reviewer withholds oestrogen for 6 months in such women and prescribes medroxyprogesterone acetate 10 mg BD continuously if they have flushes or associated symptoms; he is especially unwilling to prescribe oestrogen if removal of endometriotic deposits is deemed by the surgeon to be incomplete. Our editorial panel consensus is that it is cruel to withhold oral hormone replacement therapy from these women but that the regimen should include a progestogen as well as oestrogen as in women who still have a uterus. We agree with the authors that we need data telling us how often hormone replacement therapy is associated with return of symptoms due to endometriotic deposits - in the editor's experience the problem is uncommon. Our Senior Gynaecologist Chairman states that in the few patients he has managed in whom endometriosis has been reactivated by hormone replacement therapy after pelvic clearance, the problem has been controlled by low-dose X-ray therapy - in his experience this has not resulted in ureteric obstruction although he has seen 2 women present with unilateral ureteric obstruction from previously untreated endometriosis involving the lateral pelvic wall.     

Castrating operations associated with metastatic lesions of the breast

To determine whether subsequent pelvic difficulty justified hysterectomy in cases of surgical castration performed as treatment of breast cancer, 432 cases so operated on at the Mayo Clinic for the 13 years 1955-1967 were reviewed. Oophorectomy alone was done in 353 patients, oophorectomy plus hysterectomy in 79. The age range in the oophorectomy group was 18-59 years, in the hysterectomy group 28-63 years. In each, 55% of the patients were less than 50-years-old. Of 367 patients in whom the procedure was therapeutic, 88 were found to have metastatic carcinoma in 1 or both ovaries. Inspection at the operating table had failed to reveal these metastases. Of the 79 uteri removed, 74 had demonstrable pathologic process. In 7 cases lesions were malignant. Postoperative vaginal bleeding occurred later in 14 of the 353 cases in which the uterus had been left in place. Morbidity rates, as determined by fever on 2 postoperative days, were 44% in the hysterectomy group, 26% in the oophorectomy group. Cause of the fever was not determined in half of these cases. Each group included a single case of afebrile thrombophlebitis. Hospital stay averaged 8 days for oophorectomy, 10 days for hysterectomy patients. Castration of the premenopausal patient with metastatic breast cancer offers a chance of remission. About a third of such patients are benefitted and survival may be increased 2 years. Surgical castration is preferred over irradiation because it gives more rapid hormone withdrawal. All ovarian tissue must be removed, especially when adhesions or endometriosis is present. Hysterectomy at the time of oophorectomy is considered justified except in poor-risk patients.