Pentoxifylline therapy after laparoscopic surgery for different stages of endometriosis: a prospective, double-blind, randomized, placebo-controlled study

STUDY OBJECTIVE: To evaluate the effects of pentoxifylline administration on patients with different stages of endometriosis on whom laparoscopy was performed. DESIGN: Prospective, double-blind, randomized, placebo-controlled clinical (Canadian Task Force classification I). SETTING: University and private hospitals. PATIENTS: Eighty-eight women, all with infertility, some with dysmenorrhea, dyspareunia, or pelvic pain, on whom a laparoscopic diagnosis of endometriosis was made. INTERVENTIONS: The treatment group received 800 mg pentoxifylline daily for 6 months immediately after surgery. The control group received placebo capsules. All patients were followed-up for 1 year thereafter. MEASUREMENTS AND MAIN RESULTS: A comparison of pregnancy rate and recurrence of signs and symptoms in the 2 groups was performed. Forty-three patients were studied in the pentoxifylline group and 45 in the placebo group. The cumulative pregnancy rate was 39.5% and 35.6% in the treatment and control groups, respectively. The overall recurrence of signs and symptoms was 14% in the former group and 15.6% in the latter. There were no statistically significant differences between the 2 groups in rates of pregnancy and recurrence (p = .700 and .832, respectively). Nor was there any significant statistical difference between the same stages in the 2 groups regarding immunomodulation. CONCLUSIONS: According to the results of this study, and while keeping in mind that appropriate surgery is the main aspect of endometriosis treatment, there is no evidence that immunomodulation with pentoxifylline aids fertility or lessens recurrence of signs and symptoms in women with different stages of endometriosis (i.e., minimal, mild, moderate, or severe).     

Long-term follow-up after conservative surgery for rectovaginal endometriosis

OBJECTIVE: The purpose of this study was to evaluate long-term results in patients who received conservative surgical treatment for rectovaginal endometriosis. STUDY DESIGN: We analyzed the follow-up data for 83 women who underwent surgery for rectovaginal endometriosis. The inclusion criteria were age 20 to 42 years, moderate-to-severe pain symptoms, conservative treatment with retention of the uterus, and at least 1 ovary; the follow-up period was > or =12 months. Kaplan-Meier analysis and Cox regression were used to calculate recurrence rates. RESULTS: The cumulative rates of pain recurrence, clinical or sonographic recurrence, and new treatment were 28%, 34%, and 27%, respectively. The younger patients had the higher risk of recurrence. Pregnancy had protective effects against the recurrence of symptoms and a need for a new treatment. Patients who underwent bowel resection had fewer recurrences. CONCLUSION: Segmental resection and anastomosis of the bowel, when necessary, improves the outcome without affecting chances of conception. Higher recurrence rates in younger patients seems to justify a more radical treatment in this group of women.     

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.     

Oral contraceptive pills for endometriosis after conservative surgery: a systematic review and meta-analysis

Abstract

To assess the effects of oral contraceptive pills (OCPs) for endometriosis in women after conservative surgery, we performed a search of PubMed, Embase, ISI Web of Science, Cochrane Library, Scidirect, Chinese VIP, CNKI and WANGFANG database. Randomized controlled trials (RCTs) of OCPs in postoperative medical therapy for endometriosis were collected. Articles published as of January 2013 with no language restriction were identified using defined keywords, and 15 studies comprising 1850 patients were included. There was a significantly higher rate of total endometriosis remission [OR?=?2.55, 95% CI (1.68, 3.86), p?<?0.00001] and a lower rate of recurrence [OR?=?0.31, 95% CI (0.22, 0.45), p?<?0.00001] in the OCPs group compared with surgery alone. There appears to be no statistical difference in pregnancy rates between the OCPs group as compared with surgery alone or other hormonal drug treatments in infertility patients. As for the rate of recurrence and complete remission, there were no statistical differences among OCPs and gestrinone, mifepristone or GnRH-a groups. However, OCPs users had less side effects that were more mild as compared with patients using other hormonal treatments.     

Laparoscopic uterosacral ligament resection for dysmenorrhea associated with endometriosis: results of a randomized,controlled trial

OBJECTIVE: To evaluate the efficacy of laparoscopic resection of the uterosacral ligaments in women with endometriosis and predominantly midline dysmenorrhea. DESIGN: Randomized controlled trial. SETTING: Two academic departments.One hundred eighty patients undergoing operative laparoscopy as first-line therapy for stage I to IV symptomatic endometriosis. INTERVENTION(S): Operative laparoscopy including uterosacral ligament resection or conservative surgery alone. MAIN OUTCOME MEASURE(S): Proportion of women with recurrence of moderate or severe dysmenorrhea 1 year after surgery. RESULT(S): No complications occurred. Among the patients who were evaluable 1 year after operative laparoscopy, 23 of 78 (29%) women who had uterosacral ligament resection and 21 of 78 (27%) women who had conservative surgery only reported recurrent dysmenorrhea. The corresponding numbers of patients at 3 years were 21 of 59 (36%) women and 18 of 57 (32%) women, respectively. Time to recurrence was similar in the two groups. Pain was substantially reduced, and patients in both groups experienced similar and significant improvements in health-related quality of life, psychiatric profile, and sexual satisfaction. Overall, 68 of 90 (75%) patients in the uterosacral ligament resection group and 67 of 90 (74%) patients in the conservative surgery group were satisfied at 1 year. CONCLUSION(S): Addition of uterosacral ligament resection to conservative laparoscopic surgery for endometriosis did not reduce the medium- or long-term frequency and severity of recurrence of dysmenorrhea.     

Use of intraperitoneal interferon alpha-2b therapy after conservative surgery for endometriosis and postoperative medical treatment with depot gonadotropin-releasing hormone analog: a randomized clinical trial

OBJECTIVE: To evaluate the possible therapeutic effects of interferon alpha-2b left in the peritoneum after surgery, followed by or not followed by treatment with GnRH analogs. DESIGN: A prospective, randomized clinical trial. SETTING: University hospital. PATIENT(S): Fifty-two infertile patients with moderate or severe endometriosis. INTERVENTION(S): Laparotomic conservative surgery and either interferon alpha-2b or saline alone left in the pouch of Douglas followed by administration of either GnRH analogs depot or oral indomethacin with transvaginal echography and analysis of CA-125, immunoglobulins, and lymphocyte populations. MAIN OUTCOME MEASURE(S): Recurrence of endometriosis was considered clinically, echographically, and laparoscopically. RESULT(S): Recurrence of endometriosis in four cases without interferon (15.4%) versus 11 patients (42.3%) with interferon alpha-2b. Life table analysis showed significant differences between the groups with and without interferon 21 months after conservative surgery. There were no differences in the recurrence between the groups with or without GnRH analogs. Likewise, there were no significant changes in immunoglobulins and lymphocyte populations among patients with and without recurrence of endometriosis. The patients that received GnRH analogs depot showed a decrease in the number of CD16 and an increase of CD11b cells after treatment. CONCLUSION(S): The use of interferon alpha-2b within the peritoneal cavity after conservative surgery may be inappropriate because it increased later recurrence of endometriosis. The postoperative treatment with GnRH analogs did not significantly reduce the recurrence rate. Immunoglobulins and lymphocyte populations did not change in relation to the recurrence of endometriosis.     

Spontaneous abortion: a randomized, controlled trial comparing surgical evacuation with conservative management using misoprostol

Objective: To compare the efficacy of surgical evacuation of the uterus with medical evacuation using misoprostol in cases of spontaneous abortion.

Design: A prospective, randomized, controlled trial.

Setting: A university teaching hospital.

Patient(s): Six hundred thirty-five women who aborted spontaneously and who consented to pretreatment randomization.

Intervention(s): Routine surgical evacuation or medical evacuation of the uterus using misoprostol.

Main Outcome Measure(s): Immediate, short-term (2–3 weeks), and medium-term (6 months) medical complications.

Result(s): There was a significantly lower incidence of immediate and short-term complications in the group treated with misoprostol compared with the surgically treated group. There were also fewer major complications in the 6 months after treatment in the medically treated group. Approximately 50% of the medically treated group subsequently required surgical evacuation, and these subjects required significantly more analgesia.

Conclusion(s): Treatment with misoprostol can reduce the demand for surgical evacuation in cases of spontaneous abortion, and its use is associated with fewer medical complications.     

Effectiveness of presacral neurectomy in women with severe dysmenorrhea caused by endometriosis who were treated with laparoscopic conservative surgery: a 1-year prospective randomized double-blind controlled trial

OBJECTIVE: The purpose of this study was to assess the effectiveness of presacral neurectomy in women with severe dysmenorrhea caused by endometriosis that was treated with conservative surgical intervention. STUDY DESIGN: One hundred forty-one sexually active women of fertile age with chronic severe dysmenorrhea caused by endometriosis were treated with conservative laparoscopic surgery. Patients were assigned randomly to not receive (group A) or receive (group B) presacral neurectomy. At 6 and 12 months after the surgical procedures, the cure rate was evaluated in each patient. The frequency and severity of dysmenorrhea, dyspareunia, and chronic pelvic pain were also evaluated at the same time intervals. RESULTS: The cure rate was significantly higher in group B compared with group A at a follow-up examination at 6 months (87.3% vs 60.3%) and 12 months (85.7% vs 57.1%). At follow-up visits, the frequency and severity of dysmenorrhea, dyspareunia, and chronic pelvic pain were significantly lower in both groups compared with baseline values; in particular, significantly lower values were observed in group B versus group A for the severity. CONCLUSION: Presacral neurectomy improves the cure rate in women who are treated with conservative laparoscopic surgery for severe dysmenorrhea caused by endometriosis.     

Reoperation after initial treatment of endometriosis with conservative surgery

One hundred and fifty-three patients with pelvic endometriosis met the study criteria of inferility, tissue diagnosis, treatment with conservative surgery, and adequate follow-up. The extent of disease was classified according to Acosta and and associates. Pregnancy rates were 10 to 100% in various subclassifications of patients; these pregnancy rates were related to the extent of disease and the existence of concurrent inferitility factors. One hundred and seventeen patients were followed up for three years. Reoperation in this group was carried out in 28 patients for recurrent pain and/or persistent infertility. Each patient had diagnostic laparoscopy preceding relaparotomy. The reoperation rate was 40.6% in those patients who remained infertile, whereas this rate was only 3.7% in those patients who conceived following initial operation. The incidence of conception after a second conservative procedure was 12%. However, an equal number of patients in this group required total abdominal hysterectomy as a third procedure for control of recurrent pain. Thus, repeat conservative surgery should play a secondary role in the treatment of patients with infertility and recurrent endometriosis.     

Short-term postoperative GnRH analogue or danazol treatment after conservative surgery for stage III or IV endometriosis before ovarian stimulation: a prospective, randomized study

OBJECTIVE: To assess the effect of short-term use of a gonadotropin releasing hormone (GnRH) analogue for 3 months before ovarian stimulation in patients with stage III and IV endometriosis after conservative surgery. STUDY DESIGN: Eleven patients were randomly selected to receive intramuscular injections of GnRH analogue, leuprolide acetate (3.75 mg), every 28 days, or 400 mg danazol orally 2 times per day for 3 months before ovarian stimulation after conservative laparoscopic or laparotomy surgeryfor stage III and IV symptomatic endometriosis (group 1), as compared with 30 patients who had received no postoperative treatment with GnRH analogue or danazol but underwent ovarian stimulation immediately after thefirst menses within 3 months postoperatively (group 2). RESULTS: Although the number of oocytes retrieved and number of embryos per cycle were significantly higher in group 1, the pregnancy rate per cycle in group 1 was not significantly different from that in group 2 (18% vs. 20%). The cumulative pregnancy rate at 12 months was 54.5% and 56.7% in group 1 and group 2, respectively. With regard to recurrence of disease after 24 months of follow-up, group 2 had a statistically significantly higher recurrence rate (13.3%) than did group 1 (0%). CONCLUSION: Short-term use of GnRH analogue before ovarian stimulation in women with stage III or IV endometriosis confers no definite benefits on pregnancy rates per cycle when compared with patients who received ovarian stimulation within 3 months after conservative surgery.     

Repetitive conservative surgery for recurrence of endometriosis

We evaluated the recovery of fertility and the relief of pain symptoms in a long-term follow-up of 42 women undergoing repetitive conservative surgery for recurrent endometriosis. The mean age of the patients was 31.1 +/- 4.3 years. At the time of their second operation the disease was stage IV in 14 women, stage III in 25, and stage I in three. After reoperation, the patients were followed for a mean period of 41.8 +/- 30.3 months. Pain symptoms returned in eight women, dysmenorrhea and deep dyspareunia in eight, and pelvic pain in seven. Eight of the 28 women (28.6%) who attempted to conceive achieved a total of 13 pregnancies. The corrected pregnancy rate was 35%, and the cumulative rate at 27 months was 30.7%. A third operation was necessary in six women after a mean period of 35 months. Conservative surgery is an effective therapeutic option for infertile patients with recurrent endometriosis.     

子宫内膜异位症保守性手术后复发的相关因素分析

目的　确定与子宫内膜异位症 (内异症 )保守性手术后病变复发的相关因素。方法对 2 85例保守性手术治疗并经病理证实的内异症患者观察并随访 36个月 ,观察患者年龄、发病年龄、术前孕次、术前产次、后穹窿痛性结节、子宫活动度、血清CA12 5、既往内异症手术史、腹腔镜手术史、内异症病变侧别、术中和术后美国生育学会修订的内异症分期标准 (r AFS ,1985 )评分、术后孕激素治疗 6个月、术后枸橼酸氯米芬 (其他名称 :克罗米酚 )促排卵治疗、术后孕次、术后产次等 31项指标 ,随访中记录病变复发情况及复发时间。应用SPSS软件行COX回归风险分析筛查复发的相关因素。结果共有 83例 (2 9 1% ,83/2 85 )患者复发 ,每年复发例数、复发率和累积复发率为 ,第 1年 4 1例 ,14 4 % (41/2 85 )和 14 4 % (41/2 85 ) ;第 2年 30例 ,10 5 % (30 /2 85 )和 2 4 9% (71/2 85 ) ;第 3年 12例 ,4 2 % (12 /2 85 )和 2 9 1% (83/2 85 )。经单变量分析 ,危险性相关因素为既往有内异症手术史 (OR值为 13 6 30 ,P <0 0 1)、后穹窿有痛性结节 (OR值 6 133,P <0 0 1)、术后应用枸橼酸氯米芬促排卵治疗 (OR值 5 173,P <0 0 1)、左侧盆腔病变 (OR值 4 5 0 3,P <0 0 1)、双侧盆腔病变 (OR值 3 70 9,P <0 0 5 )和术后r AF     

Outcome after anterior vaginal prolapse repair: a randomized controlled trial

OBJECTIVES: To report 1-year outcomes of a randomized controlled trial comparing polypropylene mesh-reinforced anterior vaginal prolapse repair with anterior colporrhaphy. METHODS: Seventy-six patients with stage II or greater anterior vaginal prolapse were randomly assigned to either colporrhaphy or polypropylene mesh repair. The primary outcome was recurrent stage II anterior vaginal prolapse, and secondary outcomes were effects on quality of life and sexual symptom scores, operative time, blood loss, length of hospitalization, and adverse events. RESULTS: Thirty-eight women had anterior colporrhaphy, and 37 had polypropylene mesh repair. One patient allocated to mesh repair withdrew from the study before surgery. Clinical and demographic data did not differ significantly between the two treatment groups. One year after surgery, optimal and satisfactory anterior vaginal support were obtained in 21 of 38 (55%) of the colporrhaphy group and 33 of 38 (87%) of the mesh group (P=.005). Patients in both groups reported less bother after surgery in both prolapse and urinary symptoms. The rates of de novo dyspareunia were 4 of 26 (16%) and 2 of 23 (9%) in the colporrhaphy and mesh groups, respectively. Two of 37 (5%) patients had vaginal mesh extrusion. Nine anterior colporrhaphy patients would have to have recurrent anterior vaginal prolapse to prevent one vaginal mesh extrusion. Neither serious adverse events nor deaths occurred in either group. CONCLUSION: Anterior vaginal prolapse repair with polypropylene mesh reinforcement offers lower anatomic recurrence than anterior colporrhaphy at one year. However, quality of life and sexual symptoms scores improved in both groups.