Afaf Felemban

Laparoscopic treatment of polycystic ovaries with insulated needle cautery: a reappraisal

OBJECTIVE To evaluate the reproductive outcome and adhesion formation after a standardized laparoscopic treatment of polycystic ovary syndrome (PCOS) in clomiphene-resistant infertile women. DESIGN Retrospective study. SETTING University teaching hospital. PATIENT(S) One hundred twelve clomiphene-resistant anovulatory women with PCOS. INTERVENTION(S) Laparoscopic ovarian drilling using an insulated needle cautery. MAIN OUTCOME MEASURE(S) Ovulatory rate, pregnancy rate, and adhesion formation. RESULT(S) After surgery, ovulation occurred spontaneously in 73.2% of patients. The cumulative probability of conception at 12, 18, and 24 months after surgery was 54%, 68%, and 72%, respectively. With use of Coxs proportional hazards model, the effects of age, body mass index, and duration of infertility were evaluated. These factors were not associated with the pregnancy rate. Of 15 women who underwent a second-look laparoscopy, 11 women were found to be free of adhesions. Four women had periadnexal adhesions that were filmy, minimal, and found on the ovarian surface only. CONCLUSION(S) Laparoscopic ovarian drilling is an effective alternative treatment in clomiphene-resistant anovulatory women with PCOS. The use of an insulated needle cautery is associated with a minimal amount of adhesion formation.

Nerve Fibers and Histopathology of Endometriosis-Harboring Peritoneum

STUDY OBJECTIVE To evaluate the presence of nerve fibers and histopathology of normal peritoneum and endometriosis-harboring peritoneum. DESIGN Prospective, nonrandomized study (Canadian Task Force classification II-1). SETTING University hospital. MATERIALS Peritoneal specimen from 40 women with laparoscopic findings of endometriosis (24 confirmed histopathologically, group H, 16 diagnosed by laparoscopy, group L) and from 9 women with no endometriosis (controls). INTERVENTION Histopathologic examination of peritoneal specimens with nerve fibers identified by immunocytochemistry staining with an antibody to neurofilament. MEASUREMENTS AND MAIN RESULTS No differences in mean nerve score were seen among the three groups. Degrees of lymphocytic infiltration and mesothelial hyperplasia were higher in group H than in the other two groups (p <0.01 and <0.05, respectively). The degree of lymphocytic infiltration was significantly higher in group L than in the control group (p <0.05). There were no differences in all measurements between women in group H who experienced chronic pelvic pain and those who did not. CONCLUSION The presence of nerve fibers in peritoneum is not related to endometriosis. Endometriosis-harboring peritoneum contains more lymphocytic infiltration than normal peritoneum. (J Am Assoc Gynecol Laparosc 8(1):95-98, 2001)

Effects of Local Bupivacaine Instillation on Pain after Laparoscopy

STUDY OBJECTIVE To evaluate the effect of preincisional and intraperitoneal bupivacaine administration on immediate and late pain after operative laparoscopy. DESIGN Randomized study (Canadian Task Force classification I). SETTING University teaching hospital. PATIENTS One hundred fifty women undergoing laparoscopy for various gynecologic indications. INTERVENTION A dose of 0.5% bupivacaine 10 ml (50 mg) was injected into cannula sites before incisions and another 10 ml diluted with 100 ml saline into the peritoneal cavity at completion of the procedure. Equal amount of physiologic saline was used in controls. MEASUREMENTS AND MAIN RESULTS Modified McGill pain intensity scores and amount of analgesic required in the recovery room and within 24 hours postoperatively were evaluated. Of 150 women, 142 completed the study (71 bupivacaine group, 71 controls). Groups did not differ significantly in body mass index, duration of surgery, return to consciousness, and analgesic requirement during 3-hour observation in the recovery room and 24 hours after discharge. Pain scores were highest 30 minutes after the procedure in both groups. At that time the pain score in the bupivacaine group was lower than that in the control group (1.8 +/- 0.2 vs 2.3 +/- 0.2, p <0.05). Beyond that time, the groups did not differ in pain scores and analgesic requirements. CONCLUSION Postoperative pain is the highest within 30 minutes after laparoscopy. Local instillation of bupivacaine before incision and intraperitoneally was effective in reducing pain immediately after operative laparoscopy, but the effect was not seen beyond 30 minutes.

Uterine Restoration after Repeated Expulsion of Myomas after Uterine Artery Embolization

A patient passed infarcted myomas 21, 27, and 35 days after uterine artery embolization. Transvaginal ultrasound examination did not reveal a myoma and her menstruation became normal with minimal bleeding. Uterine artery embolization and expulsion of myomas vaginally can eliminate intramural and submucous myomas.

Laparoscopic Excision of a Mesenteric Cyst Diagnosed Preoperatively as an Ovarian Cyst

Mesenteric cysts are uncommon benign, abdominal tumors usually managed by general surgeons. We encountered an unusual mesenteric cyst that was diagnosed preoperatively as an ovarian cyst. It was located in the pelvic cavity inside the mesoappendix. We excised the cyst and adjacent vermiform appendix by laparoscopy. Histopathologic examination revealed mucinous cystadenoma. To the best of our knowledge, this is the first reported case of a mesenteric cyst removed by a gynecologic laparoscopist.

Hysteroscopic Appearance of the Uterine Cavity before and after Microwave Endometrial Ablation

STUDY OBJECTIVE To evaluate the appearance of the uterine cavity before and after microwave endometrial ablation (MEA). DESIGN Prospective observational study (Canadian Task Force classification II-2). SETTING University teaching hospital. PATIENTS Sixty-two women with menorrhagia. INTERVENTION Hysteroscopic examination the uterine cavity before and after MEA. MEASUREMENTS AND MAIN RESULTS Ablation was complete in 55 patients (group A). Seven women had a small island of intact endometrium (group B); the uterine cavity was severely distorted in six of these patients due to submucous myomas in five and adenomyosis in one. Another patient in this group had an acutely retroverted uterus, a 15-mm intramural myoma, and a normal uterine cavity. Women in group B had deeper uterine cavity than those in group A (101.4 +/- 15.5 and 84.7. +/- 12.8 mm, respectively, p = 0.008). The duration of ablation was also longer in group B (329.1 +/- 158.4 sec) than in group A (206.1 +/- 67.4 sec, p = 0.01). CONCLUSION Microwave endometrial ablation tends to be incomplete in women with a large and severely distorted uterine cavity. Whether, this results in a lower success rate remains to be seen. (J Am Assoc Gynecol Laparosc 8(1):83-86, 2001)

Elevated vascular endothelial growth factor (VEGF) and active and latent transforming growth factor-β (TGF-β) in the peritoneal fluid of women with pelvic adhesions and with endometriosis.

Objective: To evaluate TGF-b and VEGF concentrations in the peritoneal fluid of women with pelvic adhesions and with endometriosis. Design: Descriptive study. Materials/Methods: Patients in a university teaching hospital. Reproductive age women undergoing laparoscopy for pelvic pain or infertility. Aspiration of the peritoneal fluid during laparoscopy. Determination of the concentrations of active TGF-b, latent TGF-b and VEGF in peritoneal fluid. Results: The total (active and latent) TGF-b levels were significantly higher in women with adhesions (201.6 6 27.6 pM) and endometriosis (196.8 6 32.5 pM) compared to women without endometriosis and adhesion (control group, 108.0 6 14.4 pM). Similarly, VEGF levels were significantly higher in women with pelvic adhesions (683.7 6 81.4 pg/mL) and endometriosis (346.5 6 124.1 pg/mL) compared to the control group (64.1 6 8.3 pg/mL). More interestingly, the concentrations of VEGF and biologically active TGF-b in the adhesion group were higher than in the endometriosis group. Conclusions: The concentrations of TGF-b (both bioactive and latent) and VEGF are elevated in the peritoneal fluid of women with pelvic adhesions and with endometriosis. Also, bioactive TGF-b and VEGF levels in the adhesion group are higher than in the endometriosis group. The enhanced expression of VEGF and the increased expression and activation of TGF-b in the peritoneal fluid of women with endometriosis or post-surgical adhesions suggest that these growth factors play a role in the pathogenesis of these conditions. Whether women with elevated peritoneal fluid concentrations of active or latent TGF-b and VEGF are prone to develop adhesions remains to be determined. Supported by: McGill University.