Athanasios Protopapas

Management of ureteric injuries during gynecological operations: 10 years experience

OBJECTIVE(S) To present our 10 years experience in the management of ureteric injuries occurring during gynecological surgery. STUDY DESIGN Seventy-six patients had a variety of injuries. In 29 cases, the ureteric damage was diagnosed intraoperatively. Management of early-diagnosed injuries included suturing, ligature removal, end-to-end anastomosis, and reimplantation of the ureter. In 47 cases, the injury was diagnosed postoperatively. Ureteric catheterization was attempted in all cases presenting with obstruction. Catheterization failures were managed with ureterolysis, and reimplantation. Small ureteric fistula were managed with catheterization, and large communications with reimplantation. Two cases with urinomas were treated with surgical evacuation and anastomoses. RESULTS Management of early-diagnosed injuries was relatively easy in most cases. Postoperatively-diagnosed injuries were more difficult to treat. Catheterization failed in 28/44 (65.9%) ureters and surgical re-exploration was necessary. Long-term morbidity was minimal and no relapses occurred. CONCLUSION(S) Early recognition of a ureteric injury is the key to a complications-free repair. Unrecognized injuries cause prolonged morbidity, and their management can be difficult. Treatment of these injuries by experienced teams may minimize long-term consequences.

Laparoscopic Treatment of Ovarian Dermoid Cysts: Eleven Years' Experience

STUDY OBJECTIVE To compare laparoscopic and open approaches in the management of benign ovarian teratomas (dermoid cysts) with regard to operative outcome, complications, and postoperative follow-up. Factors that predispose to rupture of dermoid cysts during laparoscopic removal and rates of adhesion formation in women with and without cyst rupture during laparoscopic surgery also were considered. DESIGN Review of cases of women with dermoid cysts who underwent cystectomy either by laparoscopy or laparotomy in our department from 1992 through 2002 (Canadian Task Force classification III). SETTING The Infertility and Operative Laparoscopy units of the First Department of Obstetrics and Gynecology of the University of Athens, Alexandra Maternity Hospital, Athens, Greece. PATIENTS Two hundred twenty-two women with an ovarian mass requiring surgical management. Of these, 187 women with benign cystic teratomas underwent laparoscopic cystectomy, and 35 underwent cystectomy by laparotomy. INTERVENTIONS Cystectomy either by laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS Potential benefits of operative laparoscopy include reduced blood loss, less postoperative pain, shorter hospital stay, fast recovery, and an excellent cosmetic result. CONCLUSION Laparoscopy should be considered the method of choice for the removal of benign ovarian cystic teratomas as it offers the advantages of fewer postoperative adhesions, reduced pain, shorter hospital stay, and better cosmetic result. It should be performed by surgeons with considerable experience in advanced laparoscopic surgery.

Laparoscopic Management of Patients with Endometriosis and Chronic Pelvic Pain

Abstract: Endometriosis has been traditionally included among the most important causes of chronic pelvic pain (CPP) in women of reproductive age. The main clinical manifestations of endometriosis are dysmenorrhea, dyspareunia, and chronic nonmenstrual pain. Despite the high prevalence of endometriosis in women suffering from CPP, controversy still exists regarding the true association between the stage and extent of this peculiar disease and the severity of pain. Over the last decade, advances in endoscopic technology have enabled gynecologic surgeons to recognize many atypical appearances of the endometriotic implants not known to exist before, thus allowing their complete excision or destruction. Laparoscopic surgery may offer considerable relief in patients with endometriosis and CPP. Although cases with advanced endometriosis seem to benefit the most, we also support surgical treatment in patients with early endometriosis diagnosed using laparoscopy, as many will experience improvement in their symptoms.

Miliary Tuberculous Peritonitis Mimicking Advanced Ovarian Cancer

Primary peritoneal tuberculosis is a rare presentation of this disease. It is usually associated with ascites and raised CA-125 levels. Occasionally a pelvic mass may be present making the preoperative differential diagnosis from advanced ovarian cancer extremely difficult. Acid-fast stains and special cultures of the ascitic fluid for Mycobacterium tuberculosis are frequently negative, and confirmation of the diagnosis commonly requires histologic examination of biopsy specimens, in which epithelioid granulomas with central caseous necrosis can be identified. We present a case of unexplained pyrexial ascites in a postmenopausal woman in whom the diagnosis of miliary peritoneal tuberculosis was confirmed laparoscopically. The role of noninvasive tools such as measurement of ascitic fluid adenosine deaminase levels is also discussed.

Endometriosis in patients with chronic pelvic pain : Is staging predictive of the efficacy of laparoscopic surgery in pain relief?

Background/Aims: Endometriosis is considered an important cause of chronic pelvic pain. Despite its high prevalence, controversy still exists regarding the true association between the extent of endometriosis and the severity of symptoms. We conducted this prospective study to investigate the association between the stage of endometriosis and type and severity of pain, and to evaluate the efficacy of laparoscopic surgery in pain relief. Methods: Ninety-five patients complaining of chronic pain were diagnosed with endometriosis and were treated with laparoscopic surgery. The severity of pain was assessed in patients with an endometriosis AFS (American Fertility Society) score less than 16 (group 1) and those with an AFS score greater than or equal to 16 (group 2), preoperatively and 6 months after surgery, using a visual pain scale. Any reduction in pain scores by 2 points or more was considered to be an improvement. Results: Dysmenorrhea and deep dyspareunia, were significantly more frequent in patients of group 2. Preoperative pain scores were significantly higher for dysmenorrhea (p = 0.0022) and deep dyspareunia (p < 0.0001) but not for non-menstrual pain in group 2. Deep dyspareunia was correlated with the presence of dense pelvic adhesions. After surgery, dysmenorrhea improved in 43% of cases in group 1, vs. 66% of cases in group 2 (p = 0.0037). For deep dyspareunia, improvement was reported by 33% in group 1, vs. 67% in group 2 (p = 0.074). Improvement in non-menstrual pain was not significantly different between the two groups (67% vs. 56%). Conclusions: Advanced endometriosis is more frequently related to dysmenorrhea and deep dypareunia in comparison to early disease. Laparoscopic surgery may offer relief or improvement in the majority of patients with endometriosis and chronic pelvic pain. Cases with advanced disease seem to benefit the most.

LAPAROSCOPIC EVALUATION OF INFERTILE PATIENTS WITH CHRONIC PELVIC PAIN

In this study over a 10-year period, 1584 patients complaining of infertility of more than 1 year duration were evaluated for their laparoscopic findings in relation to the presence or not of chronic pelvic pain (CPP). Infertility was the only complaint in 1215 cases (group 1), whereas 369 patients complained of infertility and CPP (group 2). All cases underwent routine infertility investigation and pelvic ultrasonography, followed by diagnostic laparoscopy, with infertility-only cases acting as a control group. At laparoscopy 76.7% of patients with CPP were found with pelvic pathology, compared with only 42.6% of cases without CPP (P < or = 0.0001). Omental-abdominal wall adhesions, advanced endometriosis, endometriomas with adhesions, pelvic venous congestion, and hydrosalpinges with pelvic adhesions were significantly more frequent in cases with CPP. Dysmenorrhoea was the most frequent type of CPP. Cases with CPP and a negative laparoscopy were further investigated using a multidisciplinary approach. In conclusion, chronic pelvic pain can be the result of several pelvic pathologies. Infertile patients with CPP are much more frequently found with an abnormal pelvis in comparison with cases without CPP. Laparoscopy is an invaluable diagnostic tool especially for symptomatic patients and should be used early in their diagnostic infertility work-up.

Cystic Uterine Tumors

Background/Aims: The differential diagnosis of cystic uterine tumors includes fibroids showing cystic degeneration, cystic adenomyomas, congenital cysts, and developmental anomalies. Methods: The incidence, clinical presentation and accuracy in preoperative diagnosis of cystic uterine tumors were studied in a university hospital population over a 6-year period. Results: 29 cases were included. Of these, 8 corresponded to the diagnosis of a non-fibroid uterine cystic enlargement, and 21 to that of a fibroid with cystic degeneration. Age and parity were significantly lower in patients with non-fibroid cysts. Rates of symptomatic women (60 vs. 55.6%) were similar in both groups. The preoperative diagnosis was accurate in 20/21 (95.2%) cases with a degenerated leiomyoma. On the contrary, in 6/8 (75%) cases with a non-fibroid cystic swelling an erroneous diagnosis of an adnexal or an extrauterine mass was made preoperatively. In this group, histology of the tumor showed a cystic adenomyoma in 3, a congenital cyst in 3, and a blind rudimentary uterine horn in 2 cases, respectively. Conclusion: Uterine cystic tumors are uncommon. Frequently, non-fibroid swellings are erroneously diagnosed as adnexal enlargements and their true origin only becomes evident during surgery.

Insulin-like growth factor-1 isoform mRNA expression in women with endometriosis: eutopic endometrium versus endometriotic cyst.

Abstract:  Pathogenesis of endometriosis involves growth factors, which are synthesized locally. Insulin‐like growth factor‐1 (IGF‐1) prevents apoptosis and has mitogenic action on endometrial cells. The IGF‐1 gene undergoes alternative splicing and results in three isoforms (IGF‐1Ea, IGF‐1Eb, and IGF‐1Ec or MGF). We analyzed the mRNA expression of IGF‐1 isoforms in tissue samples of eutopic endometrium and endometriotic cyst obtained during laparoscopy from women with endometriosis. We documented that all three IGF‐1 isoforms are expressed in both eutopic endometrium and ovarian endometrioma. Furthermore, we documented a significant decrease in all IGF‐1 isoform expression in endometriotic cyst compared to endometrium of women with endometriosis. The reduction may correlate with the disease status and presence of fibrotic inactive tissue found in late stages of the disease.

Pelvic organ prolapse contributes to sexual dysfunction: a cross-sectional study.

Objective. To evaluate the effect of pelvic organ prolapse (POP) on female sexual dysfunction. Design. Cross‐sectional, observational study. Setting. Gynecological outpatient and urogynecological university clinics in Greece. Population. One hundred and one women with POP seen in the urogynecology clinic (study group) and 70 women without POP seen in the gynecology outpatient department (control group). Methods. Women with and without POP completed a condition‐specific sexual dysfunction questionnaire (DYSQ) comprising four domains: sexual behavior; physical problems other than urinary incontinence; urinary incontinence problems; and satisfaction. Pelvic organ prolapse was assessed by the International Continence Society Pelvic Organ Prolapse Quantification System grading system. The primary outcome of the study was the assessment of sexual function by DYSQ in women with and without POP. Main outcome measures. We compared sexual function in women with and without POP and evaluated the extent of the effect of various grades of POP on sexual function. Results. One hundred and seventy‐one women were recruited, 101 in the POP group and 70 in the control group. The total and factor‐specific DYSQ scores in the POP group were worse than those in the control group (p < 0.001) but did not seem to worsen with an increasing grade of prolapse. Linear regression showed that the best model to describe the DYSQ score includes the presence of POP and years of menopause. These variables explain 15.6% of the total variability in DYSQ scores. Conclusions. The presence of prolapse only partly explains impaired sexual functioning in women with POP. Sexual dysfunction is related to the presence of POP and not the grade of POP.

Postoperative ascites developing after laparoscopic surgery can become a difficult diagnostic dilemma.

Postoperative ascites is a rare complication of laparoscopic surgery. Life-threatening and serious etiologies such as unrecognized bowel or urinary tract injury should be excluded promptly to avoid prolonged morbidity and even mortality. Occasionally, no definitive cause can be identified after an extensive diagnostic work-up. In such cases, idiopathic allergic or inflammatory peritoneal reaction may be the final diagnosis.