Basim Abu-Rafea

Consensus Guidelines for the Management of Chronic Pelvic Pain. This guideline was developed by the Chronic Pelvic Pain Working Group and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada

OBJECTIVE To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates. OUTCOMES Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state. EVIDENCE Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations. VALUES The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1). RECOMMENDATIONS The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; (j) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.

Monopolar Electrosurgery through Single-Port Laparoscopy: A Potential Hidden Hazard for Bowel Burns

BACKGROUND Surveys indicate that up to 90% of general surgeons and gynecologists use monopolar radiofrequency during laparoscopy and 18% have experienced visceral burns. Monopolar electrosurgery compared with other energy sources is associated with unique characteristics and inherent risks and complications caused by inadvertent direct or capacitive coupling or insulation failure of instruments. These dangers become particularly important with the reemergence of single-port laparoscopy, which requires close proximity and crossing of multiple intraabdominal instruments outside the surgeons field of view. STUDY OBJECTIVES To determine the effects of monopolar electrosurgery on various tissues/organs during simulated single-port laparoscopic surgery in vitro and in vivo. DESIGN Simulation in a dry laboratory with fresh sheep liver, pig bowel and bowel in an anesthetized dog (Canadian Classification II-3). SETTING University-affiliated teaching hospital and animal facilities. MEASUREMENTS AND MAIN RESULTS We used Valleylab Force 2 and FX electrosurgical generators at clinically used power outputs of 40 to 60 watts, and both high- and low-voltage (coagulation and cut) waveforms and commercially-available single-port devices. The effect on tissue was recorded by pictures and video camera and graded visually and histologically with hematoxylin and eosin stains. During activation of any standard monopolar laparoscopic instrument (scissors, coagulating electrode, etc), capacitive coupled currents resulting in visible tissue burn (blanching) caused by other adjacent cold instrument (graspers, etc) including metallic suction-irrigation cannulas and the laparoscope itself were noted. Histopathologic study confirmed transmural thermal damage extending to the mucosa of small bowel, even in the presence of mild serosa blanching. With prolonged activation of the electrosurgical generator, the capacitive coupled corona discharge burned the insulation and caused rapid insulation breakdown of the electrode instrument resulting in direct coupling (sparking, arcing) to adjacent cold instruments and more severe burning to the contacted tissue/organ. CONCLUSIONS During single-port laparoscopy and use of monopolar radiofrequency, the proximity and crossing of multiple instruments generate capacitive or direct coupled currents, which may cause visceral burns.

The Levonorgestrel Intrauterine System is an Effective Treatment in Women with Abnormal Uterine Bleeding and Anticoagulant Therapy

OBJECTIVE To evaluate the efficacy of levonorgestrel intrauterine systems (LNG-IUS) in obese women with AUB on anticoagulant therapy. DESIGN Prospective observational case series (Canadian Task Force Classification II-3). SETTING University affiliated teaching hospital. PATIENTS Premenopausal women on Warfarin therapy. INTERVENTIONS From January 2002 through January 2007, 10 women were identified from the senior authors clinical practice (G.A.V.). After clinical assessment, including Papanicolaou smear, endometrial biopsy, and pelvic sonography, the LNG-IUS was placed to treat their AUB. MEASUREMENTS AND MAIN RESULTS The median and range of age, parity, and body mass index were 45 years (34-49), 1 (0-4), and 38 kg/m(2) (26-52), respectively. All women were receiving warfarin therapy (4-12.5 mg/d) for previous venous thromboembolism. Some patients had additional comorbid conditions and were at high risk for traditional medical or surgical therapies. After placement of the LNG-IUS, all women reported menstrual reduction at 3 and 6 months. By 12 months, 1 woman with large fibroids expelled the LNG-IUS and was treated with transfemoral uterine artery embolization. Two women had amenorrhea, and 7 had hypomenorrhea. At 2 to 5 years, 1 woman expelled the LNG-IUS and hysterectomy indicated extensive adenomyosis in a 195-g uterus, and 1 woman had hysteroscopic endometrial ablation, 4 were menopausal, 2 had amenorrhea, and 1 had hypomenorrhea. In the 5 women with uterine fibroids measuring 4.2 to 147 cm(3), the fibroids were reduced in volume by approximately 75% in 2, were no longer detectable in 1, were subsequently shown to be adenomyoma in 1, and required uterine artery embolization in 1. CONCLUSION In properly assessed and selected obese, premenopausal women with AUB receiving warfarin therapy and at high risk for traditional therapies, the LNG-IUS was an effective treatment in 70% of patients.

Fertility and pregnancy outcomes following hysteroscopic septum division.

OBJECTIVES We sought to evaluate retrospectively the efficacy of hysteroscopic metroplasty in a population of women with a history of recurrent pregnancy loss or infertility who were also known to have a uterine septum. METHODS Hysteroscopic metroplasty was performed on 26 women with a uterine septum and a history of either recurrent pregnancy loss or infertility. The metroplasty was performed using a Versapoint bipolar needle device (in 23% of cases) or a resectoscopic knife electrode with cutting current (in 77% of cases). The main outcome measures were rates of clinical pregnancy and live birth. RESULTS Nineteen women had a hysteroscopic metroplasty because of recurrent pregnancy loss. Postoperatively, the pregnancy rate was 95%, and the live birth rate was 72%. The seven infertile patients had pregnancy and live birth rates of 43% and 29%, respectively. CONCLUSION Hysteroscopic metroplasty using either the Versapoint bipolar needle device or a knife electrode is both safe and effective. In women with recurrent pregnancy loss, future fertility is not impaired, and live birth rates are significantly improved.

Miscellaneous Uterine Malignant Neoplasms Detected during Hysteroscopic Surgery

STUDY OBJECTIVES To estimate the incidence of incidental miscellaneous uterine malignant neoplasms other than endometrioid adenocarcinoma detected during routine resectoscopic surgery in women with abnormal uterine bleeding (AUB) and to examine the effect of hysteroscopic surgery on long-term clinical outcome. DESIGN Prospective cohort study (Canadian Task Force classification II-3). SETTING University-affiliated teaching hospital. PATIENTS Women with AUB. INTERVENTION From January 1, 1990, through December 31, 2008, one of the authors (G.A.V.) and several fellows performed primary hysteroscopic surgery at St. Josephs Health Care in 3892 women with AUB. Of the 7 with malignant disease, one underwent hysteroscopic partial (n = 1) or complete (n = 6) rollerball electrocoagulation or endomyometrial resection. After diagnosis of uterine cancer, the women were counseled about the disease and management in accord with established clinical practice guidelines. Follow-up with office visits and telephone interviews ranged from 2 to 8 years (median, 6 years). MEASUREMENTS AND MAIN RESULTS Of the 3892 women, 4 had undiagnosed and 3 had suspected miscellaneous uterine malignant neoplasms including 1 endometrial stromal sarcoma, 2 carcinosarcomas, 2 atypical polypoid adenomyomas of the endometrium, 1 minimal deviation adenocarcinoma of the cervix, and 1 smooth-muscle tumor of uncertain malignant potential. At 2 to 8 years of follow-up, 1 patient died accidentally after 1 year, 1 died of carcinomatosis of either coexisting breast cancer or a carcinosarcoma (postmortem examination was declined) after 1 year, and 5 were alive and well. CONCLUSION Resectoscopic surgery in women with miscellaneous uterine malignant lesions not adversely affect 5-year survival and long-term prognosis.

Resolution of Catamenial Epilepsy after Goserelin Therapy and Oophorectomy: Case Report of Presumed Cerebral Endometriosis

Endometriosis can develop in every organ and tissue in the female body except perhaps the spleen. The mechanism of distal metastasis is thought to be hematogenous or lymphatic spread from the uterus. Endometriotic lesions in the central nervous system are rare. Herein, we report the case of a woman with abnormal uterine bleeding who developed catamenial neurologic signs and symptoms. Computed tomography scans and magnetic resonance images demonstrated a circumscribed lesion in the left centrum semiovale of the brain. All neurologic symptoms resolved completely after treatment with gonadotropin-releasing hormone agonist for 3 months and subsequent laparoscopic bilateral oophorectomy. The patient was thought to have cerebral endometriosis, a rare phenomenon, although several cases have been reported in the literature. Temporal association of neurologic signs and symptoms with menstruation that resolves with medical or surgical menopause is highly suggestive of cerebral endometriosis.

Comparison of Clinical Outcomes with Low-Voltage (Cut) Versus High-Voltage (Coag) Waveforms during Hysteroscopic Endometrial Ablation with the Rollerball: A Pilot Study

STUDY OBJECTIVE To compare efficacy of rollerball endometrial ablation with low-voltage (cut) versus high-voltage (coag) waveforms. DESIGN Pilot comparative clinical study (Canadian Task Force Classification II-1). SETTING University-affiliated teaching hospital. PATIENTS Fifty premenopausal women with menorrhagia. INTERVENTION Women with menorrhagia were allocated randomly to thermal destruction of the endometrium by a 5-mm rollerball with unmodulated cutting current or modulated coagulating current. Complication rate, clinical outcomes, and need for reintervention were evaluated. MEASUREMENTS AND MAIN RESULTS At 2 years of follow-up, the reintervention rate was 26.3% in the cutting waveform group versus 31.4% in the coagulating waveform group. This difference was not statistically significant. Hysterectomy was performed in 3 (14%) women in the cutting waveform group and 5 (20%) women in the coagulating waveform group. There were no complications in either group. CONCLUSION Both cutting and coagulating waveforms are equally effective for hysteroscopic endometrial ablation with the rollerball.

Leiomyosarcoma Diagnosed Six Years After Laparoscopic Electromyolysis

BACKGROUND Making a histologic diagnosis of leiomyosarcoma in the specimen from a hysterectomy performed for suspected benign fibroids is rare. Currently, there are no reliable diagnostic tools to diagnose uterine sarcomas preoperatively. CASE A 38-year-old woman presented with menorrhagia and a uterine fibroid measuring 6.0 cm x 8.1 cm x 6.2 cm on ultrasonography. The patient underwent a laparoscopic myolysis with 50% shrinkage of the fibroid volume at follow-up after six months. Six years after myolysis, the patient presented with right lower quadrant pain and a rapidly enlarging uterus. Hysterectomy and bilateral salpingo-oophorectomy was performed and a diagnosis of leiomyosarcoma was histologically confirmed. CT scan was performed biannually after hysterectomy. One year after surgery, the patient presented with radiologic evidence of a right pulmonary nodule. The nodule was excised thoracoscopically and histologic examination demonstrated metastatic leiomyosarcoma. One year later, another pulmonary lesion appeared in the left lung and was excised thoracoscopically. Again, histological assessment showed metastatic leiomyosarcoma. This patient has remained healthy and asymptomatic for two years since the last thoracoscopic excision of the leiomyosarcoma metastasis. CONCLUSION The current trend in treatment for symptomatic fibroids is therapy sparing the uterus. Such treatment includes both medical therapy and fibroid necrosing therapies such as vascular occlusion, embolization, and thermal coagulation technologies. Women considering uterus-sparing treatment should be advised of the potential risk of uterine malignancy, even though that risk is quite minimal (< 0.5%). A delay in the diagnosis of uterine malignancy may ultimately compromise long-term survival.

Granulosa Cells in the Uterosacral Ligament: Case Report and Review of the Literature

Granulosa cells are components of the sex cord-stromal cells in the ovary responsible for steroidogenesis. Uncommonly, extraovarian granulosa cells have been reported to be associated with malignant processes of the ovary. We report a unique case of benign granulosa cells, found during routine laparoscopic evaluation, in the uterosacral ligaments in a 20-year-old patient with chronic pelvic pain and infertility. Possible mechanisms include implantation of released granulosa cells from a normal ovary or arising from a focus of müllerianosis. Of note, a focus of endosalpingiosis and endometriosis was also identified within the specimen.

Uterine Tumors Resembling Ovarian Sex Cord Tumors Identified at Resectoscopic Endometrial Ablation: Report of 2 Cases

STUDY OBJECTIVES To report 2 cases of uterine tumors resembling ovarian sex cord tumors (UTROSCTs) and examine the clinical significance of these tumors found during hysteroscopic endometrial ablation despite benign preoperative endometrial biopsy analysis and imaging suggestive of leiomyoma. DESIGN Case report (Canadian Task Force classification III). SETTING Tertiary care hospital. PATIENTS Two patients with abnormal uterine bleeding. INTERVENTIONS Hysteroscopic endometrial ablation/resection. MEASUREMENTS AND MAIN RESULTS Pathological analysis of intrauterine tissue/lesions obtained by curettage or resection identified 2 unexpected UTROSCTs masquerading as leiomyomas. Following hysterectomy, no residual UTROSCT was identified in the specimens, and both women are well, one at 1 year postsurgery and the other at 3 years postsurgery. CONCLUSION Obtaining additional tissue by routine curettage before endometrial ablation and/or endomyometrial resection, in conjunction with removal of any intrauterine lesions, can identify rare unexpected endometrial lesions not sampled by endometrial biopsy, not detected with ultrasound, and masquerading as leiomyomas during endometrial ablation.