Ceana Nezhat

The relationship of endometriosis and ovarian malignancy: a review

OBJECTIVE To review the malignant potential of endometriosis based on epidemiologic, histopathologic, and molecular data. DESIGN Literature review. RESULT(S) The pathogenesis of endometriosis remains unclear. The histopathologic development of endometriosis has undergone long-term investigation. Studies have confirmed histologic transition from benign endometriosis to ovarian malignancy, including malignant transformation of extraovarian endometriosis. The prevalence of endometriosis in patients with epithelial ovarian cancer, especially in endometrioid and clear cell types, has been confirmed to be higher than in the general population. Ovarian cancers and adjacent endometriotic lesions have shown common genetic alterations, such as PTEN, p53, and bcl gene mutations, suggesting a possible malignant genetic transition spectrum. Furthermore, endometriosis has been associated with a chronic inflammatory state leading to cytokine release. These cytokines act in a complex system in which they induce or repress their own synthesis and can cause unregulated mitotic division, growth and differentiation, and migration or apoptosis similar to malignant mechanisms. CONCLUSION(S) The malignant potential of endometriosis holds serious implications for management, such as the need for earlier and more meticulous surgical intervention for complete disease treatment.

Urinary tract endometriosis treated by laparoscopy

OBJECTIVE To evaluate the efficacy of the laparoscopic approach for the diagnosis and treatment of severe urinary tract endometriosis. DESIGN Retrospective review of 28 cases of severe urinary tract endometriosis. SETTING Center for Special Pelvic Surgery, a tertiary referral center. PATIENT(S) Between October 1989 and September 1994, we treated 28 women who had deeply infiltrating urinary tract endometriosis (bladder, 7, ureter, 21). INTERVENTION(S) All procedures were performed laparoscopically. MAIN OUTCOME MEASURE(S) Postoperative urinary function, pain relief, and complications. RESULT(S) Those who had vesical endometriosis underwent partial cystectomy and primary repair. Partial ureteral obstruction was found in 17 women; 10 underwent ureterolysis and excision of endometriosis, and 7 had partial wall resection. Four patients with ureter involvement had complete obstruction. Three underwent partial resection and ureteroureterostomy, and one had ureteroneocystostomy. The rate of ureteral endometriosis in the present series is higher than that reported previously. CONCLUSION(S) Severe infiltrative endometriosis of the bladder and the ureter can present without specific symptoms and can cause silent compromise of renal function. We demonstrated that the laparoscopic approach is safe and effective in the diagnosis and treatment of this entity.

Recurrence rate after laparoscopic myomectomy

STUDY OBJECTIVE To determine the recurrence rate of myomas after laparoscopic myomectomy. DESIGN Retrospective review (Canadian Task Force classification II-2). SETTING Tertiary referral center. PATIENTS One hundred fourteen women (age 25-51 yrs, median 38 yrs) who were followed for an average of 37 months (range 6-120 mo). INTERVENTION Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS Follow-up data were obtained by chart review and from returned questionnaires. Variables were date of surgery, first diagnosis of recurrence, and last follow-up visit. There were 38 (33.3%) recurrences after an average interval of 27 months. Twenty-four of these women did not require treatment. Eight underwent a second laparoscopic myomectomy, and one had a third. One patient had myomectomy and then hysterectomy, and six patients chose hysterectomy to treat the first recurrence. Cumulative risk of recurrence (Kaplan-Meier curve) was 10.6% after 1 year, 31.7% after 3 years, and 51.4% after 5 years. CONCLUSION Although laparoscopic myomectomy is associated with less morbidity than removal by laparotomy, our results suggest that recurrence of myomas may be higher with the laparoscopic approach. Of 38 women with recurrent myoma, however, only 14 (36.8%) required additional surgery.

The incidence of adhesions after prior laparotomy : a laparoscopic appraisal

Objective To relate the presence of intra-abdominal adhesions after laparotomy to the site of incision, repeat laparotomy, and the clinical indication for prior surgery. Methods Three hundred sixty women undergoing operative laparoscopy after a previous laparotomy were assessed for adhesions between the abdominal wall and the underlying omentum and bowel. Complications resulting directly from these adhesions were documented. Results Patients with prior midline incisions had significantly more adhesions (58 of 102) than those with Pfannenstiel incisions (70 of 258). Patients with midline incisions performed for gynecologic indications had significantly more adhesions (109-259) than all types of incisions performed for obstetric indications (12 of 55). The presence of adhesions in patients with previous obstetric surgery was not affected by the type of incision. Adhesions to the bowel were significantly more frequent after midline incisions above the unbilicus. Twenty-one women suffered direct injury to adherent omentum and bowel during the laparoscopic procedure. Conclusions Intra-abdominal adhesions between the abdominal scar and underlying viscera are a common consequence of laparotomy. Patients undergoing laparoscopy after a previous laparotomy should be considered at risk for the presence of adhesions between the old scar and the bowel and omentum.

Laparoscopic management of 15 patients with infiltrating endometriosis of the bladder and a case of primary intravesical endometrioid adenosarcoma

OBJECTIVE To report laparoscopic management of 15 patients with infiltrative bladder wall endometriosis and to report a case of endometrioid adenosarcoma. DESIGN Prospective chart review. SETTING Referral center for endometriosis. PATIENT(S) Fifteen women with infiltrating endometriosis of the bladder. INTERVENTION(S) Laparoscopic segmental cystectomy and pathologic review of endometriotic bladder nodules in 15 patients. MAIN OUTCOME MEASURE(S) Location and characteristics of endometriotic bladder nodules. RESULT(S) Laparoscopic and cystoscopic evaluation confirmed that the endometriotic lesions were penetrating through the bladder wall. In 8 patients, the lesions were located in the dome of the bladder. In the remaining 7, the lesions were in the posterior wall, above the trigone. It was possible to treat all the lesions by performing a laparoscopic partial cystectomy. No intraoperative complications occurred. Deeply infiltrating endometriosis was confirmed on histologic evaluation in 14 cases. One patient was diagnosed with endometriosis on frozen section, but the final pathology revealed an adenosarcoma of the bladder. CONCLUSION(S) Surgical excision of deeply infiltrating endometriosis of the bladder wall can be performed laparoscopically and offers the benefit of a definitive pathologic diagnosis to rule out an occult malignancy.

Evaluating the Risks of Electric Uterine Morcellation

Gynecologic surgeons, like many other surgical specialists, have embraced laparoscopic surgical techniques because they offer quicker recovery, less postoperative pain, and fewer wound complications than open procedures. The removal of large pieces of tissue through the small incisions of laparoscopy is difficult. However, this problem can be overcome by tissue morcellation, a technique of fragmenting tissue into smaller pieces that often prevents the need to enlarge established incisions. Surgeons have long used manual morcellation with a scalpel or scissors to remove masses abdominally and vaginally, but use of the technique has increased with wide adoption of laparoscopic approaches and with the introduction of laparoscopic electric morcellators in 1993.

Robotic versus standard laparoscopy for the treatment of endometriosis

OBJECTIVE To compare robot assisted laparoscopic platform to standard laparoscopy for the treatment of endometriosis. DESIGN A retrospective cohort controlled study. SETTING Tertiary referral center. PATIENT(S) Seventy-eight reproductive aged women. INTERVENTION(S) Robot assisted or standard laparoscopy for the treatment of endometriosis between January 2008 and January 2009. MAIN OUTCOME MEASURE(S) Operative time, estimated blood loss, hospitalization time, intraoperative and postoperative complications. RESULT(S) Seventy-eight patients underwent treatment of endometriosis, 40 by robot assisted laparoscopy and 38 by standard laparoscopy. The two groups were matched for age, body mass index (BMI), stage of endometriosis, and previous abdominal surgery. Mean operative time with the robot was 191 minutes (range 135-295 minutes) compared with 159 minutes (range 85-320 minutes) during standard laparoscopy. There were no significant differences in blood loss, hospitalization, intraoperative or postoperative complications. There were no conversions to laparotomy. CONCLUSION(S) Both robot assisted laparoscopic and standard laparoscopic treatment of endometriosis have excellent outcomes. The robotic technique required significantly longer surgical and anesthesia time, as well as larger trocars.

Dysmenorrhea is related to the number of implants in endometriosis patients

OBJECTIVE To determine whether the symptoms of endometriosis were related to the number and/or location of endometrial implants and the number and/or location of adhesions. DESIGN Prospective, double-blind study. PATIENTS Seventy consecutive female surgical patients undergoing diagnostic and operative laparoscopy for pain, infertility, or both. INTERVENTIONS Patients completed a self-administered questionnaire one day before laparoscopy. MAIN OUTCOME MEASURES The number, type, and location of endometrial implants and the number, type, and location of adhesions were evaluated during laparoscopy. These were compared with the type and severity of endometriosis symptoms as reported by patients. RESULTS The total number of ectopic endometrial implants was associated directly with the intensity of dysmenorrhea experienced by patients in the 60 days before operative laparoscopy (n = 47). Patients with low pain scores had significantly fewer implants than patients with high pain scores. CONCLUSIONS The intensity of menstrual pain is related to the number of endometrial implants in patients with endometriosis.

Use of neutral argon plasma in the laparoscopic treatment of endometriosis.

Neutral argon plasma energy can be used as a multifunctional device that has vaporization, coagulation and superficial cutting capabilities with little thermal spread.

Iatrogenic myomas: new class of myomas?

Parasitic myomas, defined as extrauterine seeding of leiomyoma, have been reported since the early 1900s. These myomas were thought to be spontaneously occuring, separate from the uterus but still hormone-dependent and can cause symptoms. What seemed to be a rare disorder developing from the natural history of pedunculated myomas has become increasingly reported over the last decade. Because it is still a rare disorder, the literature is limited to case reports. Herein, we review the literature and provide an analytic review of recent case reports, with emphasis on etiology, trends, and risk factors, to increase awareness of this problematic entity.