Claudio Peixoto Crispi

Endometriosis of the Round Ligament of the Uterus

STUDY OBJECTIVE To demonstrate the prevalence of endometriosis in the intrapelvic portion of the round ligaments of the uterus (RLUs) and to propose criteria for their excision. DESIGN Retrospective case series analysis of women undergoing laparoscopy for the treatment of deep infiltrating endometriosis (Canadian Task Force classification II-3). SETTING Tertiary referral hospital. PATIENTS We evaluated 174 patients who underwent laparoscopy for the treatment of deep infiltrating endometriosis (DIE) between April 2006 and May 2009. INTERVENTIONS All patients underwent laparoscopy for the treatment of DIE and had their RLUs removed when there was shortening, deviation, or thickening. After removal, the RLUs were sent for histopathologic analysis to verify the presence or absence of endometriosis. MEASUREMENTS AND MAIN RESULTS The prevalence of endometriosis in the RLUs and the association between the macroscopic alterations and the anatomic pathology results were determined. After the identification of macroscopic alterations, 1 or both RLUs (for a total of 42) were removed from 27 of the 174 patients who underwent laparoscopy. The positive predictive value (PPV) of the macroscopic criteria proposed for endometriosis of the RLU was 83.3% (95% confidence interval [CI] = 72.1%-94.5%), with 35 positive RLUs out of the 42 that were excised. The prevalence of endometriosis of the RLU was 13.8% (95% CI = 8.7%-18.9%), with 24 patients having a positive histopathologic examination result for endometriosis. CONCLUSIONS The prevalence of RLU endometriosis in patients with DIE was 13.8%, which emphasizes that a rigorous evaluation of this structure must be part of the routine surgical treatment of patients with endometriosis.

Double Circular Stapler Technique for Bowel Resection in Rectosigmoid Endometriosis

To reduce bladder function impairment and avert the serious complications of anastomotic leakage after segmental rectosigmoidectomy and to minimize the persistence of endometriotic lesions associated with discoid resection, we used the double circular stapling (DCS) technique. This technique enables excision of bowel endometriosis nodules larger than those that can be removed with the single-load technique of the circular stapler. Of 120 patients who underwent surgery to treat bowel endometriosis, intestinal shaving was performed in 24, discoid resection with single circular stapling in 40, and rectosigmoidectomy in 55. Eleven patients (9.2%) underwent the DCS technique. In the DCS group, the size of the rectosigmoid lesion ranged from 2.2 cm to 4.2 cm. Median operative time for the DCS technique was 100 minutes, compared with 150 minutes for rectosigmoidectomy (p = .04). Only 1 of 11 patients (9%) had urinary retention, compared with postoperative urinary retention in 14 of 55 patients (25%) who had undergone rectosigmoidectomy (difference not significant). Only 1 patient, with a 4.2-cm nodule, had a positive margin in the specimen obtained at the second stapling. DCS is a promising technique and may avert rectosigmoidectomy in selected patients.

Diagnostic hysteroscopy using liquid distention medium: comparison of pain with warmed saline solution vs room-temperature saline solution.

STUDY OBJECTIVE To compare pain intensity and degree of satisfaction reported by patients undergoing hysteroscopic examinations using saline solution kept at room temperature (control group) or saline solution heated to 37.5°C (test group). DESIGN Randomized, controlled, prospective study (Canadian Task Force Classification I). PATIENTS Sixty-four women underwent diagnostic hysteroscopy during the second half of 2008. INTERVENTION In both the test and control groups, examinations were performed using the vaginoscopy technique without use of a speculum or Pozzi tenaculum forceps. Pain was assessed using a visual analog scale immediately after the examination and at 1 and 15 minutes after the procedure. MEASUREMENTS AND MAIN RESULTS Immediately after the examination, mean (SD; 95% confidence interval) pain intensity in the warmed saline solution group was 3.84 (2.71; 2.89-4.79), and in the room-temperature saline solution group was 4.31 (3.02; 3.18-5.44) (p = .51). At 1 and 15 minutes after the procedure, pain intensity in the 2 groups was, respectively, 2.41 (2.00; 1.66-3.16) and 2.43 (2.49; 1.57-3.30) (p = .96), and 1.83 (2.30; 1.02-2.64) and 1.85 (2.06; 1.08-2.62) (p = .96). Differences were not significant. Time to complete the examination was 3.80 (1.32; 3.34-4.26) minutes in the test group, and 3.75 (1.10; 3.34-4.15) minutes in the control group (p = .82). The satisfaction rate with the warmed distention medium was 84% (95% confidence interval, 72%-96%), and with the room-temperature saline solution was 85% (73%-97%) with saline at room temperature (p = .48). CONCLUSION There was no statistically significant difference between the 2 groups insofar as pain, duration of the examination, and degree of patient satisfaction.

Risk of urinary retention after nerve‐sparing surgery for deep infiltrating endometriosis: A systematic review and meta‐analysis

Recently, nerve‐sparing (NS) techniques have been incorporated in surgeries for deep infiltrating endometriosis (DIE) to prevent urinary complications. Our aim was to perform a systematic review and meta‐analysis to assess the risk of urinary retention after NS surgery for DIE compared with classical (non‐NS) techniques.

Urodynamic observations and lower urinary tract symptoms associated with endometriosis: a prospective cross-sectional observational study assessing women with deep infiltrating disease

Introduction and hypothesisThe objective was to assess the association between lower urinary tract disease (LUTD) and the presence of endometriosis at different anatomical sites.MethodsOur prospective cross-sectional observational study evaluated 138 women with deep infiltrating endometriosis who had undergone preoperative evaluation of urodynamics and detailed assessment of lower urinary tract symptoms between August 2013 and May 2016. After laparoscopy, the anatomical sites of histologically confirmed endometriosis lesions were mapped.ResultsThe presence of endometriosis in the bladder demonstrated significant negative angular coefficients for bladder compliance (mL/cmH2O) (P = 0.007; B = −54.65; 95%CI: −93.76 to −15.51) and for maximum cystometric capacity (mL; P = 0.001; B = −39.79; 95%CI: −62.51 to −17.06), whereas endometriosis in the parametrium showed significant positive coefficients for opening pressure (cmH2O) (P = 0.016; B = 5.89; 95%CI: 1.10–10.69) and post-void residual (mL) (P = 0.015; B = 31.34; 95%CI: 6.14–56.55). The presence of endometriosis in the bladder was a statistically significant independent predictor of low bladder compliance (P < 0.001; OR = 30.10; 95%CI: 9.48–95.55), whereas endometriosis in the parametrium was a statistically significant independent predictor of both abnormal residual urine (P = 0.019; OR = 5.21; 95%CI: 1.32–20.64) and bladder outlet obstruction (P = 0.011; OR = 7.91; 95%CI: 1.61–38.86). Correspondence analysis suggested two possible independent ways through which endometriosis acts on the genesis of urinary dysfunctions.ConclusionsOur findings strongly suggest that endometriosis involving the bladder might disturb storage function, whereas endometriosis in the parametrium disturbs the voiding phase.

Can reducing the number of stitches compromise the outcome of laparoscopic Burch surgery in the treatment of stress urinary incontinence? Systematic review and meta-analysis

The retropubic colposuspension in the treatment of stress urinary incontinence has been rescued with the laparoscopic route. Some authors have reduced the number of stitches, from two to one, due to the difficulty of suturing by this route. To what extent can this modification compromise outcome? To answer this question, we performed a systematic review and meta-analysis on the MEDLINE/PubMed and LILACS/SciELO databases between 1990 and 2015. We included randomized clinical trials, cohort studies and case-control series comparing laparoscopic versus open Burch, and two versus one stitch in laparoscopic Burch, with a minimum follow-up of one year. Fourteen studies compared laparoscopic versus open Burch, in which we found no differences between the two techniques using one stitch (Relative Risk - RR - of 0.94, 95% CI 0.79-1.11) and two stitches (RR of 1.03, 95% CI 0.97-1.10). Only one study compared one stitch versus two stitches in laparoscopic Burch, with cure rates of 68% versus 87%, respectively (p-value= 0.02). We did not identify differences when compared open technique with two stitches versus laparoscopic with one stitch and open technique with two stitches versus laparoscopic with two. The study comparing one versus two laparoscopic stitches demonstrated superior results with the latter. Although there is no robust evidence, when Burch surgery is performed laparoscopically, the use of two stitches seems to be the best option.

Predictors of fluid intravasation during operative hysteroscopy: a preplanned prospective observational study with 200 cases

PURPOSE To verify the predictors of intravasation rate during hysteroscopy. METHODS Prospective observational study (Canadian Task Force classification II(-1)). All cases (n=200 women; 22 to 86 years old) were treated in an operating room setting. Considering respective bag overfill to calculate water balance, we tested two multiple linear regression models: one for total intravasation (mL) and the other for absorption rate (mL.min(-1)). The predictors tested (independent variables) were energy (mono/bipolar), tube patency (with/without tubal ligation), hysterometry (cm), age ≤ 50 years, body surface area (m(2)), surgical complexity (with/without myomectomy) and duration (min). RESULTS Mean intravasation was significantly higher when myomectomy was performed (442 ± 616 versus 223 ± 332 mL; p<0.01). In the proposed multiple linear regression models for total intravasation (adjusted R(2)=0.44; p<0.01), the only significant predictors were myomectomy and duration (p<0.01).In the proposed model for intravasation rate (R(2)=0.39; p<0.01), only myomectomy and hysterometry were significant predictors (p=0.02 and p<0.01, respectively). CONCLUSIONS Not only myomectomy but also hysterometry were significant predictors of intravasation rate during operative hysteroscopy.

Interrelationships among endometriosis-related pain symptoms and their effects on health-related quality of life: a sectional observational study

Objective To assess the correlation between different pain symptoms and different domains of womens health-related quality of life (HRQoL). Methods Seventy-seven women with deep infiltrating endometriosis were successively enrolled between June 2011 and August 2013 while being prepared to undergo laparoscopy due to pain and/or infertility. We quantified the intensities of dysmenorrhea, deep dyspareunia, chronic pelvic pain, and dyschezia (menstrual and non-menstrual) using a 11-point visual analog scale (VAS: 0–10) and the validated full versions of the Short Form 36 (SF36) and Endometriosis Health Profile (EHP30) questionnaires to assess HRQoL. The pain symptoms were considered simultaneously in a hierarchical agglomerative clustering method (exploratory multivariate approach) and the associations among scores were tested by bivariate correlation. Results Dysmenorrhea showed the lowest similarity on to the multivariate cluster analysis and no statistically significant correlation with the other pain symptoms: deep dyspareunia (P=0.244), chronic pelvic pain (P=0.108), menstrual dyschezia (P=0.238), and non-menstrual dyschezia (P=0.380). Dysmenorrhea and chronic pelvic pain were the main symptoms correlated with all domains of the SF36 and the EHP30 (core instrument) questionnaires (P<0.05). Conclusion Dysmenorrhea and chronic pelvic pain were independent factors associated with HRQoL.

MRI Aspects of Deep Endometriosis

In this chapter, we point the multiple MRI appearance of the endometriosis peritoneal lesions, such as ligament thickening, subperitoneal nodule, and plaque-like lesions. We call attention to signal intensity characteristics of deep endometriosis lesions, including glandular and fibrous components, associated inflammatory process, and adhesions.

Stratification Risk and Monitoring of Patient by MRI

In this chapter, we make a patient risk stratification according to the MRI findings, such as multifocality, associated ovarian and tubal lesions, urinary obstructive endometriosis, degree of adhesion, and the risk of malignancy.