David Soriano

Emergency laparoscopy for suspected ovarian torsion: are we too hasty to operate?

OBJECTIVEnTo reevaluate the rate of correct diagnosis of ovarian torsion (OT) in our department.nnnDESIGNnRetrospective computerized chart review.nnnSETTINGnTertiary referral center.nnnPATIENT(S)nSeventy-eight women who underwent laparoscopy for suspected OT.nnnINTERVENTION(S)nLaparoscopy.nnnMAIN OUTCOME MEASURE(S)nRate of true diagnosis of torsion, correlation with Doppler studies.nnnRESULT(S)nThe preoperative diagnosis of OT was confirmed in only 36 (46.1%) of the patients. Immediate operation (<10 hours) after admission (n = 48) was associated with a statistically significantly higher likelihood of operatively confirming OT (56.2% vs. 28.6%). We found that the lack of ovarian blood flow on Doppler sonography was a good predictor of OT; women with pathologic flow were statistically significantly more likely to have OT (77% vs. 29%). The sensitivity and specificity of abnormal ovarian flow for OT were 43.8% and 91.7%, respectively, with a positive and negative predictive value of 78% and 71%, respectively.nnnCONCLUSION(S)nDespite 20 years of research, the accuracy of the preoperative diagnosis of OT remains low. The urge to operate can be attributed to the importance of preserving ovarian function in young women as well as to the availability and the low associated complication rate of laparoscopy.

Reproductive Outcome Is Favorable After Laparoscopic Resection of Bladder Endometriosis

STUDY OBJECTIVEnTo assess the reproductive outcome (spontaneous and assisted conception rates) in women who underwent laparoscopic resection of bladder endometriosis.nnnDESIGNnThis was a retrospective, observational study analyzing prospectively recorded data (Canadian Task Force classification II-2).nnnSETTINGnA tertiary referral center.nnnPATIENTSnOver a 9-year period, we identified 69 consecutive women with symptomatic pelvic endometriosis who underwent laparoscopic resection of bladder endometriosis at our center.nnnINTERVENTIONSnGroup A patients (nxa0=xa021) had full-thickness endometriotic invasion of the bladder and underwent laparoscopic partial cystectomy. Group B (nxa0=xa048) patients had partial endometriotic bladder penetration and underwent partial-thickness excision of the detrusor muscle. Most patients (over 70%) had additional, nonbladder endometriotic lesions, which were also removed during surgery.nnnMEASUREMENTS AND MAIN RESULTSnFertility outcomes were analyzed in patients who wished to conceive (nxa0=xa042), and improvements in symptoms were assessed for all patients. The minimum follow-up after surgery was 36xa0months. Of the 42 patients who wished to conceive, 35 patients (83.3%) conceived: 16 patients spontaneously and 18 patients after IVF treatment. No difference was observed in fertility outcome between group A (partial cystectomy) and group B (partial-thickness excision of the detrusor muscle). For all patients, long-term follow-up revealed that 80% of the patients (55 patients) had no urinary/endometrial symptoms after surgery.nnnCONCLUSIONnPregnancy rates after laparoscopic surgery for bladder endometriosis by either partial cystectomy or deep excision of the detrusor muscle are favorable, both for spontaneous pregnancy and conception after IVF treatment. Additionally, urinary symptoms were improved for the majority of patients. Based on our findings, it seems warranted to offer laparoscopic surgical management to symptomatic infertile patients diagnosed with bladder endometriosis, even after IVF failure.

Fertility outcome of laparoscopic treatment in patients with severe endometriosis and repeated in vitro fertilization failures

OBJECTIVEnTo evaluate fertility outcomes in infertile women with severe endometriosis (The revised American Fertility Society classification [AFS] 3-4) and repeated IVF failures, who underwent surgery due to exacerbation of endometriosis-related symptoms.nnnDESIGNnRetrospective cohort study.nnnSETTINGnUniversity hospital.nnnPATIENT(S)nAll women who failed IVF treatment before surgery and who underwent laparoscopic surgery for severe endometriosis betweenxa0January 2006 and Decemberxa02014.nnnINTERVENTION(S)nAll patients were operated by highly skilled surgeons specializing in laparoscopic surgery for advanced endometriosis. Only patients with evidence of endometriosis in the pathology specimens were included in this study.nnnMAIN OUTCOME MEASURE(S)nDelivery rate after surgery.nnnRESULT(S)nSeventy-eight women were included in the present study. All women were diagnosed with severe endometriosis during surgery (AFS 3-4) and all women had experienced failed IVF treatments before surgery. All women were symptomatic before their surgery. After surgical treatment 33 women (42.3%) delivered. Three women (9%) conceived spontaneously and all other women conceived after IVF treatment. Women who delivered were younger (32.5 [±4.1] years vs. 35.5 [±3.8] years), were less often diagnosed with diminished ovarian reserve before surgery (6% vs. 28.8%), and were more often diagnosed with normal uterine anatomy (by preoperative transvaginal ultrasound and during operation). In addition, performing salpingectomy during surgery was associated with a trend of improvement in delivery rates after surgery (70% in women who delivered vs. 51% in women who failed to deliver).nnnCONCLUSION(S)nSymptomatic women with severe endometriosis and repeated IVF implantation failures may benefit from extensive laparoscopic surgery when performed by an experienced multidisciplinary surgical team to improve IVF outcome.

Surgically treated ovarian endometriosis association with BRCA1 and BRCA2 mutations

Endometriosis is associated with an increased risk of ovarian cancer. Few studies have also shown increased risk of breast cancer. BRCA1/2 mutations are linked to an increased risk of breast and ovarian cancers but their relation to endometriosis is unknown. The objective of this study was to examine the mutation rate of BRCA1/2 among women with surgically treated ovarian endometriosis. We collected 126 specimens from Jewish Ashkenazi women with endometriotic (76) and control non-endometriotic (50) ovarian cysts, reviewed the pathological diagnoses and extracted DNA from all samples. Using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), samples were examined for the founder germline mutations of BRCA1/2, most common among Ashkenazi Jews. The rate of mutations in each group was calculated and compared. BRCA1/2 mutation rate was 1/76 (1.3%) in the endometriotic cyst study group and 1/50 (2%) in the control non-endometriotic cysts, showing no statistically significant difference between the groups (p=0.84). BRCA1/2 mutation rate was similar to the previously reported rate among Jewish Ashkenazi women. BRCA1/2 mutation rates in patients with endometriotic ovarian cysts and with non-endometriotic ovarian cysts are similar. A larger cohort is required to completely exclude the possibility of an association between BRCA1/2 mutations and surgically treated endometriosis.

Use of magnetic resonance imaging in pregnancy to diagnose maternal malformation of inferior vena cava

Diagnosis of deep vein thrombosis (DVT) presents an important challenge in modern obstetrics, as pulmonary embolism remains the most common cause of maternal death during pregnancy (1, 2). Ultrasonography has replaced venography as the major imaging technique for diagnosis of symptomatic DVT during pregnancy (3, 4). However, venography is still the gold standard for the diagnosis of venous thrombosis of the pelvic veins, which are frequently involved during pregnancy (4). Contrast venogrdphy is an invasive technique, which may be associated with significant complications including thrombophlebitis, traumatic arteriovenous fistula, systemic contrast medium reactions, pulmonary embolism and air embolism (5 ) . It also presents an additional risk during pregnancy as it exposes the fetus to radiation. Recently, the use of magnetic resonance imaging (MRI) has been suggested as a safe and effective alternative to venography for visualization of the pelvic veins in pregnant women (6). We describe a pregnant woman with clinical symptoms of DVT and a normal Doppler ultrasound. Magnetic resonance imaging provided the diagnosis of a congenital anomaly in the inferior vena cava (IVC). ‘

Adenomyosis and Hysteroscopy: An Up-to-Date Review

Adenomyosis is a heterogeneous and benign gynecological condition that has an important impact on women in reproductive age. Adenomyosis often remains undiagnosed before a hysterectomy. An earlier diagnosis of adenomyosis requires a comprehensive medical history and a correlation of clinical examination and imaging findings, either ultrasound or MRI. Hysteroscopy can have both diagnostic and therapeutic uses regarding adenomyosis. With the improvement of the quality of mini-hysteroscopy, the hysteroscopy can be integrated as a first-line tool for diagnosis in context of abnormal uterine bleeding, infertility, or dysmenorrhea. Also, the hysteroscopy offers the possibility to perform biopsy of endomyometrial tissue under direct vision. Conservative treatment has been introduced since imaging technology and hysteroscopy have enabled the presumptive diagnosis of uterine adenomyosis in symptomatic women who want to preserve their uterus. The treatment options are depending on the age of the patients, the willingness to conceive, the type, size, and location of the lesion involve. Hysteroscopy is less invasive than laparoscopy and laparotomy for treating adenomyotic cysts. The impact of adenomyosis on fertility and failure of implantation is still debated, and treatment of adenomyosis is still lacking in the context of infertility. The aim of this chapter is to describe the importance of the diagnosis of adenomyosis by hysteroscopy and to analyze new therapeutic strategies.

OP31.04: Evidence of adenomyosis on transvaginal ultrasound and infertility management of patients with endometriosis selected for surgical intervention

Objectives: To assess the changes in the volume of endometriomas and rectovaginal endometriotic nodules (RVE) during 12-month treatment with norethindrone acetate (NETA) versus extended-cycle oral contraceptive. Methods: This patient preference prospective study included women of reproductive age with endometriosis. Patients received either continuous oral treatment with NETA (2.5 mg/day, Primolut-Nor® Schering, Milan, Italy; group A) or a 91-day extended-cycle oral contraceptive (LNG/EE 150/30 mcg for 84 days and EE 10 mcg for 7 days, Seasonique® Teva, Assago, Italy; group B) for 12 months. The volume of the lesions was assessed by virtual organ computer-aided analysis (VOCAL, GE Healthcare, USA). The changes in the volume of endometriomas and RVE were compared between baseline, after 6 and 12 months of treatment. The echogenicity of the endometriomas was subjectively evaluated by the ultrasonographer using a Likert scale. Results: 100 patients were enrolled in the study (50 in each group). 45 patients completed the treatment in group A and 38 in group B. In both study groups, the volume of the cysts significantly decreased at 6 (p<0.05) and 12 months of treatment (p<0.05; percentage reduction: 56.5% in group A and 55.7% in group B) compared with baseline. The decrease in the volume of the cyst between 6-month and 12-month treatment reached statistical significance in both study groups (p < 0.05). After 12 months of treatment, the echogenicity of the endometriomas significantly changed in both study groups (p<0.05). After 6 and 12 months of treatment, the volume of the RVE significantly decreased in both groups compared to baseline. There was a significant reduction in the volume of the RVE between the 6 and 12 months of treatment (p<0.05 for both study groups). Conclusions: Both NETA and Seasonique® are effective in reducing the volume of the endometriomas and RVE.

Progestogens and Endometriosis

In endometriosis endometrial-like tissue is found most commonly in the peritoneal cavity, ovaries and rectovaginal septum. Endometriosis is characterised by a progesterone resistant endometrium and an immunologically compromised peritoneal microenvironment. The sequelae are infertility, dysmenorrhea, dyspareunia and chronic pelvic pain. Chronic pelvic pain causes disability and distress with a very high economic impact. The main treatment modality is surgery. Progestogens are effective in controlling the pain, and for treating recurrences. However, the mode of action on the target tissue is still uncertain, due to the progesterone resistance. The most likely mechanism of effect is on the inflammatory reaction surrounding endometriotic deposits. Other therapies include:- debulking by surgery, estrogen reduction by GnRH analogues and Danazol, inducing endomerial atrophy with the levonorgestrel releasing intra-uterine contraceptive, and gestrinone. Surgery is associated with a relatively high recurrence rate, The other medical treatments apart from progestogens are associated with a wide range of side effects. Progestogens are indicated for pain relief, bleeding and other symptoms of endometriosis when long-term medication or repeated courses of treatment are indicated. The main advantage of progestogen therapy is the relative lack of side effects. However, there is little data comparing different progestogens and progestogens have no effect on endometriosis related infertility,

Management of a triplet pregnancy with two anencephalic fetuses and polyhydramnios

The occurrence of a triplet pregnancy discordant for anencephaly is rare and its management presents a clinical dilemma. We report what appears to be the first case of a triplet pregnancy with two anencephalic fetuses complicated by premature contractions and severe polyhydramnios. Its management, which results a healthy newborn weighing 1385 g is discussed.