Diego Raimondo

Segmental bowel resection for colorectal endometriosis: is there a correlation between histological pattern and clinical outcomes?

BACKGROUND Laparoscopic segmental resection as a treatment for intestinal endometriosis can be supported by favorable clinical outcomes, but carries a high risk of major complications. The purpose of this study is to evaluate histopathological patterns of colorectal endometriosis and investigate potential relationships between histological findings and clinical data. METHODS We consecutively included 47 patients treated with laparoscopic segmental resection because of symptomatic colorectal endometriosis. All patients underwent follow-up for a median of 18 months (range: 6-35). We examined the histological patterns of colorectal endometriosis and evaluated the relationships between histological findings (satellite lesions, positive margins and vertical infiltration) and clinical outcomes (incidence of recurrence, quality of life and symptom improvement). Moreover, we observed if satellite lesions could influence preoperative scores of the short form-36 health survey (SF-36) questionnaire and visual analogue score (VAS) for pain symptoms. RESULTS There were no statistically significant differences in terms of anatomical and pain recurrences, pain symptoms and quality of life improvement among patients with or without positive margins, satellite lesions and different degrees of vertical infiltration (P > 0.05). Furthermore, women with or without satellite lesions were no different in terms of preoperative VAS of pain symptoms and SF-36 scores (P > 0.05). CONCLUSIONS The presence of satellite lesions or positive resection margins does not seem to influence clinical outcomes of segmental colorectal resection. Similarly, satellite lesions do not appear to have a major role in determining preoperative clinical presentation. These results may be useful to reconsider the surgical strategy for bowel endometriosis.

Hysteroscopic treatment of symptomatic cesarean-induced isthmocele: a prospective study.

An isthmocele, also known as a cesarean scar defect, is an emerging condition that typically affects women with a history of previous cesarean section, and its presence is a novel under-recognized cause of postmenstrual abnormal uterine bleeding and/or pelvic pain. The incidence of symptoms and their resolution after hysteroscopic surgery were evaluated prospectively in 120 consecutive isthmocele patients. Patients included only symptomatic premenopausal women. Transvaginal ultrasound and office hysteroscopy were used to diagnose isthmocele. Operative hysteroscopy was performed to correct the cesarean scar defect, and histologic findings were evaluated. Correction of an isthmocele via operative hysteroscopy was successful in all cases evaluated. Isthmoplasty resulted in the resolution of postmenstrual abnormal uterine bleeding and suprapubic pelvic pain in 80% of patients. In the remaining cases, 7% of patients had an improvement of symptoms, whereas 13% did not obtain any relief. Considering the recent diagnostic recognition of isthmoceles, we conclude that surgical treatment of this pathology by operative hysteroscopy may represent the best choice in symptomatic women because of its minimal invasiveness and beneficial therapeutic results.

What is the Impact on Sexual Function of Laparoscopic Treatment and Subsequent Combined Oral Contraceptive Therapy in Women with Deep Infiltrating Endometriosis

INTRODUCTION Deep infiltrating endometriosis (DIE) is a form of endometriosis in which the lesion penetrates for more than 5 mm under the peritoneal surface. It is a chronic disease which can impair womens sexual function. There is a growing body of evidence supporting combined surgical/medical treatment in the management of DIE. AIMS The aims of this article are to evaluate the impact of the laparoscopic full excision of endometriosis and postoperative combined oral contraceptives (COC) administration on sexual function in patients with DIE and to compare sexual function outcomes of women submitted to intestinal resection and nodule excision. METHODS It is a prospective cohort study in a tertiary care university hospital on 106 sexually active women, with histologically confirmed DIE, managed by laparoscopy and subsequent COC therapy for 6 months. Patients filled preoperatively and 6-month postoperatively a quality of sexual life questionnaire, the Sexual Health Outcomes in Women Questionnaire (SHOW-Q) and they ranked their symptom intensity using a 10-point visual analogue scale (VAS). MAIN OUTCOME MEASURES Sexual function was measured through the SHOW-Q scores and pain symptoms through VAS scores. Intraoperative details, type of intervention and perioperative complications were noted. RESULTS Six months after surgery and postoperative COC treatment, a significant improvement was observed in the SHOW-Q domains of pelvic problem interference, sexual satisfaction and desire (P<0.05). Laparoscopic management of DIE did not change significantly the orgasm area of the sexual functioning (P=0.7). No significant difference was found in SHOW-Q scores between patients submitted to intestinal resection and patients submitted to intestinal nodule excision (P>0.05). CONCLUSIONS Sexual desire, satisfaction with sex and pelvic problem interference with intercourse are significantly improved after 6 months from laparoscopic excision of DIE combined with postoperative COC therapy. No difference in sexual outcomes was detected between patients submitted to intestinal resection and nodule excision.

Prevalence of adenomyosis in women undergoing surgery for endometriosis

OBJECTIVE(S) To evaluate the prevalence of adenomyosis in patients undergoing surgery for endometriosis. STUDY DESIGN Retrospective study including 1618 women with preoperative clinical and ultrasound diagnosis of endometriosis. As preoperative assessment, all patients underwent ultrasound to assess endometriosis and all features associated with adenomyosis (heterogeneous myometrial echotexture, globular-appearing uterus, asymmetrical thickness of anteroposterior wall of the myometrium, subendometrial myometrial cysts, subendometrial echogenic linear striations or poor definition of the endometrial-myometrial junction). RESULTS Adenomyosis was present in 353/1618 (21.8%) women included in the study. Multivariate analysis showed that the prevalence of adenomyosis was significantly associated with deep infiltrating endometriosis, parity, dysmenorrhea intensity and womens age (P<0.0001). CONCLUSION(S) Adenomyosis is a common condition but its aetiology and natural history are still unknown. Our experience showed a 21.8% of prevalence of adenomyosis in patients affected by endometriosis and its association with parous women, increasing age, dysmenorrhea intensity and with the presence of deep infiltrating endometriosis.

Does colorectal endometriosis alter intestinal functions? A prospective manometric and questionnaire-based study.

OBJECTIVE To objectively evaluate using anorectal manometry whether endometriotic nodules influence intestinal function and to reveal subjective intestinal dysfunctions in patients with rectosigmoid deep infiltrating endometriosis. DESIGN Prospective study. SETTING Tertiary care university hospital. PATIENT(S) Patients (n = 25) with a preoperative diagnosis of rectosigmoid endometriosis. INTERVENTION(S) Patients underwent anorectal manometry; after that, they filled a questionnaire about defecatory functions and ranked their pain symptoms. MAIN OUTCOME MEASURE(S) The parameters studied were resting pressure, maximum squeezing pressure, pushing, rectoanal inhibitory reflex, and rectal sensibility. We analyzed the responses to the defecatory function questionnaire and the scored the endometriosis pain symptoms using a Visual Analogue Scale. RESULT(S) No alterations of the rectoanal inhibitory reflex were found. Hypertone of the internal anal sphincter was found in 20 of 25 patients. Almost half of the patients had an increase of the threshold of desire to defecate, and 7 patients had a reduction of the anal sphincter squeeze pressure. According to the responses to the defecatory function questionnaire, incomplete evacuation was the most common symptom. CONCLUSION(S) We did not find marked motility or sensitive dysfunctions at the anorectal manometry, whereas subjectively patients reported some defecatory disorders. We revealed the presence of hypertone of the internal anal sphincter in most of the patients. CLINICAL TRIAL REGISTRATION NUMBER 74/2010/O/Sper.

A randomized controlled study comparing carbon dioxide versus normal saline as distension media in diagnostic office hysteroscopy: is the distension with carbon dioxide a problem?

OBJECTIVE To compare two distension media, carbon dioxide (CO2) and saline, with regards to patient discomfort and the adequacy of the panoramic view in diagnostic hysteroscopy by the vaginoscopic approach. DESIGN Randomized prospective study. SETTING Tertiary referral centers for gynecologic care. PATIENT(S) 264 patients randomly allocated to two groups: CO2 (132 women) and normal saline (132 women). INTERVENTION(S) Office hysteroscopy performed with a forward-oblique 30° telescope (total diameter 5.1 mm) and CO2 as the distension medium or with a forward-oblique 30° telescope (final diameter 5.1mm) and saline solution as the distension medium. MAIN OUTCOME MEASURE(S) Global operative time, pain experienced by patients using a visual analogue scale (VAS), severity of the pain (VAS), incidence of collateral effects (shoulder-tip pain, nausea, or dizziness), degree of difficulty, and view (VAS). RESULT(S) Pelvic discomfort was comparable between groups, without statistically significant differences in intensity or degree of difficulty. However, the visual quality was statistically significantly higher when hysteroscopy was performed with CO2 as the distension medium. CONCLUSION(S) No relevant difference in pain or technical difficulty was found between the two distension media, but CO2 was associated with better quality visualization.

Urodynamic evaluation and anorectal manometry pre- and post-operative bowel shaving surgical procedure for posterior deep infiltrating endometriosis: a pilot study.

STUDY OBJECTIVE To analyze bowel and urinary function in patients with posterior deep infiltrating endometriosis (DIE) >30 mm in largest diameter at transvaginal ultrasound before and after surgical nerve-sparing excision. DESIGN Prospective observational study (Canadian Task Force classification III). SETTING Tertiary care university hospital in Bologna, Italy. PATIENTS Twenty-five patients with posterior DIE were included in the study between June 2011 and December 2012. Patients did not receive hormone therapy for at least 3 months before and 6 months after surgery. INTERVENTIONS Patients underwent urodynamic studies and anorectal manometry before and after nerve-sparing laparoscopic excision of the posterior DIE nodule. MEASUREMENTS AND MAIN RESULTS Intestinal and urinary function was evaluated in patients with bulky posterior DIE using urodynamic and anorectal manometry. Results of urodynamic studies and anorectal manometry were similar before and after nerve-sparing surgical excision of the posterior DIE nodule. Urodynamic studies demonstrated a high prevalence of voiding dysfunction, whereas anorectal manometry showed no reduction in rectoanal inhibitory reflex and hypertone of the internal anal sphincter. CONCLUSIONS Patients with posterior DIE >30 mm in greatest diameter demonstrate preoperative dysfunction at urodynamic study and anorectal manometry, probably due to DIE per se. The nerve-sparing surgical approach seems not to influence the motility or sensory capacity of the bladder and the rectosigmoid colon.

Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series

STUDY QUESTION In women with deeply infiltrating endometriosis (DIE) what is the prevalence of involvement of endometriotic tissue and fibrosis in ureteral endometriosis (UE), as assessed by histological staining? SUMMARY ANSWER In women with DIE, ureteral involvement is more often due to endometriotic tissue rather than fibrosis. WHAT IS KNOWN ALREADY In the current literature, histological evaluation of ureteral endometriosis is mainly based on the degree of wall infiltration by endometriosis instead of the tissue composition. A few studies reported ill-defined and contradictory histological data on the tissue composition of UE. STUDY DESIGN, SIZE, DURATION Retrospective observational study based on clinical records of women affected by DIE, laparoscopically treated for UE at a tertiary referral center, between January 2010 and March 2013. All cases of ureteral nodule excision or ureterectomy with histological examination of the specimens were included. Exclusion criteria were other identified causes of hydroureteronephrosis, medical therapy for a period of at least 3 months before surgery and previous surgery for DIE. PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 77 patients were included in the study and among them seven (9%) presented with bilateral ureteral involvement, giving a total of 84 cases of UE available for analysis. All patients had stage IV endometriosis. According, respectively, to the presence of endometrial glands and/or stroma cells or of fibrotic tissue only, the endometriotic UE and fibrotic UE groups were compared with regard to hydroureteronephrosis at pre-operative urinary tract computerized tomography scan, type of surgical procedure performed to treat UE (nodule removal or ureterectomy), association with other locations of the disease and post-operative complications (ureteral fistula or stenosis). MAIN RESULTS AND THE ROLE OF CHANCE For the 84 cases of UE, 65 (77%) and 19 (23%), respectively, showed endometriotic tissue and fibrotic tissue only. Presence of hydroureteronephrosis and endometriotic pattern of UE showed a significant association [endometriotic UE 44/65 (68%) versus fibrotic UE 8/19 (42%); P = 0.04]. Fibrotic pattern of UE and presence of concomitant recto-vaginal endometriosis showed a significant association [endometriotic group: 29/65 (45%) versus fibrotic group 18/19 (95%); P < 0.001]. LIMITATIONS, REASONS FOR CAUTION The retrospective and monocentric (tertiary referral center) study design. WIDER IMPLICATIONS OF THE FINDINGS Besides the distinction between extrinsic and intrinsic UE based on the degree of wall infiltration by endometriosis, a new classification according to the histological pattern of UE could be useful for clinicians, both in the diagnostic and therapeutic fields. STUDY FUNDING/COMPETING INTERESTS None.

Sexual function in women undergoing surgery for deep infiltrating endometriosis: a comparison with healthy women

Background Endometriosis is a chronic and progressive condition of women of reproductive age. It is strongly associated with significant impairment of sexual function. Aim To objectively evaluate the impact of laparoscopic excision of endometriosis on sexual function in patients with deep infiltrating endometriosis (DIE) compared to healthy women. Setting and design Prospective study, including 250 patients with a diagnosis of DIE scheduled for laparoscopic surgery and 250 healthy women. Methods A sexual activity questionnaire, SHOW-Q (Sexual Health Outcomes in Women Questionnaire), was used to collect data pertaining to womens satisfaction, orgasm, desire and pelvic problem interference with sexual function. Women with DIE underwent complete excision of endometriotic lesions. All participants were asked to complete the SHOW-Q questionnaire before and after surgery. Results SHOW-Q scores in the endometriosis group before and 6 months after surgery were compared with the healthy group scores. A significant improvement was found between pre- and post-treatment in the scores of the satisfaction scale, desire scale and pelvic problem interference scale of SHOW-Q. The distribution of post-surgery SHOW-Q scores was comparable to healthy womens scores apart from the orgasm scale score, which was unchanged in the post-surgery group. Conclusions The surgical approach to treatment has a positive impact not only on organ impairment but also on sexual function in women affected by DIE.

Does laparoscopic shaving for deep infiltrating endometriosis alter intestinal function? A prospective study

5–12% of deep infiltrating endometriosis involves the digestive tract, especially the distal sigmoid colon and rectum. Bowel endometriosis surgery may be associated with neurological complications.