E. Giacomucci

Adhesion formation after laparoscopic myomectomy

STUDY OBJECTIVE To determine the frequency of adhesion formation after myomectomy performed by operative laparoscopy or laparotomy. DESIGN Case-control study. Setting. Academic womens hospital. PATIENTS Thirty-two premenopausal women scheduled for myomectomy by one of two techniques. INTERVENTIONS Surgical removal of myomata. MEASUREMENTS AND MAIN RESULTS Of the 32 women, 16 underwent laparotomy and 16 laparoscopy. Second-look laparoscopy was performed in 28 patients, at which time adhesions were lysed. Compared with laparotomy, laparoscopy resulted in adhesions in significantly fewer patients, and in significantly lower scores when adhesions were detected. CONCLUSION Laparoscopic removal of uterine myomata is associated with fewer adhesions than removal by laparotomy.

Vaginal Drug Delivery: The First Uterine Pass Effecta

In the past few years targeted drug delivery has been one of the prime objectives of pharmaceutical developers, who wish to maximize desired effects on a “target organ” while minimizing any adverse consequences linked to systemic activity. Recently, numerous independent investigators have reported higher accumulations of drugs in the uterus when they were administered vaginally. Higher concentrations were observed in the uterus even when levels in the blood were lower than those achieved by systemic administration (i.m., transdermal). Similar findings have been reported with substances other than progesterone, such as danazol’ and terbutaline.2 These observations support the hypothesis that there is a high degree of direct vagina-to-uterus transport or a “first uterine pass effect.” To test this hypothesis we used a human ex vivo uterine perfusion and we applied 3H-progesterone directly over the rim of vaginal tissue removed with the uterus at the time of surgery.

The efficacy of drugs in the management of endometriosis

STUDY OBJECTIVE To establish the crude effects of danazol and gonadotropin-releasing hormone (GnRH) analogs in the management of endometriosis. DESIGN Prospective case-control study. SETTING Unit of the Pathophysiology of Reproduction outpatient department. PATIENTS Two groups of 110 women each with endometriosis (American Fertility Society score 1-3) who received danazol and GnRH analogs, and a control group who did not receive any drugs. INTERVENTIONS Women in the treatment groups received danazol 200 mg every 8 hours for 6 months, or a different GnRH agonist at standard dosages for 6 months. Laparoscopy was performed twice, at the time of diagnosis and just before the end of treatment (or no therapy for controls). Surgical treatment of the implants was performed at the second laparoscopy. MEASUREMENTS AND MAIN RESULTS Samples of both eutopic and ectopic endometrium were collected during both laparoscopies. Both danazol and GnRH agonists were useful in reducing the AFS scores to inactive endometriotic implants, and there were no significant differences between the effects (p <0.001). Fibrosis was found after 6 months of observation in the implants in one control woman (0.9%), in 20 patients (18.2%) treated with danazol (p <0.001 vs controls), and in 4 patients (3.6%) treated with GnRH agonists (NS vs controls). A correlation between a clinical diagnosis of AFS score zero and histologic features of fibrosis in the ectopic specimens after therapies was observed in 28% of women, with poor agreement (k = 0.07). CONCLUSIONS Fibrosis, which represent the absence of endometrial cells within the specimens of endometriotic lesions or eutopic endometrium, did not appear in eutopic endometria but it was found in some endometriotic implants. Danazol and GnRH agonists reduced the clinical AFS scores of endometriosis, but their histologic effects in completely and permanently eliminating endometriotic implants were unacceptable.

Dysfunctional Uterine Bleeding (DUB)a

Cyclic or irregular uterine bleeding is common in perimenarchal and perimenopausal women with or without endometrial hyperplasia. The disturbance often requires surgical treatment because of its negative effects on both blood loss and abnormal endometrial growth including the development of endometrial cancer. The endometrium is often overstimulated during the perimenopausal period when estrogen/progesterone production is unbalanced. A therapeutical approach with gonadotropin-releasing hormone agonist (GnRHa) was proposed in a depot formulation (Zoladex) that induces a sustained and reversible ovarian suppression. To avoid the risk of osteoporosis and to obtain adequate endometrial proliferation and differentiation during ovarian suppression, transdermal 17-beta-estradiol and oral progestin were administered. Results of 20 cases versus 20 controls showed a reduction of metrorrhagia, a normalization of hemoglobin plasma concentration, and an adequate proliferation and secretory differentiation of the endometrium of patients with abnormal endometrial growth. Abnormal uterine bleeding is mainly due to uterine fibrosis and an inadequate estrogen and/or progesterone production or to a disordered estrogen transport from blood into the endometrium. In premenopausal women, endometrial hyperplasia may be part of a continuum that is ultimately manifested in the histological and biological pattern of endometrial carcinoma. The regression of endometrial hyperplasia obtained by using the therapeutic regimen mentioned above represents a preventive measure for endometrial cancer. Finally the normalization of blood loss offers a good medical alternative to surgery for patients with DUB.

The Financial Impact of Laparoscopy versus Laparotomy in the Treatment of Uterine Leiomyomata

To compare the efficiency of two surgical techniques to remove uterine myomata, 120 premenopausal women were included in this case control study based on the criteria of no previous operations, size of leiomyoma, and age. Sixty patients were treated by laparoscopy (group 1) and 60 by laparotomy (group 2). The hospital stay for group 1 was shorter than that for group 2 (3.53 ± 1.33 and 7.98 ± 2.05 days, p <0.001). The rate of total complications (body temperature >38° C, hemoglobin <8.5 g/100 ml, infiltration of abdominal sutures, dysuria, reduction in blood platelets) was 13% in group 1 versus 53% in group 2 (p <0.001). The mean cost for each surgical treatment was

Targeted drug delivery in gynaecology: the first uterine pass effect.

628.71 and

Reproductive failure due to spontaneous abortion and recurrent miscarriage

652.40, respectively. The mean entire cost (surgery plus hospital stay) was

Immunologically mediated abortion (IMA)

1357.23 and

Immunologically mediated abortion (IMA). A minireview.

2298.90, respectively (p <0.001). The savings were detectable after 9 and 52 operations, respectively, whether including all expenditures or only the cost of surgery. The cost saving of the entire treatment for 60 operations was

Hysterosalpingography versus laparoscopy and hysteroscopy

56,500.12.