Eleonora Fontana

The laparoscopic Vecchietti’s modified technique in Rokitansky syndrome: anatomic, functional, and sexual long-term results

OBJECTIVE The objective of the study was to assess the anatomical and functional long-term follow-up results of the laparoscopic Vecchietti approach for the creation of a neovagina in the Rokitansky syndrome. STUDY DESIGN One hundred ten patients underwent clinical follow-up visits at 1, 3, 6, and 12 months after surgery and every 6 months thereafter. The following were performed: evaluation of the quality of sexual intercourse, vaginal and rectal examinations, vaginoscopy, Schillers test, and vaginal cytology with microbiologic testing. Functional results were assessed by using Rosens Female Sexual Function Index questionnaire, of which the results were analyzed comparing normal age-matched controls. RESULTS Four patients were lost to follow-up. Anatomic and functional success was achieved in 104 of 106 (98%) and 103 of 106 (97%) patients, respectively. Female Sexual Function Index scores were comparable with those of controls. CONCLUSION Vecchiettis technique is simple, safe, and effective and allows normal and satisfying sexual intercourse, comparable with that of normal controls.

Laparoscopic findings and pelvic anatomy in Mayer-Rokitansky-Küster-Hauser syndrome

OBJECTIVE: To describe analytically the anatomic variety and laparoscopic findings observed in patients with Rokitansky syndrome throughout an 11-year span. METHODS: We analyzed the laparoscopic and chart records of 106 consecutive patients who underwent surgery for the creation of a neovagina, according to the modified laparoscopic Vecchietti procedure. RESULTS: A hypoplastic vagina was observed in 61 women. Müllerian remnants, laterally displaced in the pelvis, were identified in 92 cases; 42 (25.9%, 95% confidence interval [CI] 19.2–33.3) of 162 müllerian remnants were cavitated and contained endometrial mucosa. Ovaries were extrapelvic in 17 (16.0%, 95% CI 9.6–24.4) cases. Anomalies of the urinary tract were identified in 32 (30.2%, 95% CI 21.7–39.9) patients; unilateral renal agenesis was the most frequent finding (18 cases; 18%, 95%CI 10.4–25.5). CONCLUSION: Rokitansky syndrome has a wide variability of anatomic presentations, and, as the do other congenital anomalies of the female genital tract, it represents a continuum of embryonic malformations, which occur at different stages of development. LEVEL OF EVIDENCE: III

Pelvic endometriosis and hydroureteronephrosis

OBJECTIVE To assess whether routine renal ultrasonography may be recommended in all patients with pelvic endometriosis, in order to avoid silent ureteral involvement of the disease. DESIGN Retrospective descriptive study. SETTINGS Tertiary center for the treatment of endometriosis at the Department of Obstetrics and Gynecology of the State University of Milan, Milan, Italy. PATIENT(S) Seven-hundred-fifty patients with a primary diagnosis of endometriosis, between January 2005 and July 2007. INTERVENTION(S) Routine urinary ultrasound; recording of patient history, signs, and symptoms; gynecologic examination; blood and urinary analyses; magnetic resonance imaging; spiral multislice computerized tomography. MAIN OUTCOME MEASURE(S) Symptoms and signs of ureterohydronephrosis; diagnosis of ureterohydronephrosis. RESULT(S) Twenty-three patients (3%) of all 750 patients with endometriosis had associated ureterohydronephrosis diagnosed at renal ultrasound. Symptoms secondary to ureteral and renal involvement were present in 10 patients (43.5%); 6 reported lumbar pain (26.1%) and 4 patients (17.4%) had renal colic. CONCLUSION(S) In our study, the high number (56.5%) of asymptomatic ureteral involvement in patients with known pelvic endometriosis seems to warrant the need for further investigations regarding the possibility to avoid the high percentage of silent renal losses. Unfortunately there appears to be no specific risk factor to allow for early suspicion nor a validated preventive diagnostic and therapeutic program. It remains to be evaluated whether urinary ultrasound ensures a beneficial cost-benefit ratio if employed on a routine basis.

Medical Management of Endometriosis

Current approved medical therapies for endometriosis rely on drugs that suppress ovarian steroids and induce a hypoestrogenic state, which determines the atrophy of the ectopic endometrium. Gonadotropin-releasing hormone analogs such as danazol, progestogens and estrogen–progestin combinations have all proven effective in relieving pain and reducing the extent of endometriotic implants. However, symptoms often recur after discontinuation of therapy and hypoestrogenism-related side effects limit the long-term use of most medications. Recently, knowledge of the pathogenesis of endometriosis, particularly at the molecular level, has grown substantially, providing a rational basis for the development of new drugs with precise targets that may be safely administered over the long term.