Giovanni Pontrelli

Laparoscopic conservative surgery for stage IV symptomatic endometriosis: short-term surgical complications

OBJECTIVE To study severe endometriosis as a cause of pelvic pain, which represents one of the most challenging disorders in gynecology. DESIGN Retrospective study. SETTING Teaching hospital. PATIENT(S) A total of 1,363 women with severe endometriosis (revised American Society for Reproductive Medicine [rASRM] stage IV). INTERVENTIONS A detailed survey of all patients with severe endometriosis (rASRM stage IV) who underwent laparoscopy at our center between January 2004 and December 2007 was carried out. MAIN OUTCOME MEASURE(S) Clinical and surgical data were retrieved and assessed according to the extent of surgery performed. Intraoperative, ultra-short, and short-term clinical complications were assessed. RESULTS A total of 1,201 women underwent laparoscopic radical surgery with excision of all visible endometriotic lesions, with a significant improvement of symptoms at 1-month follow-up evaluation. The overall intraoperative complication rate was 2.0%. The morbidity was significantly increased when bowel surgery was performed, with a risk of intraoperative complications that was threefold higher. Of the patients who had bowel surgery, 18 (4.1%) required reintervention within the first week after surgery. CONCLUSION(S) We report on the safety and efficacy of laparoscopic eradication of all visible implants in cases of rASRM stage IV endometriosis when surgery is performed in a referral center.

The Influence of Adenomyosis in Patients Laparoscopically Treated for Deep Endometriosis

STUDY OBJECTIVE A strong association exists between adenomyosis and endometriosis and a common pathogenetic mechanism was proposed. The aim of this study was to evaluate whether and how the presence of concurrent adenomyosis can affect the outcome of laparoscopic excision of deep endometriosis. DESIGN Data were retrospectively collected from our computerized medical records (Canadian Task Force classification II-3). SETTING General hospital. INTERVENTION Restrospective evaluation. PATIENTS From January 2003 through July 2005, 40 consecutive patients affected by concomitant endometriosis and adenomyosis were included in group A and another 40 affected by endometriosis only were included in group B. MEASUREMENTS AND MAIN RESULTS In group A, 20 women required bowel surgery (17 segmental and 3 full-thickness discoid resections) versus 16 patients in the other group (13 segmental bowel resections with end-to-end anastomosis and 3 discoid resections). Dysmenorrhea and dyspareunia after treatment improved (p<.01) in both groups, whereas dyschezia improved only in group A. The persistence of menometrorrhagia was more frequent in group B (p<.01). During follow-up, patients of group A underwent medical treatment for a longer time than those of group B (p<.001). Clinical detection of endometriosis recurrence was more frequent in patients with adenomyosis (p<.01), whereas no difference existed in the incidence of the recurrence detected by ultrasound. The overall number of pregnancies after surgery was significantly lower in the group with adenomyosis (p=.03). CONCLUSION Complete excision of deep endometriosis is not always feasible because of adenomyosis. For this reason, preoperative imaging screening for adenomyosis could be included in the preoperative workup when extensive disease is clinically suspected.

Laparoscopic Disk Resection for Bowel Endometriosis Using a Circular Stapler and a New Endoscopic Method to Control Postoperative Bleeding from the Stapler Line

BACKGROUND Complete laparoscopic excision of endometriosis offers good longterm symptomatic relief, especially for those with severe or debilitating symptoms. Intestinal endometriosis affect between 3% and 36% of women with endometriosis and 50% of women with disease severe enough that intestinal surgery, with or without intestinal segmental resection, may be required. STUDY DESIGN Between January 2003 and September 2006, we performed 35 laparoscopic complete excisions of endometriosis with full thickness disk resections of bowel endometriosis using the CEEA stapler (US Surgical) inserted transanally. RESULTS The endometriotic nodule of the bowel was completely removed in all patients. No major or minor surgical complications occurred during the primary surgical procedure. One patient underwent a diverting temporary ileostomy because of air loss after insufflation of the rectosigmoid colon, which was closed successfully 1 month after surgery. In three of seven cases of rectal bleeding from the stapler line, for the first time, we successfully used conservative endoscopic management. CONCLUSIONS In properly selected patients, full thickness disk excision using a circular stapler is a feasible procedure that avoids the potential morbidities of a low anastomosis. We suggest conservative management by endoscopic hemostasis before referring patients for a new operation in cases of rectal bleeding from the anastomotic site.

Hysteroscopy and menopause: past and future.

Purpose of review The main aim in investigating post-menopausal women is to exclude endometrial cancer. The purpose of this review is to define up-to-date clinical guidelines for the management of all post-menopausal women (asymptomatic as well as symptomatic). Recent findings Thanks to improvements in both the technology and the technique, hysteroscopy has become a simple and painless procedure that can easily be performed in an office or outpatient setting without any particular discomfort for the patient. The new, easier procedure, well tolerated by patients, has excellent diagnostic and surgical accuracy. Assuming that office hysteroscopy could offer a better visualization of the uterine cavity without increasing patient discomfort if compared to ultrasound, various authors have recently proposed the use of hysteroscopy as a first-line procedure in the approach to the menopausal patient. This could be defined as a change in strategy that has yielded very interesting results in terms of a better understanding of the appearance of the uterine cavity and the clinical value of small intra-cavitary pathologies (and their related treatment), particularly in asymptomatic women. Summary Hysteroscopy can be considered a routine outpatient method providing immediate results and causing minimal discomfort, especially when performed with the vaginoscopic approach. This technique has ushered in a new era of very-low-cost hysteroscopy, because only the hysteroscope is required in the outpatient procedure, with no need for additional instruments, medication, extra personnel or dedicated theatre. The time taken is comparable to that required for transvaginal sonography.

Laparoscopical management of cornual pregnancies: a report of three cases

OBJECTIVE Cornual pregnancy refers to the implantation and development of a gestation in one of the upper and lateral portions of the uterus; authors report their experience in laparoscopic therapeutic procedures on three singleton cornual pregnancies. STUDY DESIGN Three healthy women were admitted in General Hospitals with suspect of cornual pregnancies by clinical examination, increasing of beta-hCG value and transvaginal ultrasonography. One of them had a haemoperitoneum. Surgeons performed all operative laparoscopies, by incision and enucleating of ectopic cornual mass, coagulating of its surrounding vessels and suturing of the uterine incision site. RESULTS Patients were successfully treated only by laparoscopy, post-operative recovery period was normal in all women, with no further therapeutically intervention in the follow-up course. The aftermath was uneventful at the follow-up of 2 years. CONCLUSION In cornual pregnancies, the minimally invasive surgical treatment by salpingotomy or resection of the cornual region of the uterus and the suturing of the incision site, should be the option in women interested in future fertility.

Cyclic sciatica in a patient with deep monolateral endometriosis infiltrating the right sciatic nerve.

Study Design Case report. Objective To show by case presentation, the potential for endometriosis to infiltrate the somatic nerves causing lower extremity neuropathic pain and to discuss possible surgical remedy and the effectiveness of laparoscopic neurolysis. Summary of Background Data Pelvic endometriosis may infiltrate the pelvic wall and somatic nerves causing severe neuropathic symptoms. Methods We report a case of a 41-year-old woman with a history of severe dysmenorrhea, dyspareunia, and chronic pelvic pain with concomitant monolateral right sciatica because of deep infiltrating pelvic endometriosis involving the sciatic nerve and pelvic wall. Results The patient was treated by laparoscopic neurolysis of the involved somatic nerves according to the Possover operation. Conclusions Endometriosis is a chronic inflammatory disease, potentially infiltrating the somatic nerves. Laparoscopic neurolysis is a therapeutic aetiological therapy, which can relieve neurological symptoms deriving from nerve infiltration/compression.

Rare case of giant cystic adenomyoma mimicking a uterine malformation, diagnosed and treated by hysteroscopy

We describe a case of giant cystic uterine adenomyoma that was diagnosed and treated by hysteroscopy. In a 27‐year‐old woman with menometrorrhagia, severe dysmenorrhea, and chronic pelvic pain, pelvic ultrasonography revealed an enlarged uterine cavity filled with homogeneous low echogenic fluid content. A large cornual hematometra of 8.0 cm in diameter in a bicornuate uterus was suspected, and this hypothesis was also supported by magnetic resonance imaging findings. On the contrary, hysteroscopy revealed a bilocular huge cystic lesion of the posterior uterine wall that was removed by means of monopolar loop resection. The operative finding and the histopathologic examination confirmed the diagnosis of cystic adenomyoma of the uterus. Hysteroscopy may represent a valid tool for diagnosis and minimally invasive treatment of cystic adenomyoma, including those of large volume. Its use is helpful in differential diagnosis between cystic adenomyoma and uterine malformations as a possible cause of pelvic pain.

Comment on "Longitudinal transvaginal ultrasound evaluation of cesarean scar niche incidence and depth in the first two years after single- or double-layer uterotomy closure: A randomized controlled trial"

Sir, We read with interest a recent article published by Bamberg et al. (1) that takes up an interesting issue previously published in the same journal by Kataoka et al. (2) on uterine niche after a cesarean section (CS). These two prospective studies assessed the risk of developing a uterine wall defect at the site of cesarean scar with relation to the surgical closure technique. Both studies assessed the residual myometrium thickness and the depth of the niche as it appears immediately after CS (Kataoka et al.) and on long-term outcomes (24 months in Bamberg et al.) using saline contrast sonohysterography and a classical sonographic midsagittal view, respectively. These studies are very well conducted and presented but we would share with you some doubts about the method we currently use to evaluate the characteristics of the niche. In fact, the uterine wall defect is known to be associated to gynecological symptoms such as abnormal uterine bleeding, dysmenorrhea and infertility that sometimes requires surgical correction (3). A few years ago, we conducted a prospective longitudinal study comparing two different methods for uterine closure at CS and the long-term risk (24 months) of uterine wall defect that was assessed by ultrasonography and hysteroscopy (4). Before starting, we carried out a brief pivotal assessment of which sonographic parameter should be used and we realized that the internal defect (niche) is not even at hysteroscopy. In fact, in many cases the depth was not the main cause of clinical symptoms but rather the overall “absent” volume in the internal uterine wall. Statistical analyses demonstrated that a bell-shaped pouch area under the scar could best represent the association between ultrasonography, hysteroscopic assessment, symptoms, and need for surgical correction. In fact, in some cases the defect is shallow but wide, whereas in others it is deep but narrow, as in figure 2 in Bamberg et al. (1). Certainly, CS is one of the most common surgical operations performed worldwide and its rate has dramatically increased in most developed countries, thus becoming a big concern (5). Yet, the question of which closure technique best avoids symptomatic uterine niche remains unanswered, but it seems even more important to find a non-invasive technique to assess the uterine wall defect. The two papers used different sonographic approaches, but we are still wondering if they accurately represent the uterine wall defect. Marco Scioscia, Piergiorgio Iannone* , Danila Morano, Giovanni Pontrelli and Pantaleo Greco Department of Obstetrics and Gynecology, Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy, and Department of Morphology, Surgery and Experimental Medicine, Section of Obstetrics and Gynecology, University of Ferrara, Azienda Ospedaliero-Universitaria S. Anna, Cona, Ferrara, Italy

Prevalence of Infections After In-Office Hysteroscopy in Premenopausal and Postmenopausal Women

STUDY OBJECTIVE To estimate the incidence of infection after diagnostic and operative hysteroscopic procedures performed in an in-office setting with different distension media (saline solution or CO2). DESIGN Prospective, multicenter, observational study (Canadian Task Force classification II-2). SETTING Tertiary womens health centers. PATIENTS A total of 42,934 women who underwent hysteroscopy between 2015 and 2017. INTERVENTIONS Of the 42,934 patients evaluated, 34,248 underwent a diagnostic intervention and 8686 underwent an operative intervention; 17,973 procedures used CO2 and 24,961 used saline solution as a distension medium. Patients were contacted after the procedure to record postprocedure symptoms suggestive of infection, including 2 or more of the following signs occurring within the 3 weeks after hysteroscopy: fever; lower abdominal pain; uterine, adnexal, or cervical motion tenderness; purulent leukorrhea; vaginal discharge or itchiness; and dysuria. Vaginal culture, clinical evaluation, transvaginal ultrasound, and histological evaluation were completed to evaluate symptoms. MEASUREMENTS AND MAIN RESULTS Operative hysteroscopies comprised polypectomies (n = 7125; 82.0%), metroplasty (n = 731; 15.0%), myomectomy (n = 378; 7.8%), and tubal sterilization (n = 194; 4.0%). Twenty-five of the 42,934 patients (0.06%) exhibited symptoms of infection, including 24 patients (96%) with fever, 11 (45.8%) with fever as a single symptom, 7 (29.2%) with fever with pelvic pain, and 10 (41.7%) with fever with dysuria. In 5 patients with fever and pelvic pain, clinical examination and transvaginal ultrasound revealed monolateral or bilateral tubo-ovarian abscess. In these patients, histological examination from surgical specimens revealed the presence of endometriotic lesions. CONCLUSION The present study suggests that routine antibiotic prophylaxis is not necessary before hysteroscopy because the prevalence of infections following in-office hysteroscopy is low (0.06%).