Herbert Diebolder

Laparoscopically assisted vaginal resection of rectovaginal endometriosis

Background We wanted to establish a technique of laparoscopically assisted radical vaginal surgery for deep endometriosis of the rectovaginal septum with extensive rectal involvement. Technique The procedure is started by vaginally excising the involved area which is left on the rectum, followed by bilateral dissection of the pararectal and retrorectal spaces. Para- and retrosigmoido-rectal spaces are developed laparoscopically along the coccygeosacral bone and medially to the pelvic splanchnic nerves toward the para- and retrorectal openings that were made transvaginally. Rectal transection is done with a laparoscopic stapling device caudal to the endometriotic lesion. Using a suprapubic minilaparotomy, the bowel is transected cranial to the lesion and reintroduced into the abdomen, and a transanal circular stapler anastomosis is done. Experience Thirty-four women had this procedure. The mean distance of the anastomosis was 4 cm above the anus. None required ileostomy or colostomy and no major complications were noted. Conclusion The combination of laparoscopic and vaginal approaches is useful for removing extensive endometriotic infiltration of the rectosigmoid; bladder and rectal function and fertility can be preserved.

Hypermethylated DAPK in serum DNA of women with uterine leiomyoma is a biomarker not restricted to cancer

OBJECTIVE Ovarian cancer is most frequently diagnosed at a late stage with a poor prognosis. No markers for early diagnosis have been established. Aberrantly methylated DNA appears as a promising molecular cancer marker. The aim of this study was to analyze the methylation status of the proapoptotic cancer related gene death-associated protein kinase (DAPK) in ovarian cancer patients, healthy controls and in patients suffering from a benign proliferative disease such as uterine leiomyoma. METHODS Methylation-specific PCR (MSP) was used to detect DAPK methylation in primary tumor tissue and serum of both ovarian cancer (n=32) and uterine leiomyoma patients (n=17 primary tissue, n=30 serum). Serum samples from healthy women served as controls (n=20). MSP results were confirmed by restriction digest and sequencing analyses of cloned PCR products. RESULTS DAPK methylation was detected in 50% and 35.3% of primary tissue and 56% and 23.8% of serum samples from ovarian cancer and leiomyoma patients, respectively. However, the association of methylation frequencies in tissue and serum was low (kappa=-0.053). Sequencing experiments revealed fully methylated MSP products in sera of both ovarian cancer and leiomyoma patients. In contrast sera from control patients showed only partially methylated DAPK sequences. CONCLUSION DAPK hypermethylation was neither specific for the tissue of origin nor for cancer. The high prevalence of leiomyoma compromises the utility of this gene as a serum marker for early ovarian cancer detection. These data emphasize the necessity to co-analyze controls presenting with non-cancer proliferative disease in the quest for molecular cancer markers.

Combination of pre-emptive port-site and intraoperative intraperitoneal ropivacaine for reduction of postoperative pain: a prospective cohort study.

OBJECTIVE To evaluate the effectiveness of intraoperatively applied local ropivacaine added to standard analgesic therapy in reducing postoperative pain intensity and opioid requirement under routine hospital conditions. STUDY DESIGN In this prospective controlled cohort study, 303 consecutive patients receiving a gynaecological laparoscopic intervention at the Jena University Hospital were included. The study cohort (n=168) received, in addition to standard pain management, a port-site (PS) infiltration with ropivacaine prior to incision and intraperitoneal (IP) instillation at the end of surgery. On the first postoperative day patients answered a validated questionnaire, and requirement of rescue analgesics was assessed. RESULTS Pain intensity was assessed on an 11-point numeric rating scale (NRS) from 0=no pain to 10=most severe pain. Reported pain intensity for movement-related pain was significantly lower (p=.001) in the study group compared with the control group (4.4 (SD 2.4) vs. 5.3 (SD 2.2) respectively). Minimal pain intensity after operation was also significantly lower in the study cohort (2.6 (SD 1.7) vs. 2.1 (SD 1.8), (p=.007)). Significantly fewer patients required rescue opioids for analgesia in the ropivacaine cohort (p=.001). The requested dose of rescue opioid (piritramide) in this cohort was also lower (p=.035) with 6.5mg (SD 4.9) vs. 8.7mg (SD 6.6), and demanded later (p=.001) with 4.3h after surgery vs. 3.1h. Patients in the study cohort experienced less nausea (p=.046). Higher satisfaction scores with pain management were reported in the ropivacaine group 12.7 (SD 2.5) vs. 11.6 (SD 2.8) (p<.001) (16-point NRS with 0=not at all, 15=completely satisfied). CONCLUSION Addition of pre-emptive port-site plus intraperitoneal ropivacaine to standard postoperative analgesic therapy reduced postoperative pain intensity and opioid consumption in gynaecological laparoscopy.

Laparoscopic myomectomy in peri- and post-menopausal women is safe, efficacious and associated with long-term patient satisfaction

OBJECTIVE Women in the peri- and post-menopause may ask for uterus-preserving therapy options when presenting with benign uterine disorders such as symptomatic fibroids. Laparoscopic myomectomy (LM) for patients in the peri- and post-menopause as a surgical alternative to hysterectomy is widely considered to be non-standard treatment. The aim of this study was to analyze safety and outcome of LM beyond the reproductive period. STUDY DESIGN We evaluated the surgical outcome and patient satisfaction for a total of 451 patients: 85 peri- or post-menopausal women as group A and, for reference, 366 premenopausal women in group B, who received LM from 1998 to 2008 in our department. We analyzed data from our medical records and applied a patient questionnaire in September 2009. RESULTS The average number of fibroids removed and size of the leading fibroid were similar in both groups. Time of surgery was different in group A, at 102.8 min, compared to group B, 128.6 min (p<0.01). Rates of intra- (2.21% overall) and post-operative complications (6.22% overall) were comparable for both groups. Post-surgical hospitalization was shorter in group B (4.4 days) compared to group A (5.0 days) (p<0.01). Evaluation of the questionnaire showed high satisfaction with the results of LM in both subgroups with a significantly lower number of relapses in group A (3.5%) compared to group B (11.2%). CONCLUSION Laparoscopic myomectomy as a surgical treatment option in the peri- and post-menopause was characterized by a low rate of complications and relapses as well as a high degree of patient satisfaction in our analysis.

Coagulation versus excision of primary superficial endometriosis: a 2-year follow-up

OBJECTIVE Even the common mild forms of endometriosis can strongly affect quality of life due to dysmenorrhea, dyspareunia, dyschezia, or subfertility. We compared the effectiveness of the two laparoscopic methods, coagulation versus excision, for intraperitoneal superficial endometriosis with regard to recurrence and symptom control. STUDY DESIGN In a retrospective analysis we evaluated the postoperative follow-up of 79 patients, aged 16-42, with superficial manifestation of endometriosis (median rASRM score 9.2) operated on in the Department of Gynecology and Obstetrics at the Jena University Hospital. Forty-three patients were treated by electrocoagulation and 36 underwent sharp excision. Therapy success was evaluated by using a questionnaire after a mean follow-up of 29 months. Patients were interviewed about pain associated with endometriosis such as dysmenorrhea, dyspareunia, dyschezia and possible medical treatment after surgery. We evaluated the number of surgically proven relapses and questionnaire results using a pain score on an ordinal scale (1-5) for the three categories dysmenorrhea, dyspareunia, and dyschezia. RESULTS Both treatment methods resulted in a low number of endometriosis-related symptoms after surgical intervention and in recurrences of 2.8% in the coagulation group and 18.6% in the excision group. The recurrence rate in the coagulation group was lower (p=0.001). The coagulation group was also presented with a significantly lower postoperative pain score at our long-term follow-up (p=0.0067). CONCLUSION In cases of superficial endometriosis, laparoscopic surgery achieved low recurrence rates and good symptom control. Compared to sharp excision the use of bipolar electrocoagulation might result in fewer endometriosis-related symptoms as well as fewer relapses with need for surgical re-intervention after a more than 2-year interval. Due to the retrospective, non-randomized character of this study the results should be interpreted carefully. Further prospective studies are needed to assess the value of both surgical approaches in the treatment of endometriosis.