Ludovico Muzii

Correlation between the American Fertility Society * classifications of adnexal adhesions and distal tubal occlusion, salpingoscopy, and reproductive outcome in tubal surgery

OBJECTIVE To compare the prognostic value of salpingoscopy with a current classification system of adnexal adhesions and distal tubal occlusion in patients with tubal infertility undergoing reconstructive tubal surgery. DESIGN Prospective clinical study. SETTING Department of Obstetrics and Gynecology of the Catholic University, a tertiary care University Center in Rome, Italy. PATIENTS Fifty-five infertile patients with either adnexal adhesions (29 patients) or hydrosalpinx (26 patients) undergoing reconstructive tubal surgery. INTERVENTIONS Salpingoscopy performed concomitantly to salpingo-ovariolysis or salpingoneostomy at the time of either operative laparoscopy or laparotomy using microsurgical techniques. MAIN OUTCOME MEASURES Salpingoscopic findings were compared with a current classification system of adnexal adhesions and distal tubal occlusion. The patients were followed for a mean follow-up of 49 months; the pregnancy rates achieved were correlated with the salpingoscopic findings and the classification system used. RESULTS There was a significant correlation between the salpingoscopic grade and the occurrence of a term pregnancy for both the salpingo-ovariolysis and salpingoneostomy groups of patients. There was no significant correlation between the classification system used and the occurrence of a term pregnancy for both groups of patients. CONCLUSION Salpingoscopy plays an important role in selecting the patients who may benefit the most from reconstructive tubal surgery.

The impact of preoperative gonadotropin-releasing hormone agonist treatment on laparoscopic excision of ovarian endometriotic cysts

OBJECTIVE To compare surgical performance and recurrence rates in patients submitted to laparoscopy for endometrioma excision following GnRH agonist (GnRH-a) treatment versus no preoperative medical treatment. DESIGN Controlled clinical study. SETTING A tertiary care university hospital. PATIENTS Twenty patients with unilateral endometriomas underwent operative laparoscopy after 3-month GnRH-a treatment, whereas 21 patients underwent laparoscopic excision of endometriomas without preoperative medical treatment. INTERVENTIONS Operative laparoscopy was performed with the stripping technique using a four-puncture approach. MAIN OUTCOME MEASURE A blinded videotape review was undertaken to evaluate the duration and complexity of the different phases of surgery. Recurrence rates were evaluated at 1-year follow-up ultrasonography. RESULTS No significant difference was found between the two groups in total operative time, cyst excision time, time needed for cyst capsule stripping and coagulation of ovarian parenchyma, and the complexity of the latter phases; recurrence rates also were comparable. CONCLUSION Preoperative GnRH-a treatment for endometriomas does not seem to offer any advantage in terms of subsequent surgical performance.

Laparoscopy versus microsurgery by laparotomy for excision of ovarian cysts in patients with moderate or severe endometriosis

STUDY OBJECTIVE To compare the efficacy of laparoscopy versus microsurgery by laparotomy in the treatment of ovarian endometriomas. DESIGN Retrospective study with historical controls. SETTING A tertiary university hospital. PATIENTS One hundred thirty-two women under 40 years of age with ovarian endometriotic cysts at least 3 cm in diameter (stage III and IV endometriosis, R-AFS classification). Interventions. A single surgeon (RM) treated 83 patients by laparoscopy for excision of ovarian endometriomas by the stripping technique and 49 by microsurgery at laparotomy. MEASUREMENTS AND MAIN RESULTS Data regarding recurrence of ovarian cysts, symptomatic improvement, and reproductive outcome were comparable for the two groups. Postoperative febrile morbidity and length of hospitalization were significantly less for the laparoscopy group than for the laparotomy group (p <0.0005). CONCLUSIONS Operative laparoscopy for excision of ovarian endometrial cysts by the stripping technique is as effective as microsurgery by laparotomy. It is associated with less febrile morbidity and a shorter hospitalization.

Evaluation of stress-related hormones after surgery by laparoscopy or laparotomy

STUDY OBJECTIVE To evaluate the stress hormone response after pelvic surgery performed by laparoscopy versus laparotomy. DESIGN Prospective study. SETTING A tertiary care university hospital. PATIENTS Ten women were scheduled to undergo laparoscopic surgery and 10 laparotomy for either tubal disease or endometriosis. INTERVENTIONS Surgical procedures were performed by laparoscopy or laparotomy for stage III-IV endometriosis, pelvic adhesions, or distal tubal occlusion. The following hormones were measured before the induction of anesthesia in the ward, 60 minutes after the beginning of surgery, at the end of surgery after extubation, and 2 hours and 6 hours after the end of the operation: norepinephrine (NE), epinephrine (E), dopamine (D), adrenocorticotropic hormone (ACTH), cortisol, prolactin (PRL), and GH. MEASUREMENTS AND MAIN RESULTS The mean duration of surgery was not significantly different between the two groups. Surgery-related adrenergic activation (E, NE, D) appears more pronounced in the laparotomy group (p<0.005) during surgery and in the postoperative period. More elevated values for laparotomy were observed also for the other stress hormones (ACTH, cortisol, PRL, GH), even though statistical significance was not always reached. CONCLUSIONS Compared with laparotomy, activation of stress-related factors during laparoscopy seems to be less intense and of shorter duration.

Laparoscopy versus laparotomy for ovarian conservative surgery: A randomized trial in the rabbit model

OBJECTIVE Our purpose was to compare postoperative adhesion formation and reproductive outcome after the same ovarian surgical procedure performed by laparoscopy or laparotomy by means of microsurgical techniques. STUDY DESIGN Twenty-eight New Zealand White female rabbits were randomly assigned to laparotomy or laparoscopy for the same standardized surgical procedure: both ovaries were grasped with atraumatic forceps and longitudinally incised on the antimesenteric side from the cortex to the hilum with a microelectrode delivering a tissue power density of 66,666 W/cm. The rabbits were then mated, and 2 weeks later a second-look laparotomy was performed by a blinded observer for the evaluation of postoperative adhesions, number of corpora lutea in each ovary, number of embryos in the ipsilateral uterine horn, and nidation index for each side. RESULTS At second look no statistically significant differences were found in postoperative adhesion formation, number of corpora lutea, number of embryos, and nidation index between the laparoscopy and the laparotomy groups. CONCLUSION Laparoscopy or laparotomy for ovarian conservative surgery do not appear significantly different in postoperative adhesion formation and reproductive outcome in the rabbit model.

Prognostic role of laparoscopic salpingoscopy of the only remaining tube after contralateral ectopic pregnancy

OBJECTIVE To evaluate the prognostic value of laparoscopic salpingoscopy in detecting patients who are at increased risk for a repeat ectopic pregnancy (EP). DESIGN Patients with secondary infertility after a previous contralateral salpingectomy for EP were evaluated by laparoscopy with tubal perfusion and salpingoscopy of the only remaining tube. Subsequent reproductive outcome was evaluated and correlated to laparoscopic and salpingoscopic findings. SETTING Department of Obstetrics and Gynecology of the Catholic University, a tertiary care university center in Rome, Italy. PATIENTS Eighteen patients submitted to laparoscopy and salpingoscopy after a previous salpingectomy for EP. INTERVENTION A two- to three-puncture laparoscopy with tubal perfusion and salpingoscopy. MAIN OUTCOME MEASURE Reproductive outcome after a mean follow-up of 42.6 months. RESULTS Salpingoscopy revealed a normal tubal mucosa in 13 patients (72%) and intra-ampullary adhesions in 5 patients (28%). Eight of the 13 patients with a normal mucosa conceived an intrauterine pregnancy. In the 5 patients with intra-ampullary adhesions, there were 3 repeat EPs, with one patient having first a term pregnancy and then a repeat EP. The presence of peritubal adhesions at laparoscopy was not of prognostic significance. CONCLUSION Direct visualization of the ampullary mucosa by salpingoscopy can allow the detection of intraluminal adhesions that put the patient at increased risk for a repeat EP.

Salpingoscopy in patients with contralateral ectopic pregnancy

Patients who experience a tubal pregnancy have a poor prognosis in terms of reproductive potential and are at increased risk of a repeat EP. Salpingoscopy is a new endoscopic technique that allows the detection of abnormalities of the tubal mucosa. In seven patients with a follow-up longer than 6 months, an IUP occurred only in patients with a normal ampullary mucosa, whereas a recurrent tubal pregnancy occurred in the patient that conceived with an abnormal tubal mucosa. These preliminary results suggest that salpingoscopy may constitute an important prognostic factor in these patients.

Use of Fibrin Sealant for Reproductive Surgery: A Randomized Study in the Rabbit Model

The present study was undertaken to compare adhesion formation and reproductive outcome after reproductive surgery with or without the application of fibrin sealant. At laparotomy, the ovaries and uterine horns of 20 rabbits were longitudinally incised on the antimesenteric side using a monopolar microneedle. At random, one ovary and the ipsilateral uterine horn were covered with fibrin sealant, while those on the contralateral side were left uncovered without application of sutures. The rabbits were then mated, and 2 weeks later a second-look laparotomy was performed by a blinded observer. No statistically significant differences were found in postoperative adhesions, number of corpora lutea in each ovary, number of embryos in the ipsilateral uterine horn, and nidation index for each side. Fibrin sealant for conservative surgery does not appear to significantly affect either postoperative adhesion formation or reproductive outcome.

The prognostic significance of minimal intracystic vegetations during operative laparoscopy for adnexal masses in women of reproductive age.

STUDY OBJECTIVE To evaluate the prognostic significance of minimal intracystic vegetations in ovarian cysts approached by laparoscopy. DESIGN Prospective study. SETTING A tertiary care university hospital. PATIENTS Ten of 208 women with adnexal cysts and minimal intracystic vegetations, under 40 years of age, carefully selected for operative laparoscopy on the basis of a preoperative sonogram suggestive of a unilocular cyst, with no thick septa or solid components in the absence of ascites. INTERVENTIONS Adnexal cyst excision at operative laparoscopy. MEASUREMENTS AND MAIN RESULTS In all 208 women evaluation of the abdomen, pelvis, and external surface of the cyst was negative. In 10 patients minimal intracystic vegetations, not detected by preoperative sonography, were identified during endocystic evaluation. In all these cases frozen section examination was negative. Definitive histologic diagnosis confirmed the presence of benign cysts. CONCLUSION The presence of minimal intracystic vegetations alone when diagnosed in highly selected patients under 40 years of age may not justify immediate midline laparotomy if frozen section is negative.

Correlation between AFS classification systems of adnexal adhesions and distal tubal occlusion, tubal mucosa at salpingoscopy and reproductive outcome of the patient

From November 1988 to December 1991, 45 infertile patients underwent salpingo-ovariolysis and/or salpingoneostomy during laparotomy or laparoscopy. Findings at surgery were scored according to the AFS classification. Salpingoscopy was performed to evaluate the status of the ampullary mucosa. The mean age of the patients was 29.5 years and the mean length of infertility prior to surgery was 4.4 years. All patients were contacted by phone to obtain information on reproductive outcome with a minimum period of 18 months of follow-up. Statistical analysis of data was performed using the Fishers exact test. AFS scores were not correlated with reproductive outcome, while the status of the tubal mucosa at salpingoscopy was significantly correlated with reproductive outcome.