Marco Aurélio Pinho de Oliveira

Risk factors for abdominal scar endometriosis after obstetric hysterotomies: a case–control study

Objective. to identify risk factors that are associated with the development of scar endometriosis after obstetric hysterotomies. The hypothesis is that early hysterotomy in pregnancy (before 22nd week) is the main risk factor for the development of scar endometriosis. Methods. The authors conducted a case–control study between April 2000 and June 2003. A total of 117 women were selected, including 39 cases and 78 controls. Exposure and confounding variables were measured by a standardized questionnaire, which included sociodemographic characteristics, reproductive/physiologic history, past pathological history, history of obstetric surgeries, family history, and social history. The odds ratio (OR) and its 95% confidence interval (CI) were calculated using bivariate analysis for each possible risk factor. These estimates were obtained by multivariate analysis using unconditional logistic regression. Tests were made to assess the fit of the final model. Results. In the multivariate analysis, positive assoc...Objective. to identify risk factors that are associated with the development of scar endometriosis after obstetric hysterotomies. The hypothesis is that early hysterotomy in pregnancy (before 22nd week) is the main risk factor for the development of scar endometriosis. Methods. The authors conducted a case–control study between April 2000 and June 2003. A total of 117 women were selected, including 39 cases and 78 controls. Exposure and confounding variables were measured by a standardized questionnaire, which included sociodemographic characteristics, reproductive/physiologic history, past pathological history, history of obstetric surgeries, family history, and social history. The odds ratio (OR) and its 95% confidence interval (CI) were calculated using bivariate analysis for each possible risk factor. These estimates were obtained by multivariate analysis using unconditional logistic regression. Tests were made to assess the fit of the final model. Results. In the multivariate analysis, positive associations were observed between scar endometriosis and hysterotomy type (early versus late: OR = 42.99; CI 8.77–210.81), amount of the menstrual blood flow (heavy versus light/normal: OR = 11.97; CI 2.35–60.82), and alcoholic consumption (yes versus no: OR = 5.31; CI 1.22–23.11). Negative association was observed between scar endometriosis and parity (OR = 0.61; CI 0.31–1.23), however it was not statistically significant (p>0.05). Conclusions. Early hysterotomy in pregnancy is the main risk factor for scar endometriosis. Increased menstrual flow and alcohol consumption are also risk factors, while high parity may be a protecting factor.

Sexual Function in Patients with Deep Infiltrating Endometriosis

INTRODUCTION Endometriosis is a benign condition that causes pain and infertility. Sexual dysfunction, particularly deep dyspareunia, is common in patients with endometriosis and interferes with quality of life and conjugal satisfaction. AIM The study aims to assess sexual function in women with deep infiltrating endometriosis. METHOD Fifty-seven women diagnosed with deep infiltrating endometriosis were recruited from Hospital Universitário Pedro Ernesto (HUPE) between July and December 2011. The control group comprised 38 healthy women recruited at the HUPE family planning clinic. MAIN OUTCOME MEASURES The main outcomes are full-scale and individual domain scores on the Female Sexual Function Index (FSFI), a validated questionnaire for functional assessment of sexual function in women. RESULTS Patients with endometriosis had more pain in intercourse than controls, which correlates with lower scores in the FSFI pain domain. However, there were no statistically significant between-group differences in overall (full-scale) FSFI scores. CONCLUSION Women with endometriosis exhibit significant dysfunction in the pain domain of the FSFI questionnaire, but this finding was not sufficient to affect the overall sexual function.

Endometriosis of the Round Ligament of the Uterus

STUDY OBJECTIVE To demonstrate the prevalence of endometriosis in the intrapelvic portion of the round ligaments of the uterus (RLUs) and to propose criteria for their excision. DESIGN Retrospective case series analysis of women undergoing laparoscopy for the treatment of deep infiltrating endometriosis (Canadian Task Force classification II-3). SETTING Tertiary referral hospital. PATIENTS We evaluated 174 patients who underwent laparoscopy for the treatment of deep infiltrating endometriosis (DIE) between April 2006 and May 2009. INTERVENTIONS All patients underwent laparoscopy for the treatment of DIE and had their RLUs removed when there was shortening, deviation, or thickening. After removal, the RLUs were sent for histopathologic analysis to verify the presence or absence of endometriosis. MEASUREMENTS AND MAIN RESULTS The prevalence of endometriosis in the RLUs and the association between the macroscopic alterations and the anatomic pathology results were determined. After the identification of macroscopic alterations, 1 or both RLUs (for a total of 42) were removed from 27 of the 174 patients who underwent laparoscopy. The positive predictive value (PPV) of the macroscopic criteria proposed for endometriosis of the RLU was 83.3% (95% confidence interval [CI] = 72.1%-94.5%), with 35 positive RLUs out of the 42 that were excised. The prevalence of endometriosis of the RLU was 13.8% (95% CI = 8.7%-18.9%), with 24 patients having a positive histopathologic examination result for endometriosis. CONCLUSIONS The prevalence of RLU endometriosis in patients with DIE was 13.8%, which emphasizes that a rigorous evaluation of this structure must be part of the routine surgical treatment of patients with endometriosis.

Double Circular Stapler Technique for Bowel Resection in Rectosigmoid Endometriosis

To reduce bladder function impairment and avert the serious complications of anastomotic leakage after segmental rectosigmoidectomy and to minimize the persistence of endometriotic lesions associated with discoid resection, we used the double circular stapling (DCS) technique. This technique enables excision of bowel endometriosis nodules larger than those that can be removed with the single-load technique of the circular stapler. Of 120 patients who underwent surgery to treat bowel endometriosis, intestinal shaving was performed in 24, discoid resection with single circular stapling in 40, and rectosigmoidectomy in 55. Eleven patients (9.2%) underwent the DCS technique. In the DCS group, the size of the rectosigmoid lesion ranged from 2.2 cm to 4.2 cm. Median operative time for the DCS technique was 100 minutes, compared with 150 minutes for rectosigmoidectomy (p = .04). Only 1 of 11 patients (9%) had urinary retention, compared with postoperative urinary retention in 14 of 55 patients (25%) who had undergone rectosigmoidectomy (difference not significant). Only 1 patient, with a 4.2-cm nodule, had a positive margin in the specimen obtained at the second stapling. DCS is a promising technique and may avert rectosigmoidectomy in selected patients.

Diagnostic hysteroscopy using liquid distention medium: comparison of pain with warmed saline solution vs room-temperature saline solution.

STUDY OBJECTIVE To compare pain intensity and degree of satisfaction reported by patients undergoing hysteroscopic examinations using saline solution kept at room temperature (control group) or saline solution heated to 37.5°C (test group). DESIGN Randomized, controlled, prospective study (Canadian Task Force Classification I). PATIENTS Sixty-four women underwent diagnostic hysteroscopy during the second half of 2008. INTERVENTION In both the test and control groups, examinations were performed using the vaginoscopy technique without use of a speculum or Pozzi tenaculum forceps. Pain was assessed using a visual analog scale immediately after the examination and at 1 and 15 minutes after the procedure. MEASUREMENTS AND MAIN RESULTS Immediately after the examination, mean (SD; 95% confidence interval) pain intensity in the warmed saline solution group was 3.84 (2.71; 2.89-4.79), and in the room-temperature saline solution group was 4.31 (3.02; 3.18-5.44) (p = .51). At 1 and 15 minutes after the procedure, pain intensity in the 2 groups was, respectively, 2.41 (2.00; 1.66-3.16) and 2.43 (2.49; 1.57-3.30) (p = .96), and 1.83 (2.30; 1.02-2.64) and 1.85 (2.06; 1.08-2.62) (p = .96). Differences were not significant. Time to complete the examination was 3.80 (1.32; 3.34-4.26) minutes in the test group, and 3.75 (1.10; 3.34-4.15) minutes in the control group (p = .82). The satisfaction rate with the warmed distention medium was 84% (95% confidence interval, 72%-96%), and with the room-temperature saline solution was 85% (73%-97%) with saline at room temperature (p = .48). CONCLUSION There was no statistically significant difference between the 2 groups insofar as pain, duration of the examination, and degree of patient satisfaction.

Genetic analysis of the cause of endometrial osseous metaplasia.

OBJECTIVE: To analyze solitary bone fragments from the uterine cavity through DNA genotyping, thus elucidating whether they originate from metaplasia, from previous abortion, or both. METHODS: We conducted a case series study on 14 patients, of whom eight yielded bone DNA. The patients selected had histopathologic diagnoses of bone fragments inside the uterine cavity or previously removed samples available for analysis. We extracted DNA from blood and bone fragments. To identify the bone tissue origin, these materials were genotyped using polymerase chain reactions for DNA loci. Six mini short tandem repeat loci frequently used for human tissue identification were analyzed using automated sequencing. RESULTS: Among these eight patients, blood and tissue samples from the same individual produced exactly the same pair of alleles for all six loci. This indicated that the DNA profile was completely the same for the bone samples and the mother’s blood (95% confidence interval 63–100%), thus confirming that the DNA had the same origin and that these were cases of metaplasia. CONCLUSION: In all of the eight cases, bone formation was caused by osseous metaplasia, because the DNA in the bone fragment and in the patient’s blood was identical. Although all of the women had histories of previous abortion, no difference in DNA was detected in the bone tissue in any of the cases, as would be expected if abortion had occurred. This result was completely unexpected, differing greatly from what the literature suggests. LEVEL OF EVIDENCE: III

Bowel complications in endometriosis surgery

Endometriosis surgery by laparoscopy or laparotomy can be associated with various types of intestinal complications that may occur in the immediate postoperative period or later. They include bowel anastomotic dehiscence, rectovaginal fistula, anastomotic bleeding, intra-abdominal infections, wound infections, bowel stricture, intestinal obstruction, chronic constipation, and diarrhea. There is growing evidence that bowel injuries can be repaired by primary closure in two layers even without previous bowel preparation. Surgical treatments of deep bowel endometriosis include conservative surgery (including shaving technique or discoid resection) or a more radical approach such as bowel resection that is associated with increased complications. Good perfusion and no tension at the anastomosis site are essential when segmental resection is performed. Early recognition of bowel complications during surgery or in the immediate postoperative period is fundamental to decreased morbidity and mortality. This chapter will deal with the prevention of bowel complication in minimally invasive surgery for endometriosis.

Are Patients with Polycystic Ovarian Syndrome Ideal Candidates for Oocyte Donation

Background. The use of donated oocytes for in vitro fertilization treatment in patients with ovarian failure is universally recognized. But would patients with polycystic ovarian syndrome (PCOS) be a good choice for egg donation programs? Objective. Comparing the pregnancy rates of egg receptors from donor patients diagnosed with PCOS to receptors from donors without PCOS. Design. Retrospective cohort study. Methods. A total of 234 patients who had undergone egg reception program were separated into two groups: Group I, receptors from PCOS donors (n = 36); Group II, receptors from donors without PCOS (n = 198). Medical records were reviewed and the fertilization, implantation, and pregnancy rates were calculated. Results. PCOS patients had an average of 3.23 more oocytes retrieved, but there were no differences in the number of mature oocytes that were used for donation between the groups. We also observed that the number of transferred embryos was also not significantly different, as well as the fertilization and implantation rates. The clinical pregnancy rates were not significantly different: 28% and 26% in Group I and Group II, respectively. Conclusions. Women with PCOS should not be excluded from egg donation programs.

Increased expression of the leptin receptor in human ovaries affected by endometrioma and detection of high levels of leptin in the ovarian endometriomal fluid

BackgroundThis study was designed to investigate leptin levels in the fluid in ovarian endometriomas (OEs) and to compare the expression of leptin and its receptors (OBR) in ovarian tissue affected by endometrioma in infertile women to its expression in the normal ovarian tissue of fertile controls without endometriosis.MethodsIn this case–control observational study, ovarian tissue, blood samples and peritoneal fluid were obtained from 20 women (10 fertile controls without endometriosis or any ovarian disease, who were undergoing tubal ligation surgery, and 10 infertile women with severe endometriosis and OE). The ovarian endometriomal fluid (EF) was aspirated, and peritoneal-implant (PI) biopsies were performed. The tissues removed during the surgeries were immediately frozen in liquid nitrogen to determine expression levels by western blot and leptin levels by ELISA.ResultsOBR was expressed at higher levels in the ovarian tissue affected by endometrioma than in the normal ovarian tissue (control = 0.38 ± 0.05, study = 0.60 ± 0.09, p = 0.03), but there was no significant difference in leptin levels between these groups (control = 0.57 ± 0.1, study = 0.35 ± 0.1, p = 0.18). Positive and significant correlations were observed between leptin and OBR in the OE (r = 0.85, p = 0.004) and in the PI (r = 0.87, p = 0.001). ELISA results demonstrate a greater leptin concentration within the EF compared with the serum and the PF (serum = 14.25 ± 1.63, PF = 5.98 ± 2.0, EF = 73.8 ± 16.2, p = 0.0001), but there was no correlation between these variables. A positive, significant and strong correlation was observed between PF leptin levels and the expression of leptin and OBR in PI (leptin: r = 0.78, p = 0.007/OBR: r = 0.68, p = 0.04) and between the EF leptin levels and the expression of leptin and OBR in the OE (leptin: r = 0.88, p = 0.008/OBR: r = 0.89, p = 0.005).ConclusionsThese data suggest that leptin may play an important role in the physiopathology of OE through a modulatory interaction with its active receptor.

A Simple and Effective Traction Device for Laparoscopic Formation of a Neovagina Using The Vecchietti Technique

We sought to present a simple new traction device that was used with success in 4 cases of laparoscopic creation of a neovagina using a modified Vecchietti technique. Four patients were treated with laparoscopic creation of a neovagina. All women had Rokitansky-Küster-Hauser syndrome and no more than a 1-cm vestibule dimple. A 3-cm diameter and 10-cm long plastic tube (mold) was used for traction. We developed 2 independent wood traction devices. They were based on tuning pegs of a guitar. The 1-cm demarcation in the external face of the mold allowed easy observation of the effects of traction. The patients were hospitalized from 7 to 10 days and the postoperative courses were uneventful. One patient was lost after 3 months of follow-up. After a year, the other 3 patients were having intercourse and were satisfied with the results. The laparoscopic technique has several advantages: it does not need grafts, it does not need a dissection of the space between the bladder and the rectum, it uses the mucous membrane of the vestibular area, the time of hospitalization is relatively short, and it possesses good long-term results.