Mauro Busacca

Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation

OBJECTIVE To assess the efficacy of two laparoscopic methods for the management of endometriomas with regard to pain relief, pregnancy rate, and disease recurrence. DESIGN Prospective, randomized clinical trial. SETTING Tertiary care hospital. PATIENT(S) Sixty-four patients with advanced stages of endometriosis. INTERVENTION(S) Patients were randomly allocated at the time of laparoscopy to undergo either cystectomy of the endometrioma (group 1) or drainage of the endometrioma and bipolar coagulation of the inner lining (group 2). MAIN OUTCOME MEASURE(S) Pain relief and pregnancy rate. RESULT(S) Thirty-two patients were enrolled in each group. The 24-month cumulative recurrence rates of dysmenorrhea, deep dyspareunia, and nonmenstrual pelvic pain were lower in group 1 than in group 2 (dysmenorrhea: 15.8% versus 52.9%; deep dyspareunia: 20% versus 75%; nonmenstrual pelvic pain: 10% versus 52.9%). The median interval between the operation and the recurrence of moderate to severe pelvic pain was longer in group 1 than in group 2 (19 months [range, 13.5-24 months] versus 9.5 months [range, 3-20 months]). The 24-month cumulative pregnancy rate was higher in group 1 than in group 2 (66.7% versus 23.5%). CONCLUSION(S) For the treatment of ovarian endometriomas, a better outcome with a similar rate of complications is achieved with laparoscopic cystectomy than with drainage and coagulation.

Recurrence of ovarian endometrioma after laparoscopic excision

OBJECTIVE Our purpose was to evaluate the recurrence rate after laparoscopic excision of ovarian endometrioma. STUDY DESIGN An unrandomized prospective clinical study was performed at 2 tertiary-care centers of 366 patients who had a minimum of 6 months of postoperative follow-up or 6 months after the suspension of medical therapy after laparoscopic ovarian endometrioma excision. Patients underwent clinical examination and vaginal ultrasonography 3, 6, and 12 months after surgery and subsequently at least once a year. We evaluated the cumulative recurrence rate of pain and clinical findings of ovarian endometrioma, the rate of repeated surgery, and the recovery of fertility. RESULTS During follow-up we observed ultrasonographic recurrence in 26 (7.1%) cases; surgery was repeated in 12 (3.3%) cases. The cumulative rate of ultrasonographic recurrence over 48 months was 11.7%, whereas the cumulative rate of a second surgery was 8.2%. Ultrasonographic cyst recurrence was associated with pain recurrence in 73% of cases, whereas in the remaining 27% the recurrence was asymptomatic. Significant factors related to recurrence of endometriomas would appear to be the stage of disease (P =.03) and previous surgery for endometriosis (P =.003). Eighty-five (23.2%) women conceived during follow-up. CONCLUSIONS Laparoscopic treatment of endometriomas seems to be both effective and reliable. The rate of recurrence appears to be correlated to the duration of follow-up. Stage IV disease and previous surgery for endometriosis are unfavorable prognostic factors.

Postsurgical medical treatment of advanced endometriosis: Results of a randomized clinical trial

OBJECTIVE Our purpose was to investigate the efficacy of postsurgical treatment with nafarelin in women with advanced endometriosis. STUDY DESIGN Eligible for trial were women < or = 38 years old with unexplained infertility with or without chronic pelvic pain and stage III or IV endometriosis according to the American Fertility Society, revised, classification who underwent laparotomy as first surgical treatment for debulking or radical surgery of endometriotic lesions. Patients were assigned according to a randomization list to nasal nafarelin, 400 micrograms/day (36 subjects) or placebo nasal spray (39 subjects) for 3 months. Pelvic pain was assessed before first surgery and at the 12-month follow-up visit in women with pelvic pain by means of a multidimensional score system and a 10-point linear pain scale. RESULTS No marked differences in pain scores emerged among women allocated to different treatments. The mean reduction of the multidimensional score was 3.6 and 4.0, respectively, in women allocated to nafarelin and placebo and of the 10-point linear scale scores was 7.0 and 6.9. These differences were not statistically significant. Within 1 year from randomization, of the 36 women allocated to nafarelin and the 39 allocated to placebo, seven (19%) and seven (18%), respectively, became pregnant. CONCLUSION This study suggests that medical treatment with nafarelin does not markedly improve pelvic pain and short-term reproductive prognosis in women with stages III and IV endometriosis.

Laparoscopic uterosacral ligament resection for dysmenorrhea associated with endometriosis: results of a randomized, controlled trial

OBJECTIVE To evaluate the efficacy of laparoscopic resection of the uterosacral ligaments in women with endometriosis and predominantly midline dysmenorrhea. DESIGN Randomized controlled trial. SETTING Two academic departments. One hundred eighty patients undergoing operative laparoscopy as first-line therapy for stage I to IV symptomatic endometriosis. INTERVENTION(S) Operative laparoscopy including uterosacral ligament resection or conservative surgery alone. MAIN OUTCOME MEASURE(S) Proportion of women with recurrence of moderate or severe dysmenorrhea 1 year after surgery. RESULT(S) No complications occurred. Among the patients who were evaluable 1 year after operative laparoscopy, 23 of 78 (29%) women who had uterosacral ligament resection and 21 of 78 (27%) women who had conservative surgery only reported recurrent dysmenorrhea. The corresponding numbers of patients at 3 years were 21 of 59 (36%) women and 18 of 57 (32%) women, respectively. Time to recurrence was similar in the two groups. Pain was substantially reduced, and patients in both groups experienced similar and significant improvements in health-related quality of life, psychiatric profile, and sexual satisfaction. Overall, 68 of 90 (75%) patients in the uterosacral ligament resection group and 67 of 90 (74%) patients in the conservative surgery group were satisfied at 1 year. CONCLUSION(S) Addition of uterosacral ligament resection to conservative laparoscopic surgery for endometriosis did not reduce the medium- or long-term frequency and severity of recurrence of dysmenorrhea.

Endometriosis: novel etiopathogenetic concepts and clinical perspectives

OBJECTIVE To discuss current ideas about therapy for endometriosis derived from new observations generated by using molecular biology techniques and in vivo animal models of disease. METHOD(S) The MEDLINE database was reviewed for English-language articles on new drugs that affect the endocrine or immunologic system, the possibility that endometriosis has multiple forms, and the association of endometriosis with cancer. Specific attention was given to in vivo studies in animals or humans. CONCLUSION(S) Among the novel potential candidate drugs, aromatase inhibitors and raloxifene should be considered for treatment of postmenopausal women with endometriosis. Notable observations have emerged from studies of immunomodulators and antiinflammatory agents in animal models of disease. These findings must be confirmed in women. The histogenesis of ovarian endometriomas is still unclear, thus limiting new experimental approaches to this form of disease. Given the low but established risk for malignant transformation of endometriosis, efforts should be directed toward identification of susceptibility loci for the disease and its potential transformation into cancer.

Laparoscopic creation of a neovagina in Mayer-Rokitansky-Küster-Hauser syndrome by modification of Vecchietti's operation

A neovagina was created by a laparoscopic modification of Vecchiettis operation in two women with Mayer-Rokitansky-Küster-Hauser syndrome. A plastic olive was applied to the vaginal dimple and pulled upward by two threads passed through the potential neovaginal space at laparoscopy, without the need for laparotomy or dissection of the vesicorectal space. In both cases we obtained very good results in anatomic and sexual functional terms.

Endometrioma Excision and Ovarian Reserve: A Dangerous Relation

Endometrioma is one of the most frequent pathologies in gynecologic surgery. Laparoscopic cyst excision is considered the best treatment in terms of lower recurrence and improved fertility. However, it was recently questioned whether the excision of the endometrioma could decrease the function of the operated ovary and if it could affect the subsequent fertility. Even if a consistent amount of ovarian tissue is unintentionally removed together with the capsule of the cyst, resulting in does not show the follicular pattern observed in working ovaries. Currently, no definitive data clarify whether the damage to the ovarian reserve, observed in patient with endometrioma, is related to the surgical procedure, to the previous presence of the cyst, or both. Electrosurgial coagulation during hemostasis could play an important role in terms of damage to ovarian stroma and vascularization. Particular attention must be paid in presence of bilateral endometriotic cysts. In fact, an increase in premature ovarian failure rate was reported when both the ovaries are involved in surgery. Incase of assisted reproductive techniques, no clear evidence indicates which is the best approach for concomitant endometriotic cyst. On the base of these considerations endometriomas Should be treated only in case of pain, infertility, and in asymptomatic patients if the cyst diameter is greater than 4 cm.

Ovarian endometriosis: from pathogenesis to surgical treatment.

Purpose of review This review analyzes the literature on ovarian endometrioma, examining the controversies on pathogenesis, malignant transformation and surgical therapy. Recent findings Recent literature reflects the necessity of clearly defining the ethiologic and pathologic factors that determine the origin of ovarian endometriosis and explain the increase in the condition with the prospect of developing effective prevention therapy. The possibility that ovarian endometriomas undergo malignant transformation is widely reported in the literature. Recent studies underline the importance of detecting histological differences in endometriosis (hyperplasia and atypia) and several studies of molecular biology support the theory of genetic alterations interfering with malignant transformation of ovarian endometriosis. Summary The surgical approach must take into account all this information and, when the therapy is conservative, complete excision of the disease must be laparoscopically performed without affecting the healthy ovarian tissue.

Bowel Perforation During Insertion of Tension-free Vaginal Tape (TVT)

Abstract: A 56-year-old non-obese woman with a previous history of pelvic surgery underwent an uneventful TVT procedure for the treatment of genuine stress incontinence. Postoperatively she began to report an acute low abdominal pain and a secondary laparoscopy was performed. The view of the right iliac region showed the tape passing through a loop of the small intestine. The tape was cut in its intraperitoneal portion and the ileum freed and repaired. After the operation the patient recovered well and was discharged on the fifth day after laparoscopy. Despite the section of the tape, 1 year later the patient is objectively cured by the procedure.

Expression of intercellular adhesion molecule-1 (ICAM-1) on cultured human endometrial stromal cells and its role in the interaction with natural killers

PROBLEM: Recent evidence emphasizes the role of natural killer cells (NKs) as potential effectors of peritoneal immune surveillance directed against the outgrowth of endometrial cells, refluxed with menstrual debris, in ectopic sites. This NK‐mediated cytotoxicity toward autologous endometrial antigens seems to be significantly decreased in endometriosis patients.