Paul Caruana

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.

Laparoscopic Excision of Adnexal Masses

STUDY OBJECTIVE The purpose of the present study was to evaluate a prospective series of consecutive patients with adnexal masses selected with strict preoperative clinical and ultrasonographic criteria. DESIGN Prospective series of consecutive patients (Canadian Task Force classification II-2). SETTING Tertiary care university hospitals. PATIENTS Six hundred and eighty-three consecutive patients under 40 years of age with ultrasonographic evidence of an adnexal cystic mass without thick septa, internal wall papillation, or solid components, except for sonographic pattern suggestive of dermoid. INTERVENTIONS Operative laparoscopy and follow-up. MEASUREMENTS AND MAIN RESULTS After initial diagnostic laparoscopy in 13 patients with stage 4 endometriosis and extensive bowel adhesions, in 2 patients with large-volume dermoids, and in 1 patient with suspect ovarian and peritoneal implants, the procedure was converted to laparotomy. Therefore, 667 patients were completely managed by laparoscopy. There were 1069 cysts excised. Histologic diagnosis was endometrioma in 57% of the excised cysts, serous cyst in 13%, dermoid in 12%, paratubal in 8%, mucinous cysts in 5.3%, functional cyst in 2.8%, other benign histotypes in 1.1%, and ovarian malignancies (seven borderline tumors and one endometrioma with a microfocus of G1 endometrioid carcinoma) in 0.7% of the cysts and 1.2% of the patients. These last patients are alive with no evidence of disease after a mean follow-up of 62 months. CONCLUSIONS In the present series, with accurate preoperative and intraoperative selection, the rate of unexpected borderline or focally invasive malignancies was 1.2% of the patients, and the laparoscopic management of these adnexal masses did not adversely impact on prognosis.

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.

Laparoscopically Assisted Vaginal Hysterectomy as an Alternative to Abdominal Hysterectomy

Laparoscopically assisted vaginal hysterectomy (LAVH) allows for conversion of some abdominal hysterectomies to a vaginal route. LAVH may be particularly useful when adnexectomy is indicated. In this study the authors evaluate the results obtained in a series of 21 patients prospectively selected for LAVH. The mean operative time was 96 min (range 58-155), with an estimated blood loss of 218 ml (range 50-510). The mean uterine weight was 320 g (range 105-610). Intraoperative complications were limited to one case of bladder injury which occurred during the vaginal phase of the procedure. No patient required heterologous blood transfusion. No postoperative complications were observed. The average length of hospitalisation was 4.4 days (range 2-9). The authors conclude that LAVH allows for conversion of a significant number of abdominal hysterectomies to a vaginal route and that with respect to the former it is definitely less costly since it allows for earlier hospital discharge and resumal of a normal lifestyle.

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.

False Diagnosis of Distal Tubal Occlusion in Case of Tubal Diverticula

A 28-year-old infertile patient with a diagnosis of bilateral distal tubal occlusion made at hysterosalpingography and laparoscopy was found at a second laparoscopy to have bilateral single diverticula in patient tubes. The patient conceived an intrauterine pregnancy 5 months after discharge. This report casts doubt on the suggested association between tubal diverticula and infertility.

Endometriosis-associated dysmenorrhea is not related to typical or atypical peritoneal implants

From April 1, 1995, to December 31, 1995, 45 patients undergoing diagnostic or operative laparoscopy for infertility, pelvic pain, or both, were found to have endometriosis. No woman had undergone any preoperative medical or surgical treatment for the disease. Preoperatively they answered a questionnaire, including a visual analog scale (VAS) to evaluate their associated symptoms. All visible signs of endometriosis were evaluated at laparoscopy by a single observer and recorded. Endometriosis was classified as cysts, adhesions, typical implants (black-blue powder burn implants), and atypical implants (clear papules, red polyps, flamelike lesions, red-brown vesicles, white opacification, peritoneal defects). The revised American Fertility Society (AFS) score was also used to stage the disease. The VAS scale for dysmenorrhea correlated significantly with the AFS total score (Pearsons r = 0.510, p <0.001), the cyst subscore (r = 0.490, p <0.001), and the adhesion subscore (r = 0.381, p <0.01). There was no correlation between the VAS scale for dysmenorrhea and the AFS implant subscore (r = 0.019), or with the total number of endometriosis implants (r = 0.160), the number of typical implants (r = 0.025), or the number of atypical implants (r = 0.161). The AFS score for endometriosis, devised primarily to formulate a prognosis in infertile women, seems to be correlated also with endometriosis-associated dysmenorrhea. Although atypical implants produce higher amounts of prostaglandin F2alpha compared with typical implants, the present study does not support the suggested association between them and the severity of dysmenorrhea.