Sebastiano Campo

Reproductive outcome before and after laparoscopic or abdominal myomectomy for subserous or intramural myomas

OBJECTIVES To analyze the reproductive outcome before and after myomectomy in patients with subserous or intramural myomas, and to assess the factors influencing pregnancy rate after myomectomy. STUDY DESIGN Out of 128 patients submitted to myomectomy, we considered eligible for this study only the 41 patients wishing to conceive after surgery and who did not present any plausible infertility factor, apart from the removed myomas. We have evaluated the pregnancy outcome prior to and following myomectomy, and analyzed the correlation between conception rate after surgery and patients age at the time of the surgery, type of surgery, number and size of the myomas, location of the largest fibroid and previous pregnancies. RESULTS Nineteen patients had been submitted to abdominal (group A) and 22 to laparoscopic myomectomy (group B). Prior to surgery, 28 pregnancies had occurred in 14 of the 41 patients, with a miscarriage rate of 57.1%. Following surgery 29 pregnancies occurred in 25 patients (60.9%), pregnancy rate being similar in both groups. The postoperative delivery rate was 86.2% whereas the miscarriage rate was reduced to 13.8% (P<0.001). Overall, 60% of deliveries were vaginal. No cases of ectopic pregnancy or uterine rupture occurred. Those patients who conceived after surgery were significantly younger (32.36+/-4.06 years versus 35.88+/-3.57 years; P=0.0073), and their removed myomas were significantly larger (5.80+/-2.69 cm versus 4.28+/-1.54 cm; P=0.0274). Furthermore, a multivariate analysis shows that, apart from age and diameter, the probability of conceiving after myomectomy is higher in case of intramural myomas (intramural versus subserosal: OR 12.382, 95% CI: 1.61-95.22) or laparoscopic surgery (laparoscopy versus laparotomy: OR 14.062, 95% CI: 1.40-141.15). CONCLUSIONS Our results suggest that myomectomy significantly improves pregnancy outcome in patients with subserous or intramural fibroids, probably removing a plausible cause of altered uterine contractility or blood supply. The main determinants of pregnancy rate after surgery are patient age, diameter and intramural localization of the myomas and type of surgery.

Short-term and long-term results of resectoscopic myomectomy with and without pretreatment with GnRH analogs in premenopausal women.

Objective.  The aim of this study was to analyze the safety and efficacy of resectoscopic myomectomy and to evaluate the influence of GnRH analog pretreatment on short‐ and long‐term surgery outcome.

Laparoscopic convervative excision of ovarian dermoid cysts with and without an endobag

STUDY OBJECTIVE To compare outcomes of conservative laparoscopic treatment of dermoid cysts removed from the abdominal cavity without (group A) and with an endobag (group B). DESIGN Prospective, randomized, 4-year (June 1992-June 1996) study (Canadian Task Force classification I). SETTING Department of Obstetrics and Gynecology of the Catholic University of the Sacred Heart in Rome. PATIENTS Fifty-five premenopausal women with dermoid cysts. Intervention. Patients were randomly assigned to removal of dermoid cysts from the abdominal cavity with or without an endobag through a 10- to 12-mm cannula sleeve. MEASUREMENTS AND MAIN RESULTS We assessed surgical time, spillage, complications, length of hospitalization, recurrences, and pregnancies. In the 55 women, 58 dermoid cysts (mean diameter 5.6 +/- 2.03 cm) were enucleated and removed at operative laparoscopy through a 10- to 12-mm cannula sleeve without intraoperative or postoperative complications. Mean operating time was 73 minutes. When cysts were removed with an endobag, operating time was significantly reduced over removal without the endobag (63 vs 81 min, p <0.05). Obvious spillage of endocystic contents occurred in 13 (43.3%) patients in group A but in only 1 patient in group B because the bag ruptured (p <0.05). No signs or symptoms of peritonitis were observed in women with evident cystic spillage or in those in group A in whom spillage was possible. Average postoperative hospital stay was 1.7 days and did not differ between groups. Among 20 infertile women, 9 (45%) experienced spontaneous pregnancy within a year, with no differences between groups. Echographic follow-up did not reveal cyst recurrence. CONCLUSIONS Laparoscopic conservative cystectomy of dermoid cysts in premenopausal women is safe and effective and appears to be a valuable alternative to laparotomy. Removing cysts in an endobag significantly reduced both operating time and spillage. However, controlled intraperitoneal spillage of cyst contents does not increase postoperative morbidity as long as the peritoneal cavity is thoroughly washed.

Infertility and adenomyosis.

Classically, the diagnosis of adenomyosis has only been possible on a hysterectomy specimen, usually in women in their late fourth and fifth decades, and, therefore, evaluating any relationship with infertility was simply not possible. As a consequence, to this day, no epidemiologic data exists linking adenomyosis to a state of subfertility. Today, new imaging techniques have enabled a noninvasive diagnosis at a much earlier time and a number of single-case or small series reports have appeared showing that medical, surgical, or combined treatment can restore fertility in women with adenomyosis, an indirect proof of an association. At the functional level, several anomalies found in the so-called junctional zone, or inner myometrium, in adenomyosis patients have been shown to be associated with poor reproductive performance, mainly through perturbed uterine peristalsis. Additional evidence for an association comes from experimental data: in baboons, adenomyosis is associated with lifelong primary infertility, as well as to endometriosis. Finally, indirect proof comes from studies of the eutopic and ectopic endometrium in women with adenomyosis proving the existence of an altered endometrial function and receptivity. In conclusion, sufficient indirect proof exists linking adenomyosis to infertility to warrant systematic clinical studies.

Paracrine regulation of endometriotic tissue

Endometriosis is a chronic estrogen-dependent gynecological disease, characterized by pelvic pain and infertility, defined as the presence of endometrial glands and stroma within the pelvic peritoneum and other extrauterine sites. In the peritoneal cavity endometrial cells adhere, proliferate and induce an inflammatory response. Despite a long history of clinical and experimental research, the pathogenesis of endometriosis is still controversial. Abnormal immunological activation, the endocrine milieu and the peritoneal environment all dramatically affect endometriotic tissue function. Recent studies suggest that the peritoneal fluid of women with endometriosis contains an increased number of activated macrophages and other immune cells that secrete various local products, such as growth factors and cytokines, which exert a paracrine action on endometriotic cells. Since the peculiar biological characteristics of eutopic endometrium from women with endometriosis differ from endometrium of normal subjects, an important role in the pathogenesis of this complex disease has been suggested. All of these factors contribute to enhanced proliferative and angiogenic activity and a number of functional and structural changes, resulting in the particular behavior of this tissue.

A modified technique to reduce spillage and operative time: laparoscopic ovarian dermoid cyst enucleation 'in a bag'

Background: To describe the outcomes of a modified technique for conservative laparoscopic enucleation of ovarian dermoid cyst, placing the ovary in an endobag during enucleation to prevent intraperitoneal spillage. Methods: Laparoscopic dermoid cyst enucleation was performed in 35 cases of premenopausal patients placing the ovary in an endobag at the beginning of the procedure and removing the cyst from the abdominal cavity by the same endobag. Results: Dermoid cysts with a mean diameter of 6.3 ± 2.7 cm were enucleated and removed laparoscopically ‘in a bag’ without intra- or postoperative complications. Cyst rupture occurred in 10 cases (28.5%), but evident peritoneal contamination occurred in only 2 (5.7%; 95% confidence interval: 0.7–19.2%), because in 8 patients spillage was contained by the surrounding bag. The mean operative time was 64.6 ± 27 min. No signs or symptoms of peritonitis were observed. The mean postoperative hospitalization was 1.6 ± 1.4 days. Among the 12 infertile patients, 7 spontaneous pregnancies (58%) occurred. Conclusions: Laparoscopic conservative excision of dermoid cysts placing the ovary in an endobag at the beginning of surgery and removing the cyst by the same bag is a safe and effective approach to reduce intraperitoneal spillage and operative time.

Twin pregnancy using recombinant gonadotropins in a woman with hypogonadotropic hypogonadism.

In women with hypogonadotropic hypogonadism both follicle-stimulating hormone (FSH) and luteinizing hormone (LH) are required to induce optimal follicular growth and steroidogenesis. The development of molecular genetic technology has led to the availability of recombinant FSH and LH for the induction of follicular growth and ovulation. We describe a first case of a twin pregnancy in a 36-year-old patient presenting with primary hypogonadotropic amenorrhea and empty sella syndrome and treated with recombinant FSH and LH. This therapy led to the maturation of two follicles, both of which were fertilized. A twin pregnancy ensued and two normal infants were delivered.

Laparoscopic gonadectomy in two patients with gonadal dysgenesis

Individuals with androgen insensitivity syndrome have a high risk (20-30%) of developing malignancy in their gonads. Accordingly, bilateral gonadectomy is recommended. In a 17-year-old woman with Swyer syndrome gonads were located as streaks above the pelvic brim. In a 13-year-old with Morris syndrome they were located within the inguinal canals. Bilateral laparoscopic gonadectomy was performed under general anesthesia in both patients without complications. We suggest that in phenotypic females with 46,XY karyotype, the procedure may be performed safely, even with gonads located in inguinal canals.

Laparoscopic myomectomy using endoscopic loops under progressive tension

The Authors describe a novel technique for laparoscopic myomectomy of fibroids with a subserosal component which involves the use of endoscopic loops under progressive tension to avoid bleeding, facilitate enucleation and possibly reduce the need of conventional sutures. Data analysis from a series of 34 consecutive operations shows that the use of endoloops helps achieving a good haemostasis, and no case of haemorrhage from the fibroid bed was ever recorded. Moreover, the need of diathermy was reduced, and the enucleation of the fibroids resulted facilitated by a bloodless field and the squeezing effect induced by the progressive tension on the loops. Although a reduction of number of traditional suturing was recorded, we do not recommend this technique to surgeons who are not familiar with conventional laparoscopic suturing. Overall, the suggested use of endoscopic loops seems to facilitate laparoscopic myomectomy on fibroids with at least a partial subserosal component. We believe that this method deserves comparative studies in order to furtherly demonstrate its safety and efficacy.

Is a Positive Family History of Endometriosis a Risk Factor for Endometrioma Recurrence After Laparoscopic Surgery

A total of 148 patients were followed up for an average of 30.1 ± 17 months following to laparoscopic excision of ovarian endometriomas by a single surgical team. Bivariate and multivariate analyses were used to investigate the association between endometrioma recurrence and several factors, age, body mass index, family history, cyst diameter, number and location, adhesions or peritoneal implants, occurrence of spillage, postoperative treatment with gonadotropin-releasing hormone agonist, or pregnancies. The overall recurrence rate of the endometriomas was 18.2%. At bivariate analysis, recurrence rate was significantly higher in patients with a positive family history of endometriosis (40% vs 14.8%). Recurrence was also more frequent, albeit nonsignificantly, in patients with a history of dysmenorrhea, intraoperative spillage, and postoperative hormonal suppression. At multivariate analysis with logistic regression, a positive family history of endometriosis was the only variable independently associated with endometrioma recurrence following laparoscopic removal (odds ratio 3.245; 95% confidence interval: 1.090-9.661).