Spyros Milingos

Adhesions: Laparoscopic Surgery versus Laparotomy

Abstract: This study was undertaken to assess the effectiveness in pregnancy rates of microsurgery and operative laparoscopy in adhesiolysis. Adhesions were found to be the sole infertility factor in 15% of our patients. One hundred and ninety infertile patients with periadnexal adhesions as the only cause of their infertility were treated by microsurgery (86) or operative laparoscopy (104) and were followed up for 24 months. Our results indicate that advanced laparoscopic surgery in general is as effective as microsurgery in healthy infertile patients with adhesions but offers some advantages in comparison to laparotomy. Factors that adversely affect the postoperative success rates are the age of the women, the duration of infertility, and the severity of the adhesions.

The renin-aldosterone system during normal and hypertensive pregnancy

Abstract Gestational hypertension complicates approximately 5%–7% of pregnancies and it may be deleterious to both maternal and fetal health. Gestational hypertension is a multisystem disorder which always resolves itself after delivery; its primary pathology still remains incompletely clarified. The renin-aldosterone system is a major determinant of sodium balance in pregnancy. To evaluate the changes in renin and aldosterone levels during normal and hypertensive pregnancy we undertook this study. Plasma renin activity and aldosterone levels were measured in 71 pregnant (43 normotensive, 28 hypertensive) and 24 non-pregnant (12 normotensive, 12 hypertensive) women, aged 19–43 years (mean±SD 28±2.8). Women were allocated into the following five groups: Groups 1 and 2 consisted of 12 normotensive and 12 hypertensive non-pregnant women, respectively; group 3 consisted of 20 women (14 normotensive and 6 hypertensive) at 11–19 weeks of gestation; group 4 consisted of 24 women (14 normotensive and 10 hypertensive) at 20–29 weeks of gestation, and group 5 consisted of 27 women (15 normotensive and 12 hypertensive) at 30–37 weeks of gestation. Both plasma renin activity and aldosterone levels progressively increased during normotensive pregnancy and were higher compared to normotensive non-pregnant women. Among hypertensive pregnant women, plasma renin activity levels remained unchanged during the three trimesters of pregnancy and were higher compared to hypertensive non-pregnant women. Only during the third trimester did aldosterone levels significantly increase in hypertensive pregnant women, compared to hypertensive non-pregnant women. Despite stable renin levels, aldosterone levels increased significantly during the third trimester of hypertensive pregnancy. Thus, we conclude that aldosterone biology seems to be directly or indirectly involved in the etiology of gestational hypertension independently of renin levels.

Laparoscopic Management of Patients with Endometriosis and Chronic Pelvic Pain

Abstract: Endometriosis has been traditionally included among the most important causes of chronic pelvic pain (CPP) in women of reproductive age. The main clinical manifestations of endometriosis are dysmenorrhea, dyspareunia, and chronic nonmenstrual pain. Despite the high prevalence of endometriosis in women suffering from CPP, controversy still exists regarding the true association between the stage and extent of this peculiar disease and the severity of pain. Over the last decade, advances in endoscopic technology have enabled gynecologic surgeons to recognize many atypical appearances of the endometriotic implants not known to exist before, thus allowing their complete excision or destruction. Laparoscopic surgery may offer considerable relief in patients with endometriosis and CPP. Although cases with advanced endometriosis seem to benefit the most, we also support surgical treatment in patients with early endometriosis diagnosed using laparoscopy, as many will experience improvement in their symptoms.

Endometriosis in patients with chronic pelvic pain : Is staging predictive of the efficacy of laparoscopic surgery in pain relief?

Background/Aims: Endometriosis is considered an important cause of chronic pelvic pain. Despite its high prevalence, controversy still exists regarding the true association between the extent of endometriosis and the severity of symptoms. We conducted this prospective study to investigate the association between the stage of endometriosis and type and severity of pain, and to evaluate the efficacy of laparoscopic surgery in pain relief. Methods: Ninety-five patients complaining of chronic pain were diagnosed with endometriosis and were treated with laparoscopic surgery. The severity of pain was assessed in patients with an endometriosis AFS (American Fertility Society) score less than 16 (group 1) and those with an AFS score greater than or equal to 16 (group 2), preoperatively and 6 months after surgery, using a visual pain scale. Any reduction in pain scores by 2 points or more was considered to be an improvement. Results: Dysmenorrhea and deep dyspareunia, were significantly more frequent in patients of group 2. Preoperative pain scores were significantly higher for dysmenorrhea (p = 0.0022) and deep dyspareunia (p < 0.0001) but not for non-menstrual pain in group 2. Deep dyspareunia was correlated with the presence of dense pelvic adhesions. After surgery, dysmenorrhea improved in 43% of cases in group 1, vs. 66% of cases in group 2 (p = 0.0037). For deep dyspareunia, improvement was reported by 33% in group 1, vs. 67% in group 2 (p = 0.074). Improvement in non-menstrual pain was not significantly different between the two groups (67% vs. 56%). Conclusions: Advanced endometriosis is more frequently related to dysmenorrhea and deep dypareunia in comparison to early disease. Laparoscopic surgery may offer relief or improvement in the majority of patients with endometriosis and chronic pelvic pain. Cases with advanced disease seem to benefit the most.

LAPAROSCOPIC EVALUATION OF INFERTILE PATIENTS WITH CHRONIC PELVIC PAIN

In this study over a 10-year period, 1584 patients complaining of infertility of more than 1 year duration were evaluated for their laparoscopic findings in relation to the presence or not of chronic pelvic pain (CPP). Infertility was the only complaint in 1215 cases (group 1), whereas 369 patients complained of infertility and CPP (group 2). All cases underwent routine infertility investigation and pelvic ultrasonography, followed by diagnostic laparoscopy, with infertility-only cases acting as a control group. At laparoscopy 76.7% of patients with CPP were found with pelvic pathology, compared with only 42.6% of cases without CPP (P < or = 0.0001). Omental-abdominal wall adhesions, advanced endometriosis, endometriomas with adhesions, pelvic venous congestion, and hydrosalpinges with pelvic adhesions were significantly more frequent in cases with CPP. Dysmenorrhoea was the most frequent type of CPP. Cases with CPP and a negative laparoscopy were further investigated using a multidisciplinary approach. In conclusion, chronic pelvic pain can be the result of several pelvic pathologies. Infertile patients with CPP are much more frequently found with an abnormal pelvis in comparison with cases without CPP. Laparoscopy is an invaluable diagnostic tool especially for symptomatic patients and should be used early in their diagnostic infertility work-up.

Cystic Uterine Tumors

Background/Aims: The differential diagnosis of cystic uterine tumors includes fibroids showing cystic degeneration, cystic adenomyomas, congenital cysts, and developmental anomalies. Methods: The incidence, clinical presentation and accuracy in preoperative diagnosis of cystic uterine tumors were studied in a university hospital population over a 6-year period. Results: 29 cases were included. Of these, 8 corresponded to the diagnosis of a non-fibroid uterine cystic enlargement, and 21 to that of a fibroid with cystic degeneration. Age and parity were significantly lower in patients with non-fibroid cysts. Rates of symptomatic women (60 vs. 55.6%) were similar in both groups. The preoperative diagnosis was accurate in 20/21 (95.2%) cases with a degenerated leiomyoma. On the contrary, in 6/8 (75%) cases with a non-fibroid cystic swelling an erroneous diagnosis of an adnexal or an extrauterine mass was made preoperatively. In this group, histology of the tumor showed a cystic adenomyoma in 3, a congenital cyst in 3, and a blind rudimentary uterine horn in 2 cases, respectively. Conclusion: Uterine cystic tumors are uncommon. Frequently, non-fibroid swellings are erroneously diagnosed as adnexal enlargements and their true origin only becomes evident during surgery.

Urokinase‐Type Plasminogen Activator and Insulin‐Like Growth Factor‐Binding Protein 3 mRNA Expression in Endometriotic Lesions and Eutopic Endometrium

Abstract: The peritoneal fluid of women with endometriosis contains an increased insulin‐like growth factor 1 (IGF‐1) bioavailability, which is produced by limited hydrolysis of urokinase‐type plasminogen activator (uPA) on IGF‐binding protein 3 (IGFBP‐3). Recently, IGF‐1 was shown to inhibit apoptosis of endometrial‐like cells in vitro, suggesting that a microenvironment of increased IGF‐1 bioavailability can optimize the survival of endometrial cells grown ectopically. Here the expression of mRNA of IGFBP‐3 and uPA in tissue biopsies from eutopic endometrium and endometriotic lesions obtained at laparoscopy from women with endometriosis have been analyzed, and it is documented that both IGFBP‐3 and uPA mRNA expression are increased from 3‐ to 10‐fold in endometriotic lesions versus eutopic endometrium. Consequently, the necessary components (uPA and IGFBP‐3 expression) of endocrine/autocrine/paracrine enhancement of local IGF bioavailability mediated by uPA hydrolysis of the IGFBP‐3 were present in endometriotic lesions. These data possibly explain the origin of the increased content of uPA activity, IGF‐1 bioavailability, and NH2‐truncated forms of IGFBP‐3 in the peritoneal fluid of women with endometriosis.

Endometriosis and Reproductive Disorders

Abstract: The classic concept of endometriosis as a cause of infertility is challenged. Traditionally, both surgical and medical therapy have focused on alleviation of symptoms, prevention of disease progression, and promotion of fertility. In spite of significant developments in medical and surgical approaches, the optimal therapy for treating endometriosis‐associated infertility has yet to be established. The relationship between prevalence of fecundity and stage of the disease was studied according to the type of management. Of 151 women who were consecutively proved by laparoscopy to have endometriosis stage I and II, operative laparoscopy was performed in 49, medical treatment in 59, and expectant management in 43 cases. During a 24‐month period, the cumulative pregnancy rates were 36.7%, 30.5%, and 20.9%, respectively. Survival analysis over the 20 weeks of pregnancy showed that the probability of carrying the pregnancy beyond this week was 30.6%, 25.4%, and 16.2%, respectively. Of 64 patients with advanced disease, 34 (53%) became pregnant during the 2‐year follow‐up period. A significantly increased pregnancy rate was found for the first year as compared to the second (76% vs. 24%). The existence of adhesions affected adversely the outcome of the treatment when early achievement of pregnancy is considered. Diagnosis and treatment of endometriosis was beneficial for the infertile women. Laparoscopic surgery seems to be the best treatment in these cases, as it increases the fecundity and involves minimal risk.

Insulin-like growth factor-1 isoform mRNA expression in women with endometriosis: eutopic endometrium versus endometriotic cyst.

Abstract:  Pathogenesis of endometriosis involves growth factors, which are synthesized locally. Insulin‐like growth factor‐1 (IGF‐1) prevents apoptosis and has mitogenic action on endometrial cells. The IGF‐1 gene undergoes alternative splicing and results in three isoforms (IGF‐1Ea, IGF‐1Eb, and IGF‐1Ec or MGF). We analyzed the mRNA expression of IGF‐1 isoforms in tissue samples of eutopic endometrium and endometriotic cyst obtained during laparoscopy from women with endometriosis. We documented that all three IGF‐1 isoforms are expressed in both eutopic endometrium and ovarian endometrioma. Furthermore, we documented a significant decrease in all IGF‐1 isoform expression in endometriotic cyst compared to endometrium of women with endometriosis. The reduction may correlate with the disease status and presence of fibrotic inactive tissue found in late stages of the disease.

Laparoscopic Gonadectomy in a Patient With Testicular Feminization Syndrome

A laparoscopic technique is reported as an operative approach for gonadectomy in a case of testicular feminization syndrome. A 17-year-old phenotypic female presented with primary amenorrhea and was evaluated through a diagnostic protocol that included clinical, cytogenetic, and hormonal examinations. The findings supported the diagnosis of testicular feminization syndrome. The left gonad was found at the internal opening of the inguinal canal and removed laparoscopically. No gonad was found at the contralateral side. No complications occurred during the operation and the patient left the hospital the same day. A long-term hormonal replacement treatment was initiated postoperatively.