Stefano Cosma

Cyclic sciatica in a patient with deep monolateral endometriosis infiltrating the right sciatic nerve.

Study Design Case report. Objective To show by case presentation, the potential for endometriosis to infiltrate the somatic nerves causing lower extremity neuropathic pain and to discuss possible surgical remedy and the effectiveness of laparoscopic neurolysis. Summary of Background Data Pelvic endometriosis may infiltrate the pelvic wall and somatic nerves causing severe neuropathic symptoms. Methods We report a case of a 41-year-old woman with a history of severe dysmenorrhea, dyspareunia, and chronic pelvic pain with concomitant monolateral right sciatica because of deep infiltrating pelvic endometriosis involving the sciatic nerve and pelvic wall. Results The patient was treated by laparoscopic neurolysis of the involved somatic nerves according to the Possover operation. Conclusions Endometriosis is a chronic inflammatory disease, potentially infiltrating the somatic nerves. Laparoscopic neurolysis is a therapeutic aetiological therapy, which can relieve neurological symptoms deriving from nerve infiltration/compression.

Accuracy of a new diagnostic tool in deep infiltrating endometriosis: Positron emission tomography–computed tomography with 16α‐[18F]fluoro‐17β‐estradiol

Preoperative workup of deep infiltrating endometriosis is limited in the evaluation of extragenital and extrapelvic disease and in distinguishing between the previous surgical scar and active lesion. Histological verification remains the gold standard for diagnosis. The aim of this study was therefore to evaluate positron emission tomography–computed tomography (PET/CT) with an experimental estrogen receptor tracer (16α‐[18F]fluoro‐17β‐estradiol; [18F]FES) for accurate staging and non‐invasive diagnosis of the disease. The primary endpoint was the feasibility of this tool on comparison with histology. The secondary endpoint was the accuracy of PET/CT in comparison with magnetic resonance imaging (MRI).

Psychometric validation of the Italian version of the I-QoL questionnaire: clinical and urodynamic findings

Introduction and hypothesisThe aim was to validate the Italian version of the Incontinence-Quality of Life questionnaire (I-QoL) in women with clinical and urodynamic urinary incontinence (UI). A secondary end point was to compare the results of women with reported UI, but negative urodynamic findings.MethodsThe Italian translation of the I-QoL was administered to 267 Italian women with pelvic organ prolapse < stage III, and who had undergone previous surgical or medical therapy for UI. Cronbach’s alpha was calculated to assess internal consistency of the I-QoL items. Reproducibility was assessed using the intraclass correlation coefficient (ICC). Convergent validity involved comparison of I-QoL scores and the Short Form-36 Health questionnaire.ResultsOne hundred and sixty-seven patients were considered for the primary end point: 47 had a negative history of UI and a normal urodynamic test, 120 complained of UI confirmed by a urodynamic test, 59 had a positive history for UI and a urodynamic test negative for UI, and 35 patients not reporting UI had a positive urodynamic test. The I-QoL score revealed that the QoL was lower in patients with reported UI, irrespective of urodynamic findings. The overall I-QoL summary score and subscales showed high internal consistency (alpha ranges from 0.88 to 0.96). ICC ranged from 0.98 to 0.99, demonstrating the stability of the scores. The physical domain of the I-QoL showed a 0.27 correlation with the physical functioning subscale of the SF-36. No significant difference in I-QoL scores was found among various types of UI.ConclusionThe Italian translated version of the I-QoL is reliable, consistent and a valid instrument for assessing impact on quality of life in Italian speaking women with UI.

Nerve preserving vs standard laparoscopic sacropexy: Postoperative bowel function

AIM To compare our developed nerve preserving technique with the non-nerve preserving one in terms of de novo bowel symptoms. METHODS Patients affected by symptomatic apical prolapse, admitted to our department and treated by nerve preserving laparoscopic sacropexy (LSP) between October, 2010 and April, 2013 (Group A or “interventional group”) were compared to those treated with the standard LSP, between September, 2007 and December, 2009 (Group B or “control group”). Functional and anatomical data were recorded prospectively at the first clinical review, at 1, 6 mo, and every postsurgical year. Questionnaires were filled in by the patients at each follow-up clinical evaluation. RESULTS Forty-three women were enrolled, 25/43 were treated by our nerve preserving technique and 18/43 by the standard one. The data from the interventional group were collected at a similar follow-up (> 18 mo) as those collected for the control group. No cases of de novo bowel dysfunction were observed in group A against 4 cases in group B (P = 0.02). Obstructed defecation syndrome (ODS) was highlighted by an increase in specific questionnaires scores and documented by the anorectal manometry. There were no cases of de novo constipation in the two groups. No major intraoperative complications were reported for our technique and it took no longer than the standard procedure. Apical recurrence and late complications were comparable in the two groups. CONCLUSION Our nerve preserving technique seems superior in terms of prevention of de novo bowel dysfunction compared to the standard one and had no major intraoperative complications.

Combined sacrospinous hysteropexy and cystopexy using a single anterior incision

To evaluate the safety, efficacy, and feasibility of a minimally invasive vaginal approach for treating advanced utero‐vaginal prolapse.

A pseudoneoplastic finding of deep endometriosis: laparoscopic triple segmental bowel resection

Bowel endometriosis affects 3–37% of patients with endometriosis, involving more frequently the rectum and the rectosigmoid junction. Severe endometriosis with bowel involvement is often refractory to standard medical therapy. For these reasons, surgery for bowel treatment is frequently needed. We report the case of a 36-year-old woman with deep endometriosis of the pelvis, triple segmental bowel involvement (recto-sigma, ileum-cecum, transverse colon) and massive endometriotic ascites with secondary Glissons capsule inflammation, refractory to medical therapy. A laparoscopic triple segmental bowel resection and complete fertility sparing excision of pelvic endometriotic lesions was performed. At 48 months of follow-up, the woman was asymptomatic, with no evidence of recurrence of disease or ascites. Laparoscopic segmental bowel resection, including multiple section, is feasible in selected symptomatic patients with consequent improved quality of life, morbidity rates similar to those achieved by laparotomy and with a less detrimental effect on fertility.

Simplified laparoscopic sacropexy avoiding deep vaginal dissection

To evaluate the safety and efficacy of a “simplified” laparoscopic sacropexy approach.

Retroperitoneal and retrograde total laparoscopic hysterectomy as a standard treatment in a community hospital

OBJECTIVE To report our experience with a modified procedure for total laparoscopic hysterectomy based on a retrograde and retroperitoneal technique. This surgical approach is analyzed on a consecutive series of patients in a community hospital and theoretical educational advantages are proposed. STUDY DESIGN All patients undergoing hysterectomy from January 2012 to April 2013 were included in the study. A detailed description of the technique is given. As main outcome measures we evaluated: the number and rate of patients excluded from laparoscopic approach, the rate of late complications need readmission, the rate of transfusions, the rate of conversion to laparotomy and the number of minor complications. The main concern of the study was ureteral complications. RESULTS Overall 174 patients underwent hysterectomy in our unit. The rate of patients submitted to laparoscopic hysterectomy was 97.5%. The number of complications needing re-admission was three (2%). The rate of conversion was 2.7%. In the study period, two (1.2%) ureteral complications were observed (late fistulae). There were four bladder lesions but the patients were released on the same day as the patients with no lesion. CONCLUSIONS Opening the retroperitoneum allows rapid control of the main uterine vessels by coagulation, and constant checks on the ureter. Difficult benign situations can be managed. Even in a non-referral center about 94% of hysterectomies can be performed by laparoscopic surgery. This approach is helpful and may be reproducible in gynecological procedures.