T.S. Raymundo

Double Circular Stapler Technique for Bowel Resection in Rectosigmoid Endometriosis

To reduce bladder function impairment and avert the serious complications of anastomotic leakage after segmental rectosigmoidectomy and to minimize the persistence of endometriotic lesions associated with discoid resection, we used the double circular stapling (DCS) technique. This technique enables excision of bowel endometriosis nodules larger than those that can be removed with the single-load technique of the circular stapler. Of 120 patients who underwent surgery to treat bowel endometriosis, intestinal shaving was performed in 24, discoid resection with single circular stapling in 40, and rectosigmoidectomy in 55. Eleven patients (9.2%) underwent the DCS technique. In the DCS group, the size of the rectosigmoid lesion ranged from 2.2 cm to 4.2 cm. Median operative time for the DCS technique was 100 minutes, compared with 150 minutes for rectosigmoidectomy (p = .04). Only 1 of 11 patients (9%) had urinary retention, compared with postoperative urinary retention in 14 of 55 patients (25%) who had undergone rectosigmoidectomy (difference not significant). Only 1 patient, with a 4.2-cm nodule, had a positive margin in the specimen obtained at the second stapling. DCS is a promising technique and may avert rectosigmoidectomy in selected patients.

Diagnostic hysteroscopy using liquid distention medium: comparison of pain with warmed saline solution vs room-temperature saline solution.

STUDY OBJECTIVE To compare pain intensity and degree of satisfaction reported by patients undergoing hysteroscopic examinations using saline solution kept at room temperature (control group) or saline solution heated to 37.5°C (test group). DESIGN Randomized, controlled, prospective study (Canadian Task Force Classification I). PATIENTS Sixty-four women underwent diagnostic hysteroscopy during the second half of 2008. INTERVENTION In both the test and control groups, examinations were performed using the vaginoscopy technique without use of a speculum or Pozzi tenaculum forceps. Pain was assessed using a visual analog scale immediately after the examination and at 1 and 15 minutes after the procedure. MEASUREMENTS AND MAIN RESULTS Immediately after the examination, mean (SD; 95% confidence interval) pain intensity in the warmed saline solution group was 3.84 (2.71; 2.89-4.79), and in the room-temperature saline solution group was 4.31 (3.02; 3.18-5.44) (p = .51). At 1 and 15 minutes after the procedure, pain intensity in the 2 groups was, respectively, 2.41 (2.00; 1.66-3.16) and 2.43 (2.49; 1.57-3.30) (p = .96), and 1.83 (2.30; 1.02-2.64) and 1.85 (2.06; 1.08-2.62) (p = .96). Differences were not significant. Time to complete the examination was 3.80 (1.32; 3.34-4.26) minutes in the test group, and 3.75 (1.10; 3.34-4.15) minutes in the control group (p = .82). The satisfaction rate with the warmed distention medium was 84% (95% confidence interval, 72%-96%), and with the room-temperature saline solution was 85% (73%-97%) with saline at room temperature (p = .48). CONCLUSION There was no statistically significant difference between the 2 groups insofar as pain, duration of the examination, and degree of patient satisfaction.

CO2 Cystoscopy for Evaluation of Ureteral Patency

Gynecologic surgery is associated with various perioperative complications, especially urinary tract injuries. Intraoperative cystoscopy plays an important role in allowing assessment of the bladder to ensure the absence of injuries. Verification of the urinary jets from the ureters is a fundamental step that is not always easy to accomplish. Dyes are frequently used, but these are not always available and are associated with adverse effects. The present study aimed to demonstrate the use of CO2 as a medium for distension during cystoscopy. A total of 47 patients underwent CO2 cystoscopy after laparoscopic hysterectomy (n = 26) or bladder endometriosis nodule resection (n = 21). In all patients, the ureteral jets were readily identified, leaving no doubt as to their patency. The median interval between the onset of cystoscopy and the view of jetting from both ureteral ostia was 145 seconds (range, 80-300 seconds). All cystoscopies were normal, and no patient had any signs of accidental urinary tract injury in the follow-up period. Two patients experienced mild urinary tract infection. This cystoscopy technique using CO2 is fast, easy, safe, and efficient. We recommend bladder distension with CO2 as a reasonable alternative technique when cystoscopy is required during gynecologic procedures.

How to Use CA-125 More Effectively in the Diagnosis of Deep Endometriosis

Deep infiltrative endometriosis (DIE) is a severe form of the disease. The median time interval from the onset of symptoms to diagnosis of endometriosis is around 8 years. In this prospective study patients were divided into two groups: cases (34 DIE patients) and control (20 tubal ligation patients). The main objective of this study was to evaluate the performance of CA-125 measurement in the menstrual and midcycle phases of the cycle, as well as the difference in its levels between the two phases, for the early diagnosis of DIE. Area Under the Curve (AUC) of CA-125 in menstrual phase and of the difference between menstrual and midcycle phases had the best performance (both with AUC = 0.96), followed by CA-125 in the midcycle (AUC = 0.89). The ratio between menstrual and midcycle phases had the worst performance. CA-125 may be useful for the diagnosis of deep endometriosis, especially when both are collected during menstruation and in midcycle. These may help to decrease the long interval until the definitive diagnosis of DIE. Multicentric studies with larger samples should be performed to better evaluate the cost-effectiveness of measuring CA-125 in two different phases of the menstrual cycle.