Vadim Morozov

Use of neutral argon plasma in the laparoscopic treatment of endometriosis.

Neutral argon plasma energy can be used as a multifunctional device that has vaporization, coagulation and superficial cutting capabilities with little thermal spread.

Numbers and Types of Nonbladder Syndromes as Risk Factors for Interstitial Cystitis/Painful Bladder Syndrome

OBJECTIVES To examine the interaction of types and numbers of antecedent nonbladder syndromes (NBSs) to seek clues to the pathogenesis of interstitial cystitis/painful bladder syndrome (IC/PBS). Numerous case series have shown IC/PBS to be associated with several syndromes that do not include bladder symptoms. In a previously reported case-control study, we confirmed these findings and found that such nonbladder syndromes often preceded the onset of IC/PBS. METHODS Incident female IC/PBS cases (n = 312) and matched controls were compared for 11 antecedent NBSs. The odds ratios (ORs) for IC/PBS according to the number of antecedent NBSs per person were calculated. From this model, each NBS was serially removed, and the calculations for the ORs were repeated using the remaining 10 NBSs. We assessed the types of NBSs included in each subgroup formed by the number of NBSs. RESULTS The ORs for IC/PBS increased with the increasing number of antecedent NBSs. The types of NBSs were interchangeable in calculating these ORs. The distribution of the types of NBSs was skewed, with allergy overrepresented in those with few NBSs, and the classic functional somatic syndromes of fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome overrepresented in those with many NBSs. CONCLUSIONS Two main hypotheses were generated. One was that the incidence of a NBS initiated a process that contributed to the emergence of other NBSs and IC/PBS. The second was that each NBS and IC/PBS was a manifestation of a common, shared pathogenesis. It is likely that a well-designed prospective study will be necessary to distinguish between these 2 hypotheses.

Sexuality and Reproductive Risk Factors for Interstitial Cystitis/Painful Bladder Syndrome in Women

OBJECTIVES To determine whether interstitial cystitis/painful bladder syndrome (IC/PBS) in women is associated with antecedent sexual and reproductive characteristics. METHODS By multivariate analyses, 312 incident IC/PBS cases were compared with matched controls for antecedent sexual and reproductive characteristics, adjusted by demographics, previous surgery, and nonbladder syndromes (NBSs), such as chronic pelvic pain, irritable bowel syndrome, and panic disorder. RESULTS IC/PBS was significantly associated with previous female hormone use, a history of fewer pregnancies (in premenopausal women), and antecedent NBSs, especially when expressed by the number of such syndromes. CONCLUSIONS Three antecedents to IC/PBS were prominent. Female hormone use was consistent with a pharmacologic effect or as a marker of its indications. A history of fewer pregnancies among premenopausal, but not postmenopausal, women with IC/PBS was consistent with pregnancy postponing the occurrence of IC/PBS, a marker for decisions to avoid pregnancy, or a result of recruitment bias. NBSs, especially the total number experienced by the participant, had the strongest correlation with IC/PBS. This finding suggests that knowledge of the pathogeneses of these NBSs, many of which are functional somatic syndromes, might reveal that of IC/PBS.

Could chronic pelvic pain be a functional somatic syndrome

The cause of noncyclical chronic pelvic pain (CPP) in many women is unknown: 30% have no identifiable pelvic pathology, and in those who do the relationship of CPP and the pathology is often unclear. Moreover, epidemiologic studies demonstrate that the common findings of endometriosis and adhesions do not greatly increase the odds of having CPP. CPP and the functional somatic syndromes (fibromyalgia, irritable bowel syndrome, and others) share many characteristics including pain as a prominent symptom and comorbidity. For the functional somatic syndromes, the initial focus of etiologic investigations has been on local mechanisms and then on systemic pathogeneses. We believe that the research trajectories of the functional somatic syndromes and CPP are converging. Their juncture might reveal an important pathologic mechanism for CPP in some women that is primarily outside the pelvis. This observation would open up new areas of exploration and treatment of CPP.

Preoperative periumbilical ultrasound-guided saline infusion (PUGSI) as a tool in predicting obliterating subumbilical adhesions in laparoscopy

OBJECTIVE To report the novel technique of periumbilical ultrasound-guided saline infusion (PUGSI). DESIGN Prospective study of two noninvasive diagnostic tests to detect obliterating subumbilical adhesions. SETTING Tertiary care center. PATIENT(S) One hundred fifty patients were included in the study. Patients without risk factors for adhesions were used as a control group (n = 38), whereas the study group had risk factors for intra-abdominal adhesions (n = 112). INTERVENTION(S) Preoperative examination with the visceral slide and the PUGSI. MAIN OUTCOME MEASURE(S) The presence of obliterating subumbilical adhesions in the high-risk patient and the ability of the PUGSI to detect them preoperatively. RESULT(S) There were no obliterating umbilical adhesions in the control group. The prevalence of obliterating umbilical adhesions in the risk group was 3.6%. The visceral slide test had an accuracy of 96.4%, a sensitivity of 50%, and a specificity of 98.1%, with a negative predictive value of 98.1% and a positive predictive value of 50%. The PUGSI test was able to detect all cases of obliterating subumbilical adhesions, demonstrating sensitivity and specificity of 100%. CONCLUSION(S) The PUGSI test has excellent negative and positive predictive values and is useful in determining patients who have obliterating subumbilical adhesions. Use of both tests preoperatively appears to be helpful in identifying patients at risk for visceral injury during laparoscopic surgery.

Before the onset of interstitial cystitis/bladder pain syndrome, the presence of multiple non-bladder syndromes is strongly associated with a history of multiple surgeries.

OBJECTIVE Certain functional somatic syndromes (FSSs) such as fibromyalgia and irritable bowel syndrome are accompanied by diffuse pain amplification. Women with interstitial cystitis/bladder pain syndrome (IC/BPS) have numerous FSSs, as well as other non-bladder syndromes (NBSs) that are linked to the FSSs. They also report multiple surgeries. Since pain is a common indication for surgery, we tested the hypothesis that NBSs were associated with surgeries. METHODS We interviewed 312 incident IC/BPS cases and controls on NBSs and number of surgeries before the index date (for cases, IC/BPS onset date). Poisson and logistic regression analyses adjusted for age, race, educational level, and menopause. RESULTS Number of surgeries increased with number of NBSs in both cases and controls whether chronic pelvic pain (CPP), the only NBS generally accepted as an indication for surgery, was present or not. Logistic regression analysis showed that among cases CPP was the only individual NBS associated with a history of multiple surgeries, and then only modestly [odds ratio (OR) 1.9, confidence intervals (CI) 1.06, 3.2]. By far the strongest association was the number of NBSs. The OR for multiple surgeries increased with number of NBSs: for cases with 4-5 NBSs the OR was 14.1 (1.8, 113) and with 6-9 NBSs, 33.1 (3.9, 279). Controls had fewer syndromes and fewer surgeries and this linkage was less prominent. CONCLUSION Among IC/BPS cases, the number of NBSs was strongly correlated with the number of surgeries. Understanding temporal relationships will be necessary to explore causal linkages and may modify surgical practice.

Endometriosis in adolescents.

Background and Objectives: Women with endometriosis often report onset of symptoms during adolescence; however, the diagnosis of endometriosis is often delayed. The aim of this study was to describe the experience of adolescents who underwent laparoscopy for pelvic pain and were diagnosed with endometriosis: specifically, the symptoms, time from onset of symptoms to correct diagnosis, number and type of medical professionals seen, diagnosis, treatment, and postoperative outcomes. Methods: We reviewed a series of 25 females ≤21 years of age with endometriosis diagnosed during laparoscopy for pelvic pain over an 8-year period. These patients were followed up for 1 year after surgery. Results: The mean age at the time of surgery was 17.2 (2.4) years (range, 10–21). The most common complaints were dysmenorrhea (64%), menorrhagia (44%), abnormal/irregular uterine bleeding (60%), ≥1 gastrointestinal symptoms (56%), and ≥1 genitourinary symptoms (52%). The mean time from the onset of symptoms until diagnosis was 22.8 (31.0) months (range, 1–132). The median number of physicians who evaluated their pain was 3 (2.3) (range, 1–12). The adolescents had stage I (68%), stage II (20%), and stage III (12%) disease. Atypical endometriosis lesions were most commonly observed during laparoscopy. At 1 year, 64% reported resolved pain, 16% improved pain, 12% continued pain, and 8% recurrent pain. Conclusions: Timely referral to a gynecologist experienced with laparoscopic diagnosis and treatment of endometriosis is critical to expedite care for adolescents with pelvic pain. Once the disease is diagnosed and treated, these patients have favorable outcomes with hormonal and nonhormonal therapy.

Proposal of a Formal Gynecologic Endoscopy Curriculum

As minimally invasive surgery becomes the standard of care in the United States and around the world, the formal training of endoscopic surgeons is an issue of growing concern. With the implementation of the American Association of Gynecologic Laparoscopists/Society of Reproductive Surgeons (AAGL/SRS)-sponsored fellowship training in gynecologic endoscopy and a growing number of hands-on courses, we have the challenge of credentialing and certifying future gynecologic endoscopists. The objective of this article is to propose and to illustrate a uniform standardized core curriculum for obstetrics and gynecology residents, fellows in AAGL/SRS-sponsored fellowship programs, and participants in postgraduate courses. Consisting of 3 discrete parts, this proposal addresses formal laparoscopic training for gynecologists, already implemented and available to general surgeons, and a novel proposition for core training in hysteroscopy. The curriculum is distributed in a quarterly system with specific educational objectives in each quarter. After quarters 1 and 2, an online examination is given; after quarter 3, participants are required to take and pass a hands-on examination at a specified testing facility; and at the end of quarter 4, participants must demonstrate leadership skills in the operating room and in a teaching capacity, and promote the principles of the AAGL.

Robot-Assisted Laparoscopic Presacral Neurectomy: Feasibility, Techniques, and Operative Outcomes

STUDY OBJECTIVES To report the feasibility and description of robot-assisted presacral neurectomy (RPSN) and to compare outcomes with laparoscopic presacral neurectomy (LPSN). DESIGN Prospective case series (Canadian Task Force classification III). SETTING Tertiary care center. PATIENTS Eighteen patients with central pelvic pain who underwent RPSN and 12 patients with central pelvic pain who underwent conventional LPSN in a metropolitan hospital between July 1, 2006, and April 30, 2008. INTERVENTIONS The da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) was used for the robotic portion of the procedure. Availability of the robot was the sole determining factor for the procedure chosen. Bipolar, monopolar, and ultrasonic instruments were used for conventional laparoscopy. All patients underwent several additional procedures performed laparoscopically including adhesiolysis, treatment of endometriosis, appendectomy, enterolysis, and salpingo-ovariolysis. MEASUREMENTS AND MAIN RESULTS All presacral neurectomies in both groups were successfully completed by excising the hypogastric nervous plexus within the interiliac triangle. Presence of nerve ganglion and fibers was confirmed at pathologic analysis in all cases. Mean duration of presacral neurectomy, from incision of the posterior peritoneum at the sacral promontory to complete excision of the superior hypogastric nerve plexus at the interiliac triangle (Cotte triangle) was less than 10 minutes in both groups. Mean estimated blood loss was less than 30 mL for the entire surgical procedure (29.4 mL for RPSN, and 28.8 mL for LPSN). Median (range) patient age was 25 (19-44) years in the RPSN group, and 26 (18-36) years in the LPSN group; gravidity was 0, and parity was 0. All patients had central pelvic pain, the primary indication for presacral neurectomy. Concomitant indications for surgery included ovarian cysts, endometriosis, and adhesions. There were no intraoperative or postoperative complications. At analysis, follow-up ranged from 13 to 36 months. No short- or long-term complications related to the surgical procedure were reported. All patients reported subjective improvement of pelvic pain. CONCLUSION Robot-assisted laparoscopic presacral neurectomy is feasible and safe, without added risk of short- or long-term complications. It compares favorably to the conventional laparoscopic approach of presacral neurectomy. The surgical robot provides a better angle and 3-dimensional visualization of the operating field, similar to laparotomy, and supplemented with magnification. This combined with elimination of hand tremor enables better surgeon control.

Functional somatic syndromes as risk factors for hysterectomy in early bladder pain syndrome/interstitial cystitis

OBJECTIVE We tested the hypothesis that functional somatic syndromes (FSSs) are risk factors for hysterectomy in early bladder pain syndrome/interstitial cystitis (BPS/IC). METHODS In 312 women with incident BPS/IC, we diagnosed seven pre-BPS/IC syndromes: chronic pelvic pain (CPP), fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome (IBS), sicca syndrome, migraine, and panic disorder. Each was defined as present before 12 months (existing syndrome) or onset within 12 months (new syndrome) prior to BPS/IC onset. Retrospectively, we sought associations between prior hysterectomy and existing FSSs. Prospectively, we studied associations of existing and new syndromes with subsequent hysterectomy. Logistic regression analyses adjusted for age, race, menopause and education. RESULTS The retrospective study showed prior hysterectomy (N=63) to be associated with existing CPP and the presence of multiple existing FSSs. The prospective study revealed that 30/249 women with a uterus at baseline (12%) underwent hysterectomy in early BPS/IC. This procedure was associated with new CPP (OR 6.0; CI 2.0, 18.2), new IBS (OR 5.4; CI 1.3, 22.3), and ≥3 existing FSSs (OR 3.9; CI 1.1, 13.9). CONCLUSION Accounting for CPP and IBS, the presence of multiple FSSs (most without pelvic pain) was a separate, independent risk factor for hysterectomy in early BPS/IC. This suggests that patient features in addition to abdominopelvic abnormalities led to this procedure. Until other populations are assessed, a prudent approach to patients who are contemplating hysterectomy (and possibly other surgeries) for pain and who have IBS or numerous FSSs is first to try alternative therapies including treatment of the FSSs.