Dense Pelvic Adhesions Research Articles

Robot-Assisted Vaginal Natural Orifice Transluminal Endoscopic Surgery for Frozen Pelvis

To show feasibility and techniques used to perform a total hysterectomy, bilateral salpingectomy, endometriosis resection, and ovarian reconstruction in a patient with a frozen pelvis secondary to a history of ruptured tubo-ovarian abscess. Narrated step-by-step video demonstration. Single academic institution. In patients with a history of multiple abdominal surgeries, abdominal mesh, or in the case of this patient, a history of a ruptured tubo-ovarian abscess, a vaginal approach may be safer. Immediate access to the uterine pedicles through the vagina bypasses the need for extensive enterolysis and adhesiolysis when compared to an abdominal approach. With the use of indocyanine green injected into bilateral ureters, we highlight the benefits of immediate identification of the ureters allowing for safer and more efficient dissection. We show rotational uterine maneuvers to aid in rectosigmoid-to- posterior-uterus dissection in a limited space due to dense pelvic adhesions. Lastly, we demonstrate ovarian reconstruction and oophoropexy for the purpose of easier ovarian identification in future surgeries to possibly reduce the risks of ovarian remnant syndrome. This video highlights the feasibility and strategies used to perform robot-assisted vaginal natural orifice transluminal endoscopic surgery on a patient with a frozen pelvis.

Asymptomatic total uterine torsion led by unbalanced dense pelvic adhesions presented in a twin pregnancy.

SynopsisEarly diagnosis and recognition of altered anatomy are key to reduce maternal and fetal risks in asymptomatic uterine torsion.

Robotic hysterectomy for the treatment of refractory menometrorrhagia and squamous endometrial morules: A case report

Introduction: Abnormal uterine bleeding (AUB) is a common presentation in the field of gynecology. Proper diagnosis and management of this condition can be difficult and permanent treatment options, including robotic hysterectomy, may be necessary. In patients with a history of previous abdominal surgery, pelvic adhesions may present obstacles to this surgical approach. Case Report: In this case report, a 41-year-old woman desired permanent treatment for AUB. The patient underwent endometrial biopsy which revealed inexplicit squamous morules. She opted for permanent treatment via robotic hysterectomy. Her operation was complicated by the presence of dense pelvic adhesions caused by previous surgeries. Conclusion: This report aims to detail the potential difficulties in the clinical management of inconclusive biopsy results and in using a robotic approach to hysterectomy in the setting of pelvic adhesions. Authors encourage ongoing clinical investigation to determine the optimal methods for diagnosing and treating AUB.

CLINICAL OUTCOMES OF REVERSAL OF HARTMANN’S PROCEDURE

Background. Reversal of Hartmann’s procedure (HP) is one of the most complex surgical interven­tions in abdominal surgery with high morbidity rates of up to 58% in the patients after HP and mortality of up to 3.6%. Objective. This was a retrospective observational study to analyze the Hartmann’s reversal (HR) outcomes. Methods. The study involved 31 patients (16 males and 15 females), average age 59.6±10.31 (range 26-80), who underwent HR at Ternopil Regional Hospital in 2010 - 2021. The reasons for the HP were: cancer in 20 (64.5%) cases, perforation of the diverticulum – 6 (19.3%), traumatic rupture – 3 (9.7%) and Crohn’s disease - 2 (6.4%) cases. Results. Median time from Hartmann’s procedure to reversal was 11.13±9.24 months (interval 3-38). Intraoperative time was 210.33±56.91 minutes (range 120-330). HR was performed in 30 (96.8 %) patients. Dense pelvic adhesions of the stump of the rectum was diagnosed in 13 (41.9%) patients. Hand-sewn anastomosis was performed for 22 (71%) patients, stapler anastomosis – 4 (12.9%), pull-through technique – 3 (9.7%) patients. AL occurred in 3 (9.7%) patients on the 15th, 23rd and 35th postoperative days. pseudomembranous colitis was diagnosed in 2 (6.4%) patients with AL. The mortality rate was 1 (3.3%) as a result of septic complications due to AL; this case was not operated by a colorectal surgeon due to administrative issue in the hospital. Conclusions. Hartmann’s reversal is still one of the most difficult operations in colorectal surgery with high incidence of postoperative complications. Sound selection of patients with low comorbidity and in suitable time period is crucial for successful HR.

A randomized controlled trial of cystoinflation to prevent bladder injury in the adhesive disease of multiple caesarean sections

Caesarean sections carry the risk of urinary bladder injury due to formation of adhesions obscuring pelvic planes. Visualizing bladder during retro-fill (cystoinflation) makes it recognizable as it rises into the abdomen taking a tense rounded contour. We conducted a prospective randomized controlled trial to find out whether improved identification of bladder margins by cystoinflation could decrease bladder injury rate and blood loss without causing urological complications. This study included 214 healthy women with previous operative deliveries undergoing elective caesarean section and found to have dense pelvic adhesions. The subjects were randomly allocated into cystoinflation and control groups. Adhesiolysis was performed using bladder retro-fill with 300 cc saline in cystoinflation group, and without retro-fill in control. The bladder injury rate was significantly lower in cystoinflation group compared to control (2.8% vs 20.6%, P < .0001) with lesser blood loss in cystoinflation group (585.33 cc vs 797.10 cc, P < .0001). Mean operative time was similar in both groups. Urinary tract infection and micturition problems occurred more frequently in control group than cystoinflation group (16.8% vs 1.9%, P = .001 and .47 ± 1.63% vs 077 ± .633%, P = .021 respectively) with fistula in one subject compared to none in cystoinflation group. In this study, cystoinflation was effective to significantly reduce bladder injury rate and blood loss. This technique may also prove useful in the fields of surgery, urology and urogynecology.

Primary Fallopian Tube Carcinoma Preoperatively Diagnosed as Cervical Cancer

Primary fallopian tube carcinoma (PFTC) is an uncommon gynecologic malignancy that is often diagnosed in the advanced stage. We present herein a case of a 59-year-old female with PFTC diagnosed with an approximately 20-mm cervical tumor on visual inspection. Cervical biopsy showed carcinoma and systemic computed tomography demonstrated no evidence of metastasis. The patient was accordingly diagnosed with cervical adenocarcinoma stage IB1 (FIGO 2008). Abdominal radical hysterectomy including bilateral salpingo-oophorectomy and pelvic lymphadenectomy was performed. However, it was difficult to operate because of dense pelvic organ adhesions and pouch of Douglas obliteration accompanied with deep infiltrating endometriosis. There was no peritoneal dissemination. On histopathological examination, high-grade serous carcinomas arising from the left fallopian tube and metastasized to the endometrium, cervix, vagina and multiple pelvic lymph nodes and forming a tumor in the cervix were noted. The patient was diagnosed with PFTC stage IIIA1 (ii) (FIGO 2014), pT2aN1bM0 (eighth UICC). She received six cycles of docetaxel and carboplatin every 3 weeks and presented no evidence of disease for 6 months after the chemotherapy. In conclusion, this is a rare case in which PFTC was preoperatively diagnosed as cervical cancer. J Clin Gynecol Obstet. 2020;9(1-2):21-24 doi: https://doi.org/10.14740/jcgo630

A case of obstructed hemivagina and ipsilateral renal anomaly syndrome complicated with pyometra: tips and tricks for laparoscopic hemihysterectomy

A case of obstructed hemivagina and ipsilateral renal anomaly syndrome complicated with pyometra: tips and tricks for laparoscopic hemihysterectomy

Comprehensive Surgical Staging in Stage 1 Clear Cell and Endometrioid Ovarian Carcinomas: Is it Necessary?

The objective of this article was to evaluate the presence of occult metastasis after comprehensive surgical staging of clear cell ovarian carcinoma (CCC) and endometrioid ovarian carcinoma (EMCA) that appeared to be confined to the ovary at time of surgery. Between 1998 to 2016, 85 patients with CCC and EMCA were identified who were comprehensively staged and felt to be stage 1 intraoperatively. Of the 85 patients who underwent surgical staging, 4 (4.7%) had omental and dense pelvic side-wall tumor adhesions. On final pathology, 67 (79%) patients were diagnosed as stage 1A of which 29 (43%) patients were upstaged to 1C1 due to intraoperative rupture. The remaining 18 (21%) patients were staged as 1C2/1C3. The 1- and 5-yr disease-free survival for pathology stage 1A tumors was 94% and 76%, respectively, and for 1C2/1C3 tumors was 100% and 75%, respectively. Among patients who received adjuvant chemotherapy, the 5-yr disease-free survival was near equal for pathology stage 1A and 1C2/1C3 groups (73% vs. 74%), with a lower 5-yr disease-free survival for CCC compared with EMCA (72% vs. 78%). There were 16 (19%) recurrences with 12 being pathology stage 1A. Of these 12 patients, 9 (75%) had CCC of which 2 received adjuvant chemotherapy. Even in the presence of dense adhesions (4.7%), the likelihood of extraovarian disease in CCC and EMCA confined to the ovary was very low. Accordingly, the findings in this study indicate that comprehensive surgical staging for what appears to be stage 1 CCC and EMCA may provide no benefit in detecting occult disease that would upstage the tumor.

Hysteroscopic Placement of Platinum Microinsert in Patients With Hydrosalpinx Before In Vitro Fertilization and Embryo Transfer

To investigate the effectiveness of Tornado and Hilal (Cook Medical, Bloomington, IN) hysteroscopic proximal tubal occlusion (HPTO) for hydrosalpinx (HX) treatment before in vitro fertilization (IVF) and embryo transfer (ET) in patients with dense pelvic adhesions or low ovarian reserve. A retrospective study of patients treated between May 2014 and May 2016 (Canadian Task Force classification III). A university-affiliated center. One hundred fifty women with unilateral or bilateral HX who were not candidates for laparoscopic surgery. Tornado or Hilal HPTO before IVF-ET and/or frozen ET. The main outcome was the cumulative live birth rate. Tornado or Hilal placement was successful for 143 (95.3%) patients. Of the 132 patients who underwent 204 ET cycles, 86 (65.2%) conceived, and 78 (59.1%) resulted in live births. The overall early and late miscarriage rates per clinical pregnancy were 12.8% and 1.1%, respectively. The ectopic pregnancy rate was 2.3%. No major complications occurred. Tornado or Hilal HPTO is an effective alternative for treating HX before IVF-ET/frozen ET in patients with dense pelvic adhesions or low ovarian reserve.

20: Laparoscopic management of ovarian remnant syndrome

The purpose of this video is to review the diagnosis and risk factors of ovarian remnant syndrome and to demonstrate the laparoscopic excision of an ovarian remnant through two case presentations. Ovarian remnant syndrome is defined as the presence of a pelvic mass with residual ovarian tissue after previous oophorectomy. Predisposing factors that contribute to incomplete removal of ovarian tissue increase the risk of ovarian remnant syndrome and these include dense pelvic adhesions from multiple prior surgeries or endometriosis, anatomic variations, intraoperative bleeding, pelvic inflammatory disease, and poor surgical technique. Ovarian remnants are frequently located on the pelvic sidewall near the vaginal vault and may be encased in dense and fibrotic scar tissue, which makes surgical excision challenging. This video demonstrates advanced laparoscopic techniques for excision of an ovarian remnant through two case presentations. Ovarian remnant syndrome can be a diagnostic dilemma and surgical challenge. A high index of suspicion is essential for the diagnosis of ovarian remnant syndrome in patients with increased risk factors. Regardless of surgical approach, excision of an ovarian remnant is inherently associated with significant risks and intimate knowledge of pelvic and retroperitoneal anatomy is essential. Laparoscopic resection is considered safe and feasible, and can be a challenge even in the best of hands.

8: Retroperitoneal approach for bilateral salpingo-oophorectomy

This video outlines a step-by-step guide on how to gain simple access to the retroperitoneum while performing a laparoscopic BSO and emphasizes the importance of performing retroperitoneal dissection in difficult surgeries that are complicated by endometriosis, dense pelvic adhesions or distorted anatomy. The steps demonstrated in the video are as follows:1.Identify the IP ligament and retract medially2.Incise the peritoneum lateral and parallel to the IP ligament3.Develop the retroperitoneal space using blunt dissection4.Identify important retroperitoneal structures5.Visualize the ureter6.Incise the peritoneum superior to the ureter and inferior to the IP ligament. Many common complications, such as ureteral injury and ovarian remnant syndrome can be avoided by opening the retroperitoneum during a laparoscopic BSO.

Transient ureteral obstruction and anuria post ureteric catheterization: a case report

This is the case of a 37 years old woman presenting with a (10 cm × 6 cm) heterogenous right ovarian swelling and a history of having had previous four caesarean sections with dense pelvic adhesions. The patient was listed for exploratory laparotomy and right adnexectomy. Prophylactic bilateral ureteric catheters were inserted via cystoscopy prior to the start of the surgical procedure to reduce the risk of iatrogenic ureteral injury. The operation was completed uneventfully. In the immediate postoperative period the patient complained of severe suprapubic pain and haematuria and the ureteral catheters were removed with improvement of he symptoms though the haematuria persisted. During the 1st postoperative day, it was noted that the urine output, vital signs and laboratory investigations were within normal range. On day 2 postoperative the patient complained of severe bilateral flank pain, oliguria and haematuria. Despite intravenous fluid challenge the urine output remained minimal up to anuria (urine output of 150 cc in 12 h). Kidney function tests revealed progressive rise in serum creatinine and urea levels (296 uml/l (N: 53–97) and 7.7 mmol/l (N: 2.5–6.7) respectively. A CT scan abdomen and pelvis showed bilateral hydronephrosis and hydroureter down to the level of the urinary bladder with no evidence of obstruction in the course of the ureters. Chest X-ray revealed signs of pulmonary congestion. The patient was given 80 mg intravenous diuretic (Lasix) and was consented for ureteric recatheterization aiming to relieve the obstruction in case of failure of the conservative medical management. Surprisingly, the patient responded dramatically to the diuretic injection with improvement in the urine output and progressive decrease in serum creatinine and urea levels down to normal values within 24 h. The haematuria cleared out within the next few days. Follow up renal scans revealed gradual improvement in the hydronephrosis and hydroureter. Conclusion: It was published in series report that the incidence of obstructive anuria after ureteral catheter removal varies from 0 to 7.6% (1). So, the safety of prophylactic preoperative bilateral ureteric catheterization to reduce ureteric injury has been questioned due to reports of this rare but serious phenomenon of reflux anuria. Till now there are no proven strategies for prevention of this condition but staged removal has shown trend towards reduced incidence (2). When encountered most cases resolved with conservative management only. However, indwelling recatheterization has been advocated as an emergency management while oedema resolves. Additionally, in our case, the use of diuretic might have expedited recovery.

Technique of extraperitoneal uterosacral ligament suspension for apical suspension.

Vaginal vault prolapse can occur alone or in combination with anterior or posterior compartment prolapse. Apical prolapse has shown a strong correlation with anterior wall prolapse and a moderate correlation with posterior wall prolapse. The McCall culdoplasty uses the extraperitoneal vaginal approach to support the vault at the time of hysterectomy. Sacrospinous fixation and ileococcygeus suspension with or without mesh have also been used for the treatment of vaginal vault prolapse. The uterosacral ligaments can also be used to re-suspend the vaginal vault using the extraperitoneal or transperitoneal approach. With the extraperitoneal approach, the peritoneal sac, which can be difficult to access at times, especially when there are dense pelvic adhesions, does not need to be opened. The extraperitoneal approach also carries a lower risk of ureteric injury, as the ureters and the bladder can be retracted from the field using a Breisky-Navratil retractor. This video, which documents the surgical treatment of a woman with a complete vaginal eversion and grade 3 pelvic organ prolapse (POP), was recorded in a live workshop during the 2015 Urogynaecology and Reconstructive Pelvic Surgery Conference, held in Chennai, India, in January 2015. It is aimed at educating interested surgeons in the technique of extraperitoneal uterosacral suspension. This video demonstrates the extraperitoneal approach to uterosacral ligament suspension for apical support in women with vaginal vault prolapse.

Hand-assisted laparoscopic surgery and its applications in gynecology

Abstract Laparoscopic surgery has been used extensively since it was first applied in the 1980s. The advantages are generally accepted and include less pain, smaller incisions, faster recovery, and shorter hospital stays. However, several limitations associated with standard laparoscopic surgery (SLS) have become apparent and include the loss of tactile sensation, problems with the removal of bulky and intact specimens, and the restriction of visualization of the entire operating field. These problems with SLS helped to inspire the development of laparoscopically assisted surgery followed by hand-assisted laparoscopic surgery (HALS). In a hand-assisted laparoscopic procedure, an incision is made in the patient’s abdomen. Then, a uniquely designed appliance is introduced into the abdominal cavity through the incision to maintain pneumoperitoneum. With the inserting hand, surgeons can provide manual exposure, traction, palpation, and dissection because of the feedback of tactile sensation. HALS has gained acceptance for a wide range of abdominal procedures in general surgery and urology and is now feasible for complicated surgeries such as splenectomy, nephroureterectomy, and colectomy. It has been demonstrated in numerous specialties that HALS is a safe and efficacious technique that combines the benefits of laparoscopy with the advantages of a conventional laparotomy. Standard laparoscopic surgery also has limitations in gynecological surgery. A patient may have high risks with conventional laparoscopic surgery when she has deep invasive endometriosis, multiple or massive myoma, or dense pelvic adhesions from prior surgery. HALS overcomes many of the aforementioned limitations, has less conversion to open surgery, and broadens the indications for minimally invasive surgery, not only for benign tumors but also for pelvic malignancies.

Essure® for management of hydrosalpinx prior to in vitro fertilisation—a systematic review and pooled analysis

Hydrosalpinges in infertile women reduce the success of in vitro fertilisation (IVF) by 50%. Surgical management of hydrosalpinges before IVF improves outcome but these procedures are often contraindicated in women with dense pelvic adhesions. Tubal occlusion achieved by Essure(®) via hysteroscopy provides an alternative. To conduct a systematic review on the efficacy and safety of Essure(®) in the management of hydrosalpinx before IVF. We searched MEDLINE (January 1950 to July 2013), EMBASE (January 1980 to July 2013) and Web of Science (1899 to July 2013). We also searched reference lists of relevant articles and proceedings of relevant international conferences (2000-2013). All types of studies where women with suspected infertility and presence of hydrosalpinx had hysteroscopic tubal occlusion with Essure(®) before IVF. Two authors independently selected studies and extracted data. Where necessary, study authors were contacted for further data. In all, 115 women in 11 studies received Essure(®) , mainly in the outpatient setting where local anaesthesia by paracervical block and/or intravenous sedation was used. Successful placement of Essure(®) was achieved in 96.5% (95% confidence interval [95% CI] 91.1-98.9%) of women and tubal occlusion in 98.1% (95% CI 93.1-99.9%). Subsequent IVF resulted in 38.6% pregnancy rate (95% CI 30.9-46.8%), 27.9% live birth rate (95% CI 21.1-35.8%) and 28.6% combined ongoing pregnancy and live birth rate (95% CI 21.7-36.6%) per embryo transfer. Essure(®) appears to be an effective option for management of hydrosalpinx in women before IVF although evidence from a randomised controlled clinical trial is lacking.

The First Laparoscopic Vesicovaginal Fistula Repair in Iran

Background: Vesicovaginal fistula (VVF) is the most common acquired fistula of the urinary system. Different surgical techniques exist, but having several advantages make laparoscopy as a favorable method. According to the recent data, we have performed the first laparoscopic repair of VVF in Iran. Case report: A 19-year-old (G1P1) woman, referred to our center, complaining from continuous urinary incontinence from 7 months ago. She developed continuous wetting after her first cesarean section, performed 7 months ago. Methylene blue dye test, was positive for VVF and voiding cystourethrogram (VCUG) confirmed the diagnosis. Cystoscopy revealed the exact location of fistula in the bladder wall. Patient underwent laparoscopic VVF repair using transperitoneal transvesical approach in the supine position. Patient did not have any urinary leakage during hospitalization and discharged with urethral indwelling catheter at fourth day after the operation. Voiding cystourethrogram was done after 2 weeks, and it was normal without any extravasations. Discussion: Dense pelvic adhesions and/or inflammation from prior abdominal surgery can make this approach less desirable in some patients. Furthermore, intracorporeal laparoscopic suturing requirement for VVF repair is an advanced skill many surgeons lack. We used transabdominally transvesical laparos copic method and, according to the literature review, this is the first case of VVF laparoscopic surgery performed in Iran.

Treating symptomatic adhesions to the sigmoid colon: colectomy improves quality of life

When severe chronic pelvic pain, constipation, and bloating are due to dense pelvic adhesions fixing the sigmoid loops, patients may be offered the option of sigmoid colectomy. This study examines the effectiveness of colectomy in the treatment of such patients. Patients were identified from a surgical database, demographic data were abstracted, and charts were reviewed. Patients were interviewed postoperatively. Primary end points were morbidity, length of stay, change in bowel habit, and patient satisfaction. There were 46 patients (44 women) with a mean age of 54.7 years (±14.3). Forty-three had a history of prior pelvic surgery (93%), including 30 (65%) with hysterectomy. One quarter had been diagnosed with irritable bowel syndrome. Surgery revealed adhesive tethering of the sigmoid colon in 43 patients (94%). Mean length of stay was 6.5 days (±2.5), and complications occurred in eight (17.3%) patients. There were no deaths, and no patients required a stoma. Follow-up in 37 patients after mean of 7.2(±5.0) years showed significant reductions in abdominal pain and bloating postoperatively, with normalization of bowel function and increase in quality of life. When severe lower abdominal pain and bloating in women who have had pelvic surgery are reproduced by colonoscopy, and there is an obvious kink in the bowel, sigmoid colectomy is worth considering.

Robotic-assisted laparoscopic trachelectomy: a case series and review of surgical technique.

We present a retrospective case series of patients who underwent robotic-assisted laparoscopic trachelectomies from August 1, 2011 to August 30, 2012, with a description of the surgical technique for successful cervical removal. The patients, at the Department of Obstetrics and Gynecology, Division of Urogynecology and Minimally Invasive Surgery at Penn State Milton S. Hershey Medical Center, were identified using ICD-9 coding for robotic-assisted trachelectomy. Of the 180 patients who had robotic-assisted gynecologic surgery during the study period, eight underwent robotic-assisted laparoscopic trachelectomy. The patients' average age was 40.4years, average parity was 1.5, and mean body mass index was 28. The time interval from initial surgery of supracervical hysterectomy to robotic-assisted trachelectomy was 4years. Pre-operative cervical cytology was negative in all patients. The average length of stay was one overnight admission. The primary indication for prior supracervical hysterectomy was dense pelvic adhesions, and the main indications for robotic-assisted trachelectomy were pelvic pain due to endometriosis and cyclic vaginal bleeding. Surgical outcomes included minimal blood loss (<50ml) and mean operative time of 1.15h (74.88min), without any immediate intra-operative or post-operative complications reported. Histopathology reports on all cervical specimens were normal. Adnexectomy is the most common concomitant procedure performed with trachelectomy. Robotic-assisted laparoscopic trachelectomy is a viable option for patients requesting a minimally invasive approach to cervical stump removal.

Predictors of failure to perform pelvic peritoneal cytology in endometrial cancer staging surgery.

201 Background: The Federation of Gynecology and Obstetrics (FIGO) staging system and the National Comprehensive Cancer Network (NCCN) guidelines for endometrial cancer recommend performing pelvic peritoneal cytology to look for the presence of cancer cells in the peritoneal cavity in patients who are undergoing surgical staging of apparent non-metastatic disease. About 10% of cases have positive cytology and this information is used in formulating plans for adjuvant therapy. However, adherence to the guidelines recommending that cytology be performed is not universal. In this study, we sought to identify factors associated with failure to perform pelvic peritoneal cytology at the time of endometrial cancer staging surgery. Methods: We performed a retrospective study of women with FIGO stage I/II endometrial adenocarcinoma who underwent endometrial cancer staging surgery at our institution from 1993-2007. Predictors of failure to perform cytology that were investigated included: surgeon, presence of adhesions, intraoperative blood loss and conversion from laparoscopy to laparotomy. Results: Among 1,112 cases, peritoneal cytology was not performed in 76 (6.8%). In 30 cases cytology was not performed for valid reasons including 15 in which the surgery was performed vaginally, 10 in which the diagnosis of endometrial cancer was not known prior to surgery and 5 in which gross evidence of stage III/IV disease was found at surgery. Of the remaining 46 cases, 11 (23.9%) had surgery that was converted from laparoscopy to laparotomy, 16 (34.8%) had dense pelvic adhesions and 40 (87.0%) had an estimated blood loss greater than 100 ml. The frequency of these and other risk factors will be compared to that seen in a matched cohort of patients who did have pelvic peritoneal cytology performed. Conclusions: Our analysis will investigate predictors of failure to perform pelvic peritoneal cytology. Increased awareness of these factors has the potential to improve compliance with this accepted procedure that plays a role in planning adjuvant therapy for early stage endometrial cancer.

The relation of pelvic pain and dense adhesions to Doppler ultrasound findings in patients with ovarian endometriomas

To study the relation of pelvic pain symptoms and pelvic adhesions to Doppler ultrasound findings in patients with ovarian endometriomas. 62 patients who underwent laparoscopic surgery for endometrioma were divided into two groups according to their pelvic pain symptoms. Group 1 (n = 27) included patients with pelvic pain, group 2 (n = 35) asymptomatic patients. Patients were evaluated for the vascularization of endometrioma by transvaginal color and power Doppler ultrasonography before the surgery. The presence and amount of blood flow reported in terms of a color scale, pulsed Doppler indices, and dense pelvic adhesions were compared between the groups. The relation of Doppler ultrasound findings to the dense pelvic adhesions was also analyzed. Blood flow was present in 74.1 % (n = 20) of patients in group 1 and 68.6 % (n = 24) in group 2 (p = 0.63). The volume and vascularization of the endometriomas, pulsed Doppler indices, stage of endometriosis, and the presence of dense pelvic adhesions were also similar. Patients with dense pelvic adhesions had significantly higher amount of blood flow compared to patients without adhesions (p = 0.006), but the mean pulsatility index and resistance index were not different between the groups (p = 0.55 and 0.59, respectively). Pelvic pain symptoms were not found to be related to endometrioma vascularization. On the other hand, we observed an association between higher vascularized endometrioma and the presence of dense pelvic adhesions.