Endometriotic Nodules Research Articles

Laparoscopic Management of Vaginal Vault Fibroids

Video Objective To demonstrate a rare case of vaginal vault fibroids post hysterectomy presenting 7 years after primary surgery. Setting Tertiary Care University recognised Endoscopy Referral Unit. Case Details 49 year old patient who underwent Total laparoscopic hysterectomy 7 years back with intermittent spotting and frequency of urination with ultrasound demonstrating multiple well defined hypo-echoic masses at the vault region. Interventions Laparoscopic management of multiple parasitic fibroids at the vaginal vault. Pre-operative cystoscopy was undertaken and it was found that the fibroid was bulging into the posterior wall of the bladder with close association to the right ureter. Use of dilute vasopressin as in normal myomectomy was done. Fibroids were enucleated which remained hidden in the recto-vaginal and vesico-vaginal plane. As one fibroid was enucleated another came into view representing a tip of the iceberg phenomenon. Vault which got opened during fibroid enucleation was sutured back with standard techniques. Conclusion Such a rare entity like vaginal vault fibroids can pose a diagnostic dilemma with confusing differentials like stump carcinoma, vault granulomas, chronic infections or endometriotic nodules. Dealing with such fibroids is usually easy but can pose a challenge if large in size distorting the ureteric anatomy and its close association with bladder or the rectum. It also highlights the non-sarcomatous hazards of uncontained morcellation, be it trans-abdominal or vaginal morcellation.

1959 Laparoscopic Resection of Bladder and Uterine Cervix Endometriotic Nodule

Video Objective Laparoscopic resection of bladder endometriosis is associated to the benefits of a minimally invasive approach. In this video, we aim to describe the surgical strategy applied in the treatment of anterior compartment deep endometriosis with bladder and uterine cervix infiltration. Setting Academic and public hospital. Patients A 37-year-old patient, with dysmenorrhea since the menarche, dysuria and dyspareunia for the last 3 years, without improvement with medical treatment. Complementary exams showed a 2,18cm bladder endometriosis nodule with an extension to cervical and anterior isthmic region of 1,87cm, and a proximity to the ureters bilaterally. The patient desired possible future fertility. Interventions Laparoscopic approach for treatment of bladder and uterine lesion. Measurements and Main Results Laparoscopic surgery identified the limits of the lesion. Nodule affected the round ligament bilaterally, bladder, and uterine serous layer. Both ureters were dissected since iliac bifurcation until uterine vessels. Horizontal incision was performed on the bladder around the lesion until the foley catheter visualization to avoid de ureteral meatus. Vesicouterine space was dissected and an 5cm lesion compromising the uterine serous to the cervix was removed. Yabuki space was recognized during the nodulectomy. Vaginal closure was made primordially followed by the vesical suture using 0 and 2-0 polygactin respectively. Operation was successfully completed. Patient was discharged 5 days later. Foley catheter and prophylactic antibiotic were used for 10 days. Social, urinary and sexual activities with improvement in pain and better quality of life. Conclusion Urinary tract endometriosis is a rare disease, but when it occurs the bladder is the most affected site. Patients often complain of dysuria, hematuria, and chronic pelvic pain. Partial bladder cystectomy offers complete removal of endometriotic nodule promoting improvement of urinary symptoms and quality of life.

1927 Fertility Preserving Laparoscopic Excision of Deep Rectal Infiltrating Endometriosis. Success with a Multidisciplinary Team

Video Objective The objective of this video is to demonstrate the multidisciplinary approach for surgical excision of deep infiltrating endometriosis of the rectum. Setting 31 y/o G0P0 presented with pelvic pain & dyspareunia and pre-menstrual severe constipation. Interventions The patient underwent laparoscopic excision of deep infiltrating endometriosis of the rectum, and excision of pararectal deep endometriotic nodule. Followed by low anterior resection of rectum and intracorporeal anastomosis. Conclusion Minimally invasive surgical management of deep infiltrating endometriosis nodules of the rectum is feasible with excellent fertility and surgical outcomes.

1501 Vaporization and Coagulation Techniques for Excision and Ablation of Endometriosis

Study Objective To demonstrate technical problems from the 1980s that resurfaced in 2018. Design Review of published reports. Setting Literature and web review. Patients or Participants Cases previously published. Interventions Laparoscopic laser and non-laser vaporization and coagulation. Measurements and Main Results A 2018 YouTube on non-laser vaporization demonstrated a problem with field distortion and incomplete vaporization that was seen in the 1980s with lasers. This presentation uses images and illustrations to review and discuss what we learned 30 years ago and how that applies to laser, electrosurgical, and kinetic energy by contrasting the outcomes for superficial and deep endometriosis. Those observations encouraged some of us adopted Kurt Semm's 1980 approach to excision of deep nodules. The discussion includes single finger exams, exam under anesthesia before initiating surgery, exam during surgery, exam after ablation or excision, delineation of margins, appropriate power density, thermal damage, carbonization, techniques that obscure endometriosis, and complications including unnecessary repeat surgery. Single finger exam, discussed as early as 1869, was taught by Richard “Pete” Hollis (ACOG president 1993) by 1985 and reinforced in Steege & Siedhoff's 2014 approach to pelvic pain evaluation. Dr. Hollis discussed this with respect to excision of endometriotic nodules at laparotomy using vaginal examination before excision to localize a nodule, during excision to push lesions into the field, and after excision to confirm removal. It is important to use techniques that adequately identify and remove deep endometriosis. Low power density laser and non-laser techniques can create problems including thermal burn, inconsistent depth, and carbonization that can increase the chance of leaving endometriosis behind. Carbonization can obscure endometriosis at initial surgery, increase the chance of reoperation, and obscure endometriosis at subsequent surgery. Conclusion Vaporization and coagulation techniques may be useful for small, focal, endometriotic lesions, but can be inadequate for deep infiltrating endometriosis.

Wise Techniques for Excision of Severe Ureteric and Rectal Endometriosis

Video Objective To provide logical steps and demonstrate wise techniques to minimise complications during laparoscopic surgery for severe ureteric and rectal endometriosis. Setting A 40 year old para 2 (normal vaginal deliveries) with no significant past medical history, presented with 2 year history of dysmenorrhea, abdominal bloating with constipation. Her pelvic ultrasound showed a 13 cm left endometrioma. Recently, she also developed urinary frequency, urgency and nocturia, consistent with the pressure effect of her large cyst. Abdominal palpation revealed an 18 week size mass and pelvic examination demonstrated a tender fixed uterus. Her CA 125 was within normal range (21 U/ml). The diagnosis is severe endometriosis. Interventions The patient underwent laparoscopic excision of endometriosis including ovarian cystectomy. Conclusion Stage 4 endometriosis was confirmed by laparoscopy. Surgical steps and techniques to manage severe endometriosis are discussed as follow: The first step of surgery is to decompress the large ovarian cyst in order to obtain adequate space for the surgical working field. During decompression, we used an endo-loop to prevent spillage of the large endometrioma. The next step is to normalize pelvic anatomy with good dissection technique. In this case, an active bleeding point was very close to the left ureter on the pelvic side wall. Due to the risk of thermal damage to the ureter, direct surgical diathermy on the pelvic side wall without identifying the ureter should be avoided. Therefore, to achieve temporary haemostasis and gain an optimal surgical view, the assistant used a grasper to clamp the bleeding point during ureterolysis. To avoid rectal injury, the use of a rectal probe during rectovaginal adhesiolysis to delineate the rectum is a wise technique. In addition, appropriate uterine manipulation is important to delineate the uterosacral ligaments, so we have anatomical landmarks to safely excise endometriotic nodules.

2908 Ultrasound Findings in Patients Referred to an Endometriosis Unit in a Tertiary Centre: Does Previous Surgery Matter?

Study Objective The objective of this study is to analyze the ultrasound findings in patients referred to an endometriosis unit with and without previous endometriosis surgeries over one-year period. Design Retrospective study including 430 patients who had a first visit and an ultrasound scan at an endometriosis referral unit from January to December 2018. Information about surgical history and ultrasound findings was collected. Setting Endometriosis referral unit in a tertiary hospital in Barcelona, Spain. Patients or Participants 430 patients referred to the endometriosis unit were included. Interventions Ultrasound scan was performed according to the protocol stablished in this unit. Measurements and Main Results 177 patients (41.2%) had a previous history of endometriosis surgery. 72.9% of them had one previous surgery and 14.7% had two whereas 12.4% had three or more. Laparoscopy was the main route, which was used in 74.6% of them. The main procedures were endometrioma decapsulation (45.6%) followed by adnexal surgery (19.8%) and deep infiltrating endometriosis nodule excision (16%). Only 2.7% of patients had a previous bowel resection. When comparing the ultrasound findings between patients who have a previous endometriosis surgery with those without, statistically significant differences were found in the presence of ovarian adhesions, ovarian endometriomas, presence of intestinal endometriotic nodules and Douglas-blockage. Conclusion More than 40% of patients referred to the endometriosis unit had had a previous surgery. They had a higher rate of presence of intestinal endometriotic nodules among other ultrasound findings. Thus, it reinforces the need of referral units in order to establish a precise treatment either medical or surgical with high-skilled surgeons.

Diaphragmatic Endometriosis: Classification of Lesions in a Retrospective Series of 150 Patients Treated by Minimally-Invasive Surgery in a Single Third-Level Referral Center.

Study Objective To create a classification of diaphragmatic endometriosis (DE) in order to better select the surgical treatment of endometriotic nodules, depending on their size and localization. Design All the patients treated for deep infiltrating endometriosis (DIE) with DE between January 2004 and December 2018 were retrospectively reviewed. All the patients underwent surgery by laparoscopic approach or video-assisted thoracoscopic surgery (VATS). Diaphragmatic lesions were classified in three groups according to size, shape and depth of muscular infiltration. Setting Department of Obstetrics & Gynecology, and Thoracic Surgery, IRCCS Sacro Cuore Don Calabria Hospital – Negrar (Verona), Italy. Patients or Participants 150 patients with DE were identified. Interventions 128 patients were treated by laparoscopy, 21 by VATS and 1 of them had VATS combined with laparoscopy. Measurements and Main Results Patients were divided into 3 groups, according to the proposed classification. The first group of 99 patients (66%) included those with superficial lesions ≤ 1 cm. These lesions were called ‘foci' and were treated by diathermocoagulation (DTC) or argon laser vaporization. The second group included 17 patients (11,3%) with lesions called ‘plaques', bigger than 1cm, bidimensional and caused thickening of the involved tissue, without deep infiltration of the muscular layer of the diaphragm. These lesions were usually removed by diaphragmatic stripping. In the last group, the lesions were called ‘nodules', they were larger than 10 mm, and with deep infiltration of the diaphragm These nodules were observed in 34 patients (22,6%) and were removed by laparoscopic excision with diaphragmatic resection or by VATS. Conclusion Diaphragmatic nodules can be easily classified in one of the proposed groups. Considering this classification, different methods of surgical treatments of DE can be chosen, in order to allow a total and safe removal of the lesions, with low complications rate and a significant improvement of patients' symptoms.

2607 Hysterectomy in Women with Endometriosis

Video Objective To demonstrate that hysterectomy is not the ideal treatment for endometriosis and how to perform a hysterectomy in patients with endometriosis. Setting We describe a case of a 42 years-old woman referred to our center complaining of severe dysmenorrhea, dyspareunia and menorrhagia. The patient had 2 previous cesarean section and with no relevant past medical. The pre-operative investigation involved a transvaginal ultrasonography with bowel preparation that showed an infiltrative endometriotic nodule on the paracervix and posterior vaginal fornix, rectosigmoid and vesicouterine space besides adenomyosis. The patient was in clinical treatment with medroxyprogesterone acetate, without response. We scheduled a surgical procedure for radical eradication of the deep infiltrating endometriosis and hysterectomy. Interventions A step-by-step surgical video, demonstrating a systematic approach in case of deep infiltrating endometriosis, indicating surgical landmarks and a proper technique. It emphasizes mainly that we should start with the endometriosis treatment before the hysterectomy. Conclusion According to literature, there are no randomized controlled trials for hysterectomy as the treatment for endometriosis. We should only offer hysterectomy with a radical removal of endometriosis and for those women who have completed their families and failed to respond to more conservative treatments.

1533 Robotic-Assisted Laparoscopic Excision of Deep Infiltrating Endometriosis Involving the Ureter

Video Objective This video demonstrates a safe and effective minimally invasive technique for enterolysis, oophorectomy and subsequent ureterolysis in the face of deep infiltrating (DIE) and deep fibrotic endometriosis. Setting The index patient is a 38 y/o G3P2012 patient with a history of endometriosis and a recurrent right endometrioma causing pelvic pain, dyschezia and dyspareunia. She was referred to our center for further management after previous surgical interventions failed to adequately address her symptoms. Interventions A preoperative pelvic MRI revealed a 7.6 cm right ovarian mass, replacing the majority of the right ovary and consistent with an endometrioma. Intraoperatively, the right ovary was encased in adhesions involving the small bowel, sigmoid colon, rectum and the right pelvic side wall. A deep fibrotic endometriotic nodule was also noted to be encasing the right ureter for most of its course towards the bladder. Careful and extensive dissection was performed, freeing the diseased ovary from all its attached structures. Resection of the fibrotic tissue surrounding the ureter was then carried out with good surgical rigor, thus successfully achieving the ureterolysis. A double J right ureteral stent was subsequently placed by the urology team. The patient had complete resolution of her pain symptoms at her post-operative visit. Conclusion Extensive fibrotic endometriosis involving the ureter can make ureterolysis quite difficult. Careful planning, knowledge of anatomical variance and proper surgical techniques are beneficial in overcoming such challenges. Despite its recalcitrant nature, endometriosis affecting the ureters can be effectively resected to afford a favorable outcome for patients.

Reprint of: Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities

OBJECTIVE: To review the histogenesis of peritoneal, ovarian, and rectovaginal endometriotic lesions. DESIGN: The comparison of morphologic, morphometric, and histochemical data observed in each type of lesion. SETTING: A university hospital department of gynecology. PATIENT(S): Patients complaining of infertility or pelvic pain with laparoscopically proved endometriosis. INTERVENTION(S): Laparoscopy was performed, and biopsy specimens from the endometriotic lesions were histologically studied. RESULT(S): Three types of endometriotic lesions must be considered: peritoneal, ovarian, and rectovaginal. Morphologic and morphometric data show similarities between eutopic endometrium and red peritoneal lesions, suggesting that these lesions are the first stage of early implantation of endometrial glands and stroma. After partial shedding, the red lesions regrow constantly. The shedding induces an inflammatory reaction, provoking scarification, and the lesions become black. The subsequent fibrosis leads to areas of white opacification that are inactive. The pathogenesis of ovarian endometriomas is a source of controversy. Although there seems to be a consensus concerning the invagination theory, there is still a contradiction between the implantation theory and the metaplasia theory. We recently showed that the mesothelium covering the ovary can invaginate into the ovarian cortex, pushing back the primordial follicles. The presence of mesothelial invagination in continuum with endometriotic tissue suggests that metaplastic histogenesis of ovarian endometriotic lesions occurs. Rectovaginal endometriotic nodules must be considered adenomyomas, consisting of smooth muscle with active glandular epithelium and scanty stroma. Immunocytochemical results show poor differentiation and hormonal independence of these lesions and indicate a close relation with their mesodermal mullerian origin. CONCLUSION(S): Peritoneal, ovarian and rectovaginal endometriotic lesions must be considered as three separate entities with different pathogeneses.

OP14.02: Changes in the volume of rectosigmoid endometriotic nodules during 24‐month treatment with dienogest: prospective cohort study

OP14.02: Changes in the volume of rectosigmoid endometriotic nodules during 24‐month treatment with dienogest: prospective cohort study

Sonographic Evaluation for Endometriosis in Routine Pelvic Ultrasound

To show how the evaluation for endometriosis can be included in the routine pelvic ultrasound examination. Stepwise narrated video demonstration of the sonographic evaluation for endometriosis in routine pelvic ultrasound following the recommended sonographic approach published in the 2016 consensus paper by the International Deep Endometriosis Analysis (IDEA) group [1]. Endometriosis is a common and often debilitating gynecological disorder that affects 5-10% of women [2]. The prevalence is even higher among women with symptoms of endometriosis [2], which include chronic pelvic pain, acquired dysmenorrhea, dyspareunia, dyschezia, menorrhagia, abnormal bleeding, and infertility. Approximately 80% of women who have endometriosis have superficial lesions, whereas 20% have deep infiltrating endometriosis (DIE; [3]). Laparoscopy is the gold standard for diagnosing endometriosis, because it allows the diagnosis of all forms of endometriosis and often immediate removal of superficial endometriosis. The removal of DIE is considerably more complicated and usually cannot be completed unless it was diagnosed preoperatively. The technique to diagnose DIE with transvaginal ultrasound (TVUS) was first described in detail in 2009 [4]. Since then, the accuracy of TVUS for the prediction of DIE has been well established in the literature [5-7]. TVUS is widely used as a first-line investigation for women with gynecological symptoms. The inclusion of an assessment for endometriosis in the routine pelvic ultrasound allows earlier diagnosis and better surgical outcomes for all women with DIE. The evaluation for endometriosis in routine pelvic ultrasound based on the IDEA consensus promotes a 4-step dynamic ultrasound approach [1]: (1) routine evaluation of uterus and adnexa with particular attention for sonographic signs of adenomyosis and the presence or absence of endometriomas; (2) evaluation of transvaginal sonographic 'soft markers' such as site-specific tenderness and ovarian mobility; (3) assessment of status of pouch of Douglas using the real-time ultrasound-based "sliding sign;" and (4) assessment of DIE nodules in the anterior and posterior compartments, which involves assessment of the bladder, vaginal vault, uterosacral ligaments, and bowel, including rectum, rectosigmoid junction, and sigmoid colon. Because 5-10% of women with DIE also have ureteric endometriosis, it is useful to assess the kidneys. Silent hydronephrosis is easily identified in 50-60% of patients with ureteric involvement. Although it is possible to identify DIE involving the ureters more directly, this requires more advanced skills, and further studies are still needed to better define the accuracy of ureteric DIE detection by TVUS [8-10]. Traditionally, only pathologies of the uterus and ovaries are assessed during a routine pelvic ultrasound. Here we demonstrate that the routine ultrasound examination can easily be extended beyond the uterus and ovaries into the posterior and anterior pelvic compartments to evaluate structural mobility and to look for deep infiltrating endometriotic nodules, wherewith women suffering from DIE can benefit from a preoperative diagnosis and subsequently, a single, well-planned procedure in the hands of a well-prepared team.

Laparoscopic Reverse Technique for Posterior Rectovaginal Deep Endometriosis Nodule Step by Step

To demonstrate the application of the so-called reverse technique to approach deep infiltrating endometriosis nodules affecting the retrocervical area, the posterior vaginal fornix, and the anterior rectal wall. In Video 1, the authors describe the complete procedure in 10 steps in order to standardize it and facilitate the comprehension and the reproduction of such a procedure in a simple and safe way. A case report. A private hospital in Curitiba, Paraná, Brazil. A 32-year-old woman was referred to our service complaining about cyclic dysmenorrhea, dyspareunia, chronic pelvic pain, and cyclic dyschezia. Transvaginal ultrasound with bowel preparation showed a 2.4-cm endometriotic nodule at the retrocervical area, uterosacral ligaments, posterior vaginal fornix, and anterior rectal wall, infiltrating up to the muscularis 10 cm far from the anal verge. Not applicable. Under general anesthesia, the patient was placed in the dorsal decubitus position with her arms alongside her body and her lower limbs in abduction. Pneumoperitoneum was achieved using a Veress needle placed at the umbilicus. Four trocars were placed according to the French technique as follows: a 10-mm trocar at the umbilicus for the 0 degree laparoscope; a 5-mm trocar at the right anterosuperior iliac spine; a 5-mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10 cm inferior to the umbilical trocar; and a 5-mm trocar at the left anterosuperior iliac spine. The entire pelvis was inspected for endometriotic lesions (step 1). The implants located at the ovarian fossae were completely removed (step 2). The ureters were identified bilaterally, and both pararectal fossae were dissected, preserving the hypogastric nerves (step 3). The lesion was separated from the retrocervical area, and the posterior vaginal fornix was resected (reverse technique), leaving the disease attached to the anterior surface of the rectum (step 4). The lesion was shaved off the anterior rectal wall using a harmonic scalpel (step 5). The anterior rectal wall was closed using X-shaped stitches of 3-0 polydioxanone suture in 2 layers (step 6). The specimen was extracted through the vagina (step 7). The posterior vaginal fornix was reattached to the retrocervical area using X-shaped sutures of 0 poliglecaprone 25 (step 8). A pneumatic test was performed to check the integrity of the suture (step 9). At the end of the procedure, hemostasis was controlled, and the abdominal cavity was irrigated using Lactate ringer solution (step10). The laparoscopic reverse technique is an alternative approach to face retrocervical or rectovaginal nodules infiltrating the anterior rectal wall.In this technique, the separation of the nodule from the rectal wall is performed at the end of the surgery and not at the beginning as performed within the traditional technique. This enables the surgeon to perform a more precise dissection of the endometriotic nodule from the rectal wall because of the increased mobility of the bowel. The wider range of movements serves as an ergonomic advantage for the subsequent dissection of the lesion from the rectum, allowing the surgeon to decide the best technique to apply for the treatment of the bowel disease (rectal shaving or discoid or segmental resection).

Tigers in the Sidewall: Surgical Approaches to Excision of Lateral Deep Infiltrating Endometriosis

ObjectiveTo describe the surgical approaches and excisional techniques used in an extreme case of deep infiltrating endometriosis (DIE) affecting the lateral pelvic side wall. DesignA technical video showing the excision of advanced lateral DIE. SettingAn academic tertiary care hospital. InterventionsA 32-year-old woman, gravida 2, para 1, presented for definitive surgical management of endometriosis-associated pelvic pain. Intraoperative findings revealed severe retroperitoneal fibrosis tethering the external iliac vein, internal iliac artery, obturator nerve, medial umbilical ligament, and ureter. The patient underwent laparoscopic management of the DIE involving the lateral pelvic side wall. We demonstrate the surgical methods and tools required to overcome a unique endometriotic nodule that would not allow for traditional lysis of adhesions from the pelvic side wall. Instead, we used a nontraditional surgical approach by tunneling under the external iliac vascular to tackle the dissection from a lateral to medial direction to free the obturator nerve and internal iliac artery from the ureter and endometriotic nodule. ConclusionExtreme cases of DIE involving the pelvic side wall require surgical finesse when normal planes of dissection are obliterated. Knowledge of retroperitoneal anatomy is critical to overcome unexpected lateral pelvic side wall endometriosis because the disease is rarely confined to the surface. Innovative surgical thinking complemented by an array of surgical tools will ultimately allow the surgeon to master these difficult endometriotic resections.

Surgical Principles of Segmental Rectosigmoid Resection and Reanastomosis for Deep Infiltrating Endometriosis

To demonstrate the surgical steps involved in segmental rectosigmoid resection and reanastomosis in a deep infiltrating endometriosis (DIE) setting. Step-by-step video demonstration of the technique. Despite efforts made to identify criteria able to reliably predict which patients would be more likely to benefit from segmental bowel resection, such predictability remains an area of controversy and ambiguity. Furthermore, a standardized surgical technique has not yet been defined. Based on our experience, patients with DIE and colorectal involvement should be considered for segmental resection followed by anastomosis if they present with lesions not suitable for shaving/nodulectomy (i.e., large, deeply infiltrating nodules with extensive circumferential involvement). In our practice, careful patient selection together with the adoption of a standardized surgical technique allowed us to minimize the potential complications associated with segmental bowel resection. The patient was a 27-year-old woman diagnosed by ultrasonography with a bowel endometriotic nodule of 33 × 8 × 14 mm infiltrating the inner layer of the muscularis propria at the rectosigmoid junction, with a distance from the anal verge of approximately 12 cm and an estimated stenosis of 50%. A 3-dimensional laparoscopic segmental rectosigmoid resection was performed, and indocyanine green-enhanced fluorescent angiography was used to assess perfusion of the bowel before completion of the anastomosis. The total operative time was 135 minutes, and no intraoperative complications occurred. Complete excision of endometriosis was achieved. The estimated blood loss was 30 mL. An intra-abdominal drain was not placed, and the urinary catheter was removed at the end of surgery. The patient was discharged at 6 days after surgery and did not experience any postoperative complications. The bowel endometriotic nodule measured 34 × 8 × 13 mm in a fresh specimen. Advanced laparoscopic surgical skills are needed to properly perform segmental rectosigmoid resection. Subspecialization and adequate pretreatment evaluation are crucial to ensure the correct decision making process within a complex algorithm for surgical management of bowel endometriosis.

Laparoscopic Partial Bladder Cystectomy for Bladder Endometriosis: A Combined Cystoscopic and Laparoscopic approach

Laparoscopic Partial Bladder Cystectomy for Bladder Endometriosis: A Combined Cystoscopic and Laparoscopic approach

Senhance 3-mm robot-assisted surgery: experience on first 14 patients in France

The objective of this article is to present our experience with the 3-mm instruments using the Senhance surgical robotic system in gynecological and abdominal surgery from July to December 2017 by a retrospective observational study. All patients who underwent a robot-assisted 3-mm laparoscopic procedure with the Senhance surgical robotic system were enrolled. Two separate populations were involved: nine female gynecological patients and five digestive surgery patients. Five cholecystectomies, three annexectomies, four ovarian cystectomies, one myomectomy and one endometriotic nodule resection were performed. For the gynecological cases, the median time spent at the console was 37min (12-77), while the total duration of the intervention was 81.33min. All the interventions were performed on an outpatient basis. There were no postoperative complications. The average visual analog scale for pain (VAS) was 2.11 (± 1.91) on D0. For the abdominal surgery cases, the median time was 39min (21-64). The average total duration of the intervention was 87.4min (± 36.82). One of the five interventions was performed on an outpatient basis. There was one laparoscopy conversion. No postoperative complications in the 2weeks following the operation. There are few 3-mm instruments available with the Senhance surgical robotic system, which limits the number of interventions. However, it is possible to perform gynecological interventions with 3-mm instruments on an outpatient basis in complete safety. It is possible to perform cholecystectomies by pairing the use of 3-mm and 5-mm instruments. The recent arrival of new 3-mm instruments will enable a wider range of surgical indications.

Does the clinical information play a role in the magnetic resonance diagnostic confidence analysis of ovarian and deep endometriosis?

Some recent studies have explored how the experience in the observers change their performance in the endometriosis detection using MRI but the effects of the clinical information remains uncertain. The purpose of this study was to assess the effect of the clinical information in the diagnostic confidence in the MRI diagnosis of endometriosis. Institutional Review Board was obtained. This study is compliant to STARD method. 80 patients (mean age 32 years; range 19 - 46 years) who had undergone MRI study and surgery for suspected endometriosis were retrospectively evaluated. MRI exams were performed with a 1.5 T scanner and the following five locations were assessed: ovary, anterior compartment, vaginal fornix, utero-sacral ligaments, and Rectum\Sigmoid\Pouch of Douglas. Data sets were evaluated twice on a 5-point scale by four radiologists with different level of expertise; the first time blinded to the clinical information and the second time, after 3 months together with the clinical chart. Statistical analysis included receiver operating characteristics curve analysis, the Cohen weighted test and sensitivity, specificity, positive predictive value, negative predictive value, accuracy, LR+ and LR-. A total of 140 localization of endometriosis (47 endometriomas and 93 endometriotic nodules) were found. The pairwise comparison demonstrated that in all cases the presence of clinical information improved the Az value. The concordance analysis indicated a mixed pattern from modest agreement (weighted κ value 0.556 for anterior compartment) to excellent agreement values (weighted κ value 0.867 for ovarian endometriomas). The results of our study suggest that clinical information is useful in diagnosing endometriosis in general anterior compartment, but not in other locations. Less experienced radiologists (resident) may benefit from it at utero-sacral ligaments or Rectum\Sigmoid\Pouch of Douglas. In this era of sometimes indiscriminate use of diagnostic methods, it is important to emphasis the context for interpretation of diagnostic results. Our paper confirms that clinical information is useful in diagnosing endometriosis.

Endometriosis treatment with shock waves: A novel approach

Endometriosis affects 10–15% of women. When medication is unsatisfactory, not well tolerated or unwanted, surgery remains the sole option. There is a need for a less invasive treatment. We suggest the application of shock wave therapy (SWT) to endometriotic nodules (including deep infiltrating endometriosis), endometriomas and adenomyosis. We hypothesize pain relief via an antiinflammatory effect, an antioxidant effect and neural pathways modulation, as well as a direct effect on the lesions by the energy thus delivered. Questions to be answered before a clinical application is tested include route of administration (external versus internal transducers), dose regimen, optimal duration of treatment and type of shock waves used (focalised versus radial).

Tracing the Ureters in Patients with Deep Endometriotic Nodules

Tracing the Ureters in Patients with Deep Endometriotic Nodules