Excision Of Ovarian Cysts Research Articles

Scar Endometriosis in the Abdominal Wall: a Predictable Condition for Experienced Surgeons

Purpose: Endometriosis in surgical scars develops in 0.1% of those women who undergo Caesarean section or other obstetric surgery. Herein we analyse and discuss the clinico-pathological characteristics of 15 patients with scar endometriosis in the abdominal wall.Methods: Fifteen cases of scar endometriosis in the abdominal wall that were treated surgically in our department between 2003 and 2009 were examined retrospectively. Age, parity, complaint, medical or surgical history, pre/postoperative hormonotherapy, size of the mass, surgical procedure, follow-up and disease recurrence were analysed. Results: This retrospective study included 15 patients presenting with 17 postoperative abdominal wall masses. The mean age of the patients was 32.1 ± 6.0 years (range, 23–48). Eleven of the patients had a painful mass that became bigger before menstruation, two had palpable masses only, and two were hospitalised because of a mass with persistent pain. The locations of the masses were as follows: eight were close to the right side and three were close to the left side; two were in the middle of the Pfanenstiel incision and two were in trocar tracts. The patients’ surgical histories included Caesarean section in thirteen, bilateral laparoscopic ovarian cyst excision in one, and laparoscopic appendectomy in one.Conclusions: If a patient presents with incision pain and a palpable mass after gynaecologic surgery, an incisional endometrioma should be considered. Surgical excision and hormone therapy are effective treatment approaches in these patients.

Multiple Intraabdominal Parasitic Cystic Teratomas

We report an interesting case of multiple intraabdominal dermoids in a patient who had undergone an excision of ovarian dermoid cyst earlier and presented with recurrence of symptoms. She had masses all over the abdominal wall, omentum, and pouch of Douglas and a dermoid cyst in the ovary as well. It is generally believed that autoamputation and reimplantation of an ovarian dermoid cyst is the most common cause of omental teratomas. Abdominal pain is the main presenting symptom of these tumors, and on physical examination a mobile abdominal or pelvic mass is often found. Both ultrasonography with color-flow Doppler ultrasonography and computed tomography are helpful in the diagnosis of dermoid tumors, but the correct diagnosis of omental localization is extremely difficult. We removed all the masses laparoscopically. Literature search did not reveal such extensive parasitic dermoids in any patient.

Oxidative stress status in normal ovarian cortex surrounding ovarian endometriosis

Expression levels of 8-hydroxydeoxyguanosine, a sensitive indicator of DNA damage resulting from oxidative stress, were significantly higher in samples of normal ovarian cortex surrounding endometriotic cysts when compared with ovarian cortex surrounding dermoid and serous ovarian cysts. These findings suggest that the normal ovarian cortex surrounding endometriotic tissues is more severely affected by oxidative stress than ovarian cortex adjacent to other benign ovarian cysts.

The impact of laparoscopic ovarian cystectomy on ovarian reserve as assessed by antral follicle count and serum AMH levels

OBJECTIVE: Laparoscopic excision of ovarian cysts particularly endometrioma and dermoid cysts are commonly performed in women of reproductive age. We aimed to objectively determine if such a surgical procedure had any negative impact on ovarian reserve. DESIGN: A prospective study. MATERIALS AND METHODS: Of 16 patients (mean age ± [SE] 29.5 ± 1.9) enrolled in the study 12 had unilateral, one had bilateral endometriomas, and 3 had unilateral dermoid cysts. Ovarian reserve was determined with antral follicle count (AFC) and serum antimullerian hormone (AMH) levels measured before and one month postoperatively. Removed cysts were histologically examined for the presence of ovarian cortex and the follicles. RESULTS: The duration of the operation (mean age ± [SE]) was 44.7 ± 3.6 minutes. The mean cyst diameter was 52.5 ± 5.4 mm for endometriomas and 58.1 ± 8.5 mm for dermoid cysts. The cysts were removed completely in all patients. Pre and postoperative AFCs were similar (6.4 ± 0.6 vs. 6.7 ± 0.6 p>0.05, respectively). Serum AMH levels declined postoperatively, however, the difference was not statistically significant (3.7 ± 0.5 vs. 2.7 ± 0.4 p>0.05). Preoperative AMH levels were positively correlated with AFC (r=0.50, p<0.05) but this correlation was lost postoperatively (r=0.46, p>0.05). Both AMH and AFC were negatively correlated with age (r=-0.59 p<0.05, r=-0.61 p<0.05, respectively). On histological examination one antral follicle in one section from a patient and some clusters of primordial follicles in the others did not cause any significant decline in AMH levels postoperatively. CONCLUSIONS: Our results indicate that laparoscopic removal of ovarian cysts using a standard atraumatic technique does not adversely affect the AFC. AMH levels decreased postoperatively but the difference did not reach statistical significance, perhaps due to the small number of patients in the study. The impact of cystectomy on ovarian reserve should be assessed objectively in larger number of patients in order to reach definitive conclusions.

Management of Ovarian Dermoid Cysts in the Pediatric and Adolescent Population

Study Objective To evaluate the surgical approach used in the management of ovarian dermoid cysts in the pediatric and adolescent population. Design A descriptive retrospective chart review of all cases of ovarian dermoid cyst excision between January 2001 and January 2006. Setting The Hospital for Sick Children, Toronto, Canada. Participants Forty-one female children and adolescents who underwent operative management of an ovarian dermoid cyst. Main Outcome Measures Surgical approach (laparoscopy vs laparotomy), intraoperative cyst rupture, length of hospital stay, and postoperative complications. Results The mean age was 12.5 years. All cysts were unilateral. Twenty-three patients (56%) underwent laparoscopic cystectomy, 14 (34%) underwent cystectomy via laparotomy, and 4 (10%) oophorectomies were performed via laparotomy. Cyst size was significantly larger in the laparotomy group compared to the laparoscopy group (mean diameter 14.4 cm vs 7.1 cm, respectively, P < .001). A significantly higher rate of cyst rupture was experienced during laparoscopic cystectomy (100%), compared to excision via laparotomy (27.7%, P < .001). Length of hospital stay was significantly shorter in the laparoscopy group compared to the laparotomy group (median of 0 vs 3 days, respectively, P < .001). A single case in the laparoscopy group sustained a bladder injury and developed postoperative necrotizing fasciitis resulting in a prolonged hospitalization and recovery. There were no operative or postoperative complications related to cyst content spillage, regardless of the surgical approach. Conclusion Laparoscopic cystectomy is a safe and effective method of managing ovarian dermoid cysts in the pediatric and adolescent patient population.

High serum follistatin levels in women with ovarian endometriosis

Follistatin is an activin-binding protein produced by several tissues, including endometrium and endometriotic implants. We aimed to quantify follistatin in patients with ovarian endometriosis and investigate its value as a diagnostic marker. Women undergoing laparoscopic excision of ovarian endometrioma (n = 52) or other benign ovarian cysts (n = 52) were studied, plus women with non-ovarian endometriosis (n = 11) and healthy controls (n = 27). Serum was collected from all subjects, and peritoneal and cystic fluid from a subset with endometrioma. Follistatin was measured by enzyme-linked immunosorbent assay. The diagnostic accuracy of follistatin to detect endometrioma was evaluated by receiver operating characteristic (ROC) curve and compared with cancer antigen (CA)-125. Serum follistatin was increased in women with ovarian endometrioma (2080 +/- 94 pg/ml) compared with controls (545 +/- 49 pg/ml, P < 0.001), other benign ovarian cysts (795 +/- 60 pg/ml, P < 0.001) or non-ovarian endometriosis (1271 +/- 115 pg/ml, P < 0.001). Cystic fluid showed a higher concentration of follistatin (9850 +/- 4461 pg/ml) than peritoneal fluid (1885 +/- 261 pg/ml, P < 0.001) and serum (P < 0.001). Follistatin levels detected 48/52 cases of endometrioma (92% sensitivity) at 1433 pg/ml cut-off, corresponding to 92% specificity. CA-125 detected only 44% of endometriomas with 90% specificity. ROC curve comparison showed follistatin was more accurate than CA-125 to discriminate women with endometrioma either from controls or women with other benign ovarian cysts (P < 0.0001). Serum follistatin is increased in women with endometriosis and allows clear distinction between endometrioma and other benign ovarian cysts. Follistatin has the sensitivity and specificity to become a useful clinical marker of ovarian endometrioma.

The impact of electrocoagulation on ovarian reserve after laparoscopic excision of ovarian cysts: a prospective clinical study of 191 patients

To investigate the impact of electrocoagulation on ovarian reserve after laparoscopic excision of ovarian cysts and the possible mechanisms. A prospective study. Obstetrics and Gynecology Department of a university hospital. 191 patients with benign ovarian cysts undergoing ovarian cystectomy. Laparoscopic ovarian cystectomy using bipolar or ultrasonic scalpel electrocoagulation and laparotomic ovarian cystectomy using sutures after the excision of ovarian cysts. Follicle-stimulating hormone (FSH) assay and transvaginal ultrasound evaluating basal antral follicle number, mean ovarian diameter, and ovarian stromal blood flow velocity at day 3 of menstrual cycles 1, 3, 6, and 12 after surgery. When comparing the bipolar group and ultrasonic scalpel group with the suture group, a statistically significant increase of the mean FSH value was found in bilateral-cyst patients at 1-, 3-, 6-, and 12-month follow-up evaluations and in unilateral-cyst patients at the 1-month follow-up evaluation. Statistically significant decreases of basal antral follicle number and mean ovarian diameter were found during the 3-, 6-, 12-month follow-up evaluations as well as statistically significant decreases of peak systolic velocity at all of the follow-up evaluations. Electrocoagulation after laparoscopic excision of ovarian cysts is associated with a statistically significant reduction in ovarian reserve, which is partly a consequence of the damage to the ovarian vascular system.

Is the stripping technique a tissue-sparing procedure in large simple ovarian cysts in children?

Background Stripping of the cystic wall is performed by gynecologists to treat large ovarian cysts. Information in the pediatric population is poor. We prospectively evaluated the pathologic specimens of large ovarian cyst to determine whether the stripping technique is a tissue-sparing procedure even in this age. Methods We evaluated 5 patients. Samples were taken from the intermediate part of the cystic wall and from the layer covering the cyst during excision. The presence of ovarian tissue adjacent to the cyst wall, and the morphological features of the surrounding tissue were both evaluated. Pelvic ultrasound follow-up was also performed. Results Patients' mean age was 4.5 years (7 days to 12 years). All cysts were removed because all were symptomatic. The mean diameter was 86.6 mm (74-100 mm). Cysts were follicular in 2 cases, serous in other two, and endometriotic in 1 case. Adjacent ovarian tissue was present in 1 of 5 specimens and was approximately 1 to 2 mm in thickness. The layer adjacent to the cystic wall always appeared as normal ovarian tissue. Ultrasound scans at follow-up revealed presence of ovarian tissue. Conclusion The stripping procedure for large ovarian cyst excision allows to spare the adjacent normal ovarian tissue even in pediatric age because ovarian tissue is rarely excised with the cyst wall during the procedure.

Suture of ovary after laparoscopic excision of ovarian cysts preserves more ovarian function than bipolar electro-coagulation

Suture of ovary after laparoscopic excision of ovarian cysts preserves more ovarian function than bipolar electro-coagulation

Deranged expression of follistatin and follistatin-like protein in women with ovarian endometriosis

To evaluate the messenger RNA (mRNA) expression and peptide localization of follistatin and follistatin-like protein (FLRG) in ovarian endometriosis, compared to healthy human endometrium. Samples of ovarian endometriotic and healthy endometrial tissues were processed by semiquantitative reverse transcriptase-polymerase chain reaction and immunohistochemistry. Academic health centers in Siena, Italy, and Belo Horizonte, Brazil. Women with endometrioma who underwent laparoscopic excision of ovarian endometriotic cysts (n = 16), and healthy, nonpregnant women (n = 18, control group). Immunostaining and relative quantification of follistatin and FLRG mRNA in ovarian endometriosis and eutopic endometrium. Both ovarian endometriosis and healthy endometrium expressed and localized follistatin and FLRG. In endometriotic glands, follistatin immunostaining was homogeneously distributed throughout the cytoplasm of the epithelial cells, contrasting with normal eutopic endometrium, where follistatin expression was focal, irregular, and confined to the basal side of the glands. Follistatin-like protein was immunolocalized in the nuclei of both glandular epithelial cells and stromal cells, with less intense staining in endometriotic samples. The relative intensity of follistatin and FLRG immunostaining was significantly higher and lower, respectively, in endometriosis than in controls. The expression of follistatin mRNA was higher, while that of FLRG mRNA was lower, in ovarian endometriosis than in healthy eutopic endometrium. Ovarian endometriotic lesions show a deranged expression of FLRG and follistatin, which are activin A-binding proteins. This may result in an altered effect of activin A on angiogenesis and/or endometrial differentiation.

Laparoscopic excision of a giant ovarian cyst after ultrasound-guided drainage

The laparoscopic approach to giant ovarian cysts in pediatric population may be difficult regarding the risk of cyst rupture and limited working space. We herein report a 16-year-old adolescent girl that presented with a giant ovarian cyst. To reduce the limitations of the laparoscopy, we performed laparoscopy after draining the cyst under ultrasonographic guidance. Under local anesthesia, a nephrostomy catheter was placed into the cyst by the Seldinger technique. During laparoscopy, abdominal cavity was explored by the scope and then the nephrostomy catheter was removed. Laparoscopic procedure was completed easily. No pre- and postoperative complications were encountered and the patient was discharged on the second postoperative day. The pathologic examination of the cyst revealed as follicular cyst. Laparoscopic excision of giant ovarian cysts after ultrasound-guided drainage seems to be safe and applicable treatment modality in children.

Does laparoscopic removal of nonendometriotic benign ovarian cysts affect ovarian reserve?

The objective of this study was to investigate whether laparoscopic excision of nonendometriotic benign ovarian cysts is associated with a significant injury to ovarian reserve. Women selected for IVF-ICSI cycles who previously underwent laparoscopic excision of a monolateral nonendometriotic benign ovarian cyst were retrospectively identified. The operated ovary and the contralateral intact gonad of the same patient were compared in term of basal ovarian volume before initiating ovarian stimulation and number of dominant follicles at the time of human chorionic gonadotropin administration. Non-parametric Wilcoxon Rank test was used to investigate differences between the two ovaries. Seventeen cases were recruited. The numbers of dominant follicles were 4.6 +/- 2.5 and 2.7 +/- 2.4 in the control ovary and in the previously operated ovary, respectively (p = 0.01). This drop corresponded to a mean reduction of 42% (95% confidence interval: 10-74%). Basal volumes of the intact and the operated gonads were 5.7 +/- 3.3 and 3.4 +/- 2.3 cm3 respectively (p = 0.01), corresponding to a mean reduction of 39% (95% confidence interval: 12-66%). Laparoscopic excision of nonendometrioid benign ovarian cysts is associated with a significant injury to ovarian reserve.

Laparoscopic excision of ovarian cysts does not result in antiovarian humoral autoimmunity

To determine whether the ovarian trauma consequent to the laparoscopic removal of a cyst could result in the development of a humoral immunity, antiovarian antibodies were assayed in serum samples obtained from 40 women before and after cystectomy.

Ovarian recovery after laparoscopic enucleation of ovarian cysts: Insights from echographic short-term postsurgical follow-up

Study objective To evaluate damage to ovarian reserve following laparoscopic cystectomy of benign ovarian cysts. Design Prospective study (Canadian Task Force classification II-3). Setting Tertiary gynecologic endoscopic unit at a university-affiliated hospital. Patients Thirty-one patients who underwent excision of monolateral (n = 25) or bilateral (n = 6) benign ovarian cysts. Interventions Serial transvaginal ultrasound examinations during the first and third postsurgical menstrual cycles. The following ovarian echographic variables were evaluated: antral follicle count, ovarian volume, stromal blood flow, and side of ovulation. Two types of statistical analysis were performed: a paired analysis comparing operated and intact ovaries of the same patient and a prospective analysis comparing ecographic characteristics of the operated gonad at first and second evaluation. Measurements and main results Antral follicle count and stromal blood flow were not significantly affected by surgery. While ovarian volume was similar in the operated and in the contralateral intact gonad at the first ultrasound evaluation, the volume of the operated ovary was significantly reduced at the second assessment. The median (interquartile range) of the percentage of this reduction was 33% (18%–81%). This progressive reduction was confirmed by prospectively analyzing the operated ovaries. An increased probability of ovulation in the intact gonad was observed at both assessments. Conclusion Laparoscopic excision of ovarian cysts is associated with damage to ovarian reserve, at least immediately after surgery. This effect does not appear to be consequent to an injury to ovarian vascularization.

Does laparoscopic excision of endometriotic ovarian cysts significantly affect ovarian reserve? Insights from IVF cycles.

Residual ovarian function after laparoscopic excision of endometriotic ovarian cysts is a major and still unsolved topic. Ultrasonographic evaluation of ovarian response to ovulation stimulation represents a simple yet poorly employed tool to assess residual ovarian function after surgery. Data from patients referred for IVF or ICSI between January 2001 and December 2002 were reviewed. Patients were included who previously underwent laparoscopic excision of a monolateral endometriotic ovarian cyst. The operated ovary and contralateral intact ovary were compared in terms of number of follicles with a mean diameter >15 mm at the time of hCG administration. Basal volume of the two ovaries before initiating stimulation was also compared. A paired Student's t-test was used to investigate differences between the two ovaries. In total, 32 patients and 46 cycles were identified. The mean (+/- SD) number of follicles >15 mm was 4.2 +/- 2.5 in the control ovary and 2.0 +/- 1.5 in the previously operated ovary (P < 0.001); this corresponded to a mean reduction of 53% (95% CI 35-72%) but did not seem to be related to the dimension of the excised ovarian cyst. The basal volume of the operated ovaries was also statistically significantly diminished, though this reduction was less relevant. Excision of endometriotic ovarian cysts is associated with a significant reduction in ovarian reserve. Further studies are required to clarify whether the damage is related to the surgical procedure or to the previous presence of a cyst.

Does laparoscopic excision of ovarian cysts significantly affect ovarian reserve? insights from in vitro fertilization cycles

Objective: Residual ovarian function after laparoscopic excision of ovarian cysts is a major and still unsolved topic. Ultrasonographic evaluation of ovarian response to ovulation stimulation represents a simple and still poorly employed tool to assess residual ovarian function of an operated ovary. The few currently available studies on this topic have produced conflicting results. The aim of the present study was to evaluate the response to ovarian stimulation in patients who previously underwent monolateral excision of ovarian cysts.

Laparoscopic excision of large ovarian cysts.

The aim of this study was to check the ability of operative laparoscopy to help in the management of large ovarian cysts that may reach above the level of the umbilicus. Fifteen cases of large ovarian cysts reaching above the level of the umbilicus were chosen. Clinical and ultrasonic diagnosis denied any signs of malignancy. Pneumoperitoneum and a 5 mm trocar were inserted safely in the left midclavicular line below the ninth costal margin. This trocar allowed us to inspect the peritoneal cavity thoroughly. Another 5 mm trocar was inserted suprapubically in the contralateral side of the cyst and better inspection of the cyst and peritoneal cavity was then done. In the case of an apparently benign cyst, aspiration of the cyst fluid was done after puncturing its wall, then the cyst was removed as usual. In all of these cases, there was no laparoconversion and no other complications were recorded. Nine cases were mucinous and six were serous cystadenomas. The mean operation time was 53.66 +/- 14.7 min. Laparoscopic excision of large ovarian cysts is possible, and safe in suitable conditions, with immediate laparoconversion at hand at any time.

Evaluation of pancreatic allograft dysfunction by laparoscopic biopsy.

Histologic evaluation of a failing pancreatic allograft is necessary for accurate classification of graft dysfunction. Unlike percutaneous or transcystoscopic techniques, laparoscopic biopsy allows visualization of the allograft in addition to obtaining tissue for histologic examination. We retrospectively reviewed all laparoscopic pancreas transplant biopsies performed over a 15-month period ending February 2002. There were 12 laparoscopic pancreas biopsies performed in 11 patients between 6 weeks and 8 years (mean 2.5+/-2.8 years) after transplant. Indications for biopsy were hyperglycemia (n=8), hyperamylasemia (n=3), and graft tenderness (n=1). Adequate tissue was obtained in 11 of 12 biopsies. Two patients received definitive treatment at the time of laparoscopy (pseudocyst debridement, ovarian cyst excision). Laparoscopic pancreas transplant biopsy allows safe visualization of the allograft and effective specimen retrieval, and in some cases provides the opportunity for therapeutic intervention.

Laparoscopic excision of ovarian cysts: is the stripping technique a tissue-sparing procedure?

Objective: To determine whether the stripping technique by laparoscopy is a tissue-sparing procedure. Design: Prospective study. Setting: University hospital. Patient(s): Forty-two women, 21 to 35 years of age, who had a unilateral ovarian cyst (26 endometriomas, 7 serous, 6 dermoid, and 3 mucinous cysts). Intervention(s): Laparoscopic excision of ovarian cysts by using the stripping technique. Main Outcome Measure(s): Histologic analysis of the excised specimens was done to evaluate the presence and nature of ovarian tissue adjacent to the cyst wall. Result(s): Recognizable ovarian tissue adjacent to the cyst wall was present in 15 of 42 excised specimens (36%). A significant difference was present for endometriomas versus nonendometriosis cysts (ovarian tissue was present in 14 of 26 specimens [54%] vs. 1 of 16 specimens [6%]; P<.005). No specimen showed the normal follicular pattern observed in healthy ovaries. Conclusion(s): The stripping technique appears to be a tissue-sparing procedure. In 36% of the cysts, ovarian tissue is excised together with the cyst wall, but this tissue does not show the morphologic characteristics observed in normal ovarian tissue.

Evidence for local production of inhibin A and activin A in patients with ovarian endometriosis

Objective: To evaluate the expression of inhibin A and activin A in ovarian endometriosis. Design: Uncontrolled cross-sectional study and controlled prospective in vitro study. Setting: Academic health centers in Siena, Udine, Sassari, and Milan, Italy. Patient(s): A group of women ( n = 19) who underwent laparoscopic excision of ovarian endometriotic cysts. Intervention(s): Specimens of serum, peritoneal fluid, and cystic fluid, ovarian tissue for immunohistochemistry, and endometriotic cells for primary culture were collected. Cell cultures were also prepared from proliferative endometrium of women without endometriosis. Main Outcome Measures(s): Dimeric inhibin A and activin A concentrations in biological fluids; immunostaining of α and βA subunits in ovarian endometrioma; α and βA gene expression in cultured endometriotic cells compared with normal endometrium. Result(s): Inhibin A and activin A concentrations in the cystic fluid were slightly higher than in peritoneal fluid and significantly higher than in serum ( P<.05). Immunoreactive α and βA subunits were strongly expressed both in the epithelial and stromal components of ovarian endometrioma. The relative abundance of βA mRNA was significantly decreased in endometriotic cells compared with eutopic stromal cells. Conclusion(s): The results of the present study provide evidence for a local production and secretion of inhibin A and activin A in ovarian endometriotic cysts.