Laparoscopic Surgery For Severe Endometriosis Research Articles

Editorial introductions

Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of obstetrics and gynecology is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS David L. OliveDavid L. OliveDr David Olive is certified by the American Board of Obstetrics and Gynecology in both Obstetrics and Gynecology as well as Reproductive Endocrinology and Infertility. He is also certified in advanced gynecologic laparoscopy and hysteroscopy by the Accreditation Council of Gynecologic Endoscopy. Dr Olive received his medical degree from Baylor College of Medicine, Houston, TX, USA in 1979. He completed a residency in obstetrics and gynecology at Northwestern University, Chicago, IL, USA, and a fellowship in reproductive endocrinology at Duke University, Durham, NC, USA. Dr Olive was previously a faculty member at the University of Arkansas, USA, the University of Texas, USA, professor and chief of Reproductive Endocrinology at Yale University, USA, and more recently professor, chief of reproductive Endocrinology, and vice chairman of Academic Development at the University of Wisconsin-Madison, USA. Dr Olive has authored more than 300 publications in scientific journals and the popular press. He has acted as an editor or reviewer for over 20 professional journals and has been an investigator on numerous scientific grants. He has lectured extensively around the world on topics such as infertility, endometriosis, fibroids, and clinical epidemiology. He is a past president of the American Association of Gynecologic Laparoscopists and the Board of Trustees of the AAGL/SRS Fellowship in Gynecologic Endoscopy. Dr Olive is currently President of Wisconsin Fertility and Reproductive Surgery Associates and co-founder of the Wisconsin Fertility Institute. Recently he was named to the steering committee to develop a maternal-child health center in Leogane, Haiti, to which he devotes considerable time and effort. Colin J. DavisColin J. DavisMr Colin Davis is a Consultant Obstetrician and Gynaecologist and Honorary Senior Lecturer for Gynaecology at St Bartholomew's and the Royal London Hospitals, UK. He is a Fellow of the Royal College of Obstetricians and Gynaecologists and obtained his Doctorate of Medicine from Imperial College London, UK. He is one of the few surgeons in the UK leading the way in new endoscopic techniques including; laparoscopic tubal microsurgery, laparoscopic surgery for severe endometriosis, laparoscopic myomectomy and hysterectomy. He has established a nationally recognised minimal access training centre at St Bartholomew's Hospital. Mr Colin Davis is the Training Programme Director for the London Deanery for Obstetrics and Gynaecology as well as an Inspector for the Royal College of Obstetricians and Gynaecologists subspecialty training programme in Reproductive Medicine and Surgery. He has a PhD research programme examining genetic expression in endometriosis and has written a number of papers and books on the topics of tubal surgery and endometriosis. He co-authored the 3rd Atlas of Endometriosis. He practices at St Bartholomew's Hospital London as well as the Princess Grace Hospital, The Portland Hospital and the London Clinic, UK.

Vaginal Cuff Abscess that Developed after Laparoscopic Surgery for Severe Endometriosis: Case Report

Vaginal Cuff Abscess that Developed after Laparoscopic Surgery for Severe Endometriosis: Case Report

Safety of transient abdominal ovariopexy in patients with severe endometriosis

ObjectiveTo evaluate complications of transient ovariopexy performed to reduce adhesions in patients with severe endometriosis. MethodsA bicentric retrospective study involved 193 consecutive patients who underwent laparoscopic surgery for severe endometriosis at 2 French university hospitals from 1997 to 2009. At the end of surgery, unilateral or bilateral transient ovariopexy was performed on 297 ovaries. Immediate (e.g. reproducibility, tolerance, and hospital stay) and long-term (evaluated via vaginal access to the ovaries, ovarian function, and ovarian vascularization) complications were assessed. ResultsThe technique, which was easy and reproducible, did not increase hospital stay and was well tolerated. There were 2 (0.7%) immediate complications. There was no difference in ovarian accessibility before and after surgery (177/183 [96.7%] vs 176/183 [96.1%]). Potential vaginal oocyte retrieval for in vitro fertilization was possible for all patients. The antral follicle count and the pulsatility index of suspended ovaries were not different from those of contralateral unsuspended ovaries. Endometrioma excision did not modify these results. ConclusionThe short- and long-term safety results of transient ovariopexy for adnexal adhesions in patients with severe endometriosis were encouraging.

Prevalence and Management of Urinary Tract Endometriosis: A Clinical Case Series

To report on the prevalence, surgical management, and outcome of urinary tract endometriosis (UTE) in a cohort of 221 patients undergoing laparoscopic surgery for severe endometriosis. UTE can cause significant morbidity, such as silent kidney or progressive renal function loss. Its frequency is underestimated and data on laparoscopic management are scarce. Between 2007 and 2010, 43 patients were eligible for this single-center, retrospective study. The inclusion criterion was the presence of UTE (ie, bladder and/or ureteral endometriosis). All patients were operated laparoscopically. The prevalence of UTE was 19.5% (43/221). There was no correlation between bladder and ureteral endometriosis (P >.05). Ureteral endometriosis was associated with patient's age (P <.01). Patients with bladder, but not ureteral, involvement complained more frequently about dysuria, hematuria, and urinary tract infections. Intraoperative and magnetic resonance imaging (MRI) findings revealed a moderate to good correlation. UTE was not associated with rectovaginal or bowel endometriosis, but rather with involvement of the uterosacral ligaments (P <.01). Twenty-two patients with bladder endometriosis were treated by mucosal skinning and 11 patients underwent partial cystectomy. Superficial ureteral excision was performed in 4 patients, whereas resection with ureteroureterostomy was done in 9 patients. There was no difference regarding the intra- and postoperative complications in patients with or without UTE. In severe pelvic endometriosis, involvement of the urinary tract is quite common. Laparoscopic management is feasible and safe. Because of the lack of specific symptoms, the preoperative diagnosis of ureteral endometriosis still remains a challenge. Pelvic MRI represents a useful preoperative diagnostic tool.

Prevalence and outcome of urinary retention after laparoscopic surgery for severe endometriosis—does histology provide answers?

Urinary retention after radical laparoscopic surgery for severe endometriosis is a clinically relevant complication. We hypothesized a relationship between the amount of resected nerves and the occurrence of urinary retention. We evaluated, retrospectively, a cohort of 221 patients. The expression of nerves in the resected specimens was investigated in patients with urinary retention and matched controls using standardized immunohistochemistry techniques. The prevalence of urinary retention was 4.6% (n = 10). Importantly, there was no difference between cases and controls regarding the quantity of nerves in the resected specimens. The cumulative probability of 50% to overcome urinary retention was reached after 5.6 months. Age was the main risk factor for persistent retention (40.3 years with vs. 31.6 years without, p = 0.01). In older endometriosis patients, surgical radicality should be balanced against preservation of organ function. There is a fairly good chance to recover, even after 6 months, which is important for patient counseling.

Advanced Techniques of Adhesiolysis for Severe Endometriosis

Laparoscopic surgery for severe endometriosis requires advanced technical skill for adhesiolysis, which is mainly operator-dependent. We will present our techniques of adhesiolysis for severe endometriosis cases. There are two types of adhesions; thin adhesions and dense adhesions containing fibrotic tissue. Thin adhesions can be bluntly dissected, while sharp dissection is required to free dense adhesions. Our video presentation demonstrates various types of adhesiolysis, including lysis of adhesions surrounding the ovary, dissection of a chocolate cyst wall, and opening of obliterated cul-de-sac. There are three technical tips to accomplish the procedures: 1) to apply contra-lateral traction; 2) to adapt sharp or blunt dissection according to the type of adhesions; and 3) to care thermal injury of the adjacent organs. Our techniques are quite useful and safe, offering efficientl contribution to surgical treatment of endometriosis.

Rhabdomyolyse et syndrome des loges des deux avant-bras lors d’une chirurgie robotique de longue durée

Robotic assisted laparoscopic surgery allows for a more precise dissection than classical laparoscopic surgery. However, it sometimes imposes specific exaggerated postures and extralong procedure duration. Combining these two factors may increase the risk for postural complications in at-risk patients. We report the case of an obese 30-year-old female patient who underwent a 12-hour duration robotic laparoscopic surgery for severe endometriosis, in Trendelenburg position. This was complicated by a two forearms rhabdomyolysis, with subsequent compartment syndrome with multiple neuropathy. Physicians must be aware of the cumulative risk for postural complications when extreme positions are associated to long duration procedures in predisposed patients.

The use of JJ stent in the management of deep endometriosis lesion, affecting or potentially affecting the ureter: a review of our practice

Objective With the increasing number of operative laparoscopies performed for the treatment of deep pelvic endometriosis, technical difficulties and risk of complications inevitably increase. We report our experience using JJ stents, in women treated for deep pelvic endometriosis, with regard to prevention and management of ureteral lesions. Design Descriptive retrospective analysis between March 2004 and March 2007. Setting Department of Obstetrics and Gynaecology, University Hospital, Strasbourg, France. Population and methods Cases of women who underwent laparoscopic surgery for severe endometriosis and who needed a JJ stent in their management were recorded. Laparoscopic surgery was performed at the Department of Obstetrics and Gynaecology at CMCO-SIHCUS and Hautepierre Hospitals, Strasbourg, which are referral centres in the treatment of deep endometriosis. Main outcome measures To evaluate the contribution of JJ stent in the prevention and management of ureteral lesions from endometriotic origin and/or iatrogenic origin in women treated for deep pelvic endometriosis. Results A total of 145 women had surgery for deep pelvic endometriosis. Seventeen (11.7%) women had a JJ ureteral stent inserted. In 82.4% of women, the stent was inserted pre- or peroperatively. We noted three ureteral complications, of which only one needed management by laparotomy. Conclusions Except in extreme cases, management of ureteral endometriosis should be performed laparoscopically. Ureteral lesions whether iatrogenic, or secondary to endometriotic disease, can be treated by cystoscopy, JJ stent and laparoscopy. The combination of these three elements is the optimal management and is unlikely to cause subsequent complications. Laparotomy and its associated morbidity should be avoided.

The use of JJ stent in the management of deep endometriosis lesion, affecting or potentially affecting the ureter: a review of our practice

With the increasing number of operative laparoscopies performed for the treatment of deep pelvic endometriosis, technical difficulties and risk of complications inevitably increase. We report our experience using JJ stents, in women treated for deep pelvic endometriosis, with regard to prevention and management of ureteral lesions. Descriptive retrospective analysis between March 2004 and March 2007. Department of Obstetrics and Gynaecology, University Hospital, Strasbourg, France. Cases of women who underwent laparoscopic surgery for severe endometriosis and who needed a JJ stent in their management were recorded. Laparoscopic surgery was performed at the Department of Obstetrics and Gynaecology at CMCO-SIHCUS and Hautepierre Hospitals, Strasbourg, which are referral centres in the treatment of deep endometriosis. To evaluate the contribution of JJ stent in the prevention and management of ureteral lesions from endometriotic origin and/or iatrogenic origin in women treated for deep pelvic endometriosis. A total of 145 women had surgery for deep pelvic endometriosis. Seventeen (11.7%) women had a JJ ureteral stent inserted. In 82.4% of women, the stent was inserted pre- or peroperatively. We noted three ureteral complications, of which only one needed management by laparotomy. Except in extreme cases, management of ureteral endometriosis should be performed laparoscopically. Ureteral lesions whether iatrogenic, or secondary to endometriotic disease, can be treated by cystoscopy, JJ stent and laparoscopy. The combination of these three elements is the optimal management and is unlikely to cause subsequent complications. Laparotomy and its associated morbidity should be avoided.

Laparoscopic management of ureteral endometriosis: Our experience

Study objective Ureteral endometriosis is rare, accounting for less than 0.3% of all endometriotic lesions. The aim of our study is to evaluate the prevalence of extrinsic ureteral endometriosis in women undergoing laparoscopic surgery for severe endometriosis and to suggest that laparoscopic ureterolysis represents a mandatory measure in all cases to avoid ureteral injury. Methods A retrospective analysis was performed of all cases of patients who underwent laparoscopic surgery for severe endometriosis at the departments of obstetrics and gynecology at CMCO-SIHCUS and Hautepierre Hospital, Strasbourg, from November 2004 through January 2006. Measurements and main results We recorded 54 patients with a mean age of 31 years and a mean body mass index of 21.9. Reported symptoms were dysmenorrhea (88%), severe dyspareunia (88%), severe pelvic pain (38.8%), and infertility (74%). Five women presented with dysuria, frequency, recurrent urinary tract infections, and pain in the renal angle, and 2 patients had hydronephrosis. We observed 3 patients (5.6%) with ureteral stenosis, 35 (64.8%) with adenomyotic tissue surrounding the ureter without stenosis, and 16 (29.6%) with adenomyotic tissue adjacent to the ureter. It was on the left side in 47.4% of cases, on the right side in 31.6% cases, and bilaterally in 21% of cases. In 9 patients, ureteral involvement was associated with bladder endometriosis (16.7%). In all patients, ureterolysis was performed. There was 1 case of ureteral injury during the procedure, 2 of transitory urinary retention, and 1 of uretero-vaginal fistula after surgery. During the first year of follow-up, the disease recurred in 4 patients, with no evidence of the disease in the urinary tract. Conclusion Conservative laparoscopic surgery to relieve ureteral obstruction and remove pathologic tissue is the management of choice. Resection of part of the ureter should be performed only in exceptional cases. Ureterolysis should be performed in all patients before endometriotic nodule resection to recognize and prevent any ureteral damage.

Laparoscopic treatment of endometriosis in teenagers

Objectives To determine the frequency and severity of endometriosis in adolescent and teenager girls with chronic pelvic pain (CPP) who fail to respond to medical treatment and to evaluate the outcome of radical laparoscopic surgery for severe endometriosis. Design Retrospective review of case records of all girls under the age of 21 years who underwent diagnostic and/or operative laparoscopy for CPP unresponsive to medical treatment between January 2001 and December 2003. The operative findings and the response to surgery were retrospectively reviewed. Results Thirty-one girls were referred. No pelvic abnormalities were detected in 11 patients (35.5%). Endometriosis was detected in 11 (35.5%). Six had severe endometriosis. Other diagnoses included: non-functional non-endometriotic ovarian cyst (4 patients), functional ovarian cyst (1 patient), hydrosalpinx (bilateral, 1 patient; unilateral, 1 patient) and obstructed uterine horn (2 patients). Of those with severe disease all six were treated laparoscopically without complications. Five were rendered pain free and one had an improvement in symptoms. Conclusions Endometriosis can occur in adolescent and teenager girls. Laparoscopy should be carried out in all adolescents and teenagers with CPP unresponsive to medical treatment. This the first study reporting the outcome of radical excision treatment for severe endometriosis in this age group and early results are encouraging.