Resection Of Uterosacral Ligaments Research Articles

Tips and Tricks for Nerve-Sparing Modified Radical Hysterectomy for Deep Endometriosis with Firefly Technology

<h3>Study Objective</h3> To show tips and tricks for our nerve-sparing modified radical hysterectomy (NS-mRH) for deep endometriosis (DE) and provide perioperative outcomes of the procedure. <h3>Design</h3> Stepwise demonstration of this method with narrated video footage. <h3>Setting</h3> An urban general hospital. NS-mRH is known for its benefits as a definitive treatment for severe endometriosis. Furthermore, robotic surgery has become available worldwide and two meta-analyses have confirmed that robotic surgery is safe and feasible in the treatment of endometriosis, especially in advanced cases. However, reports which showed the surgical technique of robotic nerve-sparing hysterectomy for DE were limited. <h3>Patients or Participants</h3> 30 patients presented with DE and complex pelvic pathology. <h3>Interventions</h3> Our NS-mRH was performed using following 8 steps with da Vinci Xi: Step 0, observing peritoneal endometriotic lesions; Step 1, adhesiolysis and adnexal surgery; Step 2, separation of the pelvic autonomic nerve plane; Step 3, dissection of the ureter; Step 4, reopening of the pouch of Douglas; Step 5, complete removal of DE lesions while avoiding injury to the nerve plane; Step 6, hysterectomy; Step 7, checking for rectal injury using air leakage test and tissue perfusion; and Step 8, barrier agents for adhesion prevention. <h3>Measurements and Main Results</h3> 30% of patients had history of previous surgeries for endometriosis. 53% of patients presented with complete cul-de-sac obliteration and 87% of patients presented with ENZIAN B2 or B3 lesions which were predictive factors for postoperative voiding dysfunction. All procedures included NS-mRH, uterosacral ligament resection and posterior compartment peritonectomy. Mean operative time was 127 min and blood loss was 31 ml. The mean VAS score significantly decreased after surgery. No patients developed perioperative complications, including postoperative bladder, rectal, and sexual dysfunctions. <h3>Conclusion</h3> Our NS-mRH for DE using FireFly technology is safe and feasible technique with excellent outcomes. Application of ICG with NIR fluorescence appears potentially useful, not only to remove DE, but also to improve nerve-sparing.

Surgical interventions for the management of chronic pelvic pain in women.

Surgical interventions for the management of chronic pelvic pain in women.

Surgical Interventions for the Management of Chronic Pelvic Pain Syndrome in Women

<h3>Study Objective</h3> We aimed to review the effectiveness and safety of surgical interventions in the management of patients experiencing chronic pelvic pain syndrome (CPPS), which excluds those with pain known to be caused by i) endometriosis; ii) adenomyosis; iii) primary dysmenorrhoea; iv) active chronic pelvic inflammatory disease; v) irritable bowel syndrome; v) interstitial cystitis/bladder pain syndrome and vi) urethral syndrome. <h3>Design</h3> We performed a systematic review and meta-analysis for any randomized controlled trials (RCTs) for surgical interventions in patients with CPPS. Each study was independently evaluated by two reviewers for the inclusion and exclusion of trials and extracted data using the forms designed according to the Cochrane guidelines. For each included trial, information was collected regarding method of randomization, allocation concealment, blinding, data reporting and analyses. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> Female-born patients who had CPPS. <h3>Interventions</h3> RCTs of surgical interventions in CPPS. <h3>Measurements and Main Results</h3> Outcome measures were pain rating scales, quality of life (QoL) measures, and adverse events. 23 studies were identified that were retrieved in full text. A total of four studies met our inclusion criteria. For the primary outcome, the effectiveness of surgical intervention for CPPS as reported by change in pain using validated pain scales, no evidence of benefit was identified for adhesiolysis versus no surgery/diagnostic laparoscopy. Similarly, no evidence of benefit was identified for laparoscopic uterosacral ligament ablation (LUNA) versus diagnostic laparoscopy or vaginal uterosacral ligament resection. No studies were published on the psychological outcomes or requirements for analgesia. Adhesiolysis may improve health related QoL at six months after surgery when compared to diagnostic laparoscopy. <h3>Conclusion</h3> The currently available information suggests no evidence of benefit for use of adhesiolysis or LUNA in management of pain in those who suffer from CPPS. There may be a QoL benefit to adhesiolysis in improving both the emotional wellbeing and social support, as measured by the validated QoL tools.

Surgical management of endometriotic women with pregnancy intention in France: A national snapshot of centers performing a high volume of endometriosis procedures.

ObjectiveTo provide a snapshot of the surgical management of endometriosis in French high-volume activity centers. MethodsAnalysis of prospectively collected data between November 2015 and May 2017 in 21 centers with a high volume of endometriosis surgery in France. Each facility could include up to 40 patients undergoing laparoscopy for endometriosis. Data were collected before and two months after surgery. Results361 patients were enrolled in the study. Twenty-seven patients (7.48%) were lost to follow-up at the month 2 visit. Endometriosis stage was I-II in 33.70% of patients and III-IV in 66.30%. Uterosacral ligament resection was the most frequently performed procedure (50.97%) followed by rectal surgery (31.58%), ovarian procedures for endometrioma, procedures for ureters (21.33%) and the bladder (11.91%). Antiadhesion agents were employed in 215/361 (59.56%) patients. The median length of hospital stay after surgery was 2 (IQR 1 – 4) days. Post-operative complications were recorded in 9.34% of patients. Rectovaginal fistulae occurred in 8 patients (2.41%), pelvic abscess in 4 (1.20%) and bladder atony in 3 (0.90%). 17 patients (5.14%) required a second surgical procedure after a median time of 31 days (IQR 9 – 81). Two months after surgery, 95.09% of patients reported being satisfied or very satisfied with the surgery. ConclusionOur study shows that surgical management of endometriosis in centers with a high volume of endometriosis surgery, mainly concerns women presenting with severe disease and deep localizations, with an overall risk of major complications inferior to 10% and a high rate of patient satisfaction.

Systematic Nerve Sparing during Surgery for Deep-infiltrating Posterior Endometriosis Improves Immediate Postoperative Urinary Outcomes

Evaluate the feasibility and risk-benefit ratio of systematic nerve sparing by complete dissection of the inferior hypogastric nerves and afferent pelvic splanchnic nerves during surgery for deep-infiltrating endometriosis (DIE) on the basis of complication rates and postoperative bladder morbidity. Observational before (2012-2014)-and-after (2015-2017) study based on a prospectively completed database of all patients treated medically or surgically for endometriosis. Unicentric study at the Centre Hospitalier Intercommunal de Poissy-St-Germain-en-Laye. This study included patients undergoing laparoscopic surgery for DIE (pouch of Douglas resection with or without colpectomy or bilateral uterosacral ligament resection), with complete excision of all identifiable endometriotic lesions, with or without an associated digestive procedure, between 2012 and 2017. The exclusion criteria included prior history of surgery for DIE or colorectal DIE excision, unilateral uterosacral ligament resection, and bladder endometriotic lesions. For the patients in group 1 (2012-2014, n = 56), partial dissection of the pelvic nerves was carried out only if they were macroscopically caught in endometriotic lesions, without dissection of the pelvic splanchnic nerves. The patients in group 2 (2015-2017, n = 65) systematically underwent nerve sparing during DIE surgery, with dissection of the inferior hypogastric nerves and pelvic splanchnic nerves. Both groups were comparable in terms of patient age, parity, body mass index, and previous abdominal surgery. The operating times were similar in both groups (228 ± 105 minutes in group 2 vs 219 ± 71 minutes in group 1), as were intra- and postoperative complication rates. Time to voiding was significantly longer in the patients in group 1 (p <.01), with 7 (12.9%) patients requiring self-catheterization in this group compared with no patients (0%) in group 2. The duration of self-catheterization for the 7 patients in group 1 was 28, 21, 3, 60, 21, 1 (stopped by the patient), and 28 days, respectively. Uroflowmetry on postoperative day 10 was abnormal in 5/25 patients in group 1 compared with 1/33 in group 2 (p = .031). Systematic and complete nerve sparing, including pelvic splanchnic nerve dissection, during surgery for posterior DIE improves immediate postoperative urinary outcomes, reducing the need for self-catheterization without increasing operating time or complication rates.

Laparoscopic Resection of Uterosacral Ligaments in Deeply Infiltrating Endometriosis, Technique for the Prevention of Complications

Laparoscopic Resection of Uterosacral Ligaments in Deeply Infiltrating Endometriosis, Technique for the Prevention of Complications

ダグラス窩閉鎖を伴う症例に対する腹腔鏡下仙骨子宮靱帯切除術～合併症を減らす工夫～

ダグラス窩閉鎖を伴う症例に対する腹腔鏡下仙骨子宮靱帯切除術～合併症を減らす工夫～

Persistent urinary retention after surgery for deep infiltrating endometriosis: a multi-center series of 16 cases.

Persistent urinary retention (UR) is a complication of 3.5-14.3% of patients having undergone deep pelvic endometriosis (DPE) surgery of posterior compartment, and it is prone to persist. The purpose of this study is to identify surgical procedures and clinical circumstances associated with persistent UR, and consider its treatment. We undertook a multi-center retrospective study studying medical records of patients who had surgery for DPE between January 2005 and December 2012. Patients who suffered from UR defined as a post-void residual (PVR) volume >100 mL needing intermittent self-catheterizations more than 30 days after surgery were included. Preoperative data (functional complaints, clinical examination, imaging, medical treatment) were recorded. Types of surgery and detailed postoperative urinary symptoms were noted. 881 patients had surgery for DPE and 16 patients were included (1.8%). In 93.8% of cases, a lesion of posterior compartment was clinically significant. Mean lesion size was 28.8 ± 7.3 mm. Colorectal resection and colpectomy were necessary in 93.8 and 87.5% of cases, respectively. Loss of bladder sensation and straining during urination were the two most common post-operative symptoms. 11 patients still required self-catheterization up to 1 year after the intervention. Patients with increased risks of UR present with a symptomatic and clinically palpable deep pelvic endometriotic lesion of the posterior compartment. Treatment implies surgery with colorectal resection. Bilateral resection of utero-sacral ligaments and posterior colpectomy tend to increase that risk. Complications due to PVR volume and straining during urination may be prevented by self-catheterization.

Bladder function after radical hysterectomy for cervical cancer

To report the effects of radical hysterectomy and nerve-sparing techniques on lower urinary tract function in women. A literature search was performed in Pubmed and Medline using the keywords bladder after radical hysterectomy, nerve sparing radical hysterectomy, and urinary dysfunction following radical hysterectomy. Significant results and citations were reviewed manually by the authors. The sympathetic and parasympathetic systems innervating the lower urinary tract may be disrupted due to resection of uterosacral and rectovaginal ligaments, the dorsal and lateral paracervix, the caudal part of the vesico-uterine ligaments, and the vagina. This supports the neurogenic etiology of early and late bladder dysfunction after radical surgery. Bladder disorders are also related to the extent of radical surgery. The neuropathopysiology of lower urinary tract symptoms after radical hysterectomy is not fully understood. Recent data have highlighted the role of urethral sphincter pressure in the etiology of postoperative incontinence. Various surgical approaches have been developed to preserve autonomic pelvic innervation. Nerve-sparing techniques appear to improve bladder function without compromising overall survival. Studies comparing the effects of nerve-sparing radical hysterectomy with standard surgery yielded encouraging results in respect of postoperative lower urinary tract function. Clinical trials with a long period of follow-up are required for better comprehension of the complex pathophysiology of bladder dysfunction after radical hysterectomy.

Deep Infiltrating Colorectal Endometriosis Treated With Robotic-Assisted Rectosigmoidectomy

Deep infiltrating pelvic endometriosis with bowel involvement is one of the most aggressive forms of endometriosis. Nowadays, robotic technology and telemanipulation systems represent the latest developments in minimally invasive surgery. The aim of this study is to present our preliminary results and evaluate the feasibility of robotic-assisted laparoscopic colorectal resection for severe endometriosis. Between September 2009 and December 2011, 10 women with colorectal endometriosis underwent surgery with the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA). We evaluated the following parameters: short-term complications, clinical outcomes and long-term follow-up, pain relief recurrence rate, and fertility outcomes. Extensive ureterolysis was required in 8 women (80%). Ovarian cystectomy with removal of the cystic wall was performed in 7 women (70%). Torus resection was performed in all women, with unilateral and bilateral uterosacral ligament resection in 1 woman (10%) and 8 women (80%), respectively. In addition to segmental colorectal resection in all cases, partial vaginal resection was necessary in 2 women (20%). An appendectomy was performed in 2 patients (20%). The mean operative time with the robot was 157 minutes (range, 90-190 minutes). The mean hospital stay was 3 days. Six patients had infertility before surgery, with a mean infertility time of 2 years. After a 12-month follow-up period, 4 women (67%) conceived naturally and 2 (33%) underwent in vitro fertilization. We show that robotic-assisted laparoscopic surgery for the treatment of deep infiltrating bowel endometriosis is feasible, effective, and safe.

Uterine Vein Rupture at Delivery as a Delayed Consequence of Laparoscopic Surgery for Endometriosis: A Case Report

Laparoscopic resection of deep infiltrating endometriosis (DIE) has been reported to be an effective method for reduction of endometriosis-associated pain. As its complications, bowel perforation, urinary tract injury and neurogenic bladder are well known; however, uterine vein rupture during pregnancy has not been reported previously. We encountered a case of hemoperitoneum resulting from uterine vein rupture at a delivery as a delayed consequence of laparoscopic resection of DIE. A 31-year-old, para 2 woman underwent laparoscopic resection of lateral pelvic peritoneum, uterosacral ligaments, and bilateral endometriomas, exposing uterine vessels, which we covered with fibrin glue. Endometriosis-associated pain disappeared, and then the patient conceived 4 months later. The course of pregnancy and induction of labor with controlled oxytocin infusion was uneventful, and the patient delivered a female baby without asphyxia. Immediately after delivery, low abdominal pain with hypotension occurred despite absence of abnormal vaginal bleeding. Ultrasonography and the blood hemoglobin value suggested hemorrhagic shock owing to hemoperitoneum; therefore emergency exploratory laparotomy was performed. Active bleeding was found at the right uterine vein, which was then sutured for hemostasis. The patient received a blood transfusion and recovered without any problems. The bleeding lesion was located at the vein on which the peritoneum had been removed at the first laparoscopy, which suggested that the operation for DIE included a risk of uterine vessel rupture during pregnancy.

Urinary Complications After Surgery for Posterior Deep Infiltrating Endometriosis are Related to the Extent of Dissection and to Uterosacral Ligaments Resection

Surgery for deep infiltrating endometriosis can relieve symptoms and improve quality of life. However, few data are available on complications, especially urinary disorders. The aim of this longitudinal study (Canadian Task Force classification II-3) was to evaluate urinary complications of laparoscopic surgery for deep infiltrating endometriosis in 86 patients. The main locations of endometriosis were colorectum (58 patients), uterosacral ligaments (21 patients), and rectovaginal septum (7 patients). Patients requiring surgical resection for posterior deep pelvic endometriosis completed before and after surgery the Bristol Female Lower Urinary Tract Symptom Questionnaire. After surgery, almost all the patients reported significant urinary complications, consisting of hesitancy (p = .02), strain to start (p = .04), stopping flow (p = .01), incomplete emptying (p = .008), and reduced stream (p = .02). Most symptoms were observed postoperatively in the colorectum group. De novo hesitancy (p = .02), stopping flow (p = .02), and incomplete emptying (p = .004) occurred more frequently after colorectal resection than after resection of other locations. The risk of de novo urinary symptoms did not depend on uterosacral ligament resection, except for incomplete emptying (p = .003) when bilateral resection was performed. Extensive dissection in the colorectum group, when combined with uterosacral ligament resection, was associated with significant urinary complications. Urinary complications mainly occurred after segmental colorectal endometriosis resection combined with bilateral uterosacral ligament resection. Surgery designed to spare the pelvic autonomic nerves could reduce the incidence of urinary complications.

Histopathologic findings on uterosacral ligaments in women with chronic pelvic pain and visually normal pelvis at laparoscopy

Study objective To determine the prevalence and type of microscopic findings on laparoscopically resected uterosacral ligaments in women with chronic pelvic pain and no visible pelvic disease. The effect of this procedure on the patients’ level of pain also was assessed as a secondary objective. Design Prospective follow-up (Canadian Task Force classification II-2). Setting University-affiliated hospital. Patients Twenty-seven premenopausal women undergoing diagnostic laparoscopy for chronic pelvic pain had a normal pelvis on visual inspection. All patients underwent resection and histologic evaluation of the uterosacral ligaments. Pain relief was evaluated by use of a questionnaire administered before and at 3, 6, and 12 months after surgery. Measurements and main results Microscopic examination identified endometriosis in 2 (7.4%), endosalpingiosis in 3 (11.1%), and inflammation in 14 (51.9%) patients. Laparoscopic uterosacral ligament resection was associated with a reduction in dysmenorrhea (p ≤.001), with 14 (52%) patients reporting improved or resolved symptoms. There was a statistically significant decrease in dyspareunia (p ≤.01) and in the severity of noncyclical pain (p ≤.002). Thirty-five percent of patients no longer required medication for pain control (p ≤.005). The number of days needed off work also decreased. Conclusion Despite normal laparoscopic appearance, microscopic endometriosis, endosalpingiosis, and inflammatory changes were found in uterosacral ligaments in 17 (63%) women with chronic pelvic pain. Laparoscopic resection of uterosacral ligaments improved dysmenorrhea, dyspareunia, and noncyclical pain and decreased the number of days lost from work, as well as the proportion of patients who required medication for pain control. © 2006 AAGL. All rights reserved.

Laparoscopic uterine nerve ablation versus vaginal uterosacral ligament resection in postmenopausal women with intractable midline chronic pelvic pain: A randomized study

Objective To assess and compare the laparoscopic uterine nerve ablation (LUNA) and the vaginal uterosacral ligament resection (VUSR) in postmenopausal women with chronic pelvic pain (CPP). Study design Eighty postmenopausal women with intractable and severe midline CPP were randomized to undergo LUNA or VUSR. Costs of two surgical procedures were assesses. Cure rate, severity of CPP, and deep dyspareunia were also evaluated after 6 and 12 months from surgery. Results The mean cost of LUNA resulted significantly higher in comparison with VURS (2078 ± 637 versus 1497 ± 297, P < 0.001). The cure rate was not significantly different between the two groups at 6 (33/40, 82.5% versus 35/40, 87.5% for groups A and B, respectively; P = 0.530; RR 0.94, 95% CI 0.78–1.13), and 12 months (27/36, 75.0% versus 28/38, 73.7%, for groups A and B, respectively; P = 0.901; RR 0.90, 95% CI 0.78–1.33) of follow-up. At same times, a significant ( P < 0.01) decrease in severity of CPP and deep dyspareunia was observed in both groups with no difference between them. Conclusions Both LUNA and VUSR are equally effective surgical treatments in postmenopausal women with central CPP but VUNR is significantly cheaper than LUNA.

Uterosacral ligament resection in addition to surgery for endometriosis did not reduce recurrence of dysmenorrhea

Uterosacral ligament resection in addition to surgery for endometriosis did not reduce recurrence of dysmenorrhea

Laparoscopic uterosacral ligament resection for dysmenorrhea associated with endometriosis: results of a randomized, controlled trial

Objective To evaluate the efficacy of laparoscopic resection of the uterosacral ligaments in women with endometriosis and predominantly midline dysmenorrhea. Design Randomized controlled trial. Setting Two academic departments. Patient(s) One hundred eighty patients undergoing operative laparoscopy as first-line therapy for stage I to IV symptomatic endometriosis. Intervention(s) Operative laparoscopy including uterosacral ligament resection or conservative surgery alone. Main outcome measure(s) Proportion of women with recurrence of moderate or severe dysmenorrhea 1 year after surgery. Result(s) No complications occurred. Among the patients who were evaluable 1 year after operative laparoscopy, 23 of 78 (29%) women who had uterosacral ligament resection and 21 of 78 (27%) women who had conservative surgery only reported recurrent dysmenorrhea. The corresponding numbers of patients at 3 years were 21 of 59 (36%) women and 18 of 57 (32%) women, respectively. Time to recurrence was similar in the two groups. Pain was substantially reduced, and patients in both groups experienced similar and significant improvements in health-related quality of life, psychiatric profile, and sexual satisfaction. Overall, 68 of 90 (75%) patients in the uterosacral ligament resection group and 67 of 90 (74%) patients in the conservative surgery group were satisfied at 1 year. Conclusion(s) Addition of uterosacral ligament resection to conservative laparoscopic surgery for endometriosis did not reduce the medium- or long-term frequency and severity of recurrence of dysmenorrhea.

Adhesion Formation after Laparoscopic Resection of Uterosacral Ligaments in Women with Endometriosis

Study Objective To analyze the risk of postoperative adhesions in women who undergo laparoscopic surgical management of deep endometriosis infiltrating the uterosacral ligaments (USL) Design Retrospective analysis (Canadian Task Force classification II-2). Setting University-affiliated hospital. Patients Forty-six women with deep endometriosis infiltrating the USL. Intervention Laparoscopic resection of all USL with deep endometriotic lesions and excision of all other endometriotic lesions, followed by second-look laparoscopy. Measurements and Main Results At second-look laparoscopy, 15 patients (32.6%) had no adhesions at the site where the USL had been resected, 24 (52.2%) had filmy avascular adhesions, and 7 (15.2%) had dense or vascular adhesions. No patient had adhesions of the binding type. Only two factors, the revised American Fertility Association (rAFS) score at initial laparoscopy and surgical modality (unilateral resection of the right USL, unilateral resection of the left USL, bilateral resection of USL) had a statistically significant influence on the risk of postoperative adhesions occurring. After adjustment, the relation with initial rAFS stage and surgical modality remained significant in the stepwise logistic regression model. Conclusion These encouraging results are particularly interesting for patients with infertility due to pelvic pain syndrome. Second-look laparoscopy should not be performed routinely after laparoscopic management of deep endometriosis infiltrating the USL. We propose that it be reserved for women with rAFS stages III and IV endometriosis, especially when lesions are located on the left side.

Surgical management of endometriosis

A systematic literature review of the last two decades was performed to evaluate the effect of pelvic denervations in addition to conservative surgery on dysmenorrhoea and deep dyspareunia associated with endometriosis. Chronic pelvic pain relief after hysterectomy or adhesiolysis was also assessed. In the five non-comparative studies on the effect of pre-sacral neurectomy, the frequency of dysmenorrhoea recurrence or persistence after treatment ranged from 4 to 40%. The pooled frequency of non-responders at the end of follow-up was 23% (95% confidence interval (CI), 19 to 27%). Only two of the three comparative, non-randomized trials demonstrated a significant treatment benefit of pre-sacral neurectomy, and the results of the two identified randomized controlled trials are discordant. Significant quantitative heterogeneity among studies prevented pooling of data on dysmenorrhoea. The common odds ratio of deep dyspareunia persistence was 0·69 (95% CI, 0·31 to 1·54). In the 10 non-comparative studies on the effect of uterosacral ligament resection, the frequency of dysmenorrhoea and deep dyspareunia persistence after treatment ranged, respectively, from 0 to 50% and from 6 to 42%. The pooled frequency of non-responders at the end of follow-up was 23% (95% CI, 20 to 27%) and 13% (95% CI, 8 to 18%), respectively. Routine performance of complementary denervating procedures cannot be recommended based on the quality of the evidence available. The results of the five studies on the effect of hysterectomy on chronic pelvic pain of presumed uterine origin consistently demonstrated that 83–97% of operated women reported pain relief or improvement 1 year after surgery. There is no consensus on the outcome of adhesiolysis in patients with chronic pain, and the role of pelvic adhesions in causing symptoms is under scrutiny.

Laparoscopic Assistance for Extended Radicality of Radical Vaginal Hysterectomy: Description of a Technique

Objective.We developed and standardized a surgical technique, which allows radical hysterectomy by a combined laparoscopic and vaginal approach with radicalness equivalent to a type III procedure according to Rutledge.Method.Thirty-six consecutive patients with cervical cancer stage IB1–IIIA with high risk for parametrial involvement were treated between May 1996 and March 1998.Results.Bilateral para-aortic and pelvic lymphadenectomy and resection of the cardinal ligaments was performed laparoscopically using bipolar coagulation. Dissection of the ureters and resection of bladder pillars and uterosacral ligaments was performed transvaginally. On average 6.5 cm of cardinal ligament could be removed per side.Conclusions.With the laparoscopic–vaginal technique described a radical hysterectomy type III can be performed.

Retroperitoneal Endometriosis and Pelvic Pain: Results of Laparoscopic Uterosacral Ligament Resection According to the rAFS Classification and Histopathologic Results

ABSTRACT The objective of this work was to assess the efficacy of laparoscopic surgical resection of the uterosacral ligament(s) (USL) in patients with pelvic pain associated with suspected infiltr...