Restoration Of Pelvic Anatomy Research Articles

P-743 Laparoscopic radical excision of deep endometriosis: A positive impact of fertility outcome

Abstract Study question Does laparoscopic radical excision of deep endometriosis (DE) and endometrioma enucleation impact fertility outcomes and recurrence rates when compared to partial excision group? Summary answer In stage IV endometriosis, laparoscopic radical surgery significantly reduced the recurrence rates.The laparoscopic radical excision group tended to have a higher rate of natural conception. What is known already Endometriosis-related symptoms can be significantly improved through surgery, leading to better pregnancy rates. However, the optimal surgical approach can vary due to the complexity of DE. As a result, the recurrence of postoperative symptoms and pregnancy rates can differ due to the lack of randomized trials comparing primary surgery with first-line IVF studies. Thus, the ESHRE stated that there was no evidence supporting surgical management of DE prior to ART to improve pregnancy rates. However, the higher probability of postoperative spontaneous conception in patients undergoing radical resection versus conservative treatment of DE has been reported. Study design, size, duration study design: Retrospective cohort study in a tertiary referral center. size: 77 patients diagnosed with moderate or severe endometriosis and DE. duration: between 2018 and 2020 Participants/materials, setting, methods 77 patients underwent laparoscopic surgery for dysmenorrhea or infertility. Group 1 (n = 22) underwent conservative treatment through partial excision of endometriosis, indicating incomplete resection. Group 2 (n = 55) underwent radical excision of endometriosis and restoration of pelvic anatomy, indicating complete resection. We compared the baseline characteristics, peri-operative data, and follow-up outcomes, aiming to investigate whether radical excision yields superior results in terms of recurrence rate, re-intervention, and pregnancy rate. Main results and the role of chance Main results: Group 2 showed significantly higher surgical complexity with higher revised American Fertility Society classification scores, a greater proportion of severe endometriosis, multiple sites with endometriotic lesions, and longer operation times. Both groups had comparable pregnancy, recurrence, and re-intervention outcomes during the follow-up period of 28.2±16.4 months. While Group 2 tended to have a higher pregnancy rate (84% versus 67%, p = 0.56) and higher live birth rates (80% versus 67%, p = 0.59) when compared with group 1. In the population with stage IV endometriosis, group 2 significantly reduced the recurrence rates (9% versus 50%, p = 0.04) when compared to group 1. Conclusions: The group that underwent laparoscopic endometrioma enucleation with radical excision of extra-ovarian endometriosis exhibited significantly higher surgical complexity. In the population with stage IV endometriosis, radical surgery significantly reduced the recurrence rates. Surgical excision of ovarian endometriosis and extra-ovarian disease is advisable to limit disease progression and ensure complete symptom resolution. Additionally, the laparoscopic radical excision group tended to have a higher rate of natural conception, indicating potential benefits for fertility in patients who have moderate and severe endometriosis with DE. Limitations, reasons for caution The main limitations were the small sample size and recall bias. But, additionally, the limited cases in the research group might have influenced the results and restricted the extrapolation of related conclusions. Further studies with larger sample sizes are needed in the future. Wider implications of the findings We believe that a standardized surgical technique outlining a step-by-step method to delineate all important structures and address altered planes as in endometriosis, with the aim of restoring normal pelvic anatomy, ensures the avoidance of high complication rates, leads to lower recurrence rates and positive impact on fertility outcomes. Trial registration number not applicable

Surgical treatment of pelvic organ prolapse

Female pelvic organ prolapse is a widely prevalent condition and is associated with variable morbidity. It encompasses a number of clinical conditions, including subvesical obstruction, overactive bladder symptoms, sexual dysfunction and urinary und fecal incontinence. The prevalence of pelvic insufficiency is estimated to be between 30 and 50 %. As life expectancy is increasing and the elderly population is growing, there will be an increased incidence of the condition and growing demand for pelvic floor treatment in the future. The incidence of recurrent pelvic floor prolapse is also growing. The goal of surgical management is the restoration of pelvic anatomy and bladder, vaginal and bowel function, resolution of patient symptoms and improvement in quality of life. The objective of this review is to present the main surgical procedures for different subtypes of genital prolapse and to evaluate their outcomes and complications. During the last ten years, technologies for the minimally invasive approach have advanced and robotic assisted sacrocolpopexy is now equivalent to classical vaginal and transabdominal procedures.

Patient with Chronic Pelvic Pain from Endometriosis

Endometriosis, a chronic and progressive condition characterized by the presence of endometrial tissue outside the uterus, accounts for about one third of the cases of chronic pelvic pain in women. Pain in endometriosis may be due to nociceptive, inflammatory, and/or neu­ropathic mechanisms. The clinical presentation is often variable between patients, and diagnostic laparoscopy for visualization and biopsy of lesions is the gold standard for diagnosis. The treatment may consist of two elements: chronic pelvic pain itself as a diagnosis and endometriosis as a disease. Hormonal therapy is used to reduce the amount of estrogen and hence reduce symptoms such as pelvic pain and dysmenorrhea. In patients with severe endometriosis, surgical removal of lesions, adhesions, and cysts and restoration of pelvic anatomy may be preferred. Both hormonal and surgical treatments have been shown to be effective in decreasing pain symptoms associated with endometriosis. A variety of analgesics, including nonsteroidal antiinflammatory drugs, opioids, tricyclic antidepressants, dual reuptake inhibitors of serotonin and norepinephrine, and antiepileptic drugs, have been used to ameliorate pain in endometriosis, with varying degrees of success. In patients with persistent symptoms, interventional pain management procedures may be performed to target the visceral and somatic organs and their innervations. Infertility is the most common complication of endometriosis. Between 10 and 20% of women with endometriosis have recurrence of the disease regardless of the treatment they receive. The recurrence of pain may be due to remodeling of the central nervous system, the role of the reproductive tract in reactivating pain, and incomplete removal or recurrence of lesions. This review contains 2 tables and 52 references Key words: chronic abdominal pain, chronic pelvic pain, dyschezia, dysmenorrhea, dyspareunia, endometrioma, endometriosis, hormonal therapy, infertility, retrograde menstruation, visceral pain

Single-Port Total Laparoscopic Hysterectomy in a Patient With Deep Infiltrating Endometriosis

Study ObjectiveTo present the feasibility of single-port laparoscopic surgery at patients with deep infiltrating endometriosis. DesignStep by step explanation of the surgery using videos (Canadian Task Force classification III-c). SettingSingle-port laparoscopic surgery is an emerging technique and an option for improving the benefits of laparoscopic surgery. The goals of single-port laparoscopic surgery is to further enhance the cosmetic benefits of minimally invasive surgery and minimize the potential risk and morbidity associated with multiport surgery [1,2]. This procedure is not without challenges, however, such as instrument crowding and clashing, ergonomic difficulties, loss of instrument triangulation, and the need for advanced laparoscopic skills [1,2]. Despite these challenges, technical advances in optics and instrumentation have led to the widespread use of single-port laparoscopic surgery to treat such gynecologic disorders as endometriosis, uterine myomas, and cancers [2,3]. InterventionsA 42-year-old woman was admitted to our clinic with a complaint of chronic pelvic pain dysmenorrhea and deep dyspareunia. Her medical history revealed a cesarean section delivery and a diagnosis of endometriosis. Despite treatment of her endometriosis with dienogest, there has been no decline at her complaints. Ultrasound examination performed at admission revealed a 6 × 6 cm right adnexal mass compatible with endometrioma, with a normal left ovary and uterus. Rectovaginal examination detected no endometriotic nodules. Although all treatment options were explained and discussed and laparoscopic excision of right ovarian endometrioma was recommended, the patient strongly desired removal of the uterus and the ovaries to avoid recurrence of endometriosis and related complaints. Thus, laparoscopic hysterectomy and bilateral salpingo-oophorectomy were planned. Under general anesthesia and endotracheal intubation, the patient was placed in low lithotomy position with the arms tucked. An orogastric tube and a Foley catheter were placed. Abdominal access was performed following an open Hasson technique with a 2.0- to 2.5-cm vertical umbilical incision and a 4-channel (with two 10-mm and two 5-mm channels) access port was placed into the peritoneal cavity. On pelvic examination, a 6 × 6-cm right ovarian endometrioma adherent to the pelvic sidewall was detected, along with severe adhesions on the left side between the left adnex and the pelvic sidewall. The uterus was normal. The adhesion on the left side was released using a Harmonic scalpel (Ethicon Endosurgery, Cinncinnati, OH). The pelvic sidewall peritoneum was opened, and the ureters were identified and isolated at the pelvic brim and followed toward the true pelvis. The internal iliac artery, uterine and obliterated umbilical artery, and infundibulopelvic ligament were dissected and identified. The paravesical, pararectal, and rectouterine spaces were opened. Deep infiltrating endometriosis implants on the right side located in the uterosacral ligment and pararectal space were dissected and excised. After restoration of pelvic anatomy, hysterectomy and bilateral salpingo-oophorectomy were performed. The vaginal cuff was closed with intracorporeal knots. The patient was discharged on postoperative day 1, and reported no problems at follow-up. ConclusionSingle-port laparoscopic hysterectomy appears to be a safe and feasible option in patients with deep infiltrating endometriosis, especially when performed by well-experienced surgeons.

The improvement of pelvic floor muscle function in POP patients after the Prolift procedure: results from surface electromyography

Patients with pelvic organ prolapse (POP) have lower pelvic floor muscle (PFM) function. We hypothesized that pelvic reconstructive surgery could improve PFM function and strength. The controlled, nonrandomized study recruited 37 POP patients in the Prolift group and 30 non-POP patients in the control group. Two urogynecologists performed the Prolift procedure. One experienced physiotherapist who was blinded to the grouping conducted the surface electromyography (SEMG) evaluation using an intravaginal probe. The patient was considered objectively cured if she had stage 0 or I according to the Pelvic Organ Prolapse Quantification system (POP-Q) at the 3rd month postoperatively. Two types of contractions, namely maximum voluntary contraction (MVC) and short, fast contractions (SFC) in 6 s were performed at each SEMG measurement. The SEMG data were collected once in the control group on admission and twice in the Prolift group (on admission and at the 3rd month postoperatively). The t test, Mann-Whitney U test, and Wilcoxon test were used for statistical analysis. A total of 36 POP patients were cured by the Prolift procedure. At the 3-month follow-up, the voltage and duration of MVC as well as the numbers and voltage of SFC increased significantly in the Prolift group. These variables were lower in POP patients compared to women without POP. The restoration of pelvic anatomy may account for the improved PFM function with increased electrical activity in POP patients verified by SEMG. Evaluation of PFM function may be used as a clinical tool in the overall assessment of pelvic reconstructive surgeries.

Medical and surgical therapies for pain associated with endometriosis.

Endometriosis is a common condition for which a number of treatments have been proposed. Medical treatments are based on the hormonal responsiveness of endometriosis implants. These therapies include progestins (with or without estrogens), androgens, and gonadotropin-releasing hormone (GnRH) analogs. Surgical treatments may include hysterectomy with oophorectomy or organ-sparing surgery involving ablation or resection of visible lesions of endometriosis and restoration of pelvic anatomy. There are no studies that directly compare the effectiveness or adverse effects of medical therapy and surgical therapy. Studies on medical therapy compare different treatments with placebo or with other active treatments. Hormone-based therapies for endometriosis show 80%-100% effectiveness in relief of pelvic pain over a 6-month course of therapy. Serious adverse outcomes after medical therapy are unusual. Studies on surgical therapy are largely anecdotal, with noncomparative reports on a variety of surgical methods. A few comparative surgical studies have been reported. Because of the noncomparative nature of many of the surgical studies, the use of combinations of surgical procedures and techniques in the reported studies, and the reporting of results from surgeons with an unusually high level of technical skill, the gynecological practitioner has little basis in the literature for assessing the optimum surgical approach. Surgical complications are believed to be underreported and may be related to how aggressive a surgical procedure is undertaken.

The Role of Uterosacral Ligament Resection in Conservative Operations for Recurrent Endometriosis

ABSTRACT Fifteen patients with a history of endometriosis and recurrent pelvic pain underwent conservative resection at laparotomy. Microsurgical resection of endometriotic lesions and restoration of pelvic anatomy were performed. Presacral neurectomy was carried out in 12 of 15 (80%) patients complaining of significant midline pelvic dysmenorrhea. AH patients had retroperitoneal dissections and bilateral uterosacral ligament resections regardless of whether or not there was clinical suspicion of uterosacral ligament involvement. Dysmenorrhea, dyspareunia, and dyschezia were relieved in 12 of 15 (80%), 7 of 12 (58%), and 8 of 11 (77%) patients, respectively. Eight patients (54%) had histological involvement of the uterosacral ligaments. Of this subgroup of patients, all had relief of dysmenorrhea, dyspareunia, and dyschezia postoperatively. Gross appearance was not always reliable in determining uterosacral ligament involvement. We believe that bilateral uterosacral ligament resection may benefit patients...