Laparoscopic management of endometriosis: comprehensive review of best evidence

Does Robot Assisted Laparoscopy (RAL) Have an Advantage in Preservation of Ovarian Reserve in Endometriosis Surgery? Comparison of Single-Port Access (SPA) RAL and SPA Laparoscopy

The purpose of this study was to compare single-port access (SPA) laparoscopy and SPA robot assisted laparoscopy (RAL) for endometriosis with respect to ovarian reserve preservation and surgical outcomes. Clinical factors affecting any reduction in ovarian function after surgery were also evaluated. Patients with endometriosis who underwent SPA laparoscopy (n = 87) or RAL (n = 78) were retrospectively reviewed. Patients' baseline characteristics, including the severity of endometriosis and surgical outcomes including surgical complexity, were collected. To assess the preservation of ovarian reserve after surgery, serum anti-Müllerian hormone (AMH) levels before surgery, at two weeks, and at three months after surgery were collected. Age, ovarian cyst size, location of cyst, complexity of surgery, and the severity of endometriosis were associated with the reduction in AMH levels after surgery. The severity of endometriosis was higher in the RAL group than in the SPA group. There were no significant differences in other clinical baseline characteristics, including preoperative AMH levels. For surgical outcomes, radical surgery was more frequently performed in the RAL group. In univariate and multivariate linear regression analyses, age, ovarian cyst size, location of cyst, complexity of surgery, and the severity of endometriosis were associated with the reduction in AMH levels after surgery. Incorporating surgical approaches and risk factors for postoperative ovarian function decrease, RAL was more beneficial than SPA laparoscopy for the preservation of ovarian reserve in patients with mild endometriosis (stage I/II) (postoperative 3 month AMH reduction rate (%), SPA laparoscopy vs. RAL, 33.51 ± 19.98 vs. 23.58 ± 14.98, p = 0.04) and in patients who underwent non-complex surgery (postoperative 3 month AMH reduction rate (%), SPA laparoscopy vs. RAL, 37.89 ± 22.37 vs. 22.37 ± 17.49, p = 0.022). SPA RAL may have advantages over SPA laparoscopy in ovarian function preservation, especially in patients with mild endometriosis and patients who have undergone a non-complex surgery.

Recent advances in benign gynecological laparoscopic surgery

Minimally invasive surgery continues to transform the field of gynecological surgery and is now the standard of care for the surgical treatment of many diseases in gynecology. Owing to minimally invasive surgery's clear advantages, new advances in technology are being employed rapidly and enabling even the most complicated procedures to be performed less invasively. We examine recent literature on minimally invasive surgical innovations, advances, and common practices in benign gynecology that, from our point of view, made an impact on the way laparoscopic surgery is performed and managed in the last decade.

Prevalence of Endometriosis and Peritoneal Pockets in Women with Infertility and/or Pelvic Pain

OBJECTIVE

To evaluate the prevalence of endometriosis and peritoneal pockets and to analyze whether these pockets are associated with pain.

METHODS

Analysis of prospectively registered data of all women undergoing laparoscopy for infertility or pelvic pain between 1988 and 2011 at KU Leuven University Hospital.

RESULTS

Of 4497 women, 191 had 238 pockets, with a prevalence of 4.7% in women with infertility only, 4.9% in women with infertility and pelvic pain, and 3.5% in women with pelvic pain only (P = 0.045 for all infertility vs. pelvic pain only). Prevalence did not vary by age. Pockets were associated with endometriosis (P < 0.0001), which was found in 77% of women with pockets. Among women with infertility only, the prevalence of endometriosis was higher in women with pockets (P = 0.0001) than in women without. The prevalence of endometriosis was similar in women with infertility and pelvic pain or pelvic pain only. Pelvic pain as an indication for surgery was associated simultaneously (through logistic regression) with endometriosis (P < 0.0001) and pockets (P = 0.040). Pelvic pain severity was associated simultaneously with pockets (P = 0.0026) and the severity of subtle (P = 0.001), typical (P = 0.030), cystic ovarian (P = 0.051), and deep endometriosis (P < 0.0001). Pelvic pain severity was not associated with endometriosis in the pockets or the diameter or location of pockets.

CONCLUSIONS

The prevalence of pockets was low, at between 3.5% and 5%. Women with infertility only and pockets had more endometriosis than women without. Severe pelvic pain and pelvic pain as an indication for surgery were associated with the presence of pockets as well as the presence and severity of endometriosis.

Peritoneal adhesions: Occurrence, prevention and experimental models

Peritoneal adhesions (PA) are a postoperative syndrome with high incidence rate, which can cause chronic abdominal pain, intestinal obstruction, and female infertility. Previous studies have identified that PA are caused by a disordered feedback of blood coagulation, inflammation, and fibrinolysis. Monocytes, macrophages, fibroblasts, and mesothelial cells are involved in this process, and secreted signaling molecules, such as tumor necrosis factor alpha (TNF-α), interleukin-10 (IL-10), tissue plasminogen activator (tPA), and type 1 plasminogen activator inhibitor (PAI-1), play a key role in PA development. There have been many attempts to prevent PA formation by anti-PA drugs, barriers, and other therapeutic methods, but their effectiveness has not been widely accepted. Treatment by biomaterial-based barriers is believed to be the most promising method to prevent PA formation in recent years. In this review, the pathogenesis, treatment approaches, and animal models of PA are summarized and discussed to understand the challenges faced in the biomaterial-based anti-PA treatments.

Lack of Data-driven Treatment Guidelines and Wide Variation in Management of Chronic Pelvic Pain in Adolescents and Young Adults

STUDY OBJECTIVE

Current literature lacks data-driven guidelines for surgical treatment of adolescent and young adult (AYA) patients with chronic pelvic pain. We hypothesized that there is a significant variation in treatment of these patients, which might be an indicator of over- or undertreatment by some providers.

DESIGN AND SETTING

We completed a retrospective population-based analysis of the Nationwide Inpatient Sample from 1998 to 2016.

PARTICIPANTS

We included AYA patients aged 9-25 years whose primary diagnosis was adenomyosis, endometriosis, or chronic pelvic pain. Patients who might have undergone pelvic or abdominal procedures for other primary diagnoses were excluded.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Trends of inpatient surgical intervention were calculated. Logistic regression was performed to determine the likelihood of undergoing an intervention, adjusted for patient demographic characteristics.

RESULTS

A total of 13,111 AYA patients were analyzed. Median age at diagnosis was 22 (interquartile range, 20-24) years. The overall inpatient intervention rate was 5879/13111 (45.0%) (2445/5897 (18.6%) for excision/ablation, 2057/5897 (15.7%) for hysterectomy, 1239/5897 (9.5%) for diagnostic laparoscopy, and 156/5897 (1.2%) for biopsy). Rate of hysterectomy increased in the late 2000s while rates of all other interventions decreased. Patients in the northeast were less likely to undergo an intervention than patients in the rest of the country. Rates of intervention also differed according to race, insurance status, and type of hospital.

CONCLUSION

There is wide variation in the use of surgical treatment for chronic pelvic pain in AYA patients across the country and between types of institutions. Of concern, the rate of hysterectomy has increased over time. There is a need for data-directed treatment guidelines for the management of AYA patients with chronic pelvic pain to ensure appropriate application of surgical treatments and expand high-value surgical care.

Comparison of effect of preoperative dienogest and gonadotropin-releasing hormone agonist administration on laparoscopic cystectomy for ovarian endometriomas

PURPOSE

To compare the effects of preoperative dienogest (DNG) and gonadotropin-releasing hormone (GnRH) agonist administration on the improvement of preoperative symptoms and surgical outcomes in patients who underwent laparoscopic cystectomy for ovarian endometriomas.

METHODS

Seventy patients who were scheduled for laparoscopic surgery were enrolled in the study. They were divided into two groups: 35 patients who received DNG for 4 months preoperatively (group D) and 35 patients who received low-dose sustained-release goserelin acetate for 4 months preoperatively (group G). Preoperative outcomes, including pain score associated with endometriosis, using the numerical rating scale (NRS), adverse events of hormonal therapy and Kupperman index (KI) before and after treatment, surgical outcomes including total surgical duration and blood loss, and postoperative recurrence of endometrioma were compared between the two groups.

RESULTS

Regarding preoperative symptoms, NRS and KI at 4 months after preoperative hormonal therapy were significantly lower in group D than in group G (NRS, 5.3 ± 5.5 vs. 2.7 ± 3.9; P = 0.01; KI, 16.0 ± 11.0 vs. 9.2 ± 7.6; P = 0.006). Regarding adverse events, the incidence of hot flashes was significantly lower in group D than in group G (P < 0.001). Meanwhile, the incidence of breast pain and metrorrhagia was significantly higher in group D than in group G (P = 0.04 and P < 0.001, respectively). The total surgical duration and blood loss were not significantly different between the groups. At 12 months after surgery, ovarian endometrioma did not recur in either group.

CONCLUSION

Preoperative administration of DNG is more valuable for patients with endometriosis and scheduled for laparoscopic surgery to improve symptoms with good efficacy and tolerability than the administration of GnRH agonist.

Pathophysiological Basis of Endometriosis-Linked Stress Associated with Pain and Infertility: A Conceptual Review

Women with endometriosis are often under stress due to the associated pain, infertility, inflammation-related and other comorbidities including cancer. Additionally, these women are also under stress due to taboos, myths, inter-personal troubles surrounding infertility and pain of the disease as well as due to frequent incidences of missed diagnosis and treatment recurrence. Often these women suffer from frustration and loss of valuable time in the prime phase of life. All these complexities integral to endometriosis posit a hyperstructure of integrative stress physiology with overt differentials in effective allostatic state in women with disease compared with disease-free women. In the present review, we aim to critically examine various aspects of pathophysiological basis of stress surrounding endometriosis with special emphasis on pain and subfertility that are known to affect the overall health and quality of life of women with the disease and promising pathophysiological basis for its effective management.

The Surgical Benefit of Hysterolaparoscopy in Endometriosis-Related Infertility: A Single Centre Retrospective Study with a Minimum 2-Year Follow-Up

AIM

This study examined the fertility performance of women after combined hysterolaparoscopic surgical management of endometriosis. Design: This study is a hospital-based retrospective review.

MATERIALS AND METHODS

Data collected from the records of all patients presented with endometriosis-related infertility using a checklist designed for the purpose. Result: A total of 81.3% (370/455) of women who have had the desire to have children became pregnant during the study period after the surgery. Of those who became pregnant, all three-hundred-forty-seven patients were followed to the end of their pregnancies. A successful live birth occurred in 94.2% (327/347) of individuals, and pregnancy loss occurred in 5.8% (20/347). The mean patient age was 34.1 ± 4.1 years, and the average duration of infertility was 3.4 ± 3.3 years. Pregnancy occurred spontaneously in 39.5% (146/370) of patients, after artificial insemination (AIH) in 3.8% (14/370) of women, and after in vitro fertilization-embryo transfer (IVF-ET) in 56.8% (210/370) of cases. Patients aged ≤ 35 years had a higher chance of conception post-surgery-84% versus 77%, respectively (p = 0.039). Based on the modes of pregnancy, the timely introduction of an assisted reproductive technique (ART) demonstrated a significant effect on fertility performance postsurgery. Comparatively, this effect was 91.3% vs. 74.1% among the ≤35- and >35-year-old age groups, respectively. There was no significant difference in reproductive performance based on stages of endometriosis, nor in the other parameters evaluated. Conclusion: Our data are consistent with previous clinical studies regarding the management options of endometriosis-related infertility. Overall, the combined hysterolaparoscopy treatment is a very effective and reliable procedure, and is even more effective when combined with ART. It enhances women's wellbeing and quality of life, and significantly improves reproductive performance.

Visualization of endometriosis with laparoscopy and near-infrared optics with indocyanine green

INTRODUCTION

Endometriosis is a common health problem, affecting 10% of women of reproductive age. Laparoscopic surgery is proven to relieve pain and to improve fertility in women with endometriosis. However, identifying peritoneal endometriosis lesions may be difficult due to their polymorphic aspects. Endometriosis lesions harbor a high degree of neovascularization. The visualization of tissue perfusion by the additional use of near infrared fluorescence imaging with indocyanine green (ICG) may improve the detection of endometriosis lesions.

MATERIAL AND METHODS

In a single-center, prospective, single-arm pilot study, patients undergoing laparoscopic surgery for suspected endometriosis and/or infertility were recruited. All patients first had white light imaging with systematical documentation of all suspicious areas. ICG was then administered intravenously at .3 mg/kg bodyweight and the near infrared imaging was activated and an identical documentation of suspected lesions was performed again. After removal, the specimen were sent to pathology.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov NCT03850158.

RESULTS

In total, 173 suspected lesions were identified and excised, of which 150 had histologically proven endometriosis. Of the total number, 166 suspected lesions were detected using white-light and 32 with ICG. Among the 32 suspected lesions found with ICG, 22 were confirmed to be endometriosis. Seven additional lesions were identified with ICG alone, of which only one was histologically proven endometriosis. Positive predictive values were 89.8%, 68.8% and 86.7% for white-light laparoscopy alone, near-infrared (NIR)-ICG visualization alone, and the combination of white-light and NIR-ICG, respectively. ICG exposure time, previous abdominal surgery and rARSM stage showed a statistically significant impact on the ICG detection rate. In seven patients, ICG was used for the resection of deep infiltrating nodules from the rectum. In these cases, NIR fluorescence imaging with ICG was useful to define the borders between an endometriotic nodule and healthy tissue.

CONCLUSIONS

The diagnostic value of NIR-ICG imaging in identifying endometriosis appears to be minimal. ICG exposure time over 20 minutes, no previous abdominal surgery and low rASRM stages have a significant positive effect on the ICG detection rate. NIR fluorescence imaging with ICG was helpful in the resection of deep infiltrating nodules in providing a better visualization of endometriosis.

Application of MESNA in endoscopic submucosal dissection for esophageal diseases

With the development of digestive endoscopy, early esophageal carcinoma, esophageal leiomyoma, achalasia, and mediastinal lesions, which were previously treated by thoracoscopy or thoracotomy, may be treated by digestive endoscopy. Endoscopic submucosal dissection (ESD) can achieve en bloc resection of large gastrointestinal mucosal and submucosal lesions and has become the first-line treatment for early esophageal cancer and precancerous lesions without lymph node metastasis. Submucosal tunnel endoscopy has expanded endoscopic indications by establishing a submucosal tunnel, and it has been applied in esophageal lesions originating from the muscularis propia and even mediastinal tumors. An ideal submucosal fluid infusion may shorten dissection time during ESD or submucosal tunnel endoscopy. Selecting appropriate submucosal injection is one of the important factors for ESD success. Submucosal injections of sodium-2-mercaptoethanesulfonate can soften tissues and facilitate endoscopic submucosal dissection and is worthy of clinical promotion.

The Role of GnRH Analogues in Improving Outcome in Women Undergoing Superovulation and Intrauterine Insemination after Surgical Correction of Mild Endometriosis: A Randomized Controlled Trial

Objective

Treatment with laparoscopic surgery, gonadotropin-releasing hormone analog (GnRHa) therapy, superovulation (SO), and intrauterine insemination (IUI) have individual benefits in improving fertility outcomes in women with endometriosis. The aim of the study was to evaluate the role of GnRHa in improving outcome in women undergoing SO and IUI after surgical correction of mild endometriosis.

Materials and Methods

This was a randomized controlled trial conducted in the Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India, over a period of 2 years and 6 months. Ninety women who were diagnosed with mild endometriosis on laparoscopy using the revised American Society for Reproductive Medicine criteria were included in the study. The patients in the study group (n=45) received a single dose of 3.75 mg GnRHa subcutaneously within 48 h of the surgery, and those in the control group (n=45) did not receive GnRHa. Thereafter, patients in both arms received SO and IUI from the next menstrual cycle. Four patients in the study group and three patients in the control group were lost to follow-up before the first cycle of ovulation induction. Primary outcomes measured in our study were live birth rates and clinical pregnancy rate. Secondary outcome measures were number of follicles >18 mm, endometrial thickness, dose and days of gonadotropin stimulation.

Results

Baseline characteristics, such as age and body mass index, were comparable in both groups. The SO and IUI cycles were comparable between the two groups with regard to the secondary outcome parameters. Pregnancy rate in the first cycle was 17.1% in the study group and 19.1% in the control group (p=0.81). The overall pregnancy rate was similar in both groups (study group=21.9%, control group=23.8%; p=1). As no patient had miscarriage or any other complication during pregnancy, live birth rate was similar to the clinical pregnancy rate.

Conclusion

Adding GnRHa for the suppression of mild endometriosis has shown no significant improvement in the surgical management of women undergoing SO and IUI.

Concomitant female genital tuberculosis and endometriosis

AIMS

To demonstrate an association between female genital tuberculosis (FGTB) and endometriosis.

METHODS

A total of 16 women who underwent laparoscopy (12 cases) or laparotomy (4 cases) and were found to have female genital tuberculosis and endometriosis were enrolled in this retrospective study.

RESULTS

The mean age and parity were 28.2 years and 0.2, respectively. Past history of tuberculosis was present in 75% of the women (pulmonary in 50%). Menstrual dysfunction (especially oligomenorrhoea and dysmenorrhoea), constitutional symptoms, infertility, abdominal pain and lump were the main complaints. Diagnosis of FGTB was made by positive acid-fast bacilli (AFB) on microscopy, culture of endometrial aspirate, positive polymerase chain reaction (PCR), histopathological finding of epitheliod granuloma or findings of TB on laparoscopy or laparotomy. Diagnosis of endometriosis was made by laparoscopy or laparotomy. Pelvic adhesions were seen in all women, whereas frozen pelvis was seen in 7 (43.7%) women. Surgery was performed, which was laparoscopic adhesiolysis in 12 (75%), drainage of endometrioma in 12 (75%), cystectomy in 8 (50%), and total abdominal hysterectomy with bilateral salpingo-oophorectomy in 4 (25%) cases. With more then one type of (surgery in many cases).

DISCUSSION

Female genital tuberculosis and endometriosis may have similar manifestations and can co-exist.

Laparoscopic Excision Versus Ablation for Endometriosis-associated Pain: An Updated Systematic Review and Meta-analysis

The aim of this study was to update the evidence on the surgical management of endometriosis-associated pain. Does laparoscopic excision offer any benefits over laparoscopic ablation? This is a systematic review and meta-analysis in which we searched MEDLINE, Embase, Institute for Scientific Information conference proceedings, the International Standard Randomised Controlled Trial Number registry, the Register and Meta-register for randomized controlled trials, the World Health Organization trials search portal, the Cochrane Library, and the British Library of electronic theses. Three randomized controlled trials were included, which enrolled 335 participants with a sample size per study ranging from 24 to 178 participants. Of these 3 studies, data from 2 could be pooled for meta-analysis. The primary outcome measure was the reduction in the visual analog scale score for dysmenorrhea. The secondary outcome measures included the reduction in the visual analog scale score for dyspareunia, dyschezia, and chronic pelvic pain and the reduction in Endometriosis Health Profile-30 core pain scores. The meta-analysis showed that the excision group had a significantly greater reduction in symptoms of dysmenorrhea (mean difference [MD] = 0.99; 95% confidence interval [CI], -0.02 to 2.00; p = .05) and dyschezia (MD = 1.31; 95% CI, 0.33-2.29; p = .009) compared with ablation. The symptoms of dyspareunia showed a nonsignificant benefit with excision (MD = 0.96; 95% CI, -0.07 to 1.99; p = .07). Data from 1 study showed a significant reduction in chronic pelvic pain (MD = 2.57; 95% CI, 1.27-3.87; p = .0001) and Endometriosis Health Profile-30 core pain scores (MD = 13.20; 95% CI, 3.70-22.70; p = .006) with the excision group compared with the ablation group. The limited available evidence shows that at 12 months postsurgery, symptoms of dysmenorrhea, dyschezia, and chronic pelvic pain secondary to endometriosis showed a significantly greater improvement with laparoscopic excision compared with ablation.

Retroperitoneal anatomy during excision of pelvic side wall endometriosis

Surgical management of endometriosis has been shown to improve dysmenorrhea at all disease stages and is recommended in severe disease for treatment of infertility. Deeply infiltrating endometriosis (DIE) produces thick inflammatory tissue that precludes visualization of anatomical landmarks and distorts normal anatomy. Excision of DIE poses several technical and surgical challenges that mandate a clear understanding of the anatomy of the pelvic sidewall. This review details relevant surgical anatomy and addresses the principles of safe retroperitoneal entry, ureterolysis and excision of endometriotic lesions. Proper use of these techniques should facilitate safe and successful surgery for management of DIE.

Combination of the non-invasive tests for the diagnosis of endometriosis

BACKGROUND

About 10% of women of reproductive age suffer from endometriosis, a costly chronic disease causing pelvic pain and subfertility. Laparoscopy is the gold standard diagnostic test for endometriosis, but is expensive and carries surgical risks. Currently, there are no non-invasive tests available in clinical practice to accurately diagnose endometriosis. This review assessed the diagnostic accuracy of combinations of different non-invasive testing modalities for endometriosis and provided a summary of all the reviews in the non-invasive tests for endometriosis series.

OBJECTIVES

To estimate the diagnostic accuracy of any combination of non-invasive tests for the diagnosis of pelvic endometriosis (peritoneal and/or ovarian or deep infiltrating) compared to surgical diagnosis as a reference standard. The combined tests were evaluated as replacement tests for diagnostic surgery and triage tests to assist decision-making to undertake diagnostic surgery for endometriosis.

SEARCH METHODS

We did not restrict the searches to particular study designs, language or publication dates. We searched CENTRAL to July 2015, MEDLINE and EMBASE to May 2015, as well as the following databases to April 2015: CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, DARE and PubMed.

SELECTION CRITERIA

We considered published, peer-reviewed, randomised controlled or cross-sectional studies of any size, including prospectively collected samples from any population of women of reproductive age suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE). We included studies comparing the diagnostic test accuracy of a combination of several testing modalities with the findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Three review authors independently collected and performed a quality assessment of the data from each study by using the QUADAS-2 tool. For each test, the data were classified as positive or negative for the surgical detection of endometriosis and sensitivity and specificity estimates were calculated. The bivariate model was planned to obtain pooled estimates of sensitivity and specificity whenever sufficient data were available. The predetermined criteria for a clinically useful test to replace diagnostic surgery were a sensitivity of 0.94 and a specificity of 0.79 to detect endometriosis. We set the criteria for triage tests at a sensitivity of 0.95 and above and a specificity of 0.50 and above, which 'rules out' the diagnosis with high accuracy if there is a negative test result (SnOUT test), or a sensitivity of 0.50 and above and a specificity of 0.95 and above, which 'rules in' the diagnosis with high accuracy if there is a positive result (SpIN test).

MAIN RESULTS

Eleven eligible studies included 1339 participants. All the studies were of poor methodological quality. Seven studies evaluated pelvic endometriosis, one study considered DIE and/or ovarian endometrioma, two studies differentiated endometrioma from other ovarian cysts and one study addressed mapping DIE at specific anatomical sites. Fifteen different diagnostic combinations were assessed, including blood, urinary or endometrial biomarkers, transvaginal ultrasound (TVUS) and clinical history or examination. We did not pool estimates of sensitivity and specificity, as each study analysed independent combinations of the non-invasive tests.Tests that met the criteria for a replacement test were: a combination of serum IL-6 (cut-off >15.4 pg/ml) and endometrial PGP 9.5 for pelvic endometriosis (sensitivity 1.00 (95% confidence interval (CI) 0.91 to 1.00), specificity 0.93 (95% CI, 0.80, 0.98) and the combination of vaginal examination and transvaginal ultrasound (TVUS) for rectal endometriosis (sensitivity 0.96 (95% CI 0.86 to 0.99), specificity 0.98 (95% CI 0.94 to 1.00)). Tests that met the criteria for SpIN triage tests for pelvic endometriosis were: 1. a multiplication of urine vitamin-D-binding protein (VDBP) and serum CA-125 (cut-off >2755) (sensitivity 0.74 (95% CI 0.60 to 0.84), specificity 0.97 (95% CI 0.86 to 1.00)) and 2. a combination of history (length of menses), serum CA-125 (cut-off >35 U/ml) and endometrial leukocytes (sensitivity 0.61 (95% CI 0.54 to 0.69), specificity 0.95 (95% CI 0.91 to 0.98)). For endometrioma, the following combinations qualified as SpIN test: 1. TVUS and either serum CA-125 (cut-off ≥25 U/ml) or CA 19.9 (cut-off ≥12 U/ml) (sensitivity 0.79 (95% CI 0.64 to 0.91), specificity 0.97 (95% CI 0.91 to 1.00)); 2. TVUS and serum CA 19.9 (cut-off ≥12 U/ml) (sensitivity 0.54 (95% CI 0.37 to 0.70), specificity 0.97 (95% CI 0.91 to 1.0)); 3-4. TVUS and serum CA-125 (cut-off ≥20 U/ml or cut-off ≥25 U/ml) (sensitivity 0.69 (95% CI 0.49 to 0.85), specificity 0.96 (95% CI 0.88 to 0.99)); 5. TVUS and serum CA-125 (cut-off ≥35 U/ml) (sensitivity 0.52 (95% CI 0.33 to 0.71), specificity 0.97 (95% CI 0.90 to 1.00)). A combination of vaginal examination and TVUS reached the threshold for a SpIN test for obliterated pouch of Douglas (sensitivity 0.87 (95% CI 0.69 to 0.96), specificity 0.98 (95% CI 0.95 to 1.00)), vaginal wall endometriosis (sensitivity 0.82 (95% CI 0.60 to 0.95), specificity 0.99 (95% CI 0.97 to 1.0)) and rectovaginal septum endometriosis (sensitivity 0.88 (95% CI 0.47 to 1.00), specificity 0.99 (95% CI 0.96 to 1.00)).All the tests were evaluated in individual studies and displayed wide CIs. Due to the heterogeneity and high risk of bias of the included studies, the clinical utility of the studied combination diagnostic tests for endometriosis remains unclear.

AUTHORS' CONCLUSIONS

None of the biomarkers evaluated in this review could be evaluated in a meaningful way and there was insufficient or poor-quality evidence. Laparoscopy remains the gold standard for the diagnosis of endometriosis and using any non-invasive tests should only be undertaken in a research setting.

Blood biomarkers for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of reproductive-aged women suffer from endometriosis, a costly chronic disease causing pelvic pain and subfertility. Laparoscopy is the gold standard diagnostic test for endometriosis, but is expensive and carries surgical risks. Currently, there are no non-invasive or minimally invasive tests available in clinical practice to accurately diagnose endometriosis. Although other reviews have assessed the ability of blood tests to diagnose endometriosis, this is the first review to use Cochrane methods, providing an update on the rapidly expanding literature in this field.

OBJECTIVES

To evaluate blood biomarkers as replacement tests for diagnostic surgery and as triage tests to inform decisions on surgery for endometriosis. Specific objectives include:1. To provide summary estimates of the diagnostic accuracy of blood biomarkers for the diagnosis of peritoneal, ovarian and deep infiltrating pelvic endometriosis, compared to surgical diagnosis as a reference standard.2. To assess the diagnostic utility of biomarkers that could differentiate ovarian endometrioma from other ovarian masses.

SEARCH METHODS

We did not restrict the searches to particular study designs, language or publication dates. We searched CENTRAL to July 2015, MEDLINE and EMBASE to May 2015, as well as these databases to 20 April 2015: CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, DARE and PubMed.

SELECTION CRITERIA

We considered published, peer-reviewed, randomised controlled or cross-sectional studies of any size, including prospectively collected samples from any population of reproductive-aged women suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE). We included studies comparing the diagnostic test accuracy of one or more blood biomarkers with the findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Two authors independently collected and performed a quality assessment of data from each study. For each diagnostic test, we classified the data as positive or negative for the surgical detection of endometriosis, and we calculated sensitivity and specificity estimates. We used the bivariate model to obtain pooled estimates of sensitivity and specificity whenever sufficient datasets were available. The predetermined criteria for a clinically useful blood test to replace diagnostic surgery were a sensitivity of 0.94 and a specificity of 0.79 to detect endometriosis. We set the criteria for triage tests at a sensitivity of ≥ 0.95 and a specificity of ≥ 0.50, which 'rules out' the diagnosis with high accuracy if there is a negative test result (SnOUT test), or a sensitivity of ≥ 0.50 and a specificity of ≥ 0.95, which 'rules in' the diagnosis with high accuracy if there is a positive result (SpIN test).

MAIN RESULTS

We included 141 studies that involved 15,141 participants and evaluated 122 blood biomarkers. All the studies were of poor methodological quality. Studies evaluated the blood biomarkers either in a specific phase of the menstrual cycle or irrespective of the cycle phase, and they tested for them in serum, plasma or whole blood. Included women were a selected population with a high frequency of endometriosis (10% to 85%), in which surgery was indicated for endometriosis, infertility work-up or ovarian mass. Seventy studies evaluated the diagnostic performance of 47 blood biomarkers for endometriosis (44 single-marker tests and 30 combined tests of two to six blood biomarkers). These were angiogenesis/growth factors, apoptosis markers, cell adhesion molecules, high-throughput markers, hormonal markers, immune system/inflammatory markers, oxidative stress markers, microRNAs, tumour markers and other proteins. Most of these biomarkers were assessed in small individual studies, often using different cut-off thresholds, and we could only perform meta-analyses on the data sets for anti-endometrial antibodies, interleukin-6 (IL-6), cancer antigen-19.9 (CA-19.9) and CA-125. Diagnostic estimates varied significantly between studies for each of these biomarkers, and CA-125 was the only marker with sufficient data to reliably assess sources of heterogeneity.The mean sensitivities and specificities of anti-endometrial antibodies (4 studies, 759 women) were 0.81 (95% confidence interval (CI) 0.76 to 0.87) and 0.75 (95% CI 0.46 to 1.00). For IL-6, with a cut-off value of > 1.90 to 2.00 pg/ml (3 studies, 309 women), sensitivity was 0.63 (95% CI 0.52 to 0.75) and specificity was 0.69 (95% CI 0.57 to 0.82). For CA-19.9, with a cut-off value of > 37.0 IU/ml (3 studies, 330 women), sensitivity was 0.36 (95% CI 0.26 to 0.45) and specificity was 0.87 (95% CI 0.75 to 0.99).Studies assessed CA-125 at different thresholds, demonstrating the following mean sensitivities and specificities: for cut-off > 10.0 to 14.7 U/ml: 0.70 (95% CI 0.63 to 0.77) and 0.64 (95% CI 0.47 to 0.82); for cut-off > 16.0 to 17.6 U/ml: 0.56 (95% CI 0.24, 0.88) and 0.91 (95% CI 0.75, 1.00); for cut-off > 20.0 U/ml: 0.67 (95% CI 0.50 to 0.85) and 0.69 (95% CI 0.58 to 0.80); for cut-off > 25.0 to 26.0 U/ml: 0.73 (95% CI 0.67 to 0.79) and 0.70 (95% CI 0.63 to 0.77); for cut-off > 30.0 to 33.0 U/ml: 0.62 (95% CI 0.45 to 0.79) and 0.76 (95% CI 0.53 to 1.00); and for cut-off > 35.0 to 36.0 U/ml: 0.40 (95% CI 0.32 to 0.49) and 0.91 (95% CI 0.88 to 0.94).We could not statistically evaluate other biomarkers meaningfully, including biomarkers that were assessed for their ability to differentiate endometrioma from other benign ovarian cysts.Eighty-two studies evaluated 97 biomarkers that did not differentiate women with endometriosis from disease-free controls. Of these, 22 biomarkers demonstrated conflicting results, with some studies showing differential expression and others no evidence of a difference between the endometriosis and control groups.

AUTHORS' CONCLUSIONS

Of the biomarkers that were subjected to meta-analysis, none consistently met the criteria for a replacement or triage diagnostic test. A subset of blood biomarkers could prove useful either for detecting pelvic endometriosis or for differentiating ovarian endometrioma from other benign ovarian masses, but there was insufficient evidence to draw meaningful conclusions. Overall, none of the biomarkers displayed enough accuracy to be used clinically outside a research setting. We also identified blood biomarkers that demonstrated no diagnostic value in endometriosis and recommend focusing research resources on evaluating other more clinically useful biomarkers.

Endometrial biomarkers for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of reproductive-aged women suffer from endometriosis, which is a costly, chronic disease that causes pelvic pain and subfertility. Laparoscopy is the gold standard diagnostic test for endometriosis, but it is expensive and carries surgical risks. Currently, there are no non-invasive tests available in clinical practice that accurately diagnose endometriosis. This is the first diagnostic test accuracy review of endometrial biomarkers for endometriosis that utilises Cochrane methodologies, providing an update on the rapidly expanding literature in this field.

OBJECTIVES

To determine the diagnostic accuracy of the endometrial biomarkers for pelvic endometriosis, using a surgical diagnosis as the reference standard. We evaluated the tests as replacement tests for diagnostic surgery and as triage tests to inform decisions to undertake surgery for endometriosis.

SEARCH METHODS

We did not restrict the searches to particular study designs, language or publication dates. To identify trials, we searched the following databases: CENTRAL (2015, July), MEDLINE (inception to May 2015), EMBASE (inception to May 2015), CINAHL (inception to April 2015), PsycINFO (inception to April 2015), Web of Science (inception to April 2015), LILACS (inception to April 2015), OAIster (inception to April 2015), TRIP (inception to April 2015) and ClinicalTrials.gov (inception to April 2015). We searched DARE and PubMed databases up to April 2015 to identify reviews and guidelines as sources of references to potentially relevant studies. We also performed searches for papers recently published and not yet indexed in the major databases. The search strategies incorporated words in the title, abstract, text words across the record and the medical subject headings (MeSH).

SELECTION CRITERIA

We considered published peer-reviewed, randomised controlled or cross-sectional studies of any size that included prospectively collected samples from any population of reproductive-aged women suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE).

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from each study and performed a quality assessment. For each endometrial diagnostic test, we classified the data as positive or negative for the surgical detection of endometriosis and calculated the estimates of sensitivity and specificity. We considered two or more tests evaluated in the same cohort as separate data sets. We used the bivariate model to obtain pooled estimates of sensitivity and specificity whenever sufficient data were available. The predetermined criteria for a clinically useful test to replace diagnostic surgery was one with a sensitivity of 94% and a specificity of 79%. The criteria for triage tests were set at sensitivity at or above 95% and specificity at or above 50%, which in case of negative results rules out the diagnosis (SnOUT test) or sensitivity at or above 50% with specificity at or above 95%, which in case of positive result rules in the diagnosis (SpIN test).

MAIN RESULTS

We included 54 studies involving 2729 participants, most of which were of poor methodological quality. The studies evaluated endometrial biomarkers either in specific phases of the menstrual cycle or outside of it, and the studies tested the biomarkers either in menstrual fluid, in whole endometrial tissue or in separate endometrial components. Twenty-seven studies evaluated the diagnostic performance of 22 endometrial biomarkers for endometriosis. These were angiogenesis and growth factors (PROK-1), cell-adhesion molecules (integrins α3β1, α4β1, β1 and α6), DNA-repair molecules (hTERT), endometrial and mitochondrial proteome, hormonal markers (CYP19, 17βHSD2, ER-α, ER-β), inflammatory markers (IL-1R2), myogenic markers (caldesmon, CALD-1), neural markers (PGP 9.5, VIP, CGRP, SP, NPY, NF) and tumour markers (CA-125). Most of these biomarkers were assessed in single studies, whilst only data for PGP 9.5 and CYP19 were available for meta-analysis. These two biomarkers demonstrated significant diversity for the diagnostic estimates between the studies; however, the data were too limited to reliably determine the sources of heterogeneity. The mean sensitivities and specificities of PGP 9.5 (7 studies, 361 women) were 0.96 (95% confidence interval (CI) 0.91 to 1.00) and 0.86 (95% CI 0.70 to 1.00), after excluding one outlier study, and for CYP19 (8 studies, 444 women), they were were 0.77 (95% CI 0.70 to 0.85) and 0.74 (95% CI 0.65 to 84), respectively. We could not statistically evaluate other biomarkers in a meaningful way. An additional 31 studies evaluated 77 biomarkers that showed no evidence of differences in expression levels between the groups of women with and without endometriosis.

AUTHORS' CONCLUSIONS

We could not statistically evaluate most of the biomarkers assessed in this review in a meaningful way. In view of the low quality of most of the included studies, the findings of this review should be interpreted with caution. Although PGP 9.5 met the criteria for a replacement test, it demonstrated considerable inter study heterogeneity in diagnostic estimates, the source of which could not be determined. Several endometrial biomarkers, such as endometrial proteome, 17βHSD2, IL-1R2, caldesmon and other neural markers (VIP, CGRP, SP, NPY and combination of VIP, PGP 9.5 and SP) showed promising evidence of diagnostic accuracy, but there was insufficient or poor quality evidence for any clinical recommendations. Laparoscopy remains the gold standard for the diagnosis of endometriosis, and using any non-invasive tests should only be undertaken in a research setting. We have also identified a number of biomarkers that demonstrated no diagnostic value for endometriosis. We recommend that researchers direct future studies towards biomarkers with high diagnostic potential in good quality diagnostic studies.

Imaging modalities for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of women of reproductive age suffer from endometriosis. Endometriosis is a costly chronic disease that causes pelvic pain and subfertility. Laparoscopy, the gold standard diagnostic test for endometriosis, is expensive and carries surgical risks. Currently, no non-invasive tests that can be used to accurately diagnose endometriosis are available in clinical practice. This is the first review of diagnostic test accuracy of imaging tests for endometriosis that uses Cochrane methods to provide an update on the rapidly expanding literature in this field.

OBJECTIVES

• To provide estimates of the diagnostic accuracy of imaging modalities for the diagnosis of pelvic endometriosis, ovarian endometriosis and deeply infiltrating endometriosis (DIE) versus surgical diagnosis as a reference standard.• To describe performance of imaging tests for mapping of deep endometriotic lesions in the pelvis at specific anatomical sites.Imaging tests were evaluated as replacement tests for diagnostic surgery and as triage tests that would assist decision making regarding diagnostic surgery for endometriosis.

SEARCH METHODS

We searched the following databases to 20 April 2015: MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP, ClinicalTrials.gov, MEDION, DARE, and PubMed. Searches were not restricted to a particular study design or language nor to specific publication dates. The search strategy incorporated words in the title, abstracts, text words across the record and medical subject headings (MeSH).

SELECTION CRITERIA

We considered published peer-reviewed cross-sectional studies and randomised controlled trials of any size that included prospectively recruited women of reproductive age suspected of having one or more of the following target conditions: endometrioma, pelvic endometriosis, DIE or endometriotic lesions at specific intrapelvic anatomical locations. We included studies that compared the diagnostic test accuracy of one or more imaging modalities versus findings of surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected and performed a quality assessment of data from each study. For each imaging test, data were classified as positive or negative for surgical detection of endometriosis, and sensitivity and specificity estimates were calculated. If two or more tests were evaluated in the same cohort, each was considered as a separate data set. We used the bivariate model to obtain pooled estimates of sensitivity and specificity when sufficient data sets were available. Predetermined criteria for a clinically useful imaging test to replace diagnostic surgery included sensitivity ≥ 94% and specificity ≥ 79%. Criteria for triage tests were set at sensitivity ≥ 95% and specificity ≥ 50%, ruling out the diagnosis with a negative result (SnNout test - if sensitivity is high, a negative test rules out pathology) or at sensitivity ≥ 50% with specificity ≥ 95%, ruling in the diagnosis with a positive result (SpPin test - if specificity is high, a positive test rules in pathology).

MAIN RESULTS

We included 49 studies involving 4807 women: 13 studies evaluated pelvic endometriosis, 10 endometriomas and 15 DIE, and 33 studies addressed endometriosis at specific anatomical sites. Most studies were of poor methodological quality. The most studied modalities were transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), with outcome measures commonly demonstrating diversity in diagnostic estimates; however, sources of heterogeneity could not be reliably determined. No imaging test met the criteria for a replacement or triage test for detecting pelvic endometriosis, albeit TVUS approached the criteria for a SpPin triage test. For endometrioma, TVUS (eight studies, 765 participants; sensitivity 0.93 (95% confidence interval (CI) 0.87, 0.99), specificity 0.96 (95% CI 0.92, 0.99)) qualified as a SpPin triage test and approached the criteria for a replacement and SnNout triage test, whereas MRI (three studies, 179 participants; sensitivity 0.95 (95% CI 0.90, 1.00), specificity 0.91 (95% CI 0.86, 0.97)) met the criteria for a replacement and SnNout triage test and approached the criteria for a SpPin test. For DIE, TVUS (nine studies, 12 data sets, 934 participants; sensitivity 0.79 (95% CI 0.69, 0.89) and specificity 0.94 (95% CI 0.88, 1.00)) approached the criteria for a SpPin triage test, and MRI (six studies, seven data sets, 266 participants; sensitivity 0.94 (95% CI 0.90, 0.97), specificity 0.77 (95% CI 0.44, 1.00)) approached the criteria for a replacement and SnNout triage test. Other imaging tests assessed in small individual studies could not be statistically evaluated.TVUS met the criteria for a SpPin triage test in mapping DIE to uterosacral ligaments, rectovaginal septum, vaginal wall, pouch of Douglas (POD) and rectosigmoid. MRI met the criteria for a SpPin triage test for POD and vaginal and rectosigmoid endometriosis. Transrectal ultrasonography (TRUS) might qualify as a SpPin triage test for rectosigmoid involvement but could not be adequately assessed for other anatomical sites because heterogeneous data were scant. Multi-detector computerised tomography enema (MDCT-e) displayed the highest diagnostic performance for rectosigmoid and other bowel endometriosis and met the criteria for both SpPin and SnNout triage tests, but studies were too few to provide meaningful results.Diagnostic accuracies were higher for TVUS with bowel preparation (TVUS-BP) and rectal water contrast (RWC-TVS) and for 3.0TMRI than for conventional methods, although the paucity of studies precluded statistical evaluation.

AUTHORS' CONCLUSIONS

None of the evaluated imaging modalities were able to detect overall pelvic endometriosis with enough accuracy that they would be suggested to replace surgery. Specifically for endometrioma, TVUS qualified as a SpPin triage test. MRI displayed sufficient accuracy to suggest utility as a replacement test, but the data were too scant to permit meaningful conclusions. TVUS could be used clinically to identify additional anatomical sites of DIE compared with MRI, thus facilitating preoperative planning. Rectosigmoid endometriosis was the only site that could be accurately mapped by using TVUS, TRUS, MRI or MDCT-e. Studies evaluating recent advances in imaging modalities such as TVUS-BP, RWC-TVS, 3.0TMRI and MDCT-e were observed to have high diagnostic accuracies but were too few to allow prudent evaluation of their diagnostic role. In view of the low quality of most of the included studies, the findings of this review should be interpreted with caution. Future well-designed diagnostic studies undertaken to compare imaging tests for diagnostic test accuracy and costs are recommended.

Urinary biomarkers for the non-invasive diagnosis of endometriosis

BACKGROUND

About 10% of reproductive-aged women suffer from endometriosis which is a costly chronic disease that causes pelvic pain and subfertility. Laparoscopy is the 'gold standard' diagnostic test for endometriosis, but it is expensive and carries surgical risks. Currently, there are no simple non-invasive or minimally-invasive tests available in clinical practice that accurately diagnoses endometriosis.

OBJECTIVES

1. To provide summary estimates of the diagnostic accuracy of urinary biomarkers for the diagnosis of pelvic endometriosis compared to surgical diagnosis as a reference standard.2. To assess the diagnostic utility of biomarkers that could differentiate ovarian endometrioma from other ovarian masses.Urinary biomarkers were evaluated as replacement tests for surgical diagnosis and as triage tests to inform decisions to undertake surgery for endometriosis.

SEARCH METHODS

The searches were not restricted to particular study design, language or publication dates. We searched the following databases to 20 April - 31 July 2015: CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, LILACS, OAIster, TRIP and ClinicalTrials.gov (trial register). MEDION, DARE, and PubMed were also searched to identify reviews and guidelines as reference sources of potentially relevant studies. Recently published papers not yet indexed in the major databases were also sought. The search strategy incorporated words in the title, abstract, text words across the record and the medical subject headings (MeSH) and was modified for each database.

SELECTION CRITERIA

Published peer-reviewed, randomised controlled or cross-sectional studies of any size were considered, which included prospectively collected samples from any population of reproductive-aged women suspected of having one or more of the following target conditions: ovarian, peritoneal or deep infiltrating endometriosis (DIE). We included studies comparing the diagnostic test accuracy of one or more urinary biomarkers with surgical visualisation of endometriotic lesions.

DATA COLLECTION AND ANALYSIS

Two authors independently collected and performed a quality assessment of the data from each study. For each diagnostic test, the data were classified as positive or negative for the surgical detection of endometriosis and sensitivity and specificity estimates were calculated. If two or more tests were evaluated in the same cohort, each was considered as a separate data set. The bivariate model was used to obtain pooled estimates of sensitivity and specificity whenever sufficient data sets were available. The predetermined criteria for a clinically useful urine test to replace diagnostic surgery was one with a sensitivity of 94% and a specificity of 79% to detect endometriosis. The criteria for triage tests were set at sensitivity of equal or greater than 95% and specificity of equal or greater than 50%, which in case of negative result rules out the diagnosis (SnOUT test) or sensitivity of equal or greater than 50% with specificity of equal or greater than 95%, which in case of positive result rules the diagnosis in (SpIN test).

MAIN RESULTS

We included eight studies involving 646 participants, most of which were of poor methodological quality. The urinary biomarkers were evaluated either in a specific phase of menstrual cycle or irrespective of the cycle phase. Five studies evaluated the diagnostic performance of four urinary biomarkers for endometriosis, including three biomarkers distinguishing women with and without endometriosis (enolase 1 (NNE); vitamin D binding protein (VDBP); and urinary peptide profiling); and one biomarker (cytokeratin 19 (CK 19)) showing no significant difference between the two groups. All of these biomarkers were assessed in small individual studies and could not be statistically evaluated in a meaningful way. None of the biomarkers met the criteria for a replacement test or a triage test. Three studies evaluated three biomarkers that did not differentiate women with endometriosis from disease-free controls.

AUTHORS' CONCLUSIONS

There was insufficient evidence to recommend any urinary biomarker for use as a replacement or triage test in clinical practice for the diagnosis of endometriosis. Several urinary biomarkers may have diagnostic potential, but require further evaluation before being introduced into routine clinical practice. Laparoscopy remains the gold standard for the diagnosis of endometriosis, and diagnosis of endometriosis using urinary biomarkers should only be undertaken in a research setting.

Survey on Barriers to Adoption of Laparoscopic Surgery

OBJECTIVE

To identify challenges that impede wider adoption of laparoscopy in gynecologic surgery and assessing whether the current training programs are addressing these challenges adequately.

METHODS

A survey was designed to examine barriers to adoption of laparoscopy for practicing gynecologists. The survey was piloted on gynecologic surgeons and was further refined following their feedback. Finally, the survey was deployed to 4273 gynecologists across the United States via e-mail using the national database of the American Medical Association. Respondents were grouped into two categories based on how often they report referral of patients for laparoscopy. Demographics, training, and practice characteristics were compared using Fisher exact tests for categorical variables and t tests for continuous variables. Participants rated factors that were thought to limit laparoscopy use on a 5-point Likert scale; median values of these scores were compared with Wilcoxon rank sum tests.

RESULTS

We received 210 responses (29% of people who opened the e-mail and 93% of those who opened the survey). Physicians who perform their own laparoscopies were on average younger and tended to be more subspecialized. Some of the most highly rated limiting factors included lack of adequate surgical volume, reluctance of managing unexpected surgical scenarios, difficulty with video-eye-hand coordination, altered depth perception, and laparoscopic suturing.

CONCLUSION

This survey identified barriers to adoption of laparoscopic surgical techniques beyond what has previously been identified. Based on these findings, novel simulation and continuing medical education curricula can be created to address the primary barriers in order to increase laparoscopic approach to surgery among gynecologists.

Ovarian reserve after laparoscopic treatment of unilateral ovarian endometrioma

Aim:

To evaluate the effect of laparoscopic treatment of unilateral ovarian endometrioma on ovarian reserve using ultrasonographic markers, ovarian volume and antral follicle count (AFC), and two biochemical markers, serum levels of Follicle-stimulating hormone (FSH) and Estradiol (E2).

Material and methods:

This prospective study included 40 patients in their reproductive age, between 18 and 40 years old. They were treated laparoscopically for unilateral ovarian endometrioma. Markers of ovarian reserve were investigated before and three months after surgery. Transvaginal ultrasound examination was used for measurement of ovarian volume and AFC. Biochemical markers (FSH and E2 levels) were determined by chemiluminescent tests.

Results:

Ovarian volume was significantly reduced after surgery. There was significant increase of AFC and non-significant increase of E2 levels in treated patients after three months.

Conclusions:

Laparoscopic cystectomy of unilateral ovarian endometrioma decreased ovarian reserve immediately after surgery with decrease of ovarian volume. But ovarian reserve was increased after three months with increase of AFC and estradiol levels.

Antimullerian hormone changes after laparoscopic ovarian cystectomy for endometrioma compared with the nonovarian conditions

Laparoscopic ovarian cystectomy is recommended for surgical procedure of endometrioma. The negative impact on ovarian reserve following removal had been documented. Little evidence had been reported for nonovarian originated effects. Objective. To evaluate the impact of laparoscopic ovarian cystectomy for endometrioma on ovarian reserve, measured by serum antimullerian hormone (AMH), compared to nonovarian pelvic surgery. Materials and Methods. A prospective study was conducted. Women who underwent laparoscopic ovarian cystectomy (LOC) and laparoscopic nonovarian pelvic surgery (NOS) were recruited and followed up through 6 months. Clinical baseline data and AMH were evaluated. Results. 39 and 38 participants were enrolled in LOC and NOS groups, respectively. Baseline characteristics (age, weight, BMI, and height) and preoperative AMH level between 2 groups were not statistically different. After surgery, AMH of both groups decreased since the first week, at 1 month and at 3 months. However, as compared to the LOC group at 6 months after operation, the mean AMH of the NOS group had regained its value with a highly significant difference. Conclusion. This study demonstrated the negative impact of nonovarian or indirect effects of laparoscopic surgery to ovarian reserve. The possible mechanisms are necessary for more investigations.

Impact of medical and surgical treatment of endometriosis on the cure of endometriosis and pain

This endometriosis study evaluates three different treatment strategies (hormonal medication, surgical, or combined treatment) and discusses the influence of endometriosis on the cure of this disease and pain relief. Four hundred and fifty patients with genital endometriosis, aged 18-44 years, were randomly distributed to three treatment groups at the first laparoscopy. They were reevaluated at a second-look laparoscopy (D 426/10), one to two months after the three-month hormonal therapy for groups 1 and 3 and five to six months later for group 2 (surgical treatment alone). Outcome data focussed on the recurrence of symptoms and pain. The three treatment options independent of the initial endoscopic endometriosis classification (EEC) stage including deep infiltrating endometriosis (DIE) achieved an overall cure rate of 50% or higher. The highest cure rate of 60% was achieved by the combined treatment, 55% by the exclusively hormonal therapy, and 50% by the exclusively surgical treatment. An overall pregnancy rate between 55% and 65% was achieved with no significant difference in relation to the therapeutical option.

Intercoat (Oxiplex/AP gel) for preventing intrauterine adhesions after operative hysteroscopy for suspected retained products of conception: double-blind, prospective, randomized pilot study

STUDY OBJECTIVE

To evaluate the safety and effectiveness of Oxiplex/AP gel (Intercoat) in reducing intrauterine adhesion formation after hysteroscopic treatment because of retained products of conception (RPOC).

DESIGN

Prospective double-blind, randomized, controlled pilot study (Canadian Task Force classification I).

SETTING

Tertiary medical center.

PATIENTS

All women who underwent hysteroscopic treatment because of RPOC at our institution between September 2009 and June 2012 were invited to participate. After operative hysteroscopy, participants were randomized to either have their uterine cavity filled with Oxiplex/AP gel (study group, n = 26) or not (control group, n = 26).

INTERVENTIONS

Diagnostic office hysteroscopy to assess for adhesion formation was performed after 6 to 8 weeks. Findings were graded according to the American Fertility Society classification. Rates of subsequent pregnancy in the 2 groups were assessed.

MEASUREMENTS AND MAIN RESULTS

Intraoperative complication rates were similar between the 2 groups. There were no postoperative complications after Oxiplex/AP gel application. Moderate to severe adhesions developed in 1 woman (4%) in the study group and 3 (14%) in the control group (p = .80). During follow-up of 20 months (range, 2-33 months), 7 women (27%) in the treatment group conceived, compared with 3 (14%) in the control group (p = .50).

CONCLUSION

Intrauterine application of Oxiplex/AP gel after hysteroscopic removal of RPOC is safe. In this small sample, the difference in the rate of intrauterine adhesions was not statistically significant. A larger study would enable further establishment of the safety and efficacy of use of this gel.

Combined surgical and hormone therapy for endometriosis is the most effective treatment: prospective, randomized, controlled trial

STUDY OBJECTIVE

To evaluate 3 therapy strategies: hormone therapy, surgery, and combined treatment.

DESIGN

Prospective, randomized, controlled study (Canadian Task Force classification I).

SETTING

University-based teaching hospital.

PATIENTS

Four hundred fifty patients with genital endometriosis, aged 18 to 44 years, before first laparoscopy.

INTERVENTIONS

Patients were randomly assigned to 1 of 3 treatment groups: hormone therapy, surgery, or combined treatment. Patients were reevaluated at second-look laparoscopy, at 2 to 2 months after 3-month hormone therapy in groups 1 and 3 and at 5 to 6 months in group 2 (surgical treatment alone). Outcome data were focussed on the endometriosis stage, recurrence of symptoms, and pregnancy rate.

MEASUREMENTS AND MAIN RESULTS

All treatment options, independent of the initial Endoscopic Endometriosis Classification stage, achieved an overall cure rate of ≥50%. A cure rate of 60% was achieved with the combined treatment, 55% with exclusively hormone therapy, and 50% with exclusively surgical treatment. Recurrence of symptoms was lowest in patients who received combined treatment. Significant benefit was achieved for dysmenorrhea and dyspareunia. An overall pregnancy rate of 55% to 65% was achieved, with no significant difference between the therapeutic options.

CONCLUSION

In the quest to find the most effective treatment of genital endometriosis, this clinical randomized study shows the lowest incidence of recurrence with combined surgical and medical treatment and improved pregnancy rate in any medically treated patients with or without surgery. The highest cure rate (Endoscopic Endometriosis Classification stage 0) for endometriosis was also achieved in the combined treatment group.

Improvement in chronic pelvic pain after gonadotropin releasing hormone analogue (GnRH-a) administration in premenopausal women suffering from adenomyosis or endometriosis: a retrospective study

The aim of this study was to evaluate the improvement in catamenial chronic pelvic pain (CPP) after Gonadotropin Releasing Hormone analogue (GnRH-a) administration in women affected by adenomyosis or endometriosis. We retrospectively analysed clinical data of 63 premenopausal women with clinical suspect of adenomyosis (15 women, Group A) or endometriosis (48 women, Group B), which received GnRH-a in order to reduce CPP intensity during the time on surgery waiting list. Main outcome measures were variation of CPP intensity, numbers of days requiring analgesics and lost work productivity before and three months after GnRH-a administration. Compared to baseline, a significant decrease in CPP intensity (p < 0.05) was observed in both groups, even if this reduction was significantly higher in Group A than in Group B (p < 0.001). In both groups, moreover, a significant reduction in number of days requiring analgesics (p < 0.05) and lost work productivity (p < 0.05) was detected. In conclusion, GnRH-a administration in women with clinical suspect of adenomyosis induces a greater reduction in CPP when compared to women with endometriosis, thus representing a potential ex adiuvantibus criteria, helping TV-US in the clinical diagnosis of adenomyosis.

Surgical strategy in endometriosis

Endometriosis is a common disease affecting young women. Its clinical manifestations include pain and infertility, and it can dramatically affect quality of life. Treatments should be tailored to address the wishes of women according to the specific characteristics of the disease. Although many questions remain unanswered, strong evidence supports the use of laparoscopic surgery to improve pain and infertility. The systematisation of strategy is essential to make surgery more reproducible, safer and less time-consuming. Nevertheless, even in the most expert hands, complications may occur. Further investigations are needed to compare the different approaches. Outcomes must, however, include pain, fertility, organ dysfunction, and quality of life.

Lesion kinetics in a non-human primate model of endometriosis

BACKGROUND

Endometriosis is a common cause of pelvic pain and infertility in women of reproductive age. It is characterized by the presence of endometrial tissue outside the normal location, predominantly in the pelvic peritoneum causing severe abdominal pain. However, the severity of the symptoms of endometriosis does not always correlate with the anatomic severity of the disease. This lack of correlation may be due to morphological lesion variation during disease progression. This study examined lesion kinetics in a non-human primate model of endometriosis to better understand lesion dynamics.

METHODS

Endometriosis was experimentally induced in nine normal cycling female adult olive baboons (Papio anubis) by i.p. inoculation of autologous menstrual endometrium on Day 2 of menses for two consecutive menstrual cycles. Diagnostic laparoscopies were performed between Day 8-12 post-ovulation at 1, 3, 6, 9 and 12 months, followed by a necropsy at 15 months, after the second inoculation. In two animals, lesions were excised/ablated at 6 months and they were monitored for lesion recurrence and morphological changes by serial laparoscopy. Furthermore, five control animals underwent surgeries conducted at the same time points but without inoculation.

RESULTS

A total of 542 endometriotic lesions were observed. The location, macroscopic (different colours) and microscopic appearance confirmed distinct endometriosis pathology in line with human disease. The majority of the lesions found 1 month after tissue inoculation were red lesions, which frequently changed colour during the disease progression. In contrast, blue lesions remained consistently blue while white lesions were evident at the later stages of the disease process and often regressed. There were significantly lower numbers of powder burn, blister and multicoloured lesions observed per animal in comparison to black and blue lesions (P-value≤0.05). New lesions were continually arising and persisted up to 15 months post-inoculation. Lesions reoccurred as early as 3 months after removal and 69% of lesions excised/ablated had reoccurred 9 months later. Interestingly, endometriotic lesions were also found in the non-inoculated animals, starting at the 6-month time point following multiple surgeries.

CONCLUSIONS

Documentation of lesion turnover in baboons indicated that lesions changed their colour from red to white over time. Different lesion types underwent metamorphosis at different rates. A classification of lesions based on morphological appearance may help disease prognosis and examination of the effect of the lesion on disease symptoms, and provide new opportunities for targeted therapies in order to prevent or treat endometriosis. Surgical removal of endometriotic lesions resulted in a high incidence of recurrence. Spontaneous endometriosis developed in control baboons in the absence of inoculation suggesting that repetitive surgical procedures alone can induce the spontaneous evolution of the chronic disease. Although lesion excision/ablation may have short-term benefits (e.g. prior to an IVF cycle in subfertile women), for long-term relief of symptoms perhaps medical therapy is more effective than surgical therapy.

Current strategies and future perspectives for intraperitoneal adhesion prevention

INTRODUCTION

The formation of peritoneal adhesions still is a relevant clinical problem after abdominal surgery. Until today, the most important clinical strategies for adhesion prevention are accurate surgical technique and the physical separation of traumatized serosal areas. Despite a variety of barriers which are available in clinical use, the optimal material has not yet been found.

DISCUSSION

Mesothelial cells play a crucial physiological role in friction less gliding of the serosa and the maintenance of anantiadhesive surface. The formation of postoperative adhesions results from a cascade of events and is regulated by various cellular and humoral factors. Therefore, optimization or functionalization of barrier materials by developments interacting with this cascade on a structural or pharmacological level could give an innovative input for future strategies in peritoneal adhesion prevention. For this purpose, the proper understanding of the formal pathogenesis of adhesion formation is essential. Based on the physiology of the serosa and the pathophysiology of adhesion formation, the available barriers in current clinical practice as well as new innovations are discussed in the present review.

Preliminary study on the effects of carbon dioxide and nitrogen pneumoperitoneums on endometriotic lesions

Objective

To determine the effects of carbon dioxide (CO₂) and nitrogen (N₂) pneumoperitoneums on endometriosis (EMs) lesions.

Methods

Female Wistar rats were randomized into the following 3 groups: CO₂ (N = 20), N₂ (N = 22) and air pneumoperitoneums (N = 9). After 5 weeks of establishment models, do the pneumoperitoneums. Then measure the size of EMs lesions and the related factors of serum and tissue after 1, 2, and 4 weeks of pneumoperitoneums.

Results

(1) One week after the pneumoperitoneum was established, the EMs lesions in the CO₂ group were largest in volume, whereas at 4 weeks the EMs lesions in the CO₂ group were smaller than the N₂ group. (2) The level of ICAM-1 and TIMP-2 of serum in CO₂ and N₂ group after 2 weeks of pneumoperitoneum were higher than air group. (3) The expression of CD44v6, ICAM-1, MMP-2 and VEGF of tissue in CO₂ and N₂ group after 1, 2 and 4 weeks of pneumoperitoneum were lower than air group, TIMP-2 and ENS were higher than air group.

Conclusion

After a CO₂ pneumoperitoneum, EMs lesions were reduced in volume, suggesting an inhibitory effect on EMs lesions.

Robotic presacral neurectomy - technique and results

BACKGROUND

The feasibility, safety and outcomes of robotic presacral neurectomy were evaluated.

METHODS

A retrospective analysis was performed of 33 patients with midline chronic pelvic pain, who underwent robotic presacral neurectomy. Data were collected during the period March 2004-March 2010.

RESULTS

All patients underwent robotic presacral neurectomy and additional robotic procedures. Mean operating time for robotic presacral neurectomy was 5.8 (range 4.4-6.9) min. Mean blood loss, including concomitant procedures, was 39 (range 15-150) ml. Most patients were discharged the same day (60%) and mean hospital stay was 0.39 (range 0-2) days. There were no conversions or intra-operative complications. There were two postoperative complications: one pelvic abscess and one Clostridium difficile colitis. Pain improvement was reported by 73% (22/30) of patients.

CONCLUSION

Robotic presacral neurectomy is safe and feasible, resulting in improvement of pelvic pain in selected patients.

Follicle loss after laparoscopic treatment of ovarian endometriotic cysts

OBJECTIVE

To evaluate follicle loss and its associated factors during laparoscopic cystectomy for ovarian endometrioma.

METHOD

Between October 2008 and December 2009, 140 patients with ovarian cysts undergoing laparoscopic cystectomy at Peking Union Medical Hospital were enrolled: 74 had ovarian endometrioma with no preoperative hormonal therapy (group A), 40 had ovarian endometrioma pretreated with GnRHa (group B), and 26 had non-endometriotic cysts (group C). Pre-, peri- , and postoperative clinical data were collected, and cyst specimens were evaluated histologically.

RESULTS

The number of capsules showing follicles and the mean number of follicles per capsule were lower in group C than in group A or B (P<0.05). Fewer type IIC than type IIB endometriomas showed follicles (P<0.05). The number of follicles per cyst was related negatively to disease duration but positively to pain severity. Women in group A with unilateral endometrioma had a lower mean dysmenorrhea score after the surgery (P<0.05), but no change in basal follicle-stimulating hormone (FSH).

CONCLUSION

The type of cyst, disease duration, and severity of dysmenorrhea were associated with ovarian follicle loss during laparoscopic excision of endometrioma. Laparoscopic unilateral cystectomy for endometrioma was effective in relieving pain but had little effect on serum FSH, which might reflect the remaining ovarian reserve.

Management of Endometriosis-Related Pain: An Update

Endometriosis is a chronic and recurrent condition affecting 6–10% of women of a reproductive age. It results from implantation of endometrial tissue outside the uterine cavity. It is associated with pelvic pain and infertility. Treatment for endometriosis ranges from medical management, to conservative surgery, to definitive surgery with a hysterectomy and bilateral salpingo-oophorectomy, and should be based on patient's fertility desires and tolerance. Medical treatment involves hormonal manipulation to induce a hypoestrogenic or antiestrogenic state to induce regression and apoptosis of lesions. Endometriosis can have dire effects on women's lives and productivity; this article will focus on early diagnosis, treatment and prevention of recurrence of the disease.

Intraperitoneal adhesions--an ongoing challenge between biomedical engineering and the life sciences

Peritoneal adhesions remain a relevant clinical problem despite the currently available prophylactic barrier materials. So far, the physical separation of traumatized serosa areas using barriers represents the most important clinical strategy for adhesion prevention. However, the optimal material has not yet been found. Further optimization or pharmacological functionalization of these barriers could give an innovative input for peritoneal adhesion prevention. Therefore, a more complete understanding of pathogenesis is required. On the basis of the pathophysiology of adhesion formation the main barriers currently in clinical practice as well as new innovations are discussed in the present review. Physiologically, mesothelial cells play a decisive role in providing a frictionless gliding surface on the serosa. Adhesion formation results from a cascade of events and is regulated by a variety of cellular and humoral factors. The main clinically applied strategy for adhesion prevention is based on the use of liquid or solid adhesion barriers to separate physically any denuded tissue. Both animal and human trials have not yet been able to identify the optimal barrier to prevent adhesion formation in a sustainable way. Therefore, further developments are required for effective prevention of postoperative adhesion formation. To reach this goal the combination of structural modification and pharmacological functionalization of barrier materials should be addressed. Achieving this aim requires the interaction between basic research, materials science and clinical expertise.

Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications

BACKGROUND

Many clinicians and patients believe that endometriosis-associated pain is due to the lesions. Yet causality remains an enigma, because pain symptoms attributed to endometriosis occur in women without endometriosis and because pain symptoms and severity correlate poorly with lesion characteristics. Most research and reviews focus on the lesions, not the pain. This review starts with the recognition that the experience of pain is determined by the central nervous system (CNS) and focuses on the pain symptoms.

METHODS

Comprehensive searches of Pubmed, Medline and Embase were conducted for current basic and clinical research on chronic pelvic pain and endometriosis. The information was mutually interpreted by a basic scientist and a clinical researcher, both in the field of endometriosis. The goal was to develop new ways to conceptualize how endometriosis contributes to pain symptoms in the context of current treatments and the reproductive tract.

RESULTS

Endometriotic lesions can develop their own nerve supply, thereby creating a direct and two-way interaction between lesions and the CNS. This engagement provides a mechanism by which the dynamic and hormonally responsive nervous system is brought directly into play to produce a variety of individual differences in pain that can, in some women, become independent of the disease itself.

CONCLUSIONS

Major advances in improving understanding and alleviating pain in endometriosis will likely occur if the focus changes from lesions to pain. In turn, how endometriosis affects the CNS would be best examined in the context of mechanisms underlying other chronic pain conditions.