Recurrence of ovarian endometriosis and anatomical location of the primary lesion

Recurrent endometriosis: a battle against an unknown enemy

Recurrence of endometriosis after conservative surgery is not an uncommon finding. There is no uniformity, however, on what the term 'recurrence' means. Recurrence is variously defined in the literature as the relapse of pain, clinical or instrumental detection of an endometriotic lesion, repeat rise in CA 125 levels, or evidence of recurrence found during repeat surgery. Consequently, the reported recurrence rate varies widely (0-89%) in the different series, depending on its definition and the type of study performed. As endometriosis recurrence seems to be an indeterminate enemy, we set out to examine exactly what we were fighting in our everyday battle. In this narrative review, we aimed to seek an answer to questions related to endometriosis recurrence, some of which are often asked by our patients.

Factors associated with ovarian endometriosis malignancy and its recurrence in Chinese women

In this study, the risk factors for ovarian endometriosis (OE) malignancy and its recurrence were explored in Chinese women. For OE malignancy occurrence, the age of marriage, abortion times, course of OE, body mass index (BMI), other benign uterine complications, and shorter parturition times were identified as risk factors using univariate analyses. Among them, age at marriage, course of OE, BMI, and decreased parturition times were identified as risk factors using multivariate analyses. For OE malignancy recurrence, the risk factors included clinical staging, histological classification, and chemotherapy by univariate analysis; and clinical stage, clear-cell carcinoma, and fewer chemotherapy cycles by multivariate analyses. In summary, we concluded that higher ages at marriage, longer courses of ovarian endometriosis, shorter parturition times, and additional benign uterine complications may increase the risk of OE malignancy. Advanced clinical stages, clear-cell carcinomas, and fewer chemotherapy cycles may promote OE malignancy recurrence. Impact statement What is already known on this subject? Endometriosis is one of the most common gynaecological diseases. Although endometriosis is not a malignant disease, endometriosis cells have characteristics similar to cancer cells. The risk of malignant transformation rates of ovarian endometriosis is said to be 1:18. However, epidemiological evidence based on large population research in ovarian endometriosis malignancy is lacking. In addition, there were few studies focussing on the long-term prognosis of ovarian endometriosis malignancies. What do the results of this study add? This study revealed the possible occurrence and recurrence risk factors of ovarian endometriosis malignancy using univariate and multivariate statistics analyses. What are the implications of these findings for clinical practice and/or further research? A clinical retrospective study with a longer follow-up period is suggested for assessing the occurrence and recurrence risk factors for ovarian endometriosis malignancies.

Retrospective evaluation of pathological results among women with ovarian endometriomas versus teratomas

The coexistence of endometrioma with dermoid cyst of the ovaries is an unusual entity, although they are both common and benign gynecological tumors. The present study aimed to investigate the association between ovarian dermoid cyst (teratoma) and endometrioma. We retrospectively, included 315 women with endometrioma and 172 with ovarian teratoma. Data were collected from medical and pathological reports from two different areas between 1995 and 2018. The mean age of cases with endometrioma was similar (35.8±7.2 years) to patients with ovarian teratoma (34.2±6.8 years). Considering the types of dermoid cysts, the observed proportion of mature type was 168/172 (98%), the immature type was 4/172 (2%) and struma ovarii was14/172 (8.1%) respectively. Endometrioma was significantly more frequent in the left ovary [174/266 (65.4%)] than in the right ovary [92/266 (34.6%)], P<0.001. By contrast, ovarian teratoma were predominant in the right ovary, 98/172 (60.6%), compared to the left side, 56/172 (32.5%), P<0.001. Regarding the size of the masses, we detected an inverse distribution between the two groups. Thirteen women were detected with ovarian teratoma and endometriosis, with 6 cases being in the same ovary. Our results indicate a left lateral predispostion of endometrioma and a right of ovarian teratoma and suggest that the pathogenesis between these conditions is different. The coexistence of endometriosis with dermoid cyst of the ovary, presents a challenge to the physicians and the investigators. Further research is required to establish the relationship between endometriosis and ovarian teratoma.

Progestins for the Treatment of Endometriosis: An Update

Endometriosis is a gynecological condition that affects approximately 10% of women of reproductive age, including 25–40% of infertile women. Dysmenorrhea, dyspareunia and chronic pelvic pain are the most common symptoms. Currently available medical therapies for endometriosis do not cure the disease, but are directed at symptom relief, typically utilizing the hormone responsiveness of endometriotic tissue to induce lesion atrophy. Unfortunately, pain relapse after treatment suspension is a common event. Treatment with pharmacological therapies for endometriosis should be conceived in terms of years, thus agents that must be withdrawn after a few months due to poor tolerability or severe metabolic side effects do not greatly benefit women with symptomatic endometriosis. The characteristics of progestins render this class an ideal pharmacological choice for administration over extended periods. The present paper will review the rationale for using progestins and their mechanism of action in endometriosis. Thereafter, the results obtained by various progestins in the treatment of endometriosis will be evaluated (danazol, gestrinone, norethisterone acetate, desogestrel, cyproterone acetate, megestrol acetate, medroxyprogesterone acetate, and levonorgestrel). A progestin called dienogest, recently introduced for the treatment of endometriosis, will be given special focus, describing its mechanism of action and clinical results.

A network pharmacology-based strategy deciphers the underlying molecular mechanisms of Qixuehe Capsule in the treatment of menstrual disorders

BACKGROUND

QiXueHe Capsule (QXHC) is a Chinese patent drug that is extensively used for the treatment of menstrual disorders. However, its underlying pharmacological mechanisms have not been fully elucidated.

METHODS

A list of QXHC putative targets were predicted using MetaDrug. An interaction network using links between QXHC putative targets and the known therapeutic targets of menstrual disorders was constructed. QXHC candidate targets were also identified via calculating the topological feature values of nodes in the network. Additionally, molecular docking simulation was performed to determine the binding efficiency of QXHC compound-putative target pairs.

RESULTS

A total of 1022 putative targets were predicted for 311 chemical components containing in QXHC. Following the calculation of topological features of QXHC putative target-known therapeutic target of menstrual disorder network, 66 QXHC candidate targets for the treatment of menstrual disorders were identified. Functionally, QXHC candidate targets were significantly associated with several biological pathways, such as VEGF and Chemokine signaling pathways, Alanine/aspartate/glutamate metabolism, Long-term depression and T/B cell receptor signaling pathway. Moreover, molecular docking simulation demonstrated that there were 20 pairs of QXHC chemical component-candidate target had the strong binding free energy.

CONCLUSIONS

This novel and scientific network pharmacology-based study holistically deciphers that the pharmacological mechanisms of QXHC in the treatment of menstrual disorders may be associated with its involvement into hemopoiesis, analgesia, nutrients absorption and metabolism, mood regulation, as well as immune modulation.

Risk factors and biomarkers for the recurrence of ovarian endometrioma: about the immunoreactivity of progesterone receptor isoform B and nuclear factor kappa B

Ovarian endometrioma is one of the important causes of poor ovarian reserve and up to half of them have been recurred. However, the treatment for recurrence prevention has limited efficiency and repeated surgery makes worsen the ovarian reserve. To find better management for recurrence prevention, we investigated risk factors and biomarkers for the recurrent endometriomas. The medical records of women with history of surgical dissection for ovarian endometrioma were collected. After exclusion of the cases with concurrent hysterectomy, been menopaused during follow-up, incomplete medical record, and loss of follow-up, a total of 134 women were enrolled. Immunohistochemical staining for progesterone receptor isoform B (PR-B) and nuclear factor kappa B (NFκB) was done with the fixed tissue blocks of their endometriomas which were collected at the time of surgery. Severity of dysmenorrhea and co-existence of adenomyosis had significant correlation with recurrence of endometrioma. Serum CA-125 level at the time of recurrence was higher than the highest level of CA-125 during follow-up in non-recurred group (55.6 versus 21.3 U/mL, p = 0.014). Increased PR-B (p = 0.041) and decreased NFκB (p = 0.036) immunoreactivity were found in recurrent group. However, to determine the possibility of immunoreactivity of PR-B and NFκB as biomarkers for recurrent endometrioma, further studies of various races and large numbers with prospective design are needed.

Umbilical Nodule with Cyclical Bleeding: A Case Report and Literature Review of Atypical Endometriosis

Endometriosis is defined as the presence of endometrial glands and stroma outside the uterus. It affects 3 to 10 percent of women of reproductive age. Umbilical endometriosis is rare, with an estimated incidence of 0.5–1.0% among all cases of endometriosis, and is usually secondary to prior laparoscopic surgery involving the umbilicus. In this report, we described a case of umbilical endometriosis treated with surgical resection and highlight the great importance of medical history compared to complementary diagnostic tests that can be sometimes inconclusive.

Preoperative risk factors in recurrent endometrioma after primary conservative surgery

Objective

Endometriosis is a common gynecological disorder caused by ectopic implantation of endometrial glandular and stromal cells outside the uterine cavity. Among several types of endometriosis, endometrioma is the only subtype that could be determined preoperatively using pelvic ultrasonography, and guidelines recommend pathologic confirmation of endometrioma greater than 3 cm in diameter. However, although surgery is performed in cases of endometrioma, endometrioma has a high cumulative rate of recurrence. Therefore, because determining the possibility of recurrence before performance of initial surgery is important, we examined preoperative factors associated with recurrent endometrioma.

Methods

This was a retrospective, comparative study including 236 patients who visited the outpatient clinic between January 2009 and December 2011. Patients who were pathologically diagnosed with endometrioma were included in this study. They were followed up postoperatively and were divided into two groups according to presence of recurrent endometrioma.

Results

We examined associations between baseline factors and recurrent endometrioma. In multivariate analysis, dysmenorrhea and cyst septation were statistically significant after adjusting with age, parity, surgical staging and postoperative management. We examined cumulative recurrence free survival within cases of recurrent endometriosis, based on the presence of inner cyst septation. The cumulative recurrence free survival was lower in cases with septation.

Conclusion

Our study found that recurrent endometrioma is more likely in patients with inner cyst septation and the recurrence occurred within a shorter duration of time than in patients without inner cyst septation on preoperative ultrasonography. Therefore intensive caution and postoperative long term medical therapy would be appropriate in patients with inner cyst septation on preoperative ultrasonography before undergoing primary surgery for endometrioma.

Recurrence of endometriosis: risk factors, mechanisms and biomarkers

While the incidence of endometriosis is up to 40-60% in women with severe dysmenorrhea/chronic pelvic pain, patients with subfertility carries a risk up to 20-30%. In symptomatic patients, although medical therapy is preferred in women with endometriosis, surgery might be needed in nonresponders or patients with an endometrioma. Following the surgery, recurrence of the disease and/or symptoms might be still noticed which will progressively increase as times goes by. Nevertheless, some risk factors have been identified for the risk of recurrence that decreases the success of the procedure. Those risk factors might be classified as patient-disease related and surgery-associated variables. Herein, we will address about the management of endometriosis regarding the risk factors for relapse, mechanisms of recurrence and potential biomarkers to predict the event.

Factors associated with the laterality of recurrent endometriomas after conservative surgery

We evaluated the laterality of primary endometrioma and characteristics of patients according to the laterality of recurrent endometrioma in 140 women with recurrent endometrioma after conservative surgery. Histologically confirmed recurrent endometriomas were found on the left side in 49 patients (35.0%), the right in 44 (31.4%) and bilaterally in 47 (33.6%). The sites of primary endometrioma were not associated with those of recurrent endometrioma, and the recurrence rate in the treated ovary (59.8%) was similar to that of the intact ovary (69.0%) at the primary surgery. Proportions of stage IV endometriosis and posterior cul-de-sac obliteration were higher in patients with bilateral recurrence than in those with unilateral recurrence (p < 0.01 for all comparisons) and in patients with contralateral recurrence than in those with ipsilateral recurrence (p < 0.05 for all comparisons), but no differences were found in other characteristics of participants according to the laterality or pattern of recurrence. In conclusion, the lateral distribution of recurrent endometrioma was not associated with that of the primary lesion, and endometrioma did not recur more frequently in the treated ovary. An advanced stage and the presence of posterior cul-de-sac obliteration were factors associated with bilateral or contralateral recurrence of endometrioma.

Is a positive family history of endometriosis a risk factor for endometrioma recurrence after laparoscopic surgery?

A total of 148 patients were followed up for an average of 30.1 ± 17 months following to laparoscopic excision of ovarian endometriomas by a single surgical team. Bivariate and multivariate analyses were used to investigate the association between endometrioma recurrence and several factors, age, body mass index, family history, cyst diameter, number and location, adhesions or peritoneal implants, occurrence of spillage, postoperative treatment with gonadotropin-releasing hormone agonist, or pregnancies. The overall recurrence rate of the endometriomas was 18.2%. At bivariate analysis, recurrence rate was significantly higher in patients with a positive family history of endometriosis (40% vs 14.8%). Recurrence was also more frequent, albeit nonsignificantly, in patients with a history of dysmenorrhea, intraoperative spillage, and postoperative hormonal suppression. At multivariate analysis with logistic regression, a positive family history of endometriosis was the only variable independently associated with endometrioma recurrence following laparoscopic removal (odds ratio 3.245; 95% confidence interval: 1.090-9.661).

Endometriomas in adolescents and young women

STUDY OBJECTIVE

To evaluate clinical aspects of endometriomas encountered in late adolescent females and young women and to review the issues specifically related to the disease in this age group.

DESIGN

Retrospective medical chart review study.

SETTING

Adolescent gynecology and infertility clinic of a tertiary care hospital with women's health focus.

PARTICIPANTS

Sixty-three late adolescent females and young women aged ≤ 24 years with endometrioma.

INTERVENTIONS

Operative laparoscopy for endometriomas.

MAIN OUTCOME MEASURES

Baseline clinical characteristics of the patients including age, marital status, body mass index, symptoms on admission, family history of endometriosis, past medical history, CA-125 levels, presence of a müllerian anomaly, endometriosis characteristics at the time of surgery, and correlation between ASRM scores and patient characteristics.

RESULTS

The mean age and body mass index of the patients were 22 ± 2 (range 17-24) years and 20.8 ± 2.6 (range 16.6-28.5) kg/m(2) respectively. Chronic pelvic pain was the most common symptom (44%). Two patients had a diagnosis of genital malformation. Forty-one (65%) patients had endometrioma on the right ovary, and 14 (22%) patients had bilateral endometriomas. Only one patient had posterior cul-de-sac completely obliterated. Fifty-five (87%) patients had score <16 points for adnexal adhesions calculated according to the revised American Society for Reproductive Medicine classification.

CONCLUSION

Endometriomas, although rare, can be encountered in adolescents and young women. The disease in adolescent patient group offers particular importance since early intervention is essential in order to decrease pain, prevent progression of the disease and enhance future fertility.

Recurrence of endometriosis; risk factors, mechanisms and biomarkers; review of the literature

Endometriosis has a wide clinical spectrum and induces a chronic inflammatory process. The incidence of endometriosis in women with dysmenorrhoea is up to 40-60%, whereas in women with subfertility is up to 20-30%. Recurrence of endometriosis varies greatly among different studies. The overall recurrence rates range between 6 to 67% according to the criteria that are taken into consideration. Which of the various reasons is more predictive for recurrence is still unclear and controversial. The main aim of post-operative medical treatment is suppressing ovarian activity leading to atrophy of endometriotic lesions. The success of treatment depends on the resorption of all residual visible lesions and the eradication of microscopic implants. The recurrent lesions might originate from residual lesions or from de novo cells. Determining risk factors for recurrence may allow the identification of subgroups at risk for disease control. Potential biomarkers for recurrence could also maintain targeted therapy.

Medical management of recurrent endometrioma with long-term norethindrone acetate

PURPOSE

Evaluate the efficacy of norethindrone acetate in the resolution of symptoms and regression of recurrent endometrioma.

PATIENTS AND METHODS

Retrospective chart review at SUNY Downstate Medical Center of patients with a history of surgical excision of endometrioma (with histological confirmation) and recurrent endometrioma (demonstrated by strict sonographic criterion of endometrioma) who were willing to undergo follow-up. Patients were prescribed norethindrone acetate to be taken daily with follow-up sonograms until cysts regressed. Statistical analysis included Student's t-test and a simple linear regression model to assess cyst regression over time during treatment.

RESULTS

Degree of pain was significantly lower on treatment when compared to baseline (P < 0.00001). Cyst size was significantly smaller in as little as 3 months (P < 0.0001). Average rate of regression with continuous treatment was 0.025 ± 0.015 cm/day. Total mean ± standard deviation regression time is 10.28 ± 8.25 months.

CONCLUSION

Norethindrone acetate was effective in eradicating symptoms and producing complete regression of recurrent endometriomas. It should be considered for patients who are likely to adhere to a prolonged treatment regimen and comply with recommendations for surveillance with serial sonograms.

Risk factors for recurrence and re-recurrence of ovarian endometriomas after laparoscopic excision

AIM

Since ovarian endometrioma is frequently diagnosed in women of reproductive age, laparoscopic excision of the endometrioma is performed for most cases. However, endometriomas frequently recurs even after repeated surgical procedures. The aim of our study is to identify risk factors for recurrence and re-recurrence of endometriomas after the first and second laparoscopic excision.

MATERIAL & METHODS

We retrospectively evaluated 173 patients who had a minimum of one year postoperative follow-up after the laparoscopic excision of endometriomas. Ten and eight factors were evaluated to assess their effect on the risk of recurrence and re-recurrence, respectively. Factors were analyzed using univariate and the Cox regression test.

RESULTS

The overall rate of recurrence and re-recurrence were 45.1% and 45.5%, respectively. A high revised American Society for Reproductive Medicine score (1997) was associated with an increased risk of recurrence. Only postoperative pregnancy was associated with a decreased risk of recurrence. Short periods of normal menstruation without pregnancy or gonadotrophin-releasing hormone analogues from first surgery to recurrence were associated with higher rate of re-recurrence.

CONCLUSIONS

A high revised American Society for Reproductive Medicine score was a risk factor, and postoperative pregnancy was protective against recurrence. The patient with short periods of normal menstruation without pregnancy or gonadotrophin-releasing hormone analogues from first surgery to recurrence had a high risk of re-recurrence.

Recurrence of endometriosis and its control

BACKGROUND Although surgery is currently the treatment of choice for managing endometriosis, recurrence poses a formidable challenge. To delay or to eliminate the recurrence is presently an unmet medical need in the management of endometriosis. To this end, proposals to investigate patterns of recurrence, to develop biomarkers for recurrence and to carry out biomarker-based intervention have been made. METHODS Publications pertaining to the recurrence of endometriosis and its related yet unaddressed issues were identified through MEDLINE. The reported recurrence rates, risk factors for recurrence, the effects of post-operative medication and causes of recurrence were reviewed and synthesized. In addition, several poorly explored issues such as time hazard function and mechanisms of recurrence were reviewed. Approaches to the development of biomarkers for recurrence and future intervention are discussed. RESULTS The reported recurrence rate was high, estimated as 21.5% at 2 years and 40-50% at 5 years. Few risk factors for recurrence have been consistently identified, and the evidence on the efficacy of the post-operative use of medication was scanty. The investigation on the patterns of recurrence may provide us with new insight into the possible mechanisms of recurrence and its control. The attempt to identify biomarkers for recurrence has started only very recently. CONCLUSIONS Much research is needed to better understand the patterns of recurrence and risk factors, and to develop biomarkers. One top priority is to develop biomarkers for recurrence, which may provide much needed clues to the possible mechanisms underlying recurrence and would allow the identification of patients with high recurrence risk, and permit for targeted intervention.

Postoperative oral contraceptive exposure and risk of endometrioma recurrence

OBJECTIVE

The purpose of this study was to compare the postoperative risk of endometrioma recurrence in women using oral contraception and in those undergoing simple observation.

STUDY DESIGN

After laparoscopic excision of ovarian endometriotiomas, a cyclic, low-dose, monophasic oral contraceptive pill (OCP) was offered to women not seeking pregnancy. One month after surgery, and every 6 months afterward, the patients underwent clinical and ultrasonographic assessment.

RESULTS

Of the 277 patients who entered the study, 102 used OCP for the entire follow-up period (always users), 129 used OCP discontinuously (ever users), and 46 declined treatment (never users). The median follow-up was 28 months. Recurrent endometriotic cysts were detected in 74 subjects (27%). The 36-month cumulative proportion of subjects free from endometrioma recurrence was 94% in the always users compared with 51% in the never users (P < .001); adjusted incidence rate ratio (IRR) = 0.10 (95% CI, 0.04-0.24).

CONCLUSION

Regular postoperative use of OCP effectively prevents endometrioma recurrence.

Laterality and asymmetry of endometriotic lesions

OBJECTIVE

To identify possible sources of heterogeneities in the estimation of the proportion of bilateral cases and of left-sided cases of endometriotic lesions.

DESIGN

We included 20 studies that reported estimated proportions, and examined the effect of sample size and the anatomic location of lesions on the heterogeneity using a mixed-effect logit regression model.

SETTING

Academic.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

None.

RESULT(S)

The sample size of these studies ranged from 64 to 1,407, with a median of 227 and a total sample size of 7,236 cases. There is substantial heterogeneity in the estimated proportion of both bilateral and left-sided cases. The estimated proportion of bilateral cases is positively associated with the sample size of the study, whereas that of left-sided cases is negatively associated with the sample size, irrespective of the anatomic locations of endometriotic lesions.

CONCLUSION(S)

There is an identifiable source of heterogeneity in proportion estimates, with the sample size being an apparent source. Although the precise causes for the sample size dependency are unclear, it is possible that the invasive nature of endometriotic lesions may eventually render most cases bilateral. Moreover, there are both promoting as well as mitigating or negating factors that contributing to the asymmetry of endometriotic lesions.

Management of ureteral endometriosis: areas of controversy

PURPOSE OF REVIEW

In this review we critically evaluate what we know and what we still do not know about pathogenesis, diagnosis and treatment of ureteral endometriosis, highlighting areas of controversy.

RECENT FINDINGS

Recent studies have produced new insights into diagnostic and management options for ureteral endometriosis.

SUMMARY

The diagnosis of ureteral endometriosis entails a high index of suspicion for the disorder. Imaging techniques are of limited value in providing an accurate depiction of extension of ureteral lesions. Preliminary results suggest that magnetic resonance urography is accurate in differentiating between intrinsic and extrinsic forms of ureteral involvement, but further studies are required to define its role in directing better treatment. Current controversies in the treatment of ureteral endometriosis are over whether segmental resection and anastomosis or ureterolysis are indicated, and whether minimal-access procedures are equally effective than their traditional open counterparts. Recent studies suggest that laparoscopic ureterolysis can be an effective treatment option in most patients with ureteral endometriosis but that recurrence rates are not negligible, as suggested in pioneering works. Successful application of laparoscopic surgery, even for procedures that have traditionally necessitated laparotomy, has been reported. Extensive experience with endourological techniques is prerequisite for success.

Patterns of and risk factors for recurrence in women with ovarian endometriomas

OBJECTIVE

To identify risk factors for and the patterns of recurrence of endometrioma and of dysmenorrhea in women with ovarian endometrioma.

METHODS

We evaluated 710 consecutive patients operated on for ovarian endometriomas who were followed up for an average of 22.4 months. Twenty factors were examined to assess their effect on risk of recurrence of endometrioma and of dysmenorrhea using survival analysis. Hazard rate also was estimated to examine recurrence patterns.

RESULTS

For recurrence of endometrioma, the revised American Fertility Society (rAFS) score, younger age at surgery, and previous medical treatment of endometriosis were identified to be risk factors. For recurrence of dysmenorrhea, rAFS score was the only risk factor. For both recurrences, there was a constant hazard rate in the first 28-30 months after surgery, indicating that the recurrence in that period is completely random. After that period, the hazard rate increased dramatically.

CONCLUSION

The total rAFS score, but not rAFS stage, is a risk factor for recurrence of both endometrioma and dysmenorrhea, indicating that the rAFS stage has little prognostic value. The existence of a completely random recurrence period may be a universal phenomenon, with its duration and the magnitude of recurrence risk determined by patient characteristics and quality of care. The second phase of much higher recurrence risk may reflect successful reseeding, reimplantation, and regrowth of ectopic endometrium. Therefore, the identification of risk factors as well as patterns of recurrence should shed better light on possible causes for recurrence, which is now poorly understood.

Outcome of laparoscopic ureterolysis for ureteral endometriosis

OBJECTIVE

To evaluate the adequacy of laparoscopic ureterolysis as a primary treatment option for ureteral endometriosis.

DESIGN

Prospective collaborative cohort study.

SETTING

Gynecologic departments of three university hospitals.

PATIENT(S)

Women with ureteral endometriosis exhibiting moderate-to-severe hydronephrosis on preoperative intravenous pyelography.

INTERVENTION(S)

Laparoscopic ureterolysis.

MAIN OUTCOME MEASURE(S)

Cure rate, disesase recurrence.

RESULT(S)

Thirty-three patients underwent laparoscopic ureterolysis during the study period. Bilateral involvement of ureters was found in 4 (12.1%) cases. In women with unilateral lesions the left ureter was more frequently affected (24/29 vs. 5/29). Ureteral involvement was associated with uterosacral ligaments endometriosis in 65.5% (22/34) of cases. No inadvertent ureteral injuries occurred during ureterolysis. A partial wall resection of the ureter was necessary in one case and a segmental ureteral resection with vescicopsoas hitch was required in a women with intrinsic ureteral endometriosis. The median (range) follow-up time was 16 months (range: 3-53 months). Thirty-two patients (96.7%) had a patent ureter on the 3-month postoperative intravenous pyelography. The recurrence rate of ureteral lesions was 12.1% (4/33).

CONCLUSION(S)

Our findings suggest that a conservative laparoscopic approach is an effective treatment option in most patients with ureteral endometriosis exhibiting moderate-to-severe hydronephrosis.

Recurrence of ovarian endometrioma after laparoscopic excision

BACKGROUND

To analyse risk factors that influence the recurrence of endometrioma after laparoscopic excision.

METHODS

A total of 224 patients who had a minimum of 2 years of post-operative follow-up after laparoscopic ovarian endometrioma excision were studied retrospectively. Recurrence was defined as the presence of endometrioma more than 2 cm in size, detected by ultrasonography within 2 years of surgery. Fourteen variables (age, presence of infertility, pain, uterine myoma, adenomyosis, previous medical treatment of endometriosis, previous surgery for ovarian endometriosis, single or multiple cysts, the size of the largest cyst at laparoscopy, unilateral or bilateral involvement, co-existence of deep endometriosis, revised American Society for Reproductive Medicine (ASRM) score, post-operative medical treatment and post-operative pregnancy) were evaluated to assess their independent effects on the recurrence using logistic regression analysis.

RESULTS

The overall rate of recurrence was 30.4% (68/224). Significant factors that were independently associated with higher recurrence were previous medical treatment of endometriosis [odds ratio (OR) = 2.324, 95% confidence interval (95% CI) = 1.232-4.383, P = 0.0092) and larger diameter of the largest cyst (OR = 1.182, 95% CI = 1.004-1.391, P = 0.0442). Post-operative pregnancy was associated with lower recurrence (OR = 0.292, 95% CI = 0.028-0.317, P = 0.0181).

CONCLUSIONS

Previous medical treatment of endometriosis or large cyst size was a significant factor that was associated with higher recurrence of the disease. Post-operative pregnancy is a favourable prognostic factor.

Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution

BACKGROUND

To investigate whether knowledge of the anatomical distribution of histologically proven deeply infiltrating endometriosis (DIE) lesions contributes to understanding the pathogenesis.

METHODS

Observational study between June 1992 and December 2004 (retrospective study between 1992 and 2000; prospective study between 2001 and 2004). Continuous series of 426 patients suffering from pelvic pain who underwent complete surgical exeresis of DIE. DIE lesions were classified according to four different possibilities: (i) Firstly, DIE lesions were classified as located in the anterior or posterior pelvic compartment. (ii) Secondly, DIE were classified as left, median and right. (iii) Thirdly, DIE lesions were classified as pelvic or abdominal. (iv) Fourthly, DIE lesions that could present in a right and/or left location were classified as unilateral or bilateral.

RESULTS

These 426 patients presented 759 histologically proven DIE lesions: bladder (48 lesions; 6.3%); uterosacral (USL) (400 lesions; 52.7%); vagina (123 lesions; 16.2%); ureter (16 lesions; 2.1%) and intestine (172, 22.7%). DIE lesions are significantly more often located in the pelvis (n=730 lesions) than in the abdomen (n=29 lesions) (P<0.0001). Pelvic DIE lesions are significantly more often located in the posterior compartment of the pelvis [682 DIE lesions (93.4%) versus 48 DIE lesions (6.6%); P<0.0001]. Pelvic DIE lesions are significantly more frequently located on the left side. For patients with unilateral pelvic DIE lesions, the anatomical distribution is significantly different in the three groups: left (172 lesions; 32.0%), median (284 lesions; 52.8%) and right (82 lesions; 15.2%) (P<0.0001). For patients with lateral lesions, left DIE lesions (172 lesions; 67.8%) were found significantly more frequently than right DIE lesions (82 lesions; 32.2%) (P<0.0001). A similar predisposition was observed when we included patients with bilateral pelvic DIE lesions (P=0.0031). The same significantly asymmetric distribution is observed for total (pelvic and abdominal) DIE lesions.

CONCLUSIONS

Our results demonstrate that distribution of DIE lesions is asymmetric. It is possible that this is related to the anatomical difference between the left and right hemipelvis and to the flow of peritoneal fluid. These findings support the hypothesis that retrograde menstruation of regurgitated endometrial cells is implicated in the pathogenesis of DIE.

Impact of ovarian endometrioma on oocytes and pregnancy outcome in in vitro fertilization

OBJECTIVE

To evaluate the effect of endometriosis and the presence of an ovarian endometrioma on outcomes of conventional in vitro fertilization (IVF).

DESIGN

Retrospective study.

SETTING

Reproductive Unit, Department of Obstetrics and Gynecology, Tokai University Hospital.

PATIENT(S)

Group A: 80 cycles with ovarian endometriomas; group B: 248 cycles with endometriosis but without endometrial cysts at the time of oocyte retrieval; group C: 283 cycles undergoing IVF because of tubal factor without endometriosis.

INTERVENTION(S)

All conventional in vitro fertilization-embryo transfer (IVF-ET) with previous diagnostic laparoscopy. An endometrioma was diagnosed by direct aspiration at the time of oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Retrieved number of oocytes, fertilization rate, embryo quality, implantation rate, pregnancy rate, and live birth rate for all cases. In group A, the number of retrieved oocytes in relation to the volume of the endometrioma and affected laterality.

RESULT(S)

Fewer oocytes were retrieved from groups A and B than from group C (P<.005). The number of retrieved oocytes was not dependent on the volume of endometrial cyst(s). Fertilization rates were similar among the groups. Group A had slightly but not significantly higher rates of morphologically good-quality embryos (group A: 67.2%, group B: 63.0%, group C: 58.1%), implantation (group A: 14.1%, group B: 11.7%, group C: 11.3%), and pregnancy (group A: 25.3%, group B: 22.3%, group C: 23.9%).

CONCLUSION(S)

Endometriosis affects oocyte number but not embryo quality or pregnancy outcome, irrespective of the presence of an ovarian endometrioma.

?Kissing ovaries?: A sonographic sign of moderate to severe endometriosis

OBJECTIVE

To evaluate whether the presence of kissing ovaries at ultrasound is a marker for endometriosis and whether it correlates with the severity of the disease.

DESIGN

Prospective observational study.

SETTING

Gynecologic departments of two university hospitals.

PATIENT(S)

A total of 722 consecutive premenopausal women who had laparoscopic surgery for an adnexal mass or suspected pelvic endometriosis.

INTERVENTION(S)

Preoperative ultrasound evaluation and laparoscopic surgery.

MAIN OUTCOME MEASURE(S)

Diagnostic and predictive value of ultrasound identification of kissing ovaries in the detection of endometriosis.

RESULT(S)

Kissing ovaries were diagnosed at ultrasound and confirmed laparoscopically in 32 patients. Of these, 27 had moderate to severe endometriosis and five others had benign adnexal masses. Bowel (18.5% vs. 2.5%) and fallopian tube (92.6% vs. 33%) endometriosis were significantly more frequent in patients with kissing ovaries than in patients without kissing ovaries. In infertile patients (n = 145), kissing ovaries were associated with a higher proportion of women with fallopian tube obstruction (80% vs. 8.6%). Considering patients with moderate to severe endometriosis (n = 189), the median (range) revised American Fertility Society score (74 [32-148] vs. 35 [16-146]) and the operative time (115 minutes [65-245 minutes] vs. 50 [15-180 minutes]) were significantly higher in patients with than in those without kissing ovaries.

CONCLUSION(S)

The detection of kissing ovaries at ultrasound is strongly associated with the presence of endometriosis and is a marker of the most severe form of this disease.

Deep Endometriosis: Definition, Pathogenesis, and Clinical Management

"Deep endometriosis" includes rectovaginal lesions as well as infiltrative forms that involve vital structures such as bowel, ureters, and bladder. The available evidence suggests the same pathogenesis for deep infiltrating vesical and rectovaginal endometriosis (i.e., intraperitoneal seeding of regurgitated endometrial cells, which collect and implant in the most dependent portions of the peritoneal cavity and the anterior and posterior cul-de-sac, and trigger an inflammatory process leading to adhesion of contiguous organs with creation of false peritoneal bottoms). According to anatomic, surgical, and pathologic findings, deep endometriotic lesions seem to originate intraperitoneally rather than extraperitoneally. Also the lateral asymmetry in the occurrence of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomic differences of the left and right hemipelvis. Peritoneal, ovarian, and deep endometriosis may be diverse manifestations of a disease with a single origin (i.e., regurgitated endometrium). Based on different pathogenetic hypotheses, several schemes have been proposed to classify deep endometriosis, but further data are needed to demonstrate their validity and reliability. Drugs induce temporary quiescence of active deep lesions and may be useful in selected circumstances. Progestins should be considered as first-line medical treatment for temporary pain relief. However, in most cases of severely infiltrating disease, surgery is the final solution. Great importance must be given to complete and balanced counseling, as awareness of the real possibilities of different treatments will enhance the patient's collaboration.

Ovarian endometriosis: from pathogenesis to surgical treatment

PURPOSE OF REVIEW

This review analyzes the literature on ovarian endometrioma, examining the controversies on pathogenesis, malignant transformation and surgical therapy.

RECENT FINDINGS

Recent literature reflects the necessity of clearly defining the ethiologic and pathologic factors that determine the origin of ovarian endometriosis and explain the increase in the condition with the prospect of developing effective prevention therapy. The possibility that ovarian endometriomas undergo malignant transformation is widely reported in the literature. Recent studies underline the importance of detecting histological differences in endometriosis (hyperplasia and atypia) and several studies of molecular biology support the theory of genetic alterations interfering with malignant transformation of ovarian endometriosis.

SUMMARY

The surgical approach must take into account all this information and, when the therapy is conservative, complete excision of the disease must be laparoscopically performed without affecting the healthy ovarian tissue.

Update on treatment of menstrual disorders

There is evidence from well designed randomised controlled trials that modern medical and conservative surgical therapies (including endometrial ablation) are effective treatments for heavy menstrual bleeding for many women. Submucous fibroids may be resected directly via the hysteroscope, reducing menstrual bleeding, although data are available only from case series. Endometriosis is common, may also occur in young women and may present with atypical or non-cyclical symptoms; conservative laparoscopic surgery increases fecundity and reduces dysmenorrhoea and dyspareunia. Randomised trials of the levonorgestrel intrauterine system in women with menorrhagia have shown that hysterectomy can be avoided in 80% of cases, and that this system is an effective therapy for menorrhagia. The levonorgestrel intrauterine system may also be useful for managing symptoms of endometriosis, adenomyosis and endometrial hyperplasia, based on observational data.

Twenty-year history of endometriosis-associated pelvic pain: too much surgery or not enough?

A 36-year-old woman with a 20-year history of endometriosis-associated pelvic pain was a unique case from a total of 700 patients with endometriosis recently evaluated at Yale University. Her previous treatments included 11 surgical procedures related to pelvic pain or endometriosis. Multiple recurrences of endometriosis were documented. Although clearly an unusual case, our patient highlights the importance of using even the most advanced surgical techniques judiciously.

Future directions in endometriosis research

Future research in endometriosis must focus on pathogenesis studies in the baboon model, the early interactions between endometrial and peritoneal cells in the pelvic cavity at the time of menstruation, and potential differences between eutopic endometrium and myometrium in women with and without endometriosis. More integration is needed between the areas of epidemiology and genetics. Pelvic inflammation in women with endometriosis could be the target for new diagnostic and therapeutic approaches. Important questions remain regarding the relationship between endometriosis and environmental factors. Systemic and extrapelvic manifestations of endometriosis must be analyzed carefully, and better tools are needed to measure quality of life in women with chronic pain caused by endometriosis. Most current evidence supports a causal relationship between endometriosis and subfertility, and the spontaneous progressive nature of endometriosis has been demonstrated in 30% to 60% of patients. Recurrence of endometriosis after classic medical and surgical therapy is a major and underestimated problem, especially in women with advanced disease. Integrated clinical and research teams are needed that combine expert medical, surgical, and holistic care with state-of-the-art research expertise in immunology, endocrinology, and genetics to discover new diagnostic methods and medical treatments for endometriosis.

Ovarian endometriosis and peritoneal endometriosis: are they different entities from a fertility perspective?

This review summarizes the recent literature concerning new data on the pathogenesis of peritoneal endometriosis and its natural evolution. Indeed, the main concern in endometriosis is the choice of treatment in cases of infertility problems: medical or surgical. This concern could hypothetically be avoided if endometriosis were considered as a spontaneously regressive phenomenon. The present paper also discusses the risk of recurrence and the results of in-vitro fertilization and embryo transfer in cases of ovarian endometriosis. Whatever type of surgery is performed, the results of in-vitro fertilization and embryo transfer are not impaired, especially if damage to the ovarian cortex is avoided. Further studies are required to determine if oocytes from endometriosis patients are altered and could be responsible for the development of lower quality embryos.