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Perrone U, Ferrero S, Gazzo I, Izzotti A, Leone Roberti Maggiore U, Gustavino C, Ceccaroni M, Bogliolo S, Barra F. Endometrioma surgery: Hit with your best shot (But know when to stop). Best Pract Res Clin Obstet Gynaecol 2024:102528. [PMID: 38977389 DOI: 10.1016/j.bpobgyn.2024.102528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/08/2024] [Accepted: 06/25/2024] [Indexed: 07/10/2024]
Abstract
Ovarian endometriomas (OEs) are commonly detected by ultrasound in individuals affected by endometriosis. Although surgery was widely regarded in the past as the gold standard for treating OEs, especially in the case of large cysts, the surgical management of OEs remains debated. Firstly, OEs often represent the "tip of the iceberg" of underlying deep endometriosis, and this should be considered when treating OEs to ameliorate patients' pain for focusing on the surgical objectives and providing better patient counseling. In the context of fertility care, OEs may have a detrimental effect on ovarian reserve through structural alterations, inflammatory responses, and oocyte reserve depletion. Conversely, the surgical approach may exacerbate the decline within the same ovarian reserve. While evidence suggests no improvement in in-vitro fertilization (IVF) outcomes following OE surgery, further studies are needed to understand the impact of OE surgery on spontaneous fertility. Therefore, optimal management of OEs is based on individual patient and fertility characteristics such as the woman's age, length of infertility, results of ovarian reserve tests, and surgical background. Among the available surgical approaches, cystectomy appears advantageous in terms of reduced recurrence rates, and traditionally, bipolar coagulation has been used to achieve hemostasis following this approach. Driven by concerns about the negative impact on ovarian reserve, alternative methods to obtain hemostasis include suturing the cyst bed, and novel methodologies such as CO2 laser and plasma energy have emerged as viable surgical options for OEs. In instances where sonographic OE features are non-reassuring, surgery should be contemplated to obtain tissue for histological diagnosis and rule out eventual ovarian malignancy.
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Affiliation(s)
- Umberto Perrone
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Via Gio Batta Ghio 9, 16043, Chiavari, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy; Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy.
| | - Irene Gazzo
- Department of Reproductive Medicine, Ospedale Evangelico Internazionale, Genoa, Italy
| | - Alberto Izzotti
- Unit of Mutagenesis and Cancer Prevention, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | | | - Claudio Gustavino
- Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Negrar di Valpolicella, Verona, Italy
| | - Stefano Bogliolo
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Via Gio Batta Ghio 9, 16043, Chiavari, Genoa, Italy
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Via Gio Batta Ghio 9, 16043, Chiavari, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy
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Viganò P, Somigliana E, Gentilini D, Benaglia L, Vercellini P. Back to the Original Question in Endometriosis: Implantation or Metaplasia? ACTA ACUST UNITED AC 2018. [DOI: 10.1177/228402650900100102] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The pathogenesis of some forms of endometriosis is still controversial. Different research approaches have been used to clarify this issue and an intense debate has derived over the years among scientists. This paper presents and discusses aged and modern ideas derived from various observations in different research areas on this specific topic. More specifically, data derived from histological results, animal studies, anatomical findings and basic research activity are presented. Although an increasing body of evidence tends to support the implantation theory, which currently represents the most recognized pathogenic model for endometriosis, some aspects of this disease remain obscure and the scientific and medical communities have still not made significant progress in terms of completely elucidating the histogenesis of some forms of the disease.
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Affiliation(s)
- Paola Viganò
- A.O. Sant'Anna, Como and Center for Research in Obstetrics and Gynecology (CROG), Milan
- Department of Obstetrics and Gynecology, University of Milan, Milan - Italy
| | - Edgardo Somigliana
- Fondazione Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, Milan
| | | | - Laura Benaglia
- Fondazione Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, Milan
| | - Paolo Vercellini
- Department of Obstetrics and Gynecology, University of Milan, Milan - Italy
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Abstract
Endometriosis, defined by the presence of endometrial tissue outside the uterine cavity, is a common condition affecting 10% of women in the reproductive age. Menstrual factors reported to increase risk include dysmenorrhea, early menarche, and shorter cycle lengths. The theory of retrograde menstruation with implantation of endometrial fragments, in conjunction with peritoneal factors to stimulate cell growth is the most widely accepted. There is a growing body of evidence that immunological factors and angiogenesis play a key role in the pathogenesis of endometriosis. In women with endometriosis, there appears to be an alteration in the function of peritoneal macrophages, natural killer cells and lymphocytes, with production of growth factors and inflammatory mediators in the peritoneal fluid. Survival, adhesion, proliferation, invasion and vascularization of endometrial tissue in abdominal cavity may be the consequence of retrograde menstruation and referred to as implantation theory.
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Affiliation(s)
- M. Larosa
- UOC di Urologia, Azienda AUSL Reggio Emilia, Distretto di Guastalla - Italy
| | - F. Facchini
- UOC di Urologia, Azienda AUSL Reggio Emilia, Distretto di Guastalla - Italy
| | - G. Pozzoli
- UOC di Urologia, Azienda AUSL Reggio Emilia, Distretto di Guastalla - Italy
| | - M. Leone
- UOC di Urologia, Azienda AUSL Reggio Emilia, Distretto di Guastalla - Italy
| | - M. Grande
- UOC di Urologia, Azienda AUSL Reggio Emilia, Distretto di Guastalla - Italy
| | - B. Monica
- UOC di Urologia, Azienda AUSL Reggio Emilia, Distretto di Guastalla - Italy
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Preoperative risk factors in recurrent endometrioma after primary conservative surgery. Obstet Gynecol Sci 2016; 59:286-94. [PMID: 27462595 PMCID: PMC4958674 DOI: 10.5468/ogs.2016.59.4.286] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/21/2015] [Accepted: 12/23/2015] [Indexed: 11/13/2022] Open
Abstract
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.
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Leone Roberti Maggiore U, Scala C, Venturini P, Remorgida V, Ferrero S. Endometriotic ovarian cysts do not negatively affect the rate of spontaneous ovulation. Hum Reprod 2014; 30:299-307. [DOI: 10.1093/humrep/deu308] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lee DY, Kim HJ, Yoon BK, Choi D. Factors associated with the laterality of recurrent endometriomas after conservative surgery. Gynecol Endocrinol 2013; 29:978-81. [PMID: 24004294 DOI: 10.3109/09513590.2013.824959] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Dong-Yun Lee
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , Korea
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Maccagnano C, Pellucchi F, Rocchini L, Ghezzi M, Scattoni V, Montorsi F, Rigatti P, Colombo R. Diagnosis and treatment of bladder endometriosis: state of the art. Urol Int 2012; 89:249-58. [PMID: 22813980 DOI: 10.1159/000339519] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The bladder is the most common affected site in urinary tract endometriosis, being diagnosed during gynecologic follow-up. The surgical urological treatment might lead to good results. STUDY OBJECTIVE To define the state of the art in the diagnosis and treatment of bladder endometriosis. METHODS We performed a literature review by searching the MEDLINE database for articles published between 1996 and 2011, limiting the searches to the words: urinary tract endometriosis, bladderendometriosis, symptoms, diagnosis and treatment. RESULTS Deep pelvic endometriosis usually involves the urinary system, with the bladder being affected in 85% of cases. The diagnosis has to be considered as a step-by-step procedure. Currently, the treatment is usually surgical, consisting of either transurethral resection or partial cystectomy, and eventually associated with hormonal therapy. The hormonal therapy alone counteracts only the stimulus of endometriotic tissue proliferation, with no effects on the scarring caused by this tissue. The overall recurrence rate is about 30% for combined therapies and about 35% for the hormonal treatment alone. CONCLUSIONS The bladder is the most common affected site in urinary tract endometriosis. Most of the time, this condition is diagnosed because of the complaint of urinary symptoms during gynecologic follow-up procedures for a deep pelvic endometriosis: a close collaboration between the gynecologist and the urologist is advisable, especially in highly specialized centers. The surgical urological treatment might lead to good results in terms of patients' compliance and prognosis.
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Affiliation(s)
- Carmen Maccagnano
- Department of Urology, San Raffaele Scientific Institute, Milan, Italy.
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Bricou A, Borghese B, Batt R, Piketty M, de Ziegler D, Chapron C. Étude de la distribution anatomique des lésions endométriosiques : un argument majeur en faveur de la participation de la théorie de la régurgitation dans la physiopathologie de l’endométriose. ACTA ACUST UNITED AC 2009; 37:325-33. [DOI: 10.1016/j.gyobfe.2008.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Accepted: 12/26/2008] [Indexed: 11/29/2022]
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Peritoneal fluid flow influences anatomical distribution of endometriotic lesions: Why Sampson seems to be right. Eur J Obstet Gynecol Reprod Biol 2008; 138:127-34. [DOI: 10.1016/j.ejogrb.2008.01.014] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Revised: 12/16/2007] [Accepted: 01/21/2008] [Indexed: 11/20/2022]
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Guo SW, Wang Y, Liu X, Olive DL. Laterality and asymmetry of endometriotic lesions. Fertil Steril 2008; 89:33-41. [PMID: 17675002 DOI: 10.1016/j.fertnstert.2007.02.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Revised: 02/14/2007] [Accepted: 02/21/2007] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Sun-Wei Guo
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin 53226-0509, USA.
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Poncelet C, Ducarme G. Prise en charge de l'endométriose: les bonnes pratiques de la cœlioscopie diagnostique. ACTA ACUST UNITED AC 2007; 36:135-40. [PMID: 17267138 DOI: 10.1016/j.jgyn.2006.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The interest for diagnostic laparoscopy for the diagnosis of endometriosis is not longer discussed. Indications could be pelvic pain, infertility, menorragia, and/or organic ovarian tumour. Several lesions, typical and non typical, have been described and should be recognized. Histological confirmation seems suitable even though the correlation with visual inspection is not perfect. New laparoscopic techniques seem interesting to increase diagnostic relevance. Visual inspection should be associated with palpation. For deep infiltrating endometriotic lesions diagnostic laparoscopy has shown its limits. Precisions concerning peri-operative methods and operative reports are described. The place of the different classifications has been discussed.
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Affiliation(s)
- C Poncelet
- Services de Gynécologie - Obstétrique et de Médecine de la Reproduction, CHU Jean-Verdier, APHP, avenue du 14-Juillet, 93143 Bondy cedex, France.
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Bazi T, Abi Nader K, Seoud MA, Charafeddine M, Rechdan JB, Zreik TG. Lateral distribution of endometriomas as a function of age. Fertil Steril 2006; 87:419-21. [PMID: 17094977 DOI: 10.1016/j.fertnstert.2006.06.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Revised: 06/16/2006] [Accepted: 06/16/2006] [Indexed: 11/22/2022]
Abstract
The lateral asymmetry of ovarian endometriomas, with a left-sided predilection, seems to disappear with advancing age. This asymmetry does not seem to persist in women >35 years of age.
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Affiliation(s)
- Tony Bazi
- Department of Obstetrics and Gynecology, American University of Beirut, Beirut, Lebanon
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Chapron C, Chopin N, Borghese B, Foulot H, Dousset B, Vacher-Lavenu MC, Vieira M, Hasan W, Bricou A. Deeply infiltrating endometriosis: pathogenetic implications of the anatomical distribution. Hum Reprod 2006; 21:1839-45. [PMID: 16543256 DOI: 10.1093/humrep/del079] [Citation(s) in RCA: 271] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Charles Chapron
- Service de Gynécologie Obstérique II, Unité de Chirurgie Gynécologique, Institut Cochin, IFR, Université Paris V, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Universitaire Ouest, France.
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Audebert A. Endométriome ovarien associé à une infertilité : quelle est la place de l'abstention thérapeutique? ACTA ACUST UNITED AC 2005; 33:416-22. [PMID: 15927511 DOI: 10.1016/j.gyobfe.2005.04.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Accepted: 04/15/2005] [Indexed: 11/30/2022]
Abstract
Ovarian endometrioma is not infrequently encountered in infertile patients. Its etiopathogeny, its relations with attributed symptoms and the recommanded treatment to apply, are still debated. Various therapeutic tools are available, such as abstention, ultrasonographically guided aspiration and drainage, and surgery. Each option carries specific advantages and disadvantages. Ultrasonographically guided aspiration bears infectious risks. Among various proposed surgical procedures, cystectomy appears to offer the best performances. Results of IVF are slightly or not altered, neither by an ovarian endometrioma, nor by previous surgery, except in case of iterative surgery or if operated lesions were very severe. Laparoscopic surgery is still the first line treatment in many cases. Abstention can be applied in particular circumstances. Ultrasonographically guided aspiration needs to be further evaluated.
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Vercellini P, Chapron C, Fedele L, Gattei U, Daguati R, Crosignani PG. REVIEW: Evidence for asymmetric distribution of lower intestinal tract endometriosis. BJOG 2004; 111:1213-7. [PMID: 15521865 DOI: 10.1111/j.1471-0528.2004.00453.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Paolo Vercellini
- First Department of Obstetrics and Gynecology, University of Milan, Italy
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Vercellini P, Frontino G, Pietropaolo G, Gattei U, Daguati R, Crosignani PG. Deep Endometriosis: Definition, Pathogenesis, and Clinical Management. ACTA ACUST UNITED AC 2004; 11:153-61. [PMID: 15200766 DOI: 10.1016/s1074-3804(05)60190-9] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
"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.
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Affiliation(s)
- Paolo Vercellini
- Clinica Ostetrica e Ginecologica I, Istituto Luigi Mangiagalli, University of Milan, Milan, Italy
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Abstract
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.
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Affiliation(s)
- Mauro Busacca
- Department of Obstetrics and Gynecology, University of Milan, Milan, Italy.
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