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Deep Endometriosis: the Involvement of Multiple Pelvic Compartments Is Associated with More Severe Pain Symptoms and Infertility. Reprod Sci 2022; 30:1668-1675. [PMID: 36333645 DOI: 10.1007/s43032-022-01104-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
Endometriosis can be classified into three phenotypes: superficial, ovarian, and deep. Deep endometriosis (DE) has been associated with more severe pain symptoms, although no large-scale studies have evaluated the association between pain intensity and infertility and the different compartments of the pelvis affected by superficial and DE. This retrospective study included 1116 women who underwent laparoscopy for endometriosis treatment at two referral centers between 2009 and 2019. For the evaluation of each symptom, patients were divided according to their visual analog scale score (< 7 and ≥ 7) and fertility status. On multiple logistic regression, severe dysmenorrhea and dyschezia were correlated with DE of the posterior compartment alone (odds ratio (OR) = 1.6, confidence interval (CI) 1.09-2.34, and p = 0.02 and OR = 2.09, CI 1.36-3.23, and p < 0.01, respectively) and in combination with other compartments. DE of the posterior and lateral compartments had the most consistent statistical power (OR = 3.55 for dysmenorrhea and OR = 4.4 for dyschezia). Infertility was associated with DE of the posterior compartment alone (OR = 1.6, CI 1.06-2.54, p = 0.04) and in combination with the anterior compartment (OR = 2.62, CI 1.29-5.29, p < 0.01), with the combination of posterior and anterior compartment having the highest OR value. Severe dyschezia and infertility were also correlated with the presence of multiple localizations of DE (p = 0.04 and p < 0.01). This study confirms the association between DE and severe pain symptoms as well as the influence of the number of DE compartments on the severity of symptoms and the chance of infertility.
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Dückelmann AM, Taube E, Abesadze E, Chiantera V, Sehouli J, Mechsner S. When and how should peritoneal endometriosis be operated on in order to improve fertility rates and symptoms? The experience and outcomes of nearly 100 cases. Arch Gynecol Obstet 2021; 304:143-155. [PMID: 33537880 PMCID: PMC8164581 DOI: 10.1007/s00404-021-05971-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/12/2021] [Indexed: 12/18/2022]
Abstract
Purpose To analyze the follow-up results of patients suffering from symptomatic early-stage endometriosis after a consistent laparoscopic peritoneal stripping of the altered peritoneum (peritoneal endometriosis and surrounding inflamed tissue) was performed. This type of endometriosis is resistant to medical therapy and/or impairs fertility. Methods Using our prospectively maintained database, we were able to identify all symptomatic women with the suspicion of only peritoneal endometriosis who underwent laparoscopy at our endometriosis center over a period of 5 years. All procedures were carried out in a standardized fashion by one single surgeon, who is highly experienced in minimal invasive surgery, and included a suspended hormonal pretreatment for 2 months. Postoperative outcomes including complications, fertility and recurrence rates were analysed. Results Laparoscopic peritonectomy was performed on 94 women. Follow-up data were available in 87% of these cases. At the time of surgery, almost all patients tested showed signs of stage I or II endometriosis (44.7 and 48.9%, respectively). More than three-quarters of the women reported pain relief, inter alia, due to the post-surgical hormonal therapy. About one-third of the patients wanted to have children after the procedure. 62% of them became pregnant and the majority did so without the need for assisted reproductive therapy. In seven women a re-operation was performed. Conclusion According to our data, a consistent excision of altered peritoneum followed by adjuvant hormonal therapy and multimodal concepts results in better outcomes for the patient, particularly in regards to pregnancy and recurrence rates.
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Affiliation(s)
- A M Dückelmann
- Department of Gynecology, Charité-Universitätsmedizin BerlinVirchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - E Taube
- Department of Pathology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - E Abesadze
- Department of Gynecology, Vivantes Clinic Berlin Hellersdorf, Myslowitzerstr. 45, 12621, Berlin, Germany
| | - V Chiantera
- Department of Gynecologic Oncology, University of Palermo, Piazza Marina, 61, 90133, Palermo, Italy
| | - J Sehouli
- Department of Gynecology, Charité-Universitätsmedizin BerlinVirchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - S Mechsner
- Department of Gynecology, Charité-Universitätsmedizin BerlinVirchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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Ghai V, Jan H, Shakir F, Kent A. Identifying Preoperative Factors Associated with Nonresponders in Women Undergoing Comprehensive Surgical Treatment for Endometriosis. J Minim Invasive Gynecol 2019; 27:141-147. [PMID: 30885782 DOI: 10.1016/j.jmig.2019.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 03/09/2019] [Accepted: 03/11/2019] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE To examine whether existing quality of health outcome measures can be used to predict or have an association with nonresponse surgery for endometriosis. DESIGN Retrospective cohort study. SETTINGS Single endometriosis referral center. PATIENTS Women (n = 198) undergoing surgery for endometriosis. INTERVENTIONS Validated health questionnaires and visual analogue scales. MEASUREMENTS AND MAIN RESULTS Patients were given validated health questionnaires, including Endometriosis Health Profile 30, Gastrointestinal Quality of Life Index, EuroQol-5, Hospital Anxiety and Depression Scale, preoperatively and at 12 months after full surgical excision of endometriosis. Visual analogue scales were also used that measured dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain. Surgical management was dependent on severity of disease. Superficial disease was treated by laparoscopic peritoneal excision or laser ablation. Deep infiltrating disease involving the bowel was excised completely together with laparoscopic bowel surgery (shave, disc, or segmental resection) with/without concomitant total hysterectomy and bilateral salpingo-oophorectomy. Nonresponders were defined as women who failed to demonstrate an improvement in pain scores 12 months postoperatively. We examined preoperative and postoperative questionnaires, visual analogue scores, and other variables such as age at onset of symptoms, type of surgery, and the presence of postoperative complications comparing responder and nonresponder women to identify the factors associated with nonresponse. Of 102 women treated for superficial endometriosis, 25 (24.51%) were nonresponders. No factors were associated with nonresponse at 12 months. Of 96 women treated for severe endometriosis involving the bowel, 10 (10.41%) were nonresponders. Nonresponders had significantly less preoperative pain (p = .031) and feeling of control (p = .015) than responders. There was no association between nonresponders and women who underwent a hysterectomy with bilateral salpingo-oophorectomy or those with complications. Radical bowel surgery (resection) was associated with nonresponders. CONCLUSION Minimal preoperative factors are associated with nonresponse for women having surgery for endometriosis. The severity of pain experienced by women with endometriosis may be used to predict their response to surgery.
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Affiliation(s)
- Vishalli Ghai
- Department of Obstetrics and Gynaecology (Miss. Ghai and M Jan), Epsom & St. Helier's University Hospitals NHS Trust, Surrey, United Kingdom.
| | - Haider Jan
- Department of Obstetrics and Gynaecology (Miss. Ghai and M Jan), Epsom & St. Helier's University Hospitals NHS Trust, Surrey, United Kingdom
| | - Fevzi Shakir
- Department of Obstetrics and Gynaecology (Mr. Shakir), Royal Free University Hospital NHS Trust, London, United Kingdon
| | - Andrew Kent
- Department of Obstetrics and Gynaecology (Mr. Kent), Royal Surrey County University NHS Hospital Trust, Guildford, United Kingdom
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Jarrell J, Arendt-Nielsen L. Negative laparoscopy unveiled. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2018. [DOI: 10.1177/2284026517749478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction:Studies indicate a variable proportion of laparoscopies done for the management of non-acute pelvic pain that do not identify visible pathology and are called negative laparoscopies. Possible explanations have included undetected endometriosis, observer error, and/or neural tissues in the endometrium acting as nociceptive input. The goal was to compare demographic and pain testing measures between women with negative laparoscopies and confirmed endometriosis in a cohort of women presenting with chronic pelvic pain.Methods:Women with chronic pelvic pain (n = 255) provided written consent for the study prior to entry. Data were collected at the time of clinic visit and entered contemporaneously into SPSS. Pain sensitization was identified as the presence of cutaneous allodynia. Clinical, pain, and pain sensitization variables were compared using Student’s t-test.Results:The frequency of negative laparoscopy was 13.7% (35 cases) and that of confirmed endometriosis was 27.1% (69 cases). There were no differences between women with a negative laparoscopy and women with confirmed endometriosis in clinical, dysmenorrhea, or pain testing measurements.Conclusion:The data suggest in the absence of endometriotic tissue in the pelvis, chronic visceral pain may result from a uterine origin and result in a generalized pattern of pain and pain sensitization.
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Affiliation(s)
- John Jarrell
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada
| | - Lars Arendt-Nielsen
- Center for Sensory-Motor Interaction, School of Medicine, Aalborg University, Aalborg, Denmark
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Bhatti M, Ketheeswaran A, Arnold A, Nesbitt-Hawes E, Deans R, Won H, Abbott J. Pelvic examination may be meaningfully taught to novices and be used to predict operating times for laparoscopic excision of endometriosis in one surgical procedure. Aust N Z J Obstet Gynaecol 2017; 58:239-246. [PMID: 29168563 DOI: 10.1111/ajo.12733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 09/26/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate whether pelvic examination may be meaningfully taught to novice medical students and its accuracy in predicting operating times for laparoscopic excision of endometriosis at a single surgical procedure. METHODS Women with suspected endometriosis scheduled for laparoscopy underwent pelvic examination to estimate operative time by medical students (novices), trainees, senior clinicians with <10 years surgical experience (experts) and ≥10 years (masters). Examination and intraoperative findings were compared and stage of disease recorded. RESULTS There were 138 estimations of operating time at the initial assessment and 251 estimations of operating time prior to surgery. The median surgical duration was 44 min (range 12-398) and increased progressively with revised American Society for Reproductive Medicine disease stage. Clinical predictions exceeded actual operating times by a median of 18 min (range overestimating by 180 min and underestimating by 120 min) with 80% of procedures completed in less time than predicted and none requiring a second procedure. There was no statistical difference in operative time estimations between the groups with students and trainees underestimating surgical duration by a median of two and five minutes, respectively, experts having a median time difference of zero minutes, and masters overestimating by 4.5 min. CONCLUSION Targeted pelvic examining may be taught to novices (medical students) and can be used to predict operating time at one surgical procedure. Less experienced examiners have a tendency to underestimate surgical duration, with masters overestimating surgical time when scheduling laparoscopies for endometriosis, and increasing disease stage is associated with a less precise estimation of surgical duration.
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Affiliation(s)
- Mominah Bhatti
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia
| | | | - Amy Arnold
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia.,Gynaecolgical Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Erin Nesbitt-Hawes
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia.,Gynaecolgical Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia.,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Rebecca Deans
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia.,Gynaecolgical Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia.,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - HaRyun Won
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia.,Gynaecolgical Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia.,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
| | - Jason Abbott
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia.,Gynaecolgical Research and Clinical Evaluation (GRACE) Unit, Royal Hospital for Women, Sydney, New South Wales, Australia.,Prince of Wales Private Hospital, Sydney, New South Wales, Australia
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