Recurrent pregnancy loss is associated to leaky gut: a novel pathogenic model of endometrium inflammation?

BACKGROUND

Recurrent pregnancy loss (RPL) occurs in 3-5% in about 30% of cases no cause can be found. Women with RPL show higher prevalence of undiagnosed gut disorders. Furthermore, in endometrial tissues of RPL women, higher expression of pro-inflammatory cytokines and Nalp-3 inflammasome has been observed. Aim of this study was to investigate whether an abnormal gut permeability might occur in RPL women and allow passage into systemic circulation of pro-inflammatory molecules able to induce endometrial inflammation.

METHODS

70 women with idiopathic RPL and 30 healthy women were recruited at the Recurrent Pregnancy Loss Outpatient Unit of the Gemelli Hospital of Rome from March 2013 to February 2017. Enrolled women underwent ⁵¹Cr-ethylene-diamine-tetraacetic acid absorption test to evaluate intestinal permeability. Sera obtained from enrolled women were analysed for lipopolysaccharide (LPS) by ELISA. Anxiety and depression state were evaluated by administering STAI-Y and Zung-SDS tests, respectively. Of all recruited individuals, 35 women with idiopathic RPL and 20 healthy controls accepted to undergo diagnostic hysteroscopy and endometrial biopsy. Endometrial lysates were investigated for inflammasome Nalp-3 by Western blot analysis, and caspase-1, IL-1β and IL-18 by ELISA, respectively.

RESULTS

Higher prevalence of abnormal intestinal permeability (P < 0.0001), increased circulating levels of LPS (P < 0.05), anxiety (P < 0.05) and depression (P < 0.05) were observed in RLP women compared to controls. Endometrial expression of Nalp-3, caspase-1 and IL-1β was significantly increased in RPL group (P < 0.0001; P < 0.05 and P < 0.001, respectively). IL-18 endometrial levels were not found to be higher in RPL cases. Statistically significant association between higher intestinal permeability and abnormally increased expression of endometrial Nalp-3, was observed in RPL (P < 0.01). Furthermore, higher LPS serum levels, a bacterial-derived activator of Nalp-3 complex, was shown to be statistically associated to abnormal endometrial expression of Nalp-3 inflammasome (P < 0.01) in RPL women.

CONCLUSIONS

In women with RLP, leaky gut might occur and allow passage into circulation of immune triggers, potentially able to elicit endometrial innate immune response and, thus, to contribute to miscarriage pathogenesis. Diagnosis and treatment of intestinal disorders underlying leaky gut might improve endometrial environment and pregnancy outcome.

Role of transvaginal ultrasound in evaluation of ureteral involvement in deep infiltrating endometriosis

OBJECTIVE

To assess whether routine examination of the ureters on transvaginal sonography (TVS) can identify reliably potential silent ureteral involvement by endometriosis and should therefore be recommended in all patients with deep infiltrating endometriosis (DIE).

METHODS

This was a prospective study of 200 consecutive patients scheduled for surgery for DIE, evaluated between January 2012 and December 2014 at a tertiary endometriosis center at Fondazione Policlinico Universitario A. Gemelli, Rome, Italy. Routine TVS, abdominal ultrasound and gynecological examination were performed within 3 months before surgery, and patient history, signs and symptoms were recorded. Surgical and histological findings were compared with the preoperative ultrasonographic diagnosis. The main outcome of interest was the presence of ureteral dilatation or hydronephrosis caused by endometriosis.

RESULTS

Of 200 patients with DIE, associated ureteral dilatation was diagnosed on TVS in 13 (6.5%) cases. Ureteral involvement was confirmed intraoperatively in all 13 cases by detection of ureteral dilatation caused by endometriotic tissue surrounding the ureter and causing stenosis. Of the 13 patients with ureteral dilatation, renal ultrasound detected six (46.2%) cases of hydronephrosis. Mean duration of visualization and study of dilated ureters was 5 min (range, 3-9 min). Ureteric diameter was ≥ 6 mm in all cases of ureteral dilatation, with a median diameter of 6.9 mm (range, 6-18 mm). Both ureters were identified on TVS in all 200 patients with DIE.

CONCLUSIONS

Our study confirms a relatively high incidence of ureteral involvement in patients with DIE. TVS appears to be a reliable tool for the diagnosis of ureteral involvement and, additionally, it allows the detection of both the level and degree of obstruction. Our findings confirm that TVS examination is an accurate non-invasive diagnostic tool for the detection of ureteral involvement by endometriosis. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Proteomic characterization of the qualitative and quantitative differences in cervical mucus composition during the menstrual cycle

The chemical composition of the cervical mucus (CM), its physical characteristics and the volume of secretion change cyclically throughout the menstrual cycle.

Dopamine infusion and fluid administration improve renal function during laparoscopic surgery

BACKGROUND

Previous studies have documented the negative influence of pneumoperitoneum on cardiac and renal function during laparoscopy. In this respect, regard there is a lack of data regarding the use of an appropriate management of fluid therapy to decrease these side effects. The aim of this study was to investigate the cardiac and renal responses to the administration of different amounts of crystalloid solution, alone or in association with dopamine during laparoscopy.

METHODS

Sixty ASA I patients undergoing laparoscopic surgery for endometriosis were randomly assigned to three groups. Group A was given saline solution at 5 mL/kg/h; group B received saline solution at 5 mL/kg/h and dopamine 3 mg/kg/min, and group C received saline solution at 10 mL/kg/h. Patients received A, B or C perioperatively. Renal function was evaluated by assessing total intraoperative diuresis and estimated glomerular filtration rate. Vasopressin plasmatic levels before and after surgery were measured. Transthoracic echocardiography was performed to estimate left ventricular filling pressure by using Tissue Doppler Imaging and registering the E/Ea ratio every hour after pneumoperitoneum.

RESULTS

Total intraoperative diuresis was impaired in group A and significantly increased in group C (P<0.001). In group A estimated glomerular filtration rate significantly decreased after the end of surgery (P<0.003) and vasopressin significantly increased (P<0.001). The E/Ea ratio was significantly increased in group C (P<0.001). The infusion of saline solutions with the addition of dopamine slightly affected this parameter.

CONCLUSION

A low rate of saline infusion could lead to an impaired renal function during laparoscopic surgery. This could be prevented by increasing the amount of saline solutions infused per hour or by adding a dopamine infusion.

Male fertility and reduction in semen parameters: a single tertiary-care center experience

Background. Infertility is both a clinical and a public problem, affecting the life of the couple, the healthcare services, and social environment. Standard semen analysis is the surrogate measure of male fertility in clinical practice. Objective. To provide information about the relationship between semen parameters and spontaneous conception. Methods. We evaluated retrospectively 453 pregnancies that occurred among 2935 infertile couples evaluated at an infertility clinic of a tertiary-care university hospital, between 2004 and 2009. Results. Normal semen analysis was present only in 158 patients; 295 subfertile patients showed alterations in at least one seminal parameter. A reduction in all seminal parameters was observed in 41 patients. Etiological causes of male infertility were identified in 314 patients. Conclusion. Our data highlights the possibility of a spontaneous conception with semen parameters below WHO reference values. Therefore, we support the importance of defining reference values on a population of fertile men. Finally, we analyzed the related ethical issues.

[Role of a mini-invasive approach in the diagnosis and treatment of tubo-peritoneal infertility as an altenative to IVF]

AIM

Tubal factor infertility accounts for approximately 25-35% of cases of female infertility. Identifiable causes of tubal infertility are postinfectious tubal damage, postsurgical adhesion formation, and endometriosis-related adhesions. Aim of this study was to evaluate the results of a diagnostic/therapeutic minimally invasive approach in patients with suspect or ascertained mechanical infertility in terms of obtained pregnancies.

METHODS

The study enrolled 143 patients who underwent diagnostic or operative laparoscopy, with chromopertubation, peritoneal or endometrial culture, salpingoscopy when indicated and diagnostic or operative hysteroscopy. Nine patients with submucous-intramural or multiple intramural fibroids underwent miomectomy by minilaparotomy following hysteroscopy and chromopertubation. Patients were contacted periodically by telephone to monitor the onset and outcome of pregnancy. The mean length of follow- up was 49 months (range: 11 to 118 months).

RESULTS

Of the 152 patients considered in the study, 61 became pregnant (40%). Twenty-three pregnancies resulted in miscarriage, two in tubal pregnancy and one patient aborted after a diagnosis of Down syndrome. In total, 32% of the patients achieved a term pregnancy.

CONCLUSION

The diagnostic/therapeutic mini-invasive approach allows women to become pregnant naturally and it is, therefore, an option for couples with ethical and religious concerns. The percentage of pregnancies is higher than after in-vitro fertilization. When efficacious, this approach allows additional spontaneous conceptions without renewed therapy and the course of pregnancy and the type of delivery will not differ from those in a normal population.

Decreased expression of heparin-binding epidermal growth factor-like growth factor as a newly identified pathogenic mechanism of antiphospholipid-mediated defective placentation

OBJECTIVE

Heparin-binding epidermal growth factor-like growth factor (HB-EGF) plays a role in blastocyst implantation and is down-regulated in preeclampsia and in hypertensive pregnancy disorders associated with defective extravillous trophoblast invasion. Defective placentation and severe preeclampsia are also features of the antiphospholipid syndrome (APS). The purpose of this study was to investigate whether abnormal HB-EGF expression plays a pathogenic role in antiphospholipid antibody (aPL)-mediated defective placentation.

METHODS

HB-EGF expression in placental tissue was evaluated by Western blotting and messenger RNA analysis in normal and APS placentae. Polyclonal IgG fractions or monoclonal beta(2)-glycoprotein I-dependent aPL and their respective controls were investigated for the following 4 features: their binding to human trophoblast monolayers, as determined by cell enzyme-linked immunosorbent assay (ELISA); their effect on HB-EGF expression by Western blotting in trophoblast cell extracts as well as by ELISA as a protein secreted in the culture supernatants; their inhibitory effect on in vitro trophoblast invasiveness, as evaluated by Matrigel assay; and their inhibitory effect on matrix metalloproteinase (MMP) levels, as measured by gelatin zymography. Experiments were also performed in the presence of serial concentrations of heparin or recombinant HB-EGF.

RESULTS

Placental APS tissue displayed reduced expression of HB-EGF. Polyclonal and monoclonal aPL bound to trophoblast monolayers and significantly reduced the in vitro synthesis and secretion of HB-EGF. Heparin inhibited aPL binding and restored HB-EGF expression in a dose-dependent manner. Addition of recombinant HB-EGF reduced the in vitro aPL-induced inhibition of Matrigel invasiveness as well as MMP-2 levels.

CONCLUSION

These preliminary findings suggest that the reduction of aPL-mediated HB-EGF represents an additional mechanism that is responsible for the defective placentation associated with APS and that heparin protects from aPL-induced damage by inhibiting antibody binding.

Leptin and perioperative neuroendocrine stress response with two different anaesthetic techniques

BACKGROUND

Stress response to surgery is modulated by several factors, including magnitude of the injury, pain, type of procedure and choice of anaesthesia. Our purpose was to compare intra- and post-operative hormonal changes during total intravenous anaesthesia (TIVA) using propofol and remifentanil vs. sevoflurane anaesthesia in a low stress level surgical model (laparoscopy).

METHODS

We randomly allocated 18 patients undergoing laparoscopic surgery for benign ovarian cysts in two groups to receive either TIVA (group A=9) or sevoflurane anaesthesia (group B=9). Perioperative plasma levels of norepinephrine (NE), epinephrine (E), adrenocorticotropic hormone (ACTH), cortisol and leptin were measured. Blood samples were collected pre-operatively (time 0), 30 min after the beginning of surgery (time 1), after extubation (time 2), and 2 h (time 3) and 4 h after surgery (time 4).

RESULTS

The comparative analysis between the groups shows significantly higher values of NE (P<0.001 at time 1 and P<0.01 at time 3), E (P<0.001 at times 1 and 2; P<0.01 at time 3 and P<0.05 at time 4), ACTH (P<0.001 at times 1 and 2; P<0.05 at time 3) and cortisol (P<0.001 at times 1 and 2; P<0.01 at time 3; P<0.05 at time 4) in group B. The serum values of leptin were not significantly different between the two groups.

CONCLUSION

The choice of anaesthesia does not seem to affect the leptin serum levels but influences the release of stress response markers: ACTH, cortisol, NE and E.

[Laparoscopic treatment of adnexal cystic masses]

Operative laparoscopy has become the gold standard for the surgical treatment of numerous gynecological benign conditions. In the case of ovarian cysts, however, the use of the laparoscopic approach has been debated due to the possibility of encountering an unexpected ovarian malignancy at the time of surgery. This would upstage a IA or IB ovarian malignancy to IC. In this review, the authors evaluate the preoperative parameters that could help in the selection of the patients who are candidate to a laparoscopic approach. In particular, the authors consider the age related risk of the patients, the use of sonography and color-Doppler velocimetry, the use of CA 125, and as a last diagnostic step, the findings at laparoscopy. In a personal series of 1.584 cysts in patients under 40 years of age, the first author encountered 7 unexpected borderline tumors and 1 mucinous G1 adenocarcinoma, while no malignancy was found in a group of strictly selected postmenopausal patients. These data have been compared with those found in scientific literature. There is no sound evidence that the stripping procedure determines a reduction of the ovarian reserve when performed with strict microsurgical principles. Recent evidence in the literature suggests that the decreased ovarian responsiveness reported by some authors following ovarian cystectomy may not be a consequence of surgery. The concern of a possible reduction of the ovarian reserve needs to be balanced with the benefits obtained with surgery. Finally, it should always be kept in mind the risk of an unexpected malignancy, even in cysts apparently benign, malignancy that can only be diagnosed through surgery obtaining a specimen for pathology.

Current practical application of office endoscopy

Outpatient hysteroscopy has shown good correlation of findings compared with inpatient hysteroscopy, but one limitation is pain and discomfort in some women, and vasovagal reaction. Various forms of local anaesthesia have been evaluated in the past year, with controversial results, and a narrow 3.5 mm sheath hysteroscope has been introduced. Transvaginal hydrolaparoscopy as an outpatient procedure has been further investigated.

Fallopian tube disease: the cobblestone pattern as a radiographic sign

PURPOSE

To identify radiographic signs of mucosal damage by comparing hysterosalpingography with salpingoscopy in a prospective study.

MATERIALS AND METHODS

Forty-one candidates for laparoscopy underwent hysterosalpingography and peroperative salpingoscopy; at both, tubal patency was noted. Radiographic criteria for mucosal abnormality were rounded filling defects (ie, the cobblestone pattern) and the absence of longitudinal radiolucent bands in the ampullary tract. At salpingoscopy, tubal mucosa was categorized by means of inspection into five classes of fold pattern: classes I and II, normal; classes III-V, abnormal. Hysterosalpingographic and salpingoscopic results were compared by means of a two-by-two table and kappa statistics.

RESULTS

Seventy-four tubes were evaluated. At hysterosalpingography, 31 tubes were distally nonpatent. Of these, 26 showed a distal obstruction at salpingoscopy. None of the patent tubes at hysterosalpingography showed obstruction at salpingoscopy. The agreement between hysterosalpingography and salpingoscopy in detecting abnormal mucosal pattern was 89.2% (kappa, 0.73; P: <.001). The cobblestone pattern always corresponded to intraluminal adhesions at salpingoscopy. The absence of radiolucent bands corresponded to abnormal mucosa at salpingoscopy in four of six cases. The cobblestone pattern was found only in hydrosalpinges and never in patent tubes. Six normal patent tubes at hysterosalpingography showed intraluminal adhesions at salpingoscopy.

CONCLUSION

Results indicate that the cobblestone pattern is an effective radiographic sign of intraluminal adhesions in hydrosalpinges and suggest that intraluminal disease in patent tubes might not always be excluded on normal hysterosalpingograms.

Improvement of hysterosalpingographic accuracy in the diagnosis of peritubal adhesions

OBJECTIVE

Our purpose was to compare hysterosalpingography with laparoscopy in the diagnosis of peritubal adhesions and to verify whether a combination of radiographic signs improves hysterosalpingographic accuracy.

SUBJECTS AND METHODS

Thirty candidates for laparoscopy underwent hysterosalpingography before surgery. Two radiologists evaluated the presence or absence and types of radiographic signs of peritubal adhesions (convoluted tubes, vertical tubes, loculation of contrast medium in peritoneum, halo effect, and fixed laterodeviation of the uterus) using two different criteria for normality or abnormality: no sign means a normal result, one or more signs mean an abnormal result (first criterion); no sign or one sign means a normal result, two or more signs mean an abnormal result (second criterion). Interpretation discrepancies were resolved by consensus. Peritubal and periovarian adhesions were evaluated by a single operating surgeon during laparoscopy (recorded on S-VHS videotape) and by a different surgeon reviewing the videotape. The radiographic results obtained using the two criteria in radiologically patent as well as in distally nonpatent tubes were compared with corresponding laparoscopic results by 2 x 2 tables and were statistically analyzed (kappa statistics).

RESULTS

The first criterion displayed poor diagnostic accuracy. The correlation with laparoscopy was not statistically significant in either radiologically patent or distally nonpatent tubes. The second criterion greatly improved the agreement with laparoscopy, but only in patent tubes (kappa = 0.7789; p<0.001).

CONCLUSION

Hysterosalpingographic accuracy in peritubal adhesion diagnosis can be improved in patent tubes by taking into account more than one of the reported radiographic signs.

Atypical endometriosis revisited: clinical and biochemical evaluation of the different forms of superficial implants

OBJECTIVE

To investigate the activity of different forms of endometriosis implants by clinical and biochemical evaluation.

DESIGN

Prospective, blinded study.

SETTING

Tertiary-care university hospital.

PATIENT(S)

Forty-seven infertile patients with minimal or mild endometriosis diagnosed at laparoscopy were included in the clinical investigation.

INTERVENTION(S)

Patients were submitted to a preoperative evaluation of endometriosis-associated dysmenorrhea by means of a 10-point linear analog scale and to laparoscopic staging of endometriosis following a current classification system. In the biochemical investigation, tissue samples from different endometriosis lesions and control tissues were assessed for prostaglandin (PG) F(2 alpha) production.

MAIN OUTCOME MEASURE(S)

Evaluation of the correlation between endometriosis-associated dysmenorrhea and the extent of the disease. Evaluation of the production of PGF(2 alpha) by the different tissues sampled.

RESULT(S)

No positive correlation was present between any of the implant subgroups and the associated dysmenorrhea. White peritoneal implants were associated with milder pain symptoms than black or red lesions. The biologic activity of red and black superficial implants, expressed as the production of PGF(2 alpha), was similar.

CONCLUSION(S)

No positive correlation was demonstrated between endometriosis-associated dysmenorrhea and the current classification of endometriosis, which includes characterization of the different morphologic aspects of superficial endometriosis implants.

Postoperative administration of monophasic combined oral contraceptives after laparoscopic treatment of ovarian endometriomas: a prospective, randomized trial

OBJECTIVE

We sought to evaluate the efficacy of postoperative administration of monophasic, combined, low-dose oral contraceptives on endometrioma recurrence and on persistence-recurrence of associated pain symptoms after laparoscopic treatment of moderate-to-severe endometriosis.

STUDY DESIGN

In a prospective, randomized trial 70 patients who were not attempting to conceive, aged 20 to 35 years, underwent laparoscopic excision of ovarian endometriomas, followed by either postoperative administration of low-dose cyclic oral contraceptives for 6 months or no treatment on the basis of a computer-generated sequence. At 3 and 6 months after surgery and then at 6-month intervals, both groups underwent ultrasonographic examination for possible evidence of endometrioma recurrence and for evaluation of the absence, persistence, or recurrence of pain symptoms.

RESULTS

Two patients in the oral contraceptive group did not complete the study. After a mean follow-up of 22 months (range, 12-48 months), there were 2 (6.1%) endometrioma recurrences in the 33 patients who received postoperative oral contraceptives versus 1 (2.9%) recurrence in the 35 patients in the control group (not significant). The moderate-to-severe pain recurrence rate was 9.1% in the oral contraceptive group versus 17.1% in the control group (not significant). The mean time to recurrence of either symptoms or endometriomas was 18.2 months in the oral contraceptive group versus 12.7 months in the control group. The 12-month cumulative recurrence rate at life-table analysis was significantly lower for patients receiving oral contraceptives versus control subjects, whereas no significant difference was evident at 24 and 36 months.

CONCLUSION

Postoperative administration of low-dose cyclic oral contraceptives does not significantly affect the long-term recurrence rate of endometriosis after surgical treatment. A delay in recurrence is evident at life-table analysis.

Stress responses to endoscopic surgery

Growing evidence in the literature suggests that laparoscopic surgery should be performed instead of laparotomy for the treatment of pelvic benign diseases whenever feasible, as it results in a lower stress response on the part of the patient and possibly a shorter recovery time.

The prognostic role of salpingoscopy in laparoscopic tubal surgery

The present study was designed to evaluate the prognostic value of salpingoscopy in patients undergoing tubal laparoscopic surgery for infertility due to periadnexal adhesion or distal tubal occlusion. In addition, the clinical value of salpingoscopy was compared with a current classification system of adnexal adhesions and distal tubal occlusion. A total of 51 patients with either adnexal adhesions (24 patients) or hydrosalpinx (27 patients) were prospectively evaluated. Salpingoscopy was performed concomitantly with salpingo-ovariolysis or salpingoneostomy at the time of operative laparoscopy. There was no significant correlation between salpingoscopic classes and the classification system used for both the salpingo-ovariolysis and the salpingoneostomy groups of patients. The patients had a mean follow-up of 33 months. Patients with a normal tubal mucosa (salpingoscopic classes I and II) had a 71% cumulative term pregnancy rate in the salpingo-ovariolysis group and a 64% cumulative term pregnancy rate in the salpingoneostomy group. No intrauterine pregnancies were obtained in patients with intratubal damage (salpingoscopic classes III to V). There was a statistically significant correlation between the occurrence of a term pregnancy and the salpingoscopic classes, but not with the classification system used. These results suggest that patients with tubal infertility should be offered operative laparoscopy with salpingoscopy as the first step of treatment.

Recurrence of ovarian endometrioma after laparoscopic excision

OBJECTIVE

Our purpose was to evaluate the recurrence rate after laparoscopic excision of ovarian endometrioma.

STUDY DESIGN

An unrandomized prospective clinical study was performed at 2 tertiary-care centers of 366 patients who had a minimum of 6 months of postoperative follow-up or 6 months after the suspension of medical therapy after laparoscopic ovarian endometrioma excision. Patients underwent clinical examination and vaginal ultrasonography 3, 6, and 12 months after surgery and subsequently at least once a year. We evaluated the cumulative recurrence rate of pain and clinical findings of ovarian endometrioma, the rate of repeated surgery, and the recovery of fertility.

RESULTS

During follow-up we observed ultrasonographic recurrence in 26 (7.1%) cases; surgery was repeated in 12 (3.3%) cases. The cumulative rate of ultrasonographic recurrence over 48 months was 11.7%, whereas the cumulative rate of a second surgery was 8.2%. Ultrasonographic cyst recurrence was associated with pain recurrence in 73% of cases, whereas in the remaining 27% the recurrence was asymptomatic. Significant factors related to recurrence of endometriomas would appear to be the stage of disease (P =.03) and previous surgery for endometriosis (P =.003). Eighty-five (23.2%) women conceived during follow-up.

CONCLUSIONS

Laparoscopic treatment of endometriomas seems to be both effective and reliable. The rate of recurrence appears to be correlated to the duration of follow-up. Stage IV disease and previous surgery for endometriosis are unfavorable prognostic factors.

Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study

OBJECTIVE

The objective of this study was to evaluate short-term results of laparoscopically assisted vaginal hysterectomy with those of total abdominal hysterectomy in a prospective, randomized, multicenter study.

STUDY DESIGN

One hundred sixteen patients referred for abdominal hysterectomy were randomized to either laparoscopically assisted vaginal hysterectomy (58 patients) or abdominal hysterectomy (58 patients). Inclusion criteria were one or more of the following, where a vaginal hysterectomy would be traditionally contraindicated: uterine size larger than 280 g, previous pelvic surgery, history of pelvic inflammatory disease, moderate or severe endometriosis, concomitant adnexal masses or indication for adnexectomy, and nulliparity with lack of uterine descent and limited vaginal access. An upper limit of uterine size was set at 16 weeks' gestation (ie, 700 g).

RESULTS

There were no differences in terms of patient's age, parity, preoperative hemoglobin levels, mean uterine weight, and total operating time between the 2 groups. Estimated blood losses and postoperative day 1 hemoglobin drop were significantly lower for laparoscopically assisted vaginal hysterectomy than for abdominal hysterectomy (P<.05). There were 1 major and 2 minor complications in the laparoscopically assisted vaginal hysterectomy group compared with 2 major and 5 minor complications in the abdominal hysterectomy group (P not significant). Postoperative pain was lower for laparoscopically assisted vaginal hysterectomy than for abdominal hysterectomy on postoperative days 1, 2, and 3 (P<.05). Postoperative hospital stay was significantly shorter for laparoscopically assisted vaginal hysterectomy than for abdominal hysterectomy (P<.001).

CONCLUSIONS

The present study demonstrates that, given adequate training in laparoscopic surgery, laparoscopically assisted vaginal hysterectomy may replace abdominal hysterectomy in most patients who require a hysterectomy and have contraindications to vaginal hysterectomy, with all the benefits associated with the vaginal route.

Endometriosis externa and interna: endoscopic diagnosis

Endometriosis is defined as the presence of the endometrium outside the endometrial cavity. If the ectopic mucosa is located within the endometrium, the disease is defined as endometriosis interna, or adenomyosis, whereas the localization of the endometrium outside the uterus is defined as endometriosis externa, or pelvic endometriosis. The diagnosis of pelvic endometriosis requires invasive techniques, such as laparoscopy or laparotomy, with histologic confirmation on the surgical specimen. The diagnosis of adenomyosis should be based on histology of hysterectomy specimen, since the endoscopic diagnosis is still too inaccurate. Laparoscopy allows the visualization of the different aspects of pelvic endometriosis, i.e. superficial implants, deep lesions, and associated adhesions. Staging is based on a score attributed to each location in order to establish a prognosis in terms of the patient's reproductive performance.

Tubal factor infertility

Various studies demonstrated that there is no close correlation between the intratubal damage and the extent and type of pelvic adhesions. Moreover, the results of prospective studies on the prognostic value of salpingoscopy showed that the tubal mucosal status is the most important prognostic factor in terms of reproductive outcome. Salpingoscopy has modified the management of patients with tubal infertility, since the accurate evaluation of the tubal mucosa permits the selection of patients with a normal mucosa (34-42% of the patients with hydrosalpinx and 76-80% of those with periadnexal adhesions) who can benefit from tubal reconstructive surgery. In these patients the term pregnancy rate is 60% in case of hydrosalpinx and 70% in case of periadnexal adhesions.

Operative laparoscopy

Operative laparoscopy has replaced the conventional approach by laparotomy to the treatment of most benign gynecological diseases (benign adnexal cysts, ectopic pregnancy, tubal infertility, polycystic ovarian disease, endometriosis, myomas), with advantages in terms of shorter hospital stay, less discomfort and complications for the patient, minor social costs due to the early resumption of normal working activities, and comparable results in terms of reproductive outcome.

[Usefulness of color Doppler in the differential diagnosis of adnexal masses]

BACKGROUND

The aims of this study were to verify the predictive performance of color-Doppler analysis in the differential diagnosis of adnexal masses and to evaluate the prognostic value of a new "vascular score".

METHODS

One-hundred-ninety-six patients referred to our Institute for adnexal masses were evaluated with color and pulsed Doppler within 2-3 days from surgery, and the velocimetric results were compared to histopathological data. On the basis of histopathology, patients were classified in 166 with benign and 30 with malignant ovarian tumors.

RESULTS

The predictivity obtained with color Doppler analysis ("vascular score") was compared to that of some "morphological scores" commonly used in the literature. The sensitivity was 100% for all the techniques used, but Doppler analysis had a higher specificity with respect to the others (95% vs max 76% for echographic techniques). The introduction of a new "vascular score" based on the introduction of the acceleration of flow in another score system previously presented, was not able to improve the predictive performance of color Doppler analysis.

CONCLUSIONS

Color Doppler ultrasonography of ovarian tumors seems to be a reliable method in the differential diagnosis of adnexal masses, and its potential use in the choice of a less-invasive surgical approach in selected cases (those negative to the "vascular score") should be considered.

Postoperative adhesion prevention with low-dose aspirin: effect through the selective inhibition of thromboxane production

The aim of the present study was to evaluate the efficacy of low-dose versus high-dose aspirin in the prevention of postoperative adhesion formation. Forty New Zealand White rabbits were randomized into three groups: low-dose aspirin (1.7 mg/kg per day for 5 days starting on the day of surgery), high-dose aspirin (28.0 mg/kg per day), and controls. The rabbits underwent a standardized surgical injury on the ovary, uterine horn and abdominal wall on one side at laparotomy. On postoperative day 21, a second-look laparotomy was performed for the evaluation of postoperative adhesions. In five animals in each group, peritoneal fluid samples were collected at initial surgery, then through an additional 2 cm incision performed on postoperative day 3, and at second-look laparotomy. The peritoneal concentrations of thromboxane B2 and 6-keto-prostaglandin F1alpha (the stable hydrolysis product of prostacyclin) were measured by radioimmunoassay. At second-look laparotomy, the adhesion formation rate was 46% in the low-dose aspirin group, 77% in the high-dose group, and 100% in the control group. The adhesion score in the low-dose group was significantly lower (P < 0.01) than in the high-dose and control groups. Peritoneal thromboxane decreased significantly during treatment in both low-dose and high-dose aspirin groups, whereas prostacyclin decreased only in the high-dose group. Postoperative adhesion reduction observed in this study with low-dose aspirin treatment could be due to the selective inhibition of thromboxane over prostacyclin production.

Postoperative adhesion formation and reproductive outcome using Interceed after ovarian surgery: a randomized trial in the rabbit model

The efficacy of an oxidized regenerated cellulose barrier (Interceed) in reducing postoperative adhesion formation and improving reproductive outcome after ovarian surgery was evaluated in a prospective randomized trial. Twenty-nine New Zealand White female rabbits were submitted to a mid-line laparotomy and a standardized surgical incision was made on both ovaries. At random, one ovary was entirely wrapped in a sheet of Interceed, whereas the contralateral ovary was left uncovered. Four weeks following surgery, the rabbits were mated with a male of proven fertility. Two weeks later, a second-look laparotomy was performed by a blinded observer who evaluated the incidence and score of adhesions, the number of corpora lutea in each ovary, the number of embryos in the ipsilateral uterine horn and also calculated the nidation index for each side. Adhesions were observed in 66% of Interceed-covered and in 97% of control ovaries (P < 0.0001). The adhesion score on the Interceed side was significantly lower than on the control side. The nidation index for the Interceed side was significantly higher than for the control side. The authors conclude that, in the rabbit model, Interceed significantly reduces the incidence and score of postoperative ovarian adhesions and significantly improves reproductive outcome.

Correlation between endometriosis-associated dysmenorrhea and the presence of typical or atypical lesions

OBJECTIVE

To evaluate the correlation between the severity of endometriosis-associated dysmenorrhea and the extent of the disease assessed both with a current classification system and with the number and type of endometriosis lesions.

DESIGN

Prospective, blinded study.

SETTING

Tertiary care, university hospital.

PATIENT(S)

Sixty-five consecutive patients with endometriosis diagnosed at laparoscopy performed for pelvic pain, infertility, or adnexal mass.

INTERVENTION(S)

The patients were submitted preoperatively to a questionnaire including the assessment of the severity of dysmenorrhea by means of a 10-point linear analog scale. Evaluation of all visible signs of endometriosis at laparoscopy was performed by a surgeon not aware of the patients' symptoms.

MAIN OUTCOME MEASURE(S)

The correlation between the severity of dysmenorrhea and the total score for endometriosis and the partial scores for superficial, deep, and adhesion disease as assessed with a current classification system was evaluated. The severity of dysmenorrhea was also correlated with the total number of superficial implants and with the number of typical, pigmented versus atypical, nonpigmented lesions.

RESULT(S)

The linear analog score for dysmenorrhea correlated significantly with the total endometriosis score, the partial score for deep endometriosis, and the partial score for adhesions. There was no correlation between the pain score for dysmenorrhea and the partial score for superficial endometriosis, nor with the total number of endometriosis implants, the number of typical implants, or the number of atypical implants.

CONCLUSION(S)

The current classification system for endometriosis, devised primarily to formulate a prognosis in infertile patients, correlates significantly with endometriosis-associated dysmenorrhea. The present study does not support the suggested association between atypical implants and the severity of dysmenorrhea.

Production of Prostaglandin F2alpha by the Different Forms of Endometriosis

It has been suggested that atypical, nonpigmented endometriotic lesions have an increased capacity to synthesize prostaglandin (PG)F2alpha compared with typical endometriosis, and could therefore represent the more active forms of the disease. We took biopsy specimens of various endometriotic lesions and of normal endometrium and peritoneum during operative laparoscopy in 12 infertile women. The specimens were transferred in flasks containing Krebs solution and placed in a shaking incubator for 1 hour at 37&deg; C. The incubation solution was changed every 20 minutes and assayed by radioimmunoassay procedures for the concentration of PGF2alpha. Biopsy specimens from normal peritoneum and normal endometrium were also taken from five control patients with no evidence of endometriosis. The PGF2alpha concentration/milligram of tissue was not significantly less different between typical and atypical implants, and among the different atypical forms. Endometriotic cyst wall produced significantly less PGF2alpha than both typical and atypical peritoneal implants, and significantly more than normal peritoneum. There was no difference in production for normal tissue (endometrium or peritoneum) between patients with endometriosis and controls. We did not confirm evidence from the literature of a higher production of PGF2alpha in atypical versus typical endometriotic lesions. Our data do not support selective ablation of atypical forms, since typical endometriotic lesions could be similarly active in prostaglandin production.

Operative laparoscopy for ovarian cysts. Excision vs. aspiration

OBJECTIVE

To evaluate operative laparoscopy for excision vs. aspiration of ovarian cysts.

STUDY DESIGN

From July 1, 1990, to June 30, 1993, 100 women under 40 years of age were subjected by the senior author to laparoscopic cyst excision, and 31 patients with similar characteristics underwent laparoscopic cyst aspiration by their attending physicians. Four-puncture laparoscopy was performed for laparoscopic cyst excision using the stripping technique, whereas two-puncture laparoscopy was employed for laparoscopic cyst aspiration. All patients underwent postoperative serial clinical examinations and ultrasound scans for the detection of recurrence.

RESULTS

Four recurrences (4%) were observed in the group that underwent laparoscopic cyst excision, whereas 26 (84%) recurrences occurred in the group that underwent laparoscopic cyst aspiration (P < .0001).

CONCLUSION

Provided that patients are carefully selected according to age and sonographic pattern, enucleation of adnexal masses at operative laparoscopy is the treatment of choice.

The impact of preoperative gonadotropin-releasing hormone agonist treatment on laparoscopic excision of ovarian endometriotic cysts

OBJECTIVE

To compare surgical performance and recurrence rates in patients submitted to laparoscopy for endometrioma excision following GnRH agonist (GnRH-a) treatment versus no preoperative medical treatment.

DESIGN

Controlled clinical study.

SETTING

A tertiary care university hospital.

PATIENTS

Twenty patients with unilateral endometriomas underwent operative laparoscopy after 3-month GnRH-a treatment, whereas 21 patients underwent laparoscopic excision of endometriomas without preoperative medical treatment.

INTERVENTIONS

Operative laparoscopy was performed with the stripping technique using a four-puncture approach.

MAIN OUTCOME MEASURE

A blinded videotape review was undertaken to evaluate the duration and complexity of the different phases of surgery. Recurrence rates were evaluated at 1-year follow-up ultrasonography.

RESULTS

No significant difference was found between the two groups in total operative time, cyst excision time, time needed for cyst capsule stripping and coagulation of ovarian parenchyma, and the complexity of the latter phases; recurrence rates also were comparable.

CONCLUSION

Preoperative GnRH-a treatment for endometriomas does not seem to offer any advantage in terms of subsequent surgical performance.

Distal fallopian tube occlusion: false diagnosis with hysterosalpingography in cases of tubal diverticula

PURPOSE

To evaluate the accuracy of hysterosalpingography (HSG) in the diagnosis of distal fallopian tube occlusion in infertile patients who were candidates for laparoscopic surgery.

MATERIALS AND METHODS

A retrospective review of charts was performed for 25 patients who were scheduled to undergo laparoscopic surgery. A preoperative diagnosis was made at HSG of bilateral (or unilateral in case of previous contralateral salpingectomy) distal tube occlusion.

RESULTS

At laparoscopy, in three patients (12%) who were scheduled for salpingostomy, the diagnosis of distal tube occlusion made at HSG was incorrectly positive; in the three patients, a single tubal diverticulum was present in the distal ampulla in otherwise normal, patent tubes.

CONCLUSION

Bilateral tubal diverticula appear to be often misdiagnosed at HSG as distal tube occlusion.

The prognostic significance of minimal intracystic vegetations during operative laparoscopy for adnexal masses in women of reproductive age

STUDY OBJECTIVE

To evaluate the prognostic significance of minimal intracystic vegetations in ovarian cysts approached by laparoscopy.

DESIGN

Prospective study.

SETTING

A tertiary care university hospital.

PATIENTS

Ten of 208 women with adnexal cysts and minimal intracystic vegetations, under 40 years of age, carefully selected for operative laparoscopy on the basis of a preoperative sonogram suggestive of a unilocular cyst, with no thick septa or solid components in the absence of ascites.

INTERVENTIONS

Adnexal cyst excision at operative laparoscopy.

MEASUREMENTS AND MAIN RESULTS

In all 208 women evaluation of the abdomen, pelvis, and external surface of the cyst was negative. In 10 patients minimal intracystic vegetations, not detected by preoperative sonography, were identified during endocystic evaluation. In all these cases frozen section examination was negative. Definitive histologic diagnosis confirmed the presence of benign cysts.

CONCLUSION

The presence of minimal intracystic vegetations alone when diagnosed in highly selected patients under 40 years of age may not justify immediate midline laparotomy if frozen section is negative.

Evaluation of stress-related hormones after surgery by laparoscopy or laparotomy

STUDY OBJECTIVE

To evaluate the stress hormone response after pelvic surgery performed by laparoscopy versus laparotomy.

DESIGN

Prospective study.

SETTING

A tertiary care university hospital.

PATIENTS

Ten women were scheduled to undergo laparoscopic surgery and 10 laparotomy for either tubal disease or endometriosis.

INTERVENTIONS

Surgical procedures were performed by laparoscopy or laparotomy for stage III-IV endometriosis, pelvic adhesions, or distal tubal occlusion. The following hormones were measured before the induction of anesthesia in the ward, 60 minutes after the beginning of surgery, at the end of surgery after extubation, and 2 hours and 6 hours after the end of the operation: norepinephrine (NE), epinephrine (E), dopamine (D), adrenocorticotropic hormone (ACTH), cortisol, prolactin (PRL), and GH.

MEASUREMENTS AND MAIN RESULTS

The mean duration of surgery was not significantly different between the two groups. Surgery-related adrenergic activation (E, NE, D) appears more pronounced in the laparotomy group (p<0.005) during surgery and in the postoperative period. More elevated values for laparotomy were observed also for the other stress hormones (ACTH, cortisol, PRL, GH), even though statistical significance was not always reached.

CONCLUSIONS

Compared with laparotomy, activation of stress-related factors during laparoscopy seems to be less intense and of shorter duration.

Laparoscopy versus microsurgery by laparotomy for excision of ovarian cysts in patients with moderate or severe endometriosis

STUDY OBJECTIVE

To compare the efficacy of laparoscopy versus microsurgery by laparotomy in the treatment of ovarian endometriomas.

DESIGN

Retrospective study with historical controls.

SETTING

A tertiary university hospital.

PATIENTS

One hundred thirty-two women under 40 years of age with ovarian endometriotic cysts at least 3 cm in diameter (stage III and IV endometriosis, R-AFS classification). Interventions. A single surgeon (RM) treated 83 patients by laparoscopy for excision of ovarian endometriomas by the stripping technique and 49 by microsurgery at laparotomy.

MEASUREMENTS AND MAIN RESULTS

Data regarding recurrence of ovarian cysts, symptomatic improvement, and reproductive outcome were comparable for the two groups. Postoperative febrile morbidity and length of hospitalization were significantly less for the laparoscopy group than for the laparotomy group (p <0.0005).

CONCLUSIONS

Operative laparoscopy for excision of ovarian endometrial cysts by the stripping technique is as effective as microsurgery by laparotomy. It is associated with less febrile morbidity and a shorter hospitalization.

Laparoscopically assisted vaginal hysterectomy as an alternative to abdominal hysterectomy. A pilot study

Laparoscopically assisted vaginal hysterectomy (LAVH) allows for conversion of some abdominal hysterectomies to a vaginal route. LAVH may be particularly useful when adnexectomy is indicated. In this study the authors evaluate the results obtained in a series of 21 patients prospectively selected for LAVH. The mean operative time was 96 min (range 58-155), with an estimated blood loss of 218 ml (range 50-510). The mean uterine weight was 320 g (range 105-610). Intraoperative complications were limited to one case of bladder injury which occurred during the vaginal phase of the procedure. No patient required heterologous blood transfusion. No postoperative complications were observed. The average length of hospitalisation was 4.4 days (range 2-9). The authors conclude that LAVH allows for conversion of a significant number of abdominal hysterectomies to a vaginal route and that with respect to the former it is definitely less costly since it allows for earlier hospital discharge and resumal of a normal lifestyle.

Use of fibrin sealant for reproductive surgery: a randomized study in the rabbit model

The present study was undertaken to compare adhesion formation and reproductive outcome after reproductive surgery with or without the application of fibrin sealant. At laparotomy, the ovaries and uterine horns of 20 rabbits were longitudinally incised on the antimesenteric side using a monopolar microneedle. At random, one ovary and the ipsilateral uterine horn were covered with fibrin sealant, while those on the contralateral side were left uncovered without application of sutures. The rabbits were then mated, and 2 weeks later a second-look laparotomy was performed by a blinded observer. No statistically significant differences were found in postoperative adhesions, number of corpora lutea in each ovary, number of embryos in the ipsilateral uterine horn, and nidation index for each side. Fibrin sealant for conservative surgery does not appear to significantly affect either postoperative adhesion formation or reproductive outcome.

Correlation between the American Fertility Society classifications of adnexal adhesions and distal tubal occlusion, salpingoscopy, and reproductive outcome in tubal surgery

OBJECTIVE

To compare the prognostic value of salpingoscopy with a current classification system of adnexal adhesions and distal tubal occlusion in patients with tubal infertility undergoing reconstructive tubal surgery.

DESIGN

Prospective clinical study.

SETTING

Department of Obstetrics and Gynecology of the Catholic University, a tertiary care University Center in Rome, Italy.

PATIENTS

Fifty-five infertile patients with either adnexal adhesions (29 patients) or hydrosalpinx (26 patients) undergoing reconstructive tubal surgery.

INTERVENTIONS

Salpingoscopy performed concomitantly to salpingo-ovariolysis or salpingoneostomy at the time of either operative laparoscopy or laparotomy using microsurgical techniques.

MAIN OUTCOME MEASURES

Salpingoscopic findings were compared with a current classification system of adnexal adhesions and distal tubal occlusion. The patients were followed for a mean follow-up of 49 months; the pregnancy rates achieved were correlated with the salpingoscopic findings and the classification system used.

RESULTS

There was a significant correlation between the salpingoscopic grade and the occurrence of a term pregnancy for both the salpingo-ovariolysis and salpingoneostomy groups of patients. There was no significant correlation between the classification system used and the occurrence of a term pregnancy for both groups of patients.

CONCLUSION

Salpingoscopy plays an important role in selecting the patients who may benefit the most from reconstructive tubal surgery.