Urological knowledge and tools applied to diagnosis and surgery in deep infiltrating endometriosis - a narrative review

ABSTRACT Objectives: This review discusses deep infiltrating endometriosis (DIE) diagnosis and surgery using current urological knowledge and technologies. Materials and Methods: Narrative review of deep infiltrating endometriosis that result in urological issues. We examined manuscripts from Pubmed, Embase, and Scielo's database using the following MeSH terms: ('endometriosis') AND ('urology' OR 'urological' OR 'urologist') AND ('bladder' OR'vesical') AND ('ureteral' OR 'ureter'). Selection followed PRISMA guidelines. Sample images from our records were brought to endorse the findings. Results: Thirty four related articles were chosen from 105. DIE may affect the urinary system in 52.6% of patients. Lower urinary tract symptoms may require urodynamic examination. Ultrasonography offers strong statistical yields for detecting urinary tract lesions or distortions, but magnetic resonance will confirm the diagnosis. Cystoscopy can detect active lesions, although any macroscopic visual appeal is pathognomonic. Endourology is utilized intraoperatively for bladder and ureteral assessment, however transurethral endoscopic excision of bladder lesions had higher recurrence rates. Laparoscopy is the route of choice for treatment; partial cystectomy, and bladder shaving were the most prevalent surgical treatments for bladder endometriosis. Regarding the ureteral treatment, the simple ureterolysis and complex reconstructive techniques were described in most papers. Using anatomical landmarks or neuronavigation, pelvic surgical systematization allows intraoperative neural structure identification. Conclusions: DIE in the urinary system is common, however the number of publications with high level of evidence is limited. The initial tools for diagnosis are ultrasonography and cystoscopy, but magnetic resonance is the most reliable tool. When the patient has voiding symptoms, the urodynamic examination is crucial. Laparoscopy improves lesion detection and anatomical understanding. This approach must be carried out by professionals with high expertise, since the surgery goes beyond the resection of lesions and includes the preservation of nerve structures and urinary tract reconstruction techniques.

The Effect of Neuromodulatory Drugs on the Intensity of Chronic Pelvic Pain in Women: A Systematic Review / Efeito de neuromoduladores na intensidade da dor pélvica crônica em mulheres: Revisão sistemática

Abstract Objective: To evaluate the effect of neuromodulatory drugs on the intensity of chronic pelvic pain (CPP) in women. Data sources: Searches were carried out in the PubMed, Cochrane Central, Embase, Lilacs, OpenGrey, and Clinical Trials databases. Selection of studies: The searches were carried out by two of the authors, not delimiting publication date or original language. The following descriptors were used: chronic pelvic pain in women OR endometriosis, associated with MESH/ENTREE/DeCS: gabapentinoids, gabapentin, amitriptyline, antidepressant, pregabalin, anticonvulsant, sertraline, duloxetine, nortriptyline, citalopram, imipramine, venlafaxine, neuromodulation drugs, acyclic pelvic pain, serotonin, noradrenaline reuptake inhibitors, and tricyclic antidepressants, with the Boolean operator OR. Case reports and systematic reviews were excluded. Data collection: The following data were extracted: author, year of publication, setting, type of study, sample size, intervention details, follow-up time, and results. Data synthesis: A total of 218 articles were found, with 79 being excluded because they were repeated, leaving 139 articles for analysis: 90 were excluded in the analysis of the titles, 37 after reading the abstract, and 4 after reading the articles in full, and 1 could not be found, therefore, leaving 7 articles that were included in the review. Conclusion: Most of the studies analyzed have shown pain improvement with the help of neuromodulators for chronic pain. However, no improvement was found in the study with the highest statistical power. There is still not enough evidence that neuromodulatory drugs reduce the intensity of pain in women with CPP.

Resumo Objetivo: Avaliar o efeito de drogas neuromoduladoras na intensidade da dor pélvica crônica em mulheres. Fontes de dados: As buscas foram realizadas nas bases de dados PubMed, Cochrane Central, Embase, Lilacs, OpenGrey e Clinical Trials. Seleção dos estudos: As buscas foram realizadas por dois dos autores, não delimitando data de publicação ou idioma de publicação. Foram usados os seguintes descritores: chronic pelvic pain in women OR endometriosis, associated with MESH/ENTREE/DeCS: gabapentinoids, gabapentin, amitriptyline, antidepressant, pregabalin, anticonvulsant, sertraline, duloxetine, nortriptyline, citalopram, imipramine, venlafaxine, neuromodulation drugs, acyclic pelvic pain, serotonin, noradrenaline reuptake inhibitors e tricyclic antidepressants, com o operador booleano OR. Relatos de caso e revisões sistemáticas foram excluídos. Coleta de dados: Foram extraídos os seguintes dados: autor, ano de publicação, local de origem, tipo de estudo, tamanho da amostra, detalhes da intervenção, tempo de seguimento e resultados. Síntese dos dados: Foram encontrados 218 artigos, sendo 79 deles excluídos por serem repetidos, restando 139 artigos para análise, dos quais 90 foram excluídos na análise dos títulos, 37 após a leitura do resumo e 4 após a leitura dos artigos na íntegra, e 1 não foi encontrado, restando, então, 7 artigos que foram incluídos na revisão. Conclusão: A maioria dos estudos analisados mostrou melhora da dor crônica com auxílio de neuromoduladores. No entanto, nenhuma melhora foi encontrada no artigo com maior poder estatístico. Ainda não há evidências suficientes de que drogas neuromoduladoras reduzam a intensidade da dor pélvica crônica em mulheres.

Endometriosis de la pared abdominal en relación con cicatriz de operación cesárea: serie de casos / Abdominal wall endometriosis in relation to cesarean section scar: number of cases

RESUMEN: La endometriosis (E), se define como presencia de glándulas endometriales y estroma fuera del útero. Ocasionalmente se presenta como masa sensible en la pared abdominal (PA), en relación con una cicatriz quirúrgica (EPA). Aunque el tratamiento es quirúrgico, existe poca información respecto de la morbilidad postoperatoria (MPO) y la recurrencia de la EPA. El objetivo de este estudio fue determinar MPO y recurrencia en pacientes resecadas quirúrgicamente por EPA. Serie de casos de pacientes con EPA, sometidos a cirugía de forma consecutiva, en Clínica RedSalud Mayor, entre 2011 y 2021. Las variables resultados MPO y recurrencia. Otras variables de interés fueron: tiempo quirúrgico, estancia hospitalaria y mortalidad. Las pacientes fueron seguidas de forma clínica. Se utilizó estadística descriptiva, con medidas de tendencia central y dispersión. Se intervinieron 14 pacientes, con una mediana de edad de 33 años. La medianas del tiempo quirúrgico y estancia hospitalaria; fueron 55 min y 2,5 días respectivamente. La MPO fue 14,2 % (2 casos). Con una mediana de seguimiento de 31 meses, no se verificó recurrencia. Aunque la EPA es poco común, estas lesiones deben sospecharse en mujeres en edad reproductiva con masa palpable en relación con una cicatriz de cirugía ginecológica u obstétrica. Los resultados obtenidos, en términos de MPO y recurrencia, fueron similares a series internacionales.

SUMMARY: Endometriosis (E) is defined as the presence of endometrial glands and endometrial stroma outside the uterus. Occasionally it presents as a sensitive mass in the abdominal wall (AW), in relation to a surgical scar (AWE). Although the treatment is surgical, there is scarce information regarding postoperative morbidity (POM) and recurrence of AWE. The aim of this study was to determine POM and recurrence in patients surgically resected by AWE. Case series of patients with AWE, consecutively submitted to surgery, at RedSalud Mayor Clinic, between 2011 and 2021. Outcome variables were POM and recurrence. Other variables of interest were surgical time, hospital stay and mortality. Patients were followed-up clinically. Descriptive statistics were used, applying central tendency and dispersion measures. 14 patients were intervened, with a median age of 33 years. Median of surgical time and hospital stay were 55 min and 2,5 days respectively. POM was 14.2 % (2 cases). With a median follow-up of 31 months no recurrence was verified. Although AWE is uncommon, these lesions should be suspected in women in fertile age with a palpable mass associated with a scar from gynecologic or obstetric surgery. The results obtained, in terms of POM and recurrence, were like international series.

Reparación de la pared abdominal, a propósito de un caso de endometrioma múltiple / Repair of the abdominal wall, about a case of multiple endometrioma

El endometrioma de la pared abdominal es una patología poco frecuente, principalmente cuando existe multiplicidad y compromiso del músculo recto anterior del abdomen. Se expone el caso clínico de una paciente de 22 años con múltiples lesiones de la pared abdominal, en la cual se practicó la resección amplia de ambas lesiones, utilizando en la reconstrucción parietal una malla de polipropileno en plano preperitoneal. El abordaje se realizó a través de una incisión transversa suprapúbica, lo cual fue esencial, por tratarse de una paciente joven

Effectiveness of Conservative Surgery andAdjunctive Hormone Suppression Therapy versus Surgery Alone in the Treatment of Symptomatic Endometriosis: A Systematic Review with Meta-analysis.

Background: Endometriosis is one of the common gynaecological problems mostly affecting the women in reproductive age, associated with non menstrual pelvic pain and other symptoms and recurrence of endometriosis is common after medical or even surgical treatment. Objectives: This review is done to assess, whether conservative surgery and adjunctive hor- mone suppression therapy is more beneficiary than surgery alone in the treatment of sympto- matic endometriosis in term of pelvic pain and disease recurrence. Data sources and search method: Searched had been performed on Cochrane Central Register of Controlled trials, MEDLINE, PsycINFO. Journals and reference lists had been also searched. Review methods: Only Randomized controlled trials were included if they compared the effec- tiveness of hormone therapy following conservative surgery with surgery alone or surgery plus placebo in the treatment of symptomatic endometriosis. Outcome data had been analysed by using a Mantel-Haenzel Fixed-effect model to perform meta-analysis and results had been pre- sented as Risk ratio for binary data and Standardised Mean difference for continuous data with 95% confidence intervals. Results: Out of 8 trails pelvic pain was reported in 7 trials. No significant benefit was observed both in pelvic pain recurrence (RR= 0.75, 95% Cl- 0.54 to1.04) and disease recurrence (RR 0.89, 95% Cl 0.53 to 1.49) among 5 trials (481& 447 participants) in favour of surgery and adjunctive hormone therapy. On the other hand another 2 trials (280 participants) showed sig- nificant benefit in pelvic pain score (Std. Mean difference-0.80, 95%Cl -1.05 to -0.55) but con- siderable heterogeneity (I²= 96%) was observed. Conclusion: Women who received Post-surgical hormone therapy in the treatment of sympto- matic endometriosis had no advantages in respect of endometriosis and pelvic pain recurrence in compared with surgery alone.

Laparoscopic repair of indirect inguinal hernia containing endometriosis, ovary, and fallopian tube in adult woman without genital anomalies

Indirect inguinal hernia containing an ovary is a rare condition, especially in adult women who do not have any other genital tract anomalies. In addition, inguinal hernia containing an ovary and endometriosis is exceedingly rare. In the present report, we describe a case of indirect inguinal hernia containing an ovary, fallopian tube, and endometriosis. Laparoscopic repair was performed successfully using polypropylene mesh for the treatment of the inguinal hernia.

Resection and repair of large abdominal wall lesions in gynecologic patients / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The techniques of resection and repair of large lesions in the abdominal wall are very challenging in the area of gynecology. We explored the techniques of resection and plastic surgical repair of large abdominal wall lesions in gynecologic patients.</p><p><b>METHODS</b>Twenty-six patients with large lesions in the abdominal wall underwent resection by the gynecologists and repair through abdominal plasty and V-Y plasty with or without fascia patch grafting by the gynecologists or plastic surgeons from March 2003 to October 2010.</p><p><b>RESULTS</b>All patients had a history of cesarean section. One patient had an infected sinus tract after cesarean section, one patient had an inflammatory nodule, and the others had lesions of endometriosis, including one cancer. The average largest lesion diameter was (4.79 ± 4.18) cm according to the ultrasonography results. The lesions of all patients were completely resected with pretty abdominal contour. A polypropylene biological mesh was added to the fascia in 20 patients. One patient underwent groin flap repair, and one underwent V-Y advanced skin flap repair on the left of the incision to relieve the suture tension.</p><p><b>CONCLUSIONS</b>Multi-department cooperation involving the gynecology and plastic surgery departments, and even the general surgery department, is essential for patients with large lesions in the abdominal wall. This cooperative effort enabled surgeons to completely resect large lesions. Abdominal wall plastic surgical repair can ameliorate large wounds of the abdominal wall.</p>

Minimal and mild endometriosis negatively impact on pregnancy outcome / Endometriose mínima e leve e seu impacto negativo sobre a gravidez

Endometriosis, a highly prevalent gynecological disease, can lead to infertility in moderate to severe cases. Whether minimal stages are associated with infertility is still unclear. The purpose of this systematic review is to present studies regarding the association between pregnancy rates and the presence of early stages of endometriosis. Studies regarding infertility, minimal (stage I, American Society of Reproductive Medicine [ASRM]) and mild (stage II, ASRM) endometriosis were identified by searching on the MEDLINE database from 1985 to September 2011 using the following MESH terms: endometriosis; infertility; minimal; mild endometriosis; pregnancy rate. 1188 articles published between January of 1985 and November of 2011 were retrieved; based on their titles, 1038 citations were excluded. Finally, after inclusion and exclusion criteria, 16 articles were selected to be part of this systematic review. Several reasons have been discussed in the literature to explain the impact of minimal endometriosis on fertility outcome, such as: ovulatory dysfunction, impaired folliculogenesis, defective implantation, decrease embryo quality, abnormal immunological peritoneal environment, and luteal phase problems. Despite the controversy involving the topic, the largest randomized control trial, published by Marcoux et al. in 1997 found a statistically different pregnancy rate after resection of superficial endometrial lesions. Earlier stages of endometriosis play a critical role in infertility, and most likely negatively impact pregnancy outcomes. Further studies into stage I endometriosis, especially randomized controlled trials, still need to be conducted.

RESUMO O objetivo desta revisão sistemática é apresentar estudos sobre a associação entre as taxas de gravidez e a presença de fases iniciais de endometriose. Estudos relacionados com a infertilidade e estágios mínimos e leves (estágios I,II, American Society of Reproductive Medicine [ASRM]) foram identificados por busca na base de dados MEDLINE, de 1985 a setembro de 2011. Os seguintes termos foram usados como palavras-chave: endometriose, infertilidade, taxa de gravidez; estágio mínimo; estágio leve de endometriose. Entre janeiro de 1985 e novembro de 2011, 1188 artigos foram recuperados; com base no título, 1038 citações foram excluídas e, finalmente, depois de critérios de inclusão e exclusão, 18 artigos foram selecionados para fazer parte desta revisão sistemática. Várias razões têm sido discutidas na literatura na tentativa de explicar o impacto da endometriose mínima no resultado da fertilidade, tais como: disfunção ovulatória, foliculogênese alterada prejudicada, defeito na implantação, baixa qualidade embrionária, ambiente peritoneal inflamatório e hostil e problemas da fase lútea. Apesar de toda polêmica envolvendo o tópico, o maior ensaio clínico randomizado foi publicado por Marcoux et al. Os autores encontraram uma taxa de gravidez estatisticamente significante após a ressecção de lesões superficiais de endometriose. Estágios iniciais de endometriose desempenham um papel crítico relacionado à infertilidade e, provavelmente proporcionam um impacto negativo nas taxas de gravidez em pacientes com endometriose. Outros estudos envolvendo estágios iniciais de endometriose, especialmente ensaios clínicos randomizados, ainda precisam ser realizados.

Mini-abdominoplasty combined with mesh used for abdominal wall endometriosis / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Wide excision is considered the treatment of endometriosis. It is difficult to surgeon for reconstruction of a large full-thickness defect through the abdominal-wall. We introduce a method of mini-abdominoplasty combined with mesh that can be used for reconstruction of a large full-thickness defect through the abdominal-wall after wide excision of abdominal wall endometriosis.</p><p><b>METHODS</b>This retrospective study includes a series of patients who underwent wide excision of abdominal wall endometriosis and reconstruction of a large full-thickness defect through the abdominal-wall over a 5-year period. Information obtained from chart reviews includes age, size of lesion and defect, complications and revisions.</p><p><b>RESULTS</b>The method was used for 8 patients including 2 patients with recurrence. The mean size of the masses was (3.5 ± 2.0) cm. The mean size of the fascia defects was 7.1 cm × 8.6 cm. The mean length of follow-up was (24 ± 12) months. There was no recurrence, no hernia, and no other complications. The technique generated only a horizontal scar. The scar and contour of the lower abdomen provided a more pleasant appearance than the traditional procedure.</p><p><b>CONCLUSIONS</b>Mini-abdominoplasty combined with mesh is a useful and acceptable reconstruction method for large full-thickness defects through the abdominal wall after endometriosis resection. It is feasible for wide excision with 1 cm normal tissues around the margin. It provides an aesthetically pleasing result.</p>

Adhesion formation after applying adhesion barrier in laparoscopic gynecologic surgery: Experience of 7 patients / 대한산부인과내시경학회지

OBJECTIVE: Adhesion barrier has been commonly used in gynecologic surgery. The objective of this study is to evaluate the outcome of applying adhesion barrier in preventing adhesion formation after laparoscopic surgery. METHODS: Between March 2000 and March 2010, we retrospectively reviewed the medical records of patients who performed laparoscopic surgery twice at Samsung Medical Center. The patients to whom adhesion barrier was applied at the end of the first laparoscopic surgery and had imaging files of pelvic cavity at second laparoscopic surgery were included. The patients with recurrent endometriosis and pelvic inflammatory disease which can make postoperative adhesion by itself due to the nature of the disease were excluded. RESULTS: Ten patients were eligible to be analyzed. Only 3 among 10 showed adhesion free and we could find de novo adhesion formation in 7 patients at second laparoscopic surgery. Eight patients used Intercede(R) (oxidized regenerated cellulose mesh; Johnson & Johnson, New Brunswick, NJ, USA) and two patients used Guardix(R) (sodium hyaluronic acid solution and carboxymethylcellulose: Hanmi, Seoul, Korea). In six patients, adhesion formation was found at the operation site and one patient showed postoperative adhesion distant from operation site between omentum and anterior peritoneum of pelvic wall. CONCLUSION: We observed adhesion formation despite of prior use of adhesion barrier after laparoscopic gynecological surgery. These results suggest that the use of adhesion barrier alone after gynecologic laparoscopic surgery may not guarantee adhesion prevention.

Endometrioma of the abdominal wall: a case report

This is a report of a case of endometrioma of the abdominal wall in a 34-year-old woman who had a two-year history of lower abdominal pain. The physical examination revealed an ill defined mass with tenderness. Computed tomography showed an enhancing isodense mass at the midline-right rectus abdominis muscle. The patient was treated with a mesh grafting repair following a wide radical resection with a 1 cm margin. There were no postoperative complications. The histological examination confirmed endometriosis. The patient is now on regular follow-up and doing well without any recurrence, five months after her operation.

Endometriosis e la pared abdominal / Endometriosis and the abdominal wall

ANTECEDENTES: La presencia de endometriosis de la pared abdominal (EPA) suele confundirse con otras patologías médico-quirúrgicas que aparecen en la misma zona. OBJETIVO: Evaluar las características clínicas de la EPA. MÉTODO: Se realizó un estudio retrospectivo de todas las pacientes hospitalizadas con el diagnóstico histopatológico de EPA entre enero de 1997 y diciembre de 2005. RESULTADOS: Se encontraron 14 pacientes, con edad promedio de 33,2 años. Los principales síntomas fueron: dolor cíclico (71,4%), masa abdominal (100%), dispareunia (21,4%) y dismenorrea (42,8%). Todas la pacientes tuvieron al menos una cirugía ginecológica (2 con procedimientos laparoscópicos) u obstétrica (85,7% cesárea). Sólo una paciente se había diagnosticado previamente de endometriosis. Los síntomas comenzaron en promedio 3,5 años posteriores a la última cirugía. Las EPA tenían un tamaño promedio de 3,2 cm. El diagnóstico pre-operatorio fue correcto en el 64,3% de las pacientes. Los diagnósticos incorrectos correspondieron a 3 granulomas, una hernia inguinal y un lipoma. Todas las pacientes requirieron cirugía y en el 64,3% fue necesario la utilización de mallas polytetrafluoethyleno. Cuatro pacientes (28,5%) presentaron recurrencias. 60% de los diagnósticos iniciales incorrectos v/s 11,1% de los acertados recurrieron. CONCLUSIONES: La EPA puede encontrarse en cicatrices tanto ginecológicas como obstétricas. Los síntomas comunes son masas con dolor cíclico. La ecografía de pared abdominal fue suficiente para enfrentar el diagnóstico diferencial. El diagnóstico pre-operatorio es importante para planificar la cirugía porque redujo las recurrencias. El tratamiento de elección es la cirugía con resección amplia de los bordes.

BACKGROUND: The presence of abdominal wall endometriosis (AWE) used to be confused with other surgical pathologies that may appear in these zones. Objective: To evaluate the AWE clinical characteristics. METHOD: Retrospective study of all the patients hospitalized with the histopathologycal diagnosis of AWE, between January 1997 and December 2005. RESULTS: There was found AWE only in 14 patients. Their mean age was 33.2 years old. The symptoms were: cyclic pain (71.4%), abdominal wall mass (100%), dyspareunia (21.4%) and dysmenorrhea (42.8%). All patients had at least one gynecologic (2 patients with laparoscopic procedures) or obstetric surgery (85.7% had previous cesarean section). Only one patient had previously been diagnosed with pelvic endometriosis. Their symptoms started after an average of 3.5 years after surgery. The AWE had a mean size of 3.2 cm. The preoperative diagnosis was correct in 64.3%. The incorrect preoperative diagnoses were 3 granuloma, 1 inguinal hernia and 1 lipoma. All patients required surgery. 64.3% of the patients it was necessary a polytetrafluoethylene mesh. Four patients (28.5%) had AWE recurrences. 60% of the wrong initial diagnosis recurred versus 11.1% of the correct ones. CONCLUSION: AWE may be present in gynecologic or obstetric scars. Their common symptoms are masses with cyclic pain. Ultrasonography is enough to approach the differential diagnosis. The correct preoperative diagnosis is important to plan surgery and reduce recurrences. The surgical wide excision is the preferable treatment. Establishing clear endometriosis limits reduce the recurrences.