Psychological impact and health-related quality-of-life outcomes of Mayer-Rokitansky-Küster-Hauser syndrome: A systematic review and narrative synthesis.

Mayer-Rokitansky-Küster-Hauser syndrome causes absence or underdevelopment of uterus and vagina, but women's subjective experience remains understudied. This systematic review was conducted to examine the psychological and health-related quality-of-life outcomes of Mayer-Rokitansky-Küster-Hauser syndrome. In total, 22 articles identified through electronic search matched the inclusion criteria and were included in our review. Mayer-Rokitansky-Küster-Hauser syndrome may be associated with psychological symptoms and impaired quality of life, but especially with poor sexual esteem and genital image. Women may experience difficulties managing intimacy and disclosing to partners. Mothers may be perceived as overinvolved, with consequent negative emotions in women with the disease.

'Money for nothing'. The role of robotic-assisted laparoscopy for the treatment of endometriosis.

Despite higher costs for robotic-assisted laparoscopy (RAL) than standard laparoscopy (SL), RAL treatment of endometriosis is performed without established indications. PubMed/MEDLINE was searched for 'robotic surgery' and 'endometriosis' or 'gynaecological benign disease' from January 2000 to December 2016. Full-length studies in English reporting original data were considered. Among 178 articles retrieved, 17 were eligible: 11 non-comparative (RAL only) and six comparative (RAL versus SL). Non-comparative studies included 445 patients. Mean operating time, blood loss and hospital stay were 226 min, 168 ml and 4 days. Major complications and laparotomy conversions were 3.1% and 1.3%. Eight studies reported pain improvement at 15-month follow-up. Comparative studies were all retrospective; 749 women underwent RAL and 705 SL. Operating time was longer for RAL in five studies. Major complications and laparotomy conversions for RAL and SL were 1.5% versus 0.3% and 0.3% versus 0.5%. One study reported pain reduction for RAL at 6-month follow-up. RAL treatment of endometriosis did not provide benefits over SL, overall and among subgroups of women with severe endometriosis, peritoneal endometriosis and obesity. Available evidence is low-quality, and data regarding long-term pain relief and pregnancy rates are lacking. RAL treatment of endometriosis should be performed only within controlled studies.

Self-management and psychological-sexological interventions in patients with endometriosis: strategies, outcomes, and integration into clinical care.

Endometriosis has a multifactorial etiology. The onset and progression of the disease are believed to be related to different pathogenic mechanisms. Among them, the environment and lifestyle may play significant roles. Diet, dietary supplements, physical exercise, osteopathy, massage, acupuncture, transcutaneous electrical nerve stimulation, and Chinese herbal medicine may represent a complementary and feasible approach in the treatment of symptoms related to the disease. In this narrative review, we aimed to examine the most updated evidence on these alternative approaches implicated in the self-management of the disease. In addition, several studies have demonstrated that endometriosis may negatively impact mental health and quality of life, suggesting that affected women may have an increased risk of developing psychological suffering as well as sexual problems due to the presence of pain. In light of these findings, we discuss the importance of integrating psychological interventions (including psychotherapy) and sexual therapy in endometriosis treatment.

Laparoscopic repair of a symptomatic post-cesarean section isthmocele: a video case report.

OBJECTIVE: To describe our technique for laparoscopic management of post-cesarean section isthmocele. DESIGN: Surgical video article. Local Institutional Review Board approval for the video reproduction has been obtained. SETTING: University hospital. PATIENT(S): A 36-year-old patient with a history of two previous cesarean deliveries. She complained of persistent postmenstrual spotting and chronic pelvic pain. At transvaginal ultrasound examination, a cesarean scar defect of 20.0 × 15.6 mm was identified, with a residual myometrial thickness over the defect of 2.6 mm. MAIN OUTCOME MEASURE(S): Repair of isthmocele and relief of pain. INTERVENTION(S): Isthmocele excision and myometrial repair was performed laparoscopically. The first step of the procedure was the cautious mobilization of the bladder from its adhesions with the site of the previous cesarean scar. Subsequently, the isthmocele site was identified with the aid of intraoperative transrectal ultrasonography. Transrectal ultrasonographic assistance is particularly important when a bulge of the cesarean scar is not laparoscopically visible. Once identified, the isthmocele pouch was incised and its pitchy content drained. Then the cesarean scar was excised with cold scissors, avoiding cauterization to reduce the risk of tissue necrosis. This step is considered completed when the whitish scar tissue of the isthmocele site margins are no longer present and reddish healthy myometrium is visualized. Before suturing the defect, a Hegar dilator was placed into the cervix with the aim of maintaining the continuity between the cervical canal and the uterine cavity. Then, the myometrial repair was performed with the use of a single layer of interrupted 2-0 Vycril sutures. To limit tissue ischemia, we prefer not to add a second layer of sutures. Finally, the visceral peritoneum defect was closed, with the aim of restoring the physiologic uterine anatomy. In this case, multiple peritoneal endometriotic implants were also identified and excised. RESULT(S): Operating time was 70 minutes. The postoperative course was uneventful and the patient was discharged on postoperative day 2. At 40-day postoperative follow-up, transvaginal and transabdominal ultrasonography showed complete anatomic repair of the uterine defect. At 3-month follow-up, the patient reported resolution of postmenstrual spotting and chronic pelvic pain. CONCLUSION(S): Good reproductive outcomes have been reported after hysteroscopic treatment of uterine isthmocele. However, laparoscopy has the advantage over hysteroscopy of allowing thorough repair of the uterine defect, thus restoring a normal myometrial thickness. Therefore, as demonstrated in this case, a laparoscopic approach might be considered to be the procedure of choice for the repair of a large uterine isthmocele with extreme thinning of the residual myometrium.

Hemoperitoneum Following Sexual Intercourse in a Woman with Deep Infiltrating Endometriosis.

Endometriosis is an estrogen-dependent chronic inflammatory disease, defined by the presence of endometrial glands and stroma at ectopic sites. A rare and life-threatening complication associated with endometriosis is represented by spontaneous hemoperitoneum due to the rupture of utero-ovarian vessels. Most cases of spontaneous hemoperitoneum previously described involved pregnant women affected by endometriosis; here, we present a case of acute and massive hemoperitoneum in a nulliparous woman with deep infiltrating endometriosis. When acute abdominal pain with hemoperitoneum occurs in non-gravid reproductive age women, with no positive findings for liver or spleen lesions, a possible spontaneous rupture of utero-ovarian vessels related to the presence of deep infiltrating endometriosis should be included among the possible causes of the condition.

Ureteral and vesical endometriosis. Two different clinical entities sharing the same pathogenesis.

Ureteral or vesical endometriotic lesions affect about 1% of women with endometriosis. The diagnosis may be difficult when specific symptoms are lacking. A delay in diagnosis can lead to significant morbidity. An adequate comprehension of the circumstances in which ureteral and vesical endometriosis present or should be suspected, aided by advances in imaging techniques and laparoscopic surgery, may allow a significant progress in the treatment of these conditions. The pathogenesis, diagnosis, and treatment of ureteral and vesical endometriosis are reviewed, with the aim of increasing the degree of awareness of the clinicians and helping in devising an adequate clinical management plan for the lesser understood aspects of the disease.

Reproductive performance, pain recurrence and disease relapse after conservative surgical treatment for endometriosis: the predictive value of the current classification system.

BACKGROUND: To assess the predictive value of the current classification of endometriosis in terms of response to surgical treatment, we studied to what extent disease stage, lesion type and lesion site were associated with post-operative pregnancy rate, symptom recurrence and disease relapse. METHODS: A total of 729 women with endometriosis undergoing first-line conservative laparoscopic surgery were included. Data on age at surgery, disease stage according to the revised American Fertility Society (AFS) classification, anatomical characteristics of endometriotic lesions, fertility status and types and severity of pain symptoms were collected. RESULTS: Minimal endometriosis was present in 222 patients, mild in 106, moderate in 197 and severe in 204. The cumulative probability of pregnancy at 3 years from surgery in 537 infertile women was 47% (51% at stage I, 45% at stage II, 46% at stage III and 44% at stage IV; log-rank test, chi(2)3=1.50, P=0.68). The cumulative probability of moderate or severe dysmenorrhoea recurrence in 425 symptomatic subjects was 24% (32% at stage I, 24% at stage II, 21% at stage III and 19% at stage IV; log-rank test, chi2(3)=6.39, P=0.094). The cumulative probability of disease relapse was 12% (3% at stage I, 11% at stage II, 11% at stage III and 23% at stage IV; log-rank test, chi(2)3=24.95, P=0.0001). Using Cox's multivariate proportional hazards regression analysis, no association was observed between endometriosis stage or lesion type and lesion site and any of the considered study outcomes. CONCLUSIONS: The current classification of endometriosis has an inadequate predictive value with regard to the major clinical outcomes.

Comparison of a levonorgestrel-releasing intrauterine device versus expectant management after conservative surgery for symptomatic endometriosis: a pilot study.

OBJECTIVE: To determine whether the frequency and severity of dysmenorrhea are reduced in women with symptomatic endometriosis in whom a levonorgestrel-releasing intrauterine device (Lng-IUD) is inserted after operative laparoscopy compared with those treated with surgery only. DESIGN: Open-label, parallel-group, randomized, controlled trial. SETTING: A tertiary care and referral center for patients with endometriosis. PATIENTS(S): Parous women with moderate or severe dysmenorrhea undergoing first-line operative laparoscopy for symptomatic endometriosis. INTERVENTION(S): Randomization to immediate Lng-IUD insertion or expectant management after laparoscopic treatment of endometriotic lesions. Proportions of women with recurrence of moderate or severe dysmenorrhea in the two study groups 1 year after surgery and overall degree of satisfaction with treatment. Moderate or severe dysmenorrhea recurred in 2 of 20 (10%) subjects in the postoperative Lng-IUD group and 9/20 (45%) in the surgery-only group. Thus, a medicated device inserted postoperatively will prevent the recurrence of moderate or severe dysmenorrhea in one out of three patients 1 year after surgery. A total of 15/20 (75%) women in the Lng-IUD group and 10/20 (50%) in the expectant management group were satisfied or very satisfied with the treatment received. CONCLUSION(S): Insertion of an Lng-IUD after laparoscopic surgery for symptomatic endometriosis significantly reduced the medium-term risk of recurrence of moderate or severe dysmenorrhea.

Laparoscopic uterosacral ligament resection for dysmenorrhea associated with endometriosis: results of a randomized, controlled trial.

OBJECTIVE: To evaluate the efficacy of laparoscopic resection of the uterosacral ligaments in women with endometriosis and predominantly midline dysmenorrhea. DESIGN: Randomized controlled trial. SETTING: Two academic departments. One hundred eighty patients undergoing operative laparoscopy as first-line therapy for stage I to IV symptomatic endometriosis. INTERVENTION(S): Operative laparoscopy including uterosacral ligament resection or conservative surgery alone. MAIN OUTCOME MEASURE(S): Proportion of women with recurrence of moderate or severe dysmenorrhea 1 year after surgery. RESULT(S): No complications occurred. Among the patients who were evaluable 1 year after operative laparoscopy, 23 of 78 (29%) women who had uterosacral ligament resection and 21 of 78 (27%) women who had conservative surgery only reported recurrent dysmenorrhea. The corresponding numbers of patients at 3 years were 21 of 59 (36%) women and 18 of 57 (32%) women, respectively. Time to recurrence was similar in the two groups. Pain was substantially reduced, and patients in both groups experienced similar and significant improvements in health-related quality of life, psychiatric profile, and sexual satisfaction. Overall, 68 of 90 (75%) patients in the uterosacral ligament resection group and 67 of 90 (74%) patients in the conservative surgery group were satisfied at 1 year. CONCLUSION(S): Addition of uterosacral ligament resection to conservative laparoscopic surgery for endometriosis did not reduce the medium- or long-term frequency and severity of recurrence of dysmenorrhea.