Pain and pulmonary function following laparoscopic and abdominal hysterectomy: a randomized study.

BACKGROUND: The aim of this study was to evaluate pain and pulmonary function the first two days after abdominal and laparoscopic hysterectomy. METHODS: Women scheduled for abdominal hysterectomy were prospectively randomized to either laparoscopic (n=20) or abdominal (n=20) hysterectomy. Analgesics were self-administered by the patients by means of a programable infusion pump containing morphine. Postoperative pain was evaluated using a visual analog scale. Oxygen saturation was measured with an oxymeter. Pulmonary function was assessed using a peak flow meter measuring peak expiratory flow and a vitalograph measuring forced vital capacity and forced expiratory volume in one second. RESULTS: Pain scores were lower after laparoscopic hysterectomy at the first (p<0.05) and second postoperative day (p<0.01). Lung function was impaired on days 1 and 2 postoperatively, measured as peak expiratory flow, forced vital capacity and forced expiratory volume in one second, in both groups compared to the preoperative values. The patients undergoing laparoscopic hysterectomy had less impairment of lung function measured by peak expiratory flow (p<0.01), forced vital capacity (p<0.05) and forced expiratory volume in one second (p<0.05) the first postoperative day compared to the patients undergoing abdominal hysterectomy. The second postoperative day differences between the groups remained for peak expiratory flow (p<0.05) and forced expiratory volume in one second (p<0.05). CONCLUSIONS: Laparoscopic hysterectomy results in less pain and less impairment of respiratory function compared to abdominal hysterectomy.

A randomized trial with a cost-consequence analysis after laparoscopic and abdominal hysterectomy.

OBJECTIVE: To perform a cost-consequence analysis after total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH). METHODS: Women scheduled for TAH were randomized prospectively to undergo the procedure by laparoscopic (n = 71) or abdominal (n = 72) surgery. Postoperative health status was assessed using The Medical Outcome Trust 36-Item Short-Form Health Survey questionnaire. The financial accounting system at the hospital and information from the local national health insurance office were used for the economic analysis. We evaluated changes in direct costs (hospital costs) and indirect costs (loss of production value) when performing a laparoscopic hysterectomy instead of an abdominal hysterectomy. RESULTS: Postoperative health status improved significantly faster after TLH than after TAH. The direct costs were 1.7% higher and the indirect costs 50.3% lower for patients undergoing laparoscopic surgery. The total costs were 23.1% lower after laparoscopic hysterectomy. CONCLUSION: A change in surgical technique from abdominal to laparoscopic hysterectomy was possible without compromising the health status of the patients, and it provided substantial financial benefits to society.

Evaluation of tissue trauma after laparoscopic and abdominal hysterectomy: measurements of neutrophil activation and release of interleukin-6, cortisol, and C-reactive protein.

BACKGROUND: Trauma and major surgery stimulate a cascade of events that mediate the inflammatory response. The aim of our study was to determine whether or not hysterectomy leads to release of cytokines, cortisol, and C-reactive protein (CRP), activation of neutrophils, and activation of the complement cascade. A further aim was to compare laparoscopic and abdominal hysterectomy with regard to the same parameters. STUDY DESIGN: Twenty-four consecutive patients were randomized to either abdominal (n = 12) or laparoscopic hysterectomy (n = 12). Blood samples were drawn preoperatively, intraoperatively, and then at one minute, 24 hours, and seven days postoperatively. Interleukin-6 (IL-6) levels were used to evaluate cytokine release, cortisol and CRP to evaluate the inflammatory response, and polymorphonuclear (PMN) elastase to detect neutrophil activation. To evaluate complement activation, the terminal C5b-9 complement complex (TCC) was determined. RESULTS: Interleukin-6 concentrations were significantly elevated one minute and 24 hours postoperatively in both groups. Independent of the surgical technique or operative time, the highest IL-6 concentration was reached four hours after beginning the operation. Cortisol levels were significantly elevated during and after the operation in both groups. C-reactive peptide levels were significantly elevated in both groups 24 hours and seven days after the operation. Polymorphonuclear elastase was elevated 24 hours postoperatively in both groups. There were no signs of complement activation during the operative period or postoperatively in either patient group. CONCLUSIONS: Our results indicate serious tissue trauma during both laparoscopic and abdominal hysterectomy. The extent of surgical trauma did not differ between the two operative methods.

A randomised prospective trial comparing laparoscopic and abdominal hysterectomy.

OBJECTIVE: To compare short term clinical results in a prospective randomised trial of laparoscopic hysterectomy compared with abdominal hysterectomy. METHODS: One hundred and forty-three women scheduled for total abdominal hysterectomy, with or without salpingo-oophorectomy and with a maximum uterine width of less than ll cm, were prospectively randomised to undergo the procedure by laparoscopic hysterectomy (n = 71) or abdominal hysterectomy (n = 72). During laparoscopic hysterectomy, the uterine arteries as well as the upper portion of the cardinal ligaments were transected laparoscopically. The perioperative and post-operative courses of the groups were compared. RESULTS: The number of women with a complication did not differ significantly between laparoscopic hysterectomy (27%) and abdominal hysterectomy (33%) groups. The post-operative fall in erythrocyte volume fraction was significantly greater following abdominal hysterectomy (5.6% compared with 4.1% median value, P < 0.001). Post operative pain, assessed by the patients two days after surgery on a visual analogue scale, was significantly higher following abdominal hysterectomy (4.2 compared with 3.6 units median value, P < 0.05). Although laparoscopic hysterectomy took longer (148 min compared with 85 min median value, P < 0.001), the women undergoing this procedure had a shorter post-operative time in hospital (two compared with four days median value, P < 0.001) and a shorter convalescence (16 compared with 35 days median value, P < 0.001). CONCLUSIONS: Laparoscopic hysterectomy is a safe procedure for selected patients scheduled for abdominal hysterectomy, and offers benefits to the patients in the form of less operative bleeding, less post-operative pain, shorter time in hospital and shorter convalescence time.

Steroid production in cultured thecal cells obtained from human ovarian follicles.

During follicular maturation there is a co-ordinated hormonal regulation of the theca and granulosa cells. It is generally believed that granulosa cell proliferation and differentiation are promoted mainly by follicle stimulating hormone (FSH) and that luteinizing hormone (LH) regulates the function of the theca cells. The aim of the present study was to examine the effect of LH/human chorionic gonadotrophin (HCG) on steroid production in human thecal cells. Isolated follicles (5-20 mm) were obtained during the follicular phase of the menstrual cycle in 10 women undergoing gynaecological laparotomy for reasons unrelated to ovarian pathology. The leading follicle(s) was excised and dispersed cells of the theca interna layer were isolated through combined mechanical and enzymatic techniques. The thecal cells were cultured 4-6 days with and without LH/HCG. Medium levels of androstenedione, testosterone and progesterone were measured by radioimmunoassay. Isolated thecal cells, cultured for 6 days, showed a high sensitivity to stimulation by LH/HCG. Steroid secretion was highest during days 0-2 and then declined gradually. LH/HCG stimulated steroid production in a dose-dependent way with the maximal stimulatory effect of LH at a concentration of 1-10 ng/ml, and of HCG at 0.01-0.1 IU/ml. The important question, especially in clinical situations, of the optimal level of LH for normal follicular maturation, remains to be answered. The present study is compatible with the view that thecal cell steroidogenesis in vivo is close to maximally stimulated by normal basal LH levels.

Regulation of androgen production in cultured human thecal cells by insulin-like growth factor I and insulin.

OBJECTIVES: To investigate if human thecal cells contain messenger ribonucleic acid (RNA) encoding insulin-like growth factor I (IGF-I) and insulin receptors and if IGF-I and insulin could stimulate androgen production in thecal cells. DESIGN: Poly-adenine+ RNA was extracted from fresh thecal tissue, and the expression of the genes encoding insulin and IGF-I receptors were analyzed. Isolated thecal cells were cultured 4 to 6 days with and without hormones. SETTING: Procedures were performed in a university laboratory. PATIENTS: Eight women in the follicular phase of natural cycles were undergoing gynecological laparotomy for reasons unrelated to ovarian pathology. The leading follicle(s) was excised, and dispersed cells of the theca interna layer were isolated through combined mechanical and enzymatic techniques. INTERVENTIONS: Luteinizing hormone (LH), IGF-I, and insulin were added to the cell cultures. MAIN OUTCOME MEASURE: The expression of IGF-I receptor and insulin receptor transcripts were analyzed by Northern blot. Medium levels of androstenedione and testosterone were measured by radioimmunoassay. RESULTS: In the separated thecal tissue both IGF-I receptor and insulin-receptor transcripts were detected. Insulin-like growth factor I and insulin potentiated LH-induced androgen secretion while having less pronounced effects on basal androgen production. CONCLUSION: The present study demonstrates that both insulin and IGF-I receptor genes are expressed and that insulin and IGF-I can stimulate steroid production in human thecal cells. The study provides further support for the hypothesis that IGF-I and insulin may be involved both in physiological regulation of ovarian function as well as in its pathophysiology.

Expression of functional growth hormone receptors in human granulosa cells.

Both clinical and experimental evidence suggest that growth hormone may be of importance for ovarian function. The present study investigated whether growth hormone receptors are expressed in human granulosa cells. Granulosa cells were isolated either from natural cycles or from stimulated cycles in the course of in-vitro fertilization. Total RNA hybridized with a 32P-labelled rat growth hormone receptor cRNA probe revealed one major transcript with an estimated size of 4.5 kb and one minor transcript with an estimated size of 1.3 kb. Biotinylated growth hormone was used to analyse growth hormone binding. Competitive growth hormone binding was detected in freshly isolated granulosa cells, as well as in cultured cells. Growth hormone augmented basal and/or follicle stimulating hormone-stimulated steroidogenesis in granulosa cells obtained from patients with natural cycles, but the response to growth hormone stimulation showed considerable variation. We conclude that functional growth hormone receptors are present in human granulosa cells and that growth hormone, therefore, may have an important role in ovarian function.

Effect of insulin-like growth factor I on steroidogenesis in cultured human granulosa cells.

The effect of IGF-I on steroidogenesis in human granulosa cells was studied. Granulosa cells were obtained from follicles of both natural and stimulated cycles. The cells were cultured 4 to 6 days and the effect of IGF-I (1 to 100 micrograms/l) on basal, LH- and FSH-stimulated steroidogenesis was studied. It was found that in granulosa cells from follicles of natural cycles, FSH as well as IGF-I significantly stimulated progesterone and estradiol production in a majority of the experiments. A synergistic effect of FSH and IGF-I could be seen when low (1 and 10 micrograms/l) concentrations of the two hormones were used. Also in granulosa luteal cells from stimulated cycles a stimulatory effect of IGF-I on estradiol as well as progesterone production was observed. The present results suggest that IGF-I in combination with gonadotropins has a physiological role in the human follicle in controlling differentiation of the granulosa cells.

Effects of insulin-like growth factor I and growth hormone in cultured human granulosa cells.

Human granulosa cells, obtained either from natural or stimulated cycles, were cultured, and the response to IGF-I and GH was analyzed. It was found that IGF-I alone stimulated thymidine incorporation in both types of granulosa cells. Furthermore, IGF-I alone and in combination with FSH or LH enhanced estradiol and progesterone production. In a limited series of experiments, GH in combination with FSH was found to stimulate steroidogenesis in granulosa cells obtained from natural, but not from stimulated, cycles.

Effect of insulin-like growth factor I on deoxyribonucleic acid synthesis in cultured human granulosa cells.

Insulin-like growth factor I (IGF-I) has been proposed to be an autocrine/paracrine factor involved in granulosa cell proliferation and differentiation. The present study focuses on a possible mitogenic effect of IGF-I in human granulosa cells. Insulin-like growth factor I (1 to 10 ng/mL) significantly stimulated 3H-thymidine incorporation in granulosa cells obtained from both natural cycles and from patients stimulated for in vitro fertilization, whereas luteinizing hormone (LH, 10 ng/mL), follicle-stimulating hormone (FSH, 10 ng/mL) and epidermal growth factor (EGF, 10 ng/mL) had no apparent effect on deoxyribonucleic acid (DNA) synthesis under these conditions. Luteinizing hormone and FSH stimulated progesterone secretion whereas IGF-I and EGF were without effect. Our observations that IGF-I stimulates DNA synthesis in human granulosa cells is in agreement with previous reports, in other species, indicating that IGF-I might be of importance for granulosa cell proliferation.

Effect of clomiphene isomers on oestradiol synthesis in cultured human granulosa cells.

The effects of en-clomiphene and zu-clomiphene (10(-7) - 10(-5) M) on oestradiol synthesis in human granulosa cells were studied. Granulosa cells were obtained from stimulated cycles in women undergoing oocyte retrieval, in the course of in-vitro fertilization/embryo transfer due to mechanical infertility. En-clomiphene and zu-clomiphene (10(-5) M) significantly reduced basal and LH-stimulated oestradiol synthesis after 2-4 days of culture. The LH-stimulated synthesis was also significantly and reversibly reduced by zu-clomiphene at lower concentrations (10(-6) - 10(-7) M) and by a mixture of en- and zu-clomiphene (10(-6) M). It is concluded that both the mixture of en- and zu-clomiphene and the isomers alone have direct inhibitory effects on oestradiol synthesis in human granulosa cells in vitro. Furthermore, it cannot be excluded that the LH-stimulated oestradiol synthesis is inhibited by zu-clomiphene at concentrations found in follicular fluid after administration of clomiphene citrate.

Effects of a gonadotropin-releasing hormone agonist on progesterone formation in cultured human granulosa cells.

Human granulosa cells from follicles of natural cycles (13 women) in mid- or late follicular phase were cultured in modified Medium-199. Human luteinizing hormone (100 micrograms/l), follicle-stimulating hormone (100 micrograms/l) and gonadotropin-releasing hormone agonist (GnRHa) (10(-12) to 10(-6) mol/l) alone or in combination were added to the culture medium. Medium content of progesterone was analysed. In granulosa cells obtained in the mid-follicular phase, the basal progesterone formation averaged 0.5 pg.cell-1.(48 h)-1. FSH caused a 3-fold stimulation. GnRHa (10(-6) mol/l) had a variable influence on the basal progesterone formation, whereas it consistently inhibited (40-50%) the FSH response. In granulosa cells from late follicular phase basal progesterone formation averaged 5 pg.cell-1.(48 h)-1 and was stimulated 3- to 6-fold by LH. GnRHa (10(-6) mol/l) stimulated the basal progesterone formation and caused a tended to potentiate the LH response on progesterone formation. It is concluded that GnRHa at relatively high concentrations exerts direct effects on gonadotropin-stimulated progesterone formation of human granulosa cells and that these effects are different (inhibitory or stimulatory) dependent on the degree of follicular maturation, and/or type of gonadotropin used.

Danazol concentrations in human ovarian follicular fluid and their relationship to simultaneous serum concentrations.

Danazol concentrations in follicular fluid and serum were studied in eight women scheduled for laparoscopy because of suspected endometriosis. In order to obtain some variation in follicular maturity, danazol administration was started 2 to 7 days before the expected day of ovulation. A total of nine doses were given, i.e., 200 mg four times daily for 2 days; the last 200-mg dose was given 3 hours before the laparoscopy during which the follicular fluid from the dominant follicle was aspirated. Peripheral venous blood samples were drawn before, during, and after laparoscopy. Danazol concentrations were assayed by means of a high-performance liquid chromatography method. At the time of follicular aspiration, the mean concentration of danazol was estimated at 96 ng/ml in serum and at 71 ng/ml in follicular fluid, i.e., an average of 73% of the simultaneous serum concentration. The data suggest that even short-term therapy with danazol is likely to produce intrafollicular drug concentrations that have a direct inhibitory effect on follicular steroidogenesis.

Effect of clomiphene isomers on progestin synthesis in cultured human granulosa cells.

The effect of en-clomiphene and zu-clomiphene (10(-9)-10(-5) M) on progestin synthesis in cultured human granulosa cells was studied under basal conditions and in the presence of LH (100 ng/ml). Granulosa cells were obtained from either pre-ovulatory follicles of clomiphene-HMG-stimulated cycles or from large follicles of mid-to-late follicular phase of spontaneous cycles. The basal and LH-stimulated progesterone accumulation was dose-dependently reduced by en- and zu-clomiphene (10(-6)-10(-5) M) in cells from both groups studied, an effect similar to that of oestradiol. In contrast to oestradiol, both en- and zu-clomiphene (10(-6)-10(-5) M) reduced the basal and LH-stimulated pregnenolone accumulation in cells of stimulated cycles. The effect of clomiphene on progesterone, and pregnenolone accumulation was more pronounced in LH-stimulated cells than under basal conditions. There were no qualitative differences between the two isomers and the results were principally the same in cells from both groups of follicles studied. It is concluded that en-clomiphene and zu-clomiphene have similar inhibitory effects on progestin synthesis in human granulosa cells in vitro.

Effect of danazol on gonadotropin and cAMP stimulated progesterone synthesis in cultured human granulosa cells.

The effect of danazol on progesterone formation was studied in cultured human granulosa cells obtained from 20 follicles in the mid- to late follicular phase of normally menstruating women. The cells were cultured for 2 to 6 days in the presence of danazol (0.01 to 5 mg/l) alone and in combination with one of several progesterone stimulatory agents. The medium was changed every other day and analysed for progesterone with radioimmunoassay. In all cases progesterone synthesis was markedly stimulated by human FSH (10 micrograms/l), human LH (10-100 micrograms/l), hCG (1000 IU/l), forskolin (1 mumol/l) or 8-Bromo-cAMP (1 mmol/l). In the presence of danazol (1 mg/l) the FSH-, LH- and hCG-stimulated progesterone synthesis was partially inhibited by 55 to 60%. The response to forskolin or 8-Bromo-cAMP was also inhibited by danazol although to a somewhat lower extent (35 to 50%). Basal progesterone synthesis was inconsistently inhibited in some cases. It was concluded that not only gonadotropin-stimulated steroid synthesis, as previously demonstrated for hCG, but also forskolin and 8-Bromo-cAMP-stimulated steroidogenesis is sensitive to danazol inhibition. This suggests that the effect of danazol in human granulosa cells is due, at least partly, to interference with steps distal to cAMP generation.

Inhibitory effects of danazol on steroidogenesis in cultured human granulosa cells.

The effect of danazol on steroidogenesis in cultured human granulosa cells was studied. Granulosa cells obtained from antral follicles in the mid to late follicular phase were cultured for 2 to 6 days. Danazol (0.1 to 5 micrograms/ml) and human chorionic gonadotropin (hCG, 10 IU/ml), alone or in combination, were added to the culture medium. Testosterone (T) (1 microgram/ml) was added as an aromatase substrate in certain experiments. The medium content of progesterone (P) and estradiol (E2) was determined. Basal P secretion was variably influenced by danazol, whereas a consistent dose-dependent and reversible inhibition of the hCG-stimulated P secretion was found. In the presence of T, danazol caused a dose-dependent inhibition of both basal and hCG-stimulated E2 secretion, and this effect became more pronounced with time. The results demonstrate that danazol exerts direct inhibitory effects on steroidogenesis in cultured human granulosa cells.

Effects of danazol on steroidogenesis and gonadotropic responsiveness in isolated human preovulatory follicular cells.

In order to investigate the influence of danazol on steroidogenesis and gonadotropic responsiveness of human follicular cells, granulosa and thecal cells of preovulatory follicles were isolated and separately incubated for short term periods. Human chorionic gonadotropin (hCG) (100 IU/ml), FSH (0.5 IU/ml) and danazol (10 micrograms/ml) alone or in combination were added to the incubation medium. Following incubation the cellular cyclic adenosine 3'5' monophosphate (cAMP) levels and the medium content of progesterone (P), androstenedione (A) and 17 beta-estradiol (E2) were determined. All follicles included in the study were classified as nonatretic and well developed, i.e. less than 3 days before ovulation. Human chorionic gonadotropin caused an increase in cAMP formation in both cell-types and this effect was significantly counteracted by danazol in vitro. In granulosa cells danazol tended to counteract a stimulatory effect of FSH on cAMP formation. No significant influence of danazol was found on the basal steroid formation of both cell types during short term incubation. On the other hand, danazol significantly counteracted the FSH stimulated P formation of the granulosa cells and the hCG stimulated A and E2 formation of the thecal cells. It is concluded that danazol inhibits gonadotropin-stimulated steroidogenesis locally in the human follicular cells and that this effect of danazol is mediated via the cyclic AMP system.