Pain typology and incident endometriosis.

STUDY QUESTION: What are the pain characteristics among women, with no prior endometriosis diagnosis, undergoing laparoscopy or laparotomy regardless of clinical indication? SUMMARY ANSWER: Women with surgically visualized endometriosis reported the highest chronic/cyclic pain and significantly greater dyspareunia, dysmenorrhea, and dyschezia compared with women with other gynecologic pathology (including uterine fibroids, pelvic adhesions, benign ovarian cysts, neoplasms and congenital Müllerian anomalies) or a normal pelvis. WHAT IS KNOWN ALREADY: Prior research has shown that various treatments for pain associated with endometriosis can be effective, making identification of specific pain characteristics in relation to endometriosis necessary for informing disease diagnosis and management. STUDY DESIGN, SIZE, DURATION: The study population for these analyses includes the ENDO Study (2007-2009) operative cohort: 473 women, ages 18-44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at one of 14 surgical centers located in Salt Lake City, UT or San Francisco, CA. Women with a history of surgically confirmed endometriosis were excluded. PARTICIPANTS/MATERIALS, SETTING AND METHODS: Endometriosis was defined as surgically visualized disease; staging was based on revised American Society for Reproductive Medicine (rASRM) criteria. All women completed a computer-assisted personal interview at baseline specifying 17 types of pain (rating severity via 11-point visual analog scale) and identifying any of 35 perineal and 60 full-body front and 60 full-body back sites for which they experienced pain in the last 6 months. MAIN RESULTS AND THE ROLE OF CHANCE: There was a high prevalence (≥30%) of chronic and cyclic pelvic pain reported by the entire study cohort regardless of post-operative diagnosis. However, women with a post-operative endometriosis diagnosis, compared with women diagnosed with other gynecologic disorders or a normal pelvis, reported more cyclic pelvic pain (49.5% versus 31.0% and 33.1%, P < 0.001). Additionally, women with endometriosis compared with women with a normal pelvis experienced more chronic pain (44.2 versus 30.2%, P = 0.04). Deep pain with intercourse, cramping with periods, and pain with bowel elimination were much more likely reported in women with versus without endometriosis (all P < 0.002). A higher percentage of women diagnosed with endometriosis compared with women with a normal pelvis reported vaginal (22.6 versus 10.3%, P < 0.01), right labial (18.4 versus 8.1%, P < 0.05) and left labial pain (15.3 versus 3.7%, P < 0.01) along with pain in the right/left hypogastric and umbilical abdominopelvic regions (P < 0.05 for all). Among women with endometriosis, no clear and consistent patterns emerged regarding pain characteristics and endometriosis staging or anatomic location. LIMITATIONS, REASONS FOR CAUTION: Interpretation of our findings requires caution given that we were limited in our assessment of pain characteristics by endometriosis staging and anatomic location due to the majority of women having minimal (stage I) disease (56%) and lesions in peritoneum-only location (51%). Significance tests for pain topology related to gynecologic pathology were not corrected for multiple comparisons. WIDER IMPLICATIONS OF THE FINDINGS: Results of our research suggest that while women with endometriosis appear to have higher pelvic pain, particularly dyspareunia, dysmenorrhea, dyschezia and pain in the vaginal and abdominopelvic area than women with other gynecologic disorders or a normal pelvis, pelvic pain is commonly reported among women undergoing laparoscopy, even among women with no identified gynecologic pathology. Future research should explore causes of pelvic pain among women who seek out gynecologic care but with no apparent gynecologic pathology. Given our and other's research showing little correlation between pelvic pain and rASRM staging among women with endometriosis, further development and use of a classification system that can better predict outcomes for endometriosis patients with pelvic pain for both surgical and nonsurgical treatment is needed. STUDY FUNDING/COMPETING INTERESTS: Supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts NO1-DK-6-3428, NO1-DK-6-3427, and 10001406-02). The authors have no potential competing interests.

Challenging generally accepted contraindications to vaginal hysterectomy.

OBJECTIVE: A number of preexisting clinical conditions are generally accepted as contraindications to vaginal hysterectomy. The purpose of this study was to evaluate the validity of this concept. STUDY DESIGN: The study vaginal hysterectomy group consisted of 250 consecutive patients undergoing vaginal hysterectomy. These patients (1) had a large uterus (>180 g), (2) either were nulliparous or had no previous vaginal delivery, or (3) had a previous cesarean delivery or pelvic laparotomy. Three control groups used for comparison underwent (1) laparoscopically assisted vaginal hysterectomy, (2) vaginal hysterectomy, or (3) abdominal hysterectomy. The records for all patients were analyzed for age, weight, parity, primary diagnosis, uterine size, operative time, blood loss, analgesia, hospital stay, resumption of diet, incidence of morcellation, and surgical complications. Sample size calculations were based on previous studies of complications associated with vaginal hysterectomy (alpha =.05; beta =.20). RESULTS: Hysterectomy was successfully completed by the intended vaginal route in all study patients. Major and minor complications (3.2%) were significantly less (P <.001) than in the other groups as follows: vaginal hysterectomy, 10.4%; laparoscopically assisted vaginal hysterectomy, 11.6%; and abdominal hysterectomy, 13.6%. The decrease in hematocrit was 5.7% in the study vaginal hysterectomy group compared with 6.2% for vaginal hysterectomy, 6.5% for abdominal hysterectomy (P =.009), and 6.6% for laparoscopically assisted vaginal hysterectomy (P =.002). Hospital stay was shorter for the study group (2.1 days) than for vaginal hysterectomy (2.3 days; P <.001) and abdominal hysterectomy (2.7 days; P <.001). Operative time was shorter in the study vaginal hysterectomy group (49 minutes) than with laparoscopically assisted vaginal hysterectomy (76 minutes; P <.001) or abdominal hysterectomy (61 minutes; P <.001), although morcellation was carried out more frequently in the study group (34%) than with vaginal hysterectomy (4%) or laparoscopically assisted vaginal hysterectomy (11%). CONCLUSION: Our data indicate that a large uterus, nulliparity, previous cesarean delivery, and pelvic laparotomy rarely constitute contraindications to vaginal hysterectomy.

The role of vaginal apex excision in the management of persistent posthysterectomy dyspareunia.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of vaginal apex excision in the treatment of patients with posthysterectomy dyspareunia. STUDY DESIGN: This was a case series with an independent third-party survey of patients with posthysterectomy dyspareunia managed at the University of Utah Pelvic Pain Clinic. Thirteen patients were first treated with local injections of anesthetics into localized vaginal pain foci. Further evaluation included formal psychometric testing and a diagnostic spinal block. Nine patients underwent surgical excision of the vaginal apex. An independent interviewer who did not know the patients assessed the effects of this procedure on dyspareunia and coital frequency at a mean of 36.4 +/- 3.7 months after the operation. RESULTS: The mean coital verbal analog pain score (1-10 scale) decreased from 9.22 +/- 0.27 before excision of the vaginal apex to 3.11 +/- 0.84 after the operation (P <.001), and coital frequency improved from 5.22 +/- 2.02 episodes per month before surgery to 11.11 +/- 1.82 episodes per month after surgery (P =.02). Of the 9 patients, 5 essentially had the dyspareunia cured. Dyspareunia was decreased and coital frequency was markedly increased in all but 1 of the other 4 cases. CONCLUSION: Excision of the vaginal apex is an effective treatment for carefully selected patients with posthysterectomy dyspareunia.

Dyspareunia and recurrent stress urinary incontinence after laparoscopic colposuspension with mesh and staples. A case report.

BACKGROUND: A laparoscopic colposuspension technique using hernia staples and polypropylene mesh has been introduced for the treatment of stress urinary incontinence but is not without hazards. CASE: A 32-year-old woman developed recurrent stress urinary incontinence and dyspareunia approximately one year after undergoing laparoscopic colposuspension with hernia staples and polypropylene mesh. Metal staples palpated vaginally corresponded with the area of maximal tenderness, and the bladder neck was hypermobile. Upon surgical exploration of the space of Retzius, four staples were found in the bladder wall, and polypropylene mesh densely adherent to the bladder wall had eroded into the muscularis. CONCLUSION: Laparoscopic colposuspension with hernia staples and polypropylene mesh may be associated with early recurrence of incontinence and dyspareunia.

The 4-S modification of the Roeder knot: how to tie it.

BACKGROUND: The 4-S modification of the Roeder knot may be tied laparoscopically as a single-throw knot. TECHNIQUE: It is tied by adding a fourth wrap around the suture loop and securing the loop in place with a square knot rather than a single half-hitch. EXPERIENCE: We have used this knot in laparoscopic surgeries for more than 2 years and have not observed knot slippage. CONCLUSION: This modification results in a knot comparable in strength to the strongest laparoscopic multiple-throw square knots.

Subtotal hysterectomy in modern gynecology: a decision analysis.

OBJECTIVE: Our purpose was to compare the risks and benefits of subtotal (supracervical) hysterectomy with those of total hysterectomy in women at low risk for cervical cancer. STUDY DESIGN: A decision analysis was performed. Baseline probabilities for operative and postoperative morbidity, mortality, and long-term quality of life were established for subtotal and total hysterectomy. RESULTS: Operative complication rates and ranges for total abdominal hysterectomy were infection 3.0% (3.0% to 20.0%), hemorrhage 2.0% (2.0% to 15.4%), and adjacent organ injury 1.0% (0.7% to 2.0%). Those for subtotal hysterectomy were infection 1.4% (1.0% to 5.0%), hemorrhage 2.0% (0.7% to 4.0%), and adjacent organ injury 0.7% (0.6% to 1.0%). Operative mortality, the risk for development of cervicovaginal cancer, and long-term adverse effects on sexual or vesicourethral function were low in both groups. CONCLUSIONS: Recently proposed benefits from subtotal hysterectomy are not well proven. Total hysterectomy remains the procedure of choice for most women.

Laparoscopic tubal ligation in a minimally invasive surgical unit under local anesthesia compared to a conventional operating room approach under general anesthesia.

OBJECTIVE: This study was done to compare costs, operating and recovery times, safety, and patient acceptance between (a) minimally invasive laparoscopic tubal ligation under sedation and local anesthesia and (b) conventional laparoscopic operating-room-based tubal ligations under general anesthesia. METHODS: Fourteen women desiring sterilization were randomized between tubal ligation under sedation/local analgesia versus general anesthesia. Procedures were performed by supervised residents previously unfamiliar with the minimally invasive technique. Hospital charges were used as a surrogate for cost. Operating or procedure room times, surgical complications, and recovery times were recorded. Patient acceptance was assessed using satisfaction surveys administered in the recovery room and again 1 week postoperatively. RESULTS: The cost of minimally invasive tubal ligation was significantly lower than for the conventional technique ($1,615+/-$134 vs $2,820+/-$110, p < 0.001). Surgical times were not different between the two procedures: 40.4+/-15 min for the conventional technique versus 32.9+/-10 min for minimally invasive surgery. However, the total in-room time required in the operating room significantly exceeded that for the procedure room technique (84+/-10 min vs 60+/-2 min, p < 0.05). Likewise, recovery time for the general anesthesia technique was longer (48+/-6 min vs 14+/-7 min, p < 0.03). No complications were encountered with either surgical method. Patient satisfaction for pain, fatigue, and days of missed work was similar between the two groups. CONCLUSIONS: The use of minimally invasive surgery to perform tubal ligation is advantageous over conventional laparoscopic tubal ligation under general anesthesia with regard to cost and time utilization. The minimally invasive technique appears to be easy to learn, safe, and well tolerated.

The effect of knot geometry on the strength of laparoscopic slip knots.

OBJECTIVE: To evaluate and compare the strength of six different knot geometries used in laparoscopic slip knots. METHODS: The strength of six extracorporeal slip knots used in laparoscopic surgery was measured using a tensiometer. Two multiple-throw laparoscopic square knots (the intracorporeal two-turn flat square knot and the extracorporeal sliding square knot) were used as controls. Each knot type was tied five times, and each type was tied in random order by the same primary and assisting surgeons using a laparoscopic pelvic surgery training model. One-way analysis of variance was performed to detect significant differences in knot strengths, and the variability in knot strength for each knot type was determined by Tukey's multiple comparison test. RESULTS: A statistically significant effect for knot geometry was identified. The mean knot strengths +/- standard deviation (SD), measured in newtons, from strongest to weakest, were: 4S knot (28.01 +/- 11.45), fisherman's knot (22.45 +/- 6.89), modified Roeder knot (19.86 +/- 9.30), Roeder knot (15.77 +/- 7.02), Weston knot (7.28 +/- 7.96), and Duncan knot (6.55 +/- 0.95). The mean knot strengths for the multiple-throw control square knots were as follows: intracorporeal two-turn flat square knot (41.21 +/- 2.69) and extracorporeal sliding square knot (27.81 +/- 16.27). The intracorporeal two-turn flat square knot (control) was significantly stronger (P < .05) than all slip knots except the 4S and fisherman's knot. CONCLUSION: The 4S and fisherman's knots are the strongest laparoscopic slip knots and are the only slip knots similar in strength to multiple-throw square knots.

A simple modification to add strength to the Roeder knot.

The Roeder knot is commonly used during laparoscopic suturing because it may be tied extracorporeally and slid down to the target tissue with a single pass of a knot pusher. However, it is significantly weaker than extracorporeally tied knots with several throws. We compared the usual Roeder knot to one that was modified by adding a fourth loop around the standing end of the suture and a second half-hitch to the completed knot. The modified knot (26.6 newtons +/- 15.3) was significantly stronger (p <0.05) than the standard Roeder knot (18.0 newtons +/- 12.1). If a single-pass extracorporeal knot is to be used, we recommend a modified Roeder knot when ligating pedicles at laparoscopy.

Laparoscopic sacral colpopexy and other procedures for prolapse.

The repair of pelvic support defects is a demanding task. Irrespective of the route or repair chosen by the surgeon, sound surgical judgement, complete understanding of pelvic anatomy and the mechanisms involved in pelvic organ prolapse, and expertise in pelvic surgery are required if successful outcomes are to be expected. Laparoscopic surgery offers a substitute for conventional open abdominal surgery which, in our hospital, now has a record of low complication rates, speedy discharge and recovery times with outcomes that are equal to those achieved by conventional abdominal surgery. This type of surgery is no more difficult to perform than open abdominal surgery. However, it demands the same rigorous training and a very significant amount of time and dedicated effort to learn. The pelvic surgeon who desires to practise this form of advanced laparoscopic surgery must accept these facts. Obviously, more cases and long-term follow-up are needed for meaningful statistical analysis. Randomized prospective trials are greatly preferred, however, it is difficult for the laparoscopic surgeon to carry out such studies when the majority of patients are referred specifically for the laparoscopic route. Good sound statistical data are now becoming available concerning some essential components of the procedure such as laparoscopic knot and suture strengths. It seems very reasonable to conclude that, based on early experience with laparoscopic pelvic reconstruction, the future of this approach is bright.

Laparoscopic knot strength: a comparison with conventional knots.

OBJECTIVE: To compare the strength of laparoscopic knots with those used at laparotomy. METHODS: Three types of laparoscopic knots commonly used (Roeder, extracorporeal sliding square, and intracorporeal two-turn flat square) and three widely used conventional knots (flat square, surgeon's square, and sliding square) were tied using seven suture materials. Each knot was tied five times in random order by a single surgeon in a pelvic training model. Knot strengths were scored by tensiometer readings. A two-way analysis of variance was performed to uncover differences in mean knot strength. Turkey multiple-comparisons test was performed to determine the variability in strength of different knot geometries. Knot strength was measured in newtons. RESULTS: Significant main effects for knot geometry (P < .05) and material (P < .05) as they contribute to differences in knot strength were identified, as well as an interaction for knot geometry with material (P < .05). The laparoscopic Roeder knot was significantly weaker than all other laparoscopic and conventional knots tested. The laparoscopic extracoporeal sliding square knot was significantly weaker than the conventional surgeon's square knot, and the conventional sliding square knot was significantly weaker than the conventional flat square knot and the surgeon's knot. The laparoscopic intracorporeal two-turn flat square knot was as strong as the strongest conventional knot. A significant main effect was discovered for knots with eight throws. CONCLUSION: When performing laparoscopic procedures that result in significant tension on suture lines, consideration should be given to using the stronger laparoscopic knots, such as the intracorporeal two-turn flat square knot and the extracorporeal sliding square knot, instead of the weaker Roeder knot.

Comparison of the ClearView uterine manipulator with the Cohen cannula in laparoscopy.

The ClearView Uterine Manipulator was compared with the Cohen acorn-tipped cannula for efficacy and safety in patients undergoing laparoscopy at the University of Utah Medical Center. Fifty consecutive patients were randomized by computer to have either the ClearView instrument or the Cohen cannula used as a uterine manipulator (25 patients each). The ClearView manipulator was statistically superior to the Cohen cannula for range of motion in the anterior and posterior sagittal plane (p <0.0001). The Cohen cannula was consistently inserted in less time (p <0.02). There was no statistically significant difference between the instruments in ease of uterine manipulation, ease of dye instillation, percentage of dye leakage from the cervix, overall ease of use, ease of device insertion, and ease of device removal. Two cervical perforations occurred during cervical dilatation in the ClearView manipulator group in patients with cervical stenosis requiring dilatation with metal dilators (os <2 mm). No patients in the Cohen cannula group had cervical stenosis. In that group two cervical lacerations occurred requiring suture ligation. The ClearView instrument provides a greater range of motion, does not require an assistant to maintain uterine position, and allows manipulation without a cervical tenaculum. Its insertion occasionally (36%) required tenaculum placement, uterine sounding, and cervical dilatation, increasing the time of insertion compared with placement of the Cohen cannula. In patients with cervical stenosis, use of a uterine sound and cervical dilatation increase the risk of perforation.

Cervical ripening before induction of labor: a randomized trial of prostaglandin E2 gel versus low-dose oxytocin.

OBJECTIVE: The purpose of this study was to compare prostaglandin E2 gel and a low-dose infusion of oxytocin for cervical ripening before labor induction. STUDY DESIGN: A total of 158 women were randomized to receive either two intracervical doses of 0.5 mg prostaglandin E2 gel 6 hours apart or 12 hours of intravenous oxytocin up to 4 mlU/min. After cervical ripening labor was induced with high-dose oxytocin infusion and amniotomy. RESULTS: There was no difference between the prostaglandin E2 and low-dose oxytocin groups in the likelihood of being in labor or having a Bishop score favorable for induction after ripening (64.2% vs 52.0%, p = 0.12) or in the incidence of vaginal delivery (75.9% vs 74.7%). Prostaglandin E2-treated patients were delivered sooner (20.2 +/- 8.1 hours vs 25.0 +/- 10.5 hours, p = 0.002). Among delivered patients the likelihood of vaginal delivery within 24 hours was greater with prostaglandin E2 ripening (63.7% vs 47.2%, p = 0.04), but there was no difference at 36 hours (76.2% vs 75.0%). Uterine hyperstimulation and fetal distress during ripening occurred only in the prostaglandin E2 group, at a rate of 4.8%. CONCLUSIONS: After cervical ripening with prostaglandin E2 gel or low-dose oxytocin vaginal delivery can be expected in three fourths of patients within 24 to 36 hours. We recommend that patients with an unfavorable cervix who require delivery undergo cervical ripening and induction of labor rather than automatic delivery by cesarean section.