Clinical Diagnosis and Early Medical Management for Endometriosis: Consensus from Asian Expert Group.

This work provides consensus guidance regarding clinical diagnosis and early medical management of endometriosis within Asia. Clinicians with expertise in endometriosis critically evaluated available evidence on clinical diagnosis and early medical management and their applicability to current clinical practices. Clinical diagnosis should focus on symptom recognition, which can be presumed to be endometriosis without laparoscopic confirmation. Transvaginal sonography can be appropriate for diagnosing pelvic endometriosis in select patients. For early empiric treatment, management of women with clinical presentation suggestive of endometriosis should be individualized and consider presentation and therapeutic need. Medical treatment is recommended to reduce endometriosis-associated pelvic pain for patients with no immediate pregnancy desires. Hormonal treatment can be considered for pelvic pain with a clinical endometriosis diagnosis; progestins are a first-line management option for early medical treatment, with oral progestin-based therapies generally a better option compared with combined oral contraceptives because of their safety profile. Dienogest can be used long-term if needed and a larger evidence base supports dienogest use compared with gonadotropin-releasing hormone agonists (GnRHa) as first-line medical therapy. GnRHa may be considered for first-line therapy in some specific situations or as short-term therapy before dienogest and non-steroidal anti-inflammatory drugs as add-on therapy for endometriosis-associated pelvic pain.

Laparoscopic management of 4 cases of recurrent cornual ectopic pregnancy and review of literature.

The objectives of this retrospective case series were to report our experience with laparoscopic management of recurrent cornual ectopic pregnancy in a tertiary care center and to present a review of the literature. Four patients experienced recurrent cornual ectopic pregnancy, and 1 patient had 2 consecutive recurrences. Laparoscopic surgery was performed to treat recurrent cornual ectopic pregnancy in all 4 patients. These 4 cases together with 10 cases collated from the literature review confirm that this entity is rare. Cornual ectopic pregnancy can recur as early as 4 months and as late as 5 years after the first ectopic pregnancy. There seems to be no correlation between the treatment method of the first ectopic pregnancy and the risk of recurrence. The etiology of recurrent cornual ectopic pregnancy is not fully understood, although it shares similar risk factors with tubal ectopic pregnancy. Both medical therapy and surgery are used to treat recurrent cornual ectopic pregnancy, with surgery often performed via laparotomy. These 4 cases constitute the largest case series of recurrent cornual ectopic pregnancy treated laparoscopically. Our experience with laparoscopic management of recurrent cornual ectopic pregnancy in a tertiary care center reveals that it is effective and safe.

Laparoscopic management of 53 cases of cornual ectopic pregnancy.

OBJECTIVE: To present our experience of laparoscopic management of cornual ectopic pregnancy. DESIGN: Retrospective review of 53 cases of cornual pregnancy treated laparoscopically. SETTING: K.K. Women's and Children's Hospital, Singapore. PATIENT(S): Patients who were treated for cornual pregnancy via laparoscopic surgery from 2001 to 2006. INTERVENTION(S): Laparoscopic surgery as a treatment modality for cornual pregnancy. MAIN OUTCOME MEASURE(S): Success rate of laparoscopic surgery and future reproductive outcome. RESULT(S): Fifty-two cases were managed by laparoscopy, and one was converted to laparotomy. Laparoscopic wedge resection was carried out in 33 patients, cornuostomy in 13 patients, and salpingectomy in 7 patients. Nine patients received methotrexate injection after surgery because of persistently high serum beta-hCG. Eighteen patients became pregnant, four had early miscarriages, and ten had pregnancies beyond 24 weeks' gestation. Five delivered vaginally, and three had cesarean section at term. Two patients traveled back to their native countries for delivery. There were no cases of uterine rupture or dehiscence reported. CONCLUSION(S): Laparoscopic treatment of cornual pregnancy can be safely carried out with good results in an institution with trained laparoscopist and adequate facilities.

Laparoscopic excision of rudimentary horn pregnancy in a patient with previous caesarean section.

A rudimentary uterine horn is extremely rare and often difficult to diagnose. The frequency of this pathology is approximately 1:100,000. The diagnosis is sometimes elusive even at surgery. We present a case report of pregnancy in a rudimentary horn in the patient with one caesarean and one normal vaginal delivery, and we successfully conduct a removal of the rudimentary horn pregnancy laparoscopically.

Parasitic dermoid cyst of the pouch of Douglas: a case report.

Extragonadal mature cystic teratomas (dermoid cysts) are reported occasionally, with the most common site being the omentum. Of the 3 proposed causes of such cysts, torsion of a pre-existing dermoid, leading to autoamputation and subsequent reimplantation, is most likely the preceding event. A rare case of a parasitic benign cystic teratoma was incidentally found in the pouch of Douglas in a 29-year-old woman undergoing a laparoscopic right cystectomy for an ovarian dermoid cyst. A literature review indicates that this is the third reported case of a parasitic or wandering dermoid cyst of the pouch of Douglas.

Retrospective study of the success rates and complications associated with total laparoscopic hysterectomy.

AIMS: Laparoscopic techniques are being used increasingly more in gynecologic surgery and the introduction of modern laparoscopic instruments has allowed complex operations to be performed laparoscopically. The aim of this study is to evaluate our surgical technique with regard to the success of total laparoscopic hysterectomy (TLH) for the removal of the uterus, by analyzing its intraoperative and postoperative surgical outcomes and complications in the hope of reducing their occurrence. METHODS: A retrospective observational study was carried out at KK Hospital, Singapore, based on TLH operations performed from January 2001 to June 2005. The KOH Colpotomizer System and the RUMI Uterine Manipulator were the surgical methods used. RESULTS: 435 women consented for a TLH. 427 women (98.2%) had a successful TLH with three mini-laparotomy and five laparotomy conversions (1.8% failure rate). Injuries included bowel injury (four), bladder base bleeding (one), uterine perforation (one), uterovaginal fistula (one) and vaginal laceration (four). 21 women (4.8%) encountered major complications (defined as laparotomy conversion, excessive bleeding requiring blood transfusion, hemorrhage >or=1000 mL, ureteric injury, bowel injury and pulmonary embolus), which compares favorably with previous reports (4.0-11.0%) of laparoscopic hysterectomy. Our mean operating time, mean estimated blood loss, mean hospital stay and readmission rate are similarly comparable. CONCLUSION: TLH is associated with a high success rate, and low morbidity with few complications.

Initial Asian experience in hysteroscopic sterilisation using the Essure permanent birth control device.

OBJECTIVE: To present our initial experience in the use of the Essure permanent birth control device in a predominately Asian population. DESIGN: A retrospective study. SETTING: Minimally Invasive Surgery Unit, KK Women's and Children's Hospital, Singapore. POPULATION: Eighty women seeking permanent birth control. METHODS: From 22 June 2001, women who sought sterilisation were counselled with regards to the various options of permanent birth control. Informed consent for hysteroscopic sterilisation was obtained only after the woman met the criteria for Essure permanent birth control. The sterilisation procedure was carried out without the need for general anaesthesia in a day surgery centre using the Essure permanent birth control device. The surgical details and post procedure follow up were analysed. MAIN OUTCOME MEASURES: Feasibility and safety of the Essure permanent birth control device in Asians and its non-placement rate. RESULTS: No serious adverse events or complications were encountered in using the Essure device. No pregnancies have been reported in our series to date. A significant reduction in the Essure device non-placement rate (20.0%vs 4.0%, P= 0.021) and mean operation time (27.3 vs 19.6 minutes, P= 0.006) were seen when patients were pre-medicated with spasmolytic agent and analgesia. CONCLUSIONS: The Essure permanent birth control device is safe and suitable for Asians. Its non-placement rate may be improved with pre-medication of spasmolytic agent and analgesia.