Approach to ureteral endometriosis: A single-center experience and meta-analysis of the literature.

AIM: To report single-center outcomes of laparoscopic management of patients with ureteral endometriosis and perform a meta-analysis in order to select the best approach for these patients. METHODS: The cross-sectional study was conducted during a 6-year period (2015-2021) in the referral endometriosis center on 353 patients with ureteral endometriosis. For the meta-analysis, 10 articles, including 505 patients, were found to be eligible. In our meta-analysis, as well as our study, all endometriosis-related pain symptoms and complications of surgery were evaluated, analyzed, and reported. RESULTS: Of the 326 patients whose ureteral involvement was confirmed in pathology, hydronephrosis and intrinsic ureteral lesions were detected in only 10.76% and 3.1% of the patients. Mean operating time and hospitalization were 3.25 ± 1.83 h and 86 ± 2.58 days, respectively. The most common site of concomitant involvement with endometriosis was uterosacral ligament (92.9%) and rectosigmoid (70.53%). Type II and III of Cliven-Dindo complications were seen in 5.66% and 1.13% of patients, respectively. During a follow-up period, no evidence of bladder or ureteral re-involvement was observed. Similar to our meta-analysis, all endometriosis-related pain decreased significantly following operation (p ≤ 0.001). In our meta-analysis, the rate of ureteral endometriosis recurrence, stenosis/stricture, bladder atonia, urinary tract infection, hematuria, and fistula formation after surgery were: 2.0% (I2 : 50.42%), 15.0% (I2 : 0.00%), 14.0% (I2 : 8.76%), 6.0% (I2 : 0.00%), 7.0% (I2 : 79.28%), and 2.0% (I2 : 0.0%), respectively. CONCLUSION: The laparoscopic resection of the UE could be suggested as a feasible and safe method associated with favorable functional outcomes.

Evaluation and comparison of the accuracy of transvaginal ultrasound and MRI for the diagnosis of deep rectal endometriosis: A cross-sectional study.

OBJECTIVE: To determine and compare the value of magnetic resonance imaging (MRI) and transvaginal sonography (TVS) in the diagnosis of rectal endometriosis. METHODS: In this cross-sectional study, 555 patients with rectal endometriosis, who had undergone MRI and TVS before laparoscopic operation, were included. The sensitivity, specificity, and accuracy of these two imaging modalities were evaluated and compared based on histopathologic reports and three different kinds of rectal endometriosis surgeries (shaving as a first group and disk and segmental resection methods combined as a second group). RESULTS: Sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of ultrasound in the diagnosis of rectal endometriosis were, respectively, 69.55% (65.4%-73.4%), 91.30% (72%-98.9%), 70.4% (66.4%-74.17%), 11.48% (9.77%-13.43%), 99.46% (98%-99.86%), 8.0 (2.12-30.1), and 0.3 (0.28-0.4). These values were 51.37% (47.1%-55.6%), 79.17% (57.8%-92.9%), 52.53% (48.3%-56.6%), 6.64% (5.39%-8.16%), 98.26% (96.26%-99.2%), 2.47 (1.13-5.4), and 0.6 (0.49-077) for MRI. Even though ultrasound had better accuracy for detection of superficial rectal endometriosis (Group 1) (P < 0.001), the sensitivity, specificity, and accuracy of both imaging modalities in diagnosis of deep rectal lesions (Group 2) were almost identical. CONCLUSION: TVS should be considered as a first-line modality for diagnosis of rectal endometriosis, mainly because of its greater availability, lower cost, and higher accuracy.

A comparison of the effect of short-term aromatase inhibitor (letrozole) and GnRH agonist (triptorelin) versus case control on pregnancy rate and symptom and sign recurrence after laparoscopic treatment of endometriosis.

PURPOSE: To compare the role of an aromatase inhibitor (letrozole) with a GnRH agonist (triptorelin) versus case control on the pregnancy rate and recurrence of symptoms and signs in patients with endometriosis. METHODS: In a prospective randomized clinical trial, after treatment of 144 infertile women in their reproductive age by laparoscopy (whose endometriosis was confirmed by prior laparoscopy), they were divided into 3 groups: group 1 (47 cases) who received letrozole for 2 months, group 2 (40 patients) who were prescribed triptorelin for 2 months and group 3 who were 57 patients in the control group and did not receive any medication. We followed up each group at least for 12 months after their restoration of regular cycle. RESULTS: Pregnancy rate was 23.4% in group 1, 27.5% in group 2, and 28.1% in group 3. The results did not show significant differences among the 3 groups. Recurrence rate of endometriosis was 6.4% in group 1, 5% group 2 and 5.3% in group 3, which was not statistically significantly different as well. CONCLUSION: Pregnancy rate and endometriosis recurrence rate are comparable among the 3 groups.

Determination of antiovarian antibodies after laparoscopic ovarian electrocauterization in patients with polycystic ovary syndrome.

OBJECTIVE: To determine whether ovarian damage consequent to laparoscopic ovarian electrocauterization may result in the development of humoral autoimmunity and production of antiovarian antibodies (AOA). DESIGN: Prospective study. SETTING: Infertility and gynecologic endoscopy units of one of the medical university hospitals. PATIENT(S): Sixty-four reproductive-age infertile women (

A comparison of combined laparoscopic uterine artery ligation and myomectomy versus laparoscopic myomectomy in treatment of symptomatic myoma.

OBJECTIVE: To evaluate the efficacy of uterine artery ligation before laparoscopic myomectomy compared with myomectomy alone. DESIGN: Prospective controlled, clinical trial. SETTING: Private and Shiraz University-affiliated hospitals. PATIENT(S): Of 152 women with symptomatic uterine myomas necessitating surgical intervention who wished to retain their uteri, 65 underwent laparoscopic uterine artery ligation and myomectomy (experimental group) and 87 received laparoscopic myomectomy only (control group). INTERVENTION(S): Ligation of the uterine arteries before laparoscopic myomectomy. MAIN OUTCOME MEASURE(S): Operating time, blood loss, blood transfusion, febrile morbidity, symptoms improvement, recurrence rate, and pregnancy rate. RESULT(S): The average operating time and blood loss were 112 +/- 18 minutes and 173 +/- 91 mL for the experimental group and 95 +/- 14 minutes and 402 +/- 131 mL for the control group, respectively (statistically significant). A total of 15 (17.2%) of the control group patients required a blood transfusion, but none of the experimental group patients required one. Febrile morbidity occurred in 18.5% of the experimental group and 20.7% of the control group. In the experimental group, the recurrence of myoma was 6.2%, and 98.1% of the patients reported symptoms improvement; however, in the control group, these figures were 20.75% and 83.1%, respectively (statistically significant). The pregnancy rates were not statistically significantly different in the experimental group (35%) and the control group (35.7%). CONCLUSION(S): This study demonstrated the superiority of laparoscopic uterine artery ligation combined with myomectomy in treatment of symptomatic myomas.

Laparoscopic metroplasty in bicornuate and didelphic uteri.

OBJECTIVE: To determine the feasibility of laparoscopic metroplasty in the treatment of bicornuate and didelphic uteri. DESIGN: Case report. SETTING: University and private hospitals. PATIENT(S): Four women with a diagnosis of double uterine cavity (two bicornuate and two didelphic uteri) with a history of two recurrent spontaneous abortions at less than 5 months of pregnancy. INTERVENTION(S): Laparoscopic metroplasty with diagnostic hysteroscopy was performed for the unification of the uterus. Second-look laparoscopy and hysteroscopy was performed about 3 months later. MAIN OUTCOME MEASURE(S): Evaluation of the uterine compliance to high intrauterine pressure and presence of adhesions in the pelvic and uterine cavities. RESULT(S): In all four patients, laparoscopic metroplasty resulted in a unified uterus with a good cavity and tolerance to high intrauterine pressure. Minimal pelvic adhesions were noted in the two patients at the second surgery. CONCLUSION(S): This new technique of laparoscopic metroplasty is an acceptable alternative for abdominal metroplasty, with minimal adhesion formation.

A comparison of histopathologic findings of ovarian tissue inadvertently excised with endometrioma and other kinds of benign ovarian cyst in patients undergoing laparoscopy versus laparotomy.

OBJECTIVE: To evaluate ovarian tissue inadvertently excised with benign cysts during laparotomy or laparoscopy. DESIGN: Prospective study. SETTING: Private and university hospitals. PATIENT(S): 260 women, 20 to 35 years old, with unilateral benign ovarian cysts. INTERVENTION(S): One hundred fifty women operated by laparoscopic cystectomy stripping technique, and 110 women operated by laparotomy with the same technique. MAIN OUTCOME MEASURE(S): Histopathologic findings of ovarian tissue inadvertently excised in endometrioma compared with other kinds of benign cysts in laparoscopy versus laparotomy. RESULT(S): In the laparoscopy group, ovarian tissue was present in 65% of endometrioma and in 32% of nonendometriotic cysts. In the laparotomy group, ovarian tissue was seen in 80% of endometrioma and 41% of nonendometriotic cysts. CONCLUSION(S): The surgical approach had no statistically significant impact on conservation of ovarian reserves. The nature of the ovarian cyst played a greater role in the quality and quantity of the excised ovarian tissue.

A comparison of follicular response of ovaries to ovulation induction after laparoscopic ovarian cystectomy or fenestration and coagulation versus normal ovaries in patients with endometrioma.

In a comparison of follicular responses to controlled ovarian hyperstimulation (COH) between normal ovaries and ovaries previously treated by different laparoscopic techniques for ovarian endometrioma in 65 patients with unilateral endometrioma, laparoscopic ovarian fenestration and coagulation was performed in 24 cases (group 1) and laparoscopic ovarian cystectomy in the other 41 (group 2). In 16 patients with bilateral endometrioma (group 3), cystectomy was done in one ovary and fenestration and coagulation in the contralateral side. The results indicate that the response of ovaries to COH after laparoscopic ovarian cystectomy or fenestration and coagulation was the same and that there was no difference in response to COH between normal ovaries and those operated on by the laparoscopic techniques mentioned above.

Pentoxifylline therapy after laparoscopic surgery for different stages of endometriosis: a prospective, double-blind, randomized, placebo-controlled study.

STUDY OBJECTIVE: To evaluate the effects of pentoxifylline administration on patients with different stages of endometriosis on whom laparoscopy was performed. DESIGN: Prospective, double-blind, randomized, placebo-controlled clinical (Canadian Task Force classification I). SETTING: University and private hospitals. PATIENTS: Eighty-eight women, all with infertility, some with dysmenorrhea, dyspareunia, or pelvic pain, on whom a laparoscopic diagnosis of endometriosis was made. INTERVENTIONS: The treatment group received 800 mg pentoxifylline daily for 6 months immediately after surgery. The control group received placebo capsules. All patients were followed-up for 1 year thereafter. MEASUREMENTS AND MAIN RESULTS: A comparison of pregnancy rate and recurrence of signs and symptoms in the 2 groups was performed. Forty-three patients were studied in the pentoxifylline group and 45 in the placebo group. The cumulative pregnancy rate was 39.5% and 35.6% in the treatment and control groups, respectively. The overall recurrence of signs and symptoms was 14% in the former group and 15.6% in the latter. There were no statistically significant differences between the 2 groups in rates of pregnancy and recurrence (p = .700 and .832, respectively). Nor was there any significant statistical difference between the same stages in the 2 groups regarding immunomodulation. CONCLUSIONS: According to the results of this study, and while keeping in mind that appropriate surgery is the main aspect of endometriosis treatment, there is no evidence that immunomodulation with pentoxifylline aids fertility or lessens recurrence of signs and symptoms in women with different stages of endometriosis (i.e., minimal, mild, moderate, or severe).

Management of ovarian endometrioma.

The optimal conservative treatment for endometriotic cysts is unclear, particularly when treated laparoscopically. We performed a systematic analysis of the published literature on ovarian endometrioma especially focused on comparing laparoscopic cystectomy with laparoscopic drainage and coagulation of the cyst with regard to evaluating advantage and disadvantage of each method. We observed that cystectomy was superior in terms of risk of recurrent symptoms, cyst, reoperation, pregnancy: this was true in both prospective and retrospective studies previously published. Given the evidence available, excision of cyst wall in endometrioma is strongly recommended especially in infertile patients.

A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas.

OBJECTIVE: To determine the difference between two laparoscopic methods for the management of endometriomas with regard to recurrence of signs and symptoms and pregnancy rate. DESIGN: Prospective, randomized clinical trial. SETTING: Infertility and gynecologic endoscopy units of two medical university hospitals. PATIENT(S): One hundred patients with endometriomas who had either infertility or pelvic pain. INTERVENTION(S): Patients were randomly divided into two groups; one group underwent cystectomy (group 1), and fenestration and coagulation were performed for the other (group 2). MAIN OUTCOME MEASURE(S): A comparison of recurrence of signs and symptoms of endometriomas and pregnancy rates in two groups. RESULT(S): Fifty-two patients were studied in group 1 and 48 in group 2. The recurrence of symptoms, such as pelvic pain and dysmenorrhea, was 15.8% in group 1 and 56.7% in group 2 after 2 years. The rate of reoperation was 5.8% in group 1 and 22.9% in group 2 and these differences were statistically significant. The cumulative pregnancy rate was significantly higher in group 1 (59.4%) than in group 2 (23.3%) at 1-year follow-up. CONCLUSION(S): Laparoscopic cystectomy of endometriomas is a better choice than fenestration and coagulation because the former technique leads to a lower recurrence of signs and symptoms and a lower rate of reoperation and a higher cumulative pregnancy rate than the latter.