Clinical and Sonographic Progression of Bowel Endometriosis: 3-Year Follow-up.

The aim of this study was to evaluate progression of the bowel endometriosis lesion over time. We performed a retrospective cohort with 164 patients with rectosigmoid endometriosis identified by transvaginal ultrasound (TVUS) with bowel preparation waiting for surgical treatment. Length and circumference of the bowel lesion evaluated by TVUS, painful symptoms (dysmenorrhea, dyspareunia, noncyclic pelvic pain, dyschezia, dysuria), and menopausal status were assessed at baseline and 6, 12, 24, 36, and > 36 months. A linear mixed model was used and p values < 0.05 were considered significant. We considered the length and the circumference as the main parameter; the characteristics were considered as fixed effects and the patient as random effect. This model allows to deal with missing data from longitudinal studies. All painful symptoms significantly improved during follow-up. Overall, the mean length and circumference of the greatest bowel lesion were 2.9 ± 1.8 cm and 27 ± 10%, respectively, and those did not change over time (p > 0.05). Patients with severe dyspareunia had significant greater circumference (p = 0.037) and those with severe dyschezia had significant greater length (p = 0.047) of bowel lesions. Symptoms were not related with progression of the lesion over time. The bowel lesion length significantly decreased over time in patients in menopause (p = 0.009). There was no difference in the bowel lesion length between patients with and without hormonal treatment (p > 0.05). The results suggest that bowel endometriosis does not increase over time during reproductive age and reduces after menopause. Symptoms are also not related to the bowel lesion progression.

Surgery for Endometriosis Improves Major Domains of Quality of Life: A Systematic Review and Meta-Analysis.

Because surgery for endometriosis can involve severe complications, it is important to determine if the patient's quality of life (QOL) is indeed improved after surgery. A systematic review and meta-analysis, when appropriate, was conducted and included 38 studies that assessed the QOL using validated questionnaires administered before and after surgery. Results were grouped according to the type of endometriosis reported: all types endometriosis, deep infiltrative endometriosis (DIE), and bowel endometriosis. Quantitative analysis was performed on 17 homogeneous studies. Pooled response mean differences between the 36-Item and 12-Item Short Form Survey (SF-36 and SF-12) showed significant improvement in Mental Component Score (MCS) after surgery for all types of endometriosis (.21; 95% confidence interval [CI], .04-.38); significant improvement after surgical treatment for DIE in Vitality (.67; 95% CI, .41-.94), Social Functioning (.59; 95% CI, .18-.99), Role Emotional .49; 95% CI, .02-.97), Mental Health (.39; 95% CI, .03-.74), Physical Functioning (.93; 95% CI, .49-1.38), Bodily Pain (1.23; 95% CI, .47-1.99), General Health (.57; 95% CI, .02-1.12), MCS (.55; 95% CI, .10-1.00), and Physical Component Score (PCS; .73; 95% CI, .27-1.18); and significant improvement after surgery for bowel endometriosis for all 8 domains (Vitality [1.00; 95% CI, .56-1.43], Social Functioning [.97; 95% CI, .57-1.37], Role Emotional [1.17; 95% CI, .7-1.63], Mental Health [.94; 95% CI, .5-1.38], Physical Functioning [.74; 95% CI, .3-1.18], Role Physical [1.25; 95% CI, .75-1.76], Bodily Pain [1.39; 95% CI, .79-1.98], General Health [.84; 95% CI, 1.46-1.22]), MCS (.93; 95% CI, .47-1.40), PCS (.82; 95% CI, .40-1.23), and total score (1.15; 95% CI, .48-1.83). Only 1 study assessed patients with minimal disease and showed significant improvement in PCS (p = .002) and MCS (p <.001). This systematic review reveals that surgery for endometriosis resulted in overall improvement in most health domains of health-related QOL, with the greatest improvement found in the Bodily Pain domain.

Endometriosis classification according to pain symptoms: can the ASRM classification be improved?

Endometriosis is a chronic disease that affects 5-15% of women of the reproductive age. Different classifications systems have been proposed to categorize endometriosis. In 1979, the American Fertility Society proposed a new system for the classification of endometriosis to correlate surgical findings of endometriosis with fertility, and this system was revised in 1996 (rASRM). Despite the fact that the rASRM classification system is widely used and accepted worldwide, it has limitations. The objectives of this study were to critically assess and discuss the current classification of endometriosis according to pain.

Surgical treatment of different types of endometriosis: Comparison of major society guidelines and preferred clinical algorithms.

Treatment options for patients with different types of endometriosis - superficial, ovarian, or deep - vary depending on the clinical presentation. New findings in the recent years regarding the role of preoperative imaging, efficacy of medical therapy, and effect of surgery on ovarian reserve have changed the way we understand the disease and subsequently the way we treat our patients. Practicing clinicians frequently refer to published recommendations from major societies for treatment guidelines. This paper aims to present and compare the varying major society guidelines on the indications and best surgical treatment approach for the management of the different types of endometriosis. We also present our preferred surgical treatment algorithm given the evidence in the literature and our cumulative 30-year clinical experience in a large tertiary referral center.

Fertility-Sparing Treatment of Adenomyosis in Patients With Infertility: A Systematic Review of Current Options.

Adenomyosis is a benign gynecological disease observed in women in their reproductive age. Recent studies have shown that adenomyosis might be a relevant factor for infertility, either impairing implantation or leading to early miscarriage. However, conservative treatment of infertility related to adenomyosis is still unclear. This study systematically reviews the literature for the reproductive outcomes of the available conservative treatments for patients with adenomyosis-associated infertility. We conducted a search in PubMed/Medline for studies in English published in the last 7 years and included 16 studies. Six studies evaluated surgical treatments of adenomyosis. When considering only spontaneous pregnancies, the overall clinical pregnancy rate was very low (18.2%). However, when using GnRH analogues for 24 weeks after surgery, the pooled spontaneous pregnancy rate was higher (40.7% vs 15.0%; P = .002). No significant difference was observed in the other outcomes. Ten studies evaluated exclusive assisted reproductive techniques for infertility related to adenomyosis and showed that the long stimulation protocol had better outcomes compared to short stimulation protocol in pregnancy rate (43.3% vs 31.8%; P = .0001), live birth (43.0% vs 23.1%; P = .005), and miscarriage (18.5% vs 31.1%; P < .0001).

Transvaginal Ultrasound for the Diagnosis of Adenomyosis: Systematic Review and Meta-Analysis.

Adenomyosis is characterized by the presence of ectopic foci of endometrial glandular tissue and/or stroma within the myometrium. The diagnosis of adenomyosis is traditionally made through histologic evaluation of the postsurgical specimen. More recently, imaging with transvaginal ultrasound (TVUS) has been used for the preoperative diagnosis of adenomyosis. As yet, there is no consensus regarding the best imaging feature or combination thereof for the nonsurgical diagnosis of adenomyosis. This study systematically evaluated the literature in the last 10 years to determine the accuracy of 2-dimensional (2D) TVUS, different imaging features, enhancing methods such as 3-dimensional (3D) TVUS, elastography and color Doppler in the nonsurgical diagnosis of adenomyosis. A total of 8 studies were included. Pooled sensitivity and specificity for 2D TVUS for the diagnosis of adenomyosis for all combined imaging characteristics was 83.8% and 63.9%, respectively. Pooled sensitivity for 355 total patients with use of imaging feature of heterogeneous myometrium with 2D TVUS was highest (86.0%), and pooled specificity for 283 total patients with use of globular uterus was highest (78.1%). After including the "question mark" sign with other TVUS features, higher sensitivity and specificity, of 92% and 88%, respectively, were noted. For 3D TVUS, pooled sensitivity and specificity for all combined imaging characteristics was 88.9% and 56.0%, respectively. Poor definition of junctional zone showed the highest pooled sensitivity (86%) and the highest pooled specificity (56.0%) for the diagnosis of adenomyosis with 3D TVUS. There was no improvement in overall accuracy in 3D TVUS compared with 2D TVUS. Preliminary results of TVUS with color Doppler showed a high sensitivity and specificity for the differentiation between adenomyosis and myomas (95.6% and 93.4%, respectively). Also, TVUS elastography in 1 study showed an improvement in specificity (82.9%) compared with 2D TVUS (63.9%), albeit with comparable sensitivity. Larger studies are needed to advance our understanding of the different types of adenomyosis and their clinical impact.

Advances on minimally invasive approach for benign total hysterectomy: a systematic review.

Hysterectomy is one of the most commonly performed gynecologic surgeries, mainly for uterine myomas, abnormal uterine bleeding, and prolapses. It can be performed through several routes, each of which has its advantages and disadvantages. We conducted this systematic review to evaluate recent advances in surgical outcomes of benign total hysterectomies by any route: vaginal (VH), laparoscopic (LH), laparoscopically assisted vaginal (LAVH), single-port (SP), and robotic-assisted laparoscopy (RH). The search was applied to the PubMed electronic database by using keywords "hysterectomy" and "uterine benign disease", "adenomyosis", and "myoma". Prospective and randomized trials of the last 3 years were included. Nine studies were selected and showed that VH was superior to LH, LAVH, and RH in terms of hospital stay and operation time and had the same complication rate and lower costs. SP hysterectomy had no clear advantages over VH or conventional LH.

Role of Imaging Tools for the Diagnosis of Borderline Ovarian Tumors: A Systematic Review and Meta-Analysis.

Borderline ovarian tumors (BOTs) have a low malignant potential and occur most often in young women. Its preoperative diagnosis can improve surgical strategy and reproductive approach. This study systematically reviews the literature for the accuracy of transvaginal ultrasound (TVUS), magnetic resonance (MRI), and computed tomography (CT) in the diagnostic of BOTs. We conducted a search in PubMed/Medline of articles in English from the last 5 years and included 14 studies for systematic review, 9 of them in the meta-analysis. The pooled sensibility and specificity was respectively 77.0% and 83.0% for TVUS (5 studies) and 85% and 74% for MRI (4 studies) in differentiating benign from malignant BOTs. CT and positron emission tomography (PET)-CT techniques were heterogeneous between studies, so a meta-analysis was not performed for the 4 studies on CT and PET-CT. However, these 4 studies have also shown a high accuracy in differentiating BOTs from malignant ovarian cancers.

Strategies for Management of Colorectal Endometriosis.

Endometriosis has clearly three distinct clinical presentations and deep endometriosis, especially compromising the rectosigmoid is probably the most concerning one for both patients and surgeons. Currently, with the available tools, it is mandatory to have a precise diagnostic of this type of disease prior to indication of treatment. Strategies to manage this form of endometriosis will take into account several involved aspects, such as age of the patient, reproductive desire or infertility, clinical symptoms, as well as the extension and localization of the disease. Treatment could vary from more conservative to more radical depending on those aspects. As we pointed out in this article, the key to manage colorectal endometriosis is to start with a good diagnosis. Knowing exactly what is the extension and localization of the disease and knowing the patient's wishes as well as the clinical complaints, surgeons are able to define the best option for each patient. Critical points should always be discussed; for example, patients chosen to have clinical treatment should be aware of important issues regarding the follow-up, while patients undergoing surgery must be advised about all surgical possibilities and related complications.

Avaliação de fatores associados à invasão, migração celular e transformação maligna em mulheres com endometriose profunda / Evaluation of factors related to invasion, cell migration and malignant transformation in women with deep endometriosis

INTRODUÇÃO: A endometriose é uma doença crônica de natureza benigna e de alta prevalência, definida pela presença de tecido endometrial fora da cavidade uterina. Dentre os principais sintomas, destacam-se a dor pélvica crônica, dismenorreia e infertilidade. Clinicamente, apresenta-se de três formas distintas: endometriose peritoneal ou superficial, endometriose ovariana - endometrioma - e endometriose profunda (EP). A EP apresenta um padrão de comportamento semelhante ao das doenças malignas, com capacidade de crescimento infiltrativo e destrutivo em diferentes sítios. Lesões endometrióticas já foram identificadas em linfonodos pélvicos, evidenciando a disseminação linfática das células endometrióticas. Em neoplasias malignas, as quimiocinas e seus receptores desempenham papel soberano no processo de metástase e na disseminação linfática das células tumorais. OBJETIVOS: 1) avaliar a expressão das quimiocinas que no câncer estão relacionadas ao processo de metástase - CXCL12-CXCR4, CCL19/CCL21-CCR7 - na EP do compartimento posterior da pelve e nos respectivos linfonodos-sentinela (LS); 2) avaliar a concentração dessas quimiocinas no líquido peritoneal (LP) de pacientes com e sem endometriose; 3) avaliar a expressão da proteína BAF250a, relacionada à transformação maligna, na endometriose, com ênfase na EP do compartimento posterior da pelve. MÉTODOS: 123 pacientes foram incluídas neste estudo. Nós realizamos a coloração imuno-histoquímica para avaliar a expressão das quimiocinas - ligantes e receptores - nas lesões de EP retovaginal/do compartimento posterior da pelve (n=27), nos respectivos LS (n=27) e no endométrio de pacientes-controle sem endometriose (n=20); a concentração das quimiocinas no LP foi avaliada por meio da tecnologia multiplex - Luminex® xMAP® Technology - em um subgrupo de pacientes com (n=36) e sem (n=27) endometriose; a possibilidade de transformação maligna também foi avaliada por meio da imuno-histoquímica para analisar a expressão...

INTRODUCTION: Endometriosis is a chronic disease of benign nature and of high prevalence, defined by the presence of endometrial tissue outside the uterine cavity. Among the main symptoms are highlighted chronic pelvic pain, dysmenorrhea and infertility; clinically, it may appear in three distinct ways: peritoneal endometriosis, ovarian endometriosis - endometriomas - and deep infiltrating endometriosis (DIE). DIE presents a behavioral pattern in many ways similar to that of malignancies, as capacity of infiltrative and destructive growth in different sites. Endometriotic lesions have already been identified in pelvic lymph nodes, showing the possibility of lymphatic dissemination of endometriotic cells. In malignancies, chemokines play a sovereign role in the process of metastasis and lymphatic spread of tumor cells. OBJECTIVES: 1) to evaluate the expression of cancer-related chemokines - CXCL12-CXCR4, CCL19/CCL21-CCR7 - in rectovaginal DIE (or endometriosis of the posterior compartment of the pelvis) and the respective pelvic sentinel lymph node (PSLN); 2) to evaluate the concentration levels of those chemokines in the peritoneal fluid (PF) of patients with and without endometriosis; 3) to evaluate the expression of protein BAF250a, related to malignant transformation, in endometriosis, with emphasis in rectovaginal DIE. METHODS: 123 patients were enrolled in this study. We performed immunohistochemical staining to assess the expression of all chemokines - ligands and receptors - in rectovaginal DIE (n=27), PSLN (n=27) and eutopic endometrium (EE) from patients without endometriosis as controls (n=20); chemokine concentration in the PF was assessed with multiplexing technology - Luminex® x-MAP® Technology - in a subgroup of patients with (n=36) and without (n=27) endometriosis; the possibility of malignant transformation was also assessed by means of immunohistochemistry to evaluate the expression of BAF250a protein among endometriosis lesions...