Three Types of Endometriosis: Pathogenesis, Diagnosis and Treatment. State of the Art.

At present, there is no curative treatment for endometriosis. Medical management and surgical treatment do not provide long-term relief. A detailed understanding of its pathophysiology is mandatory in order to facilitate both the diagnosis and treatment. The delay that typically precedes proper diagnosis (6 to 7 years) is probably one of the most challenging aspects of endometriosis management. In 2012, the total cost per woman due to endometriosis was estimated to be 9579€ per year in a multicenter study across the USA and Europe. According to their physiopathology and their localization, ectopic endometrial lesions, consisting of endometrial glands and stroma, can be divided into three different types: superficial peritoneal endometriosis (SPE), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). The following paper aims to review the available data in the literature on the pathogenesis, diagnosis, and treatment of different types of endometriosis.

Endométriose et supplémentation nutritionnelle: une revue de littérature / Endometriosis and nutritional supplementation : a literature review

Contexte et objectif. L'endométriose est une maladie gynécologique caractérisée par la présence des glandes et du stroma endométrial en dehors de la cavité utérine. Elle serait influencée par la nutrition. Cette maladie touche 10 à 15 % des femmes en âge de procréer et a comme composante essentielle l'inflammation chronique. Les symptômes les plus fréquents sont la douleur et l'infertilité. La littérature actuelle fait état des effets bénéfiques des aliments antiinflammatoires et antioxydants sur l'endométriose. L'objectif de la présente mini revue est d'établir des pistes de réflexion sur le bénéfice d'une supplémentation nutritionnelle dans l'endométriose. Méthodes. Nous avons effectué une recherche avec les bases de données de Pubmed, Cinahl, Cochrane Library et Embase pour identifier les articles et essais cliniques randomisés dont sept ont été retenus pour l'analyse. Résultats. La supplémentation en souches probiotiques, en vitamine E et en vitamine C a une influence positive sur les symptômes liés à l'endométriose. De plus, un ensemble des composés contenant des vitamines, sels minéraux, ferments lactiques et oméga 3 et 6 ainsi qu'une alimentation de type anti-inflammatoire et les aliments pauvres en glucides fermentés cibles auraient également une influence positive sur les symptômes. En revanche, la vitamine n'aurait aucun effet significatif. Conclusion. Une prise en charge nutritionnelle, notamment axée sur une supplémentation en antioxydants, anti-inflammatoires et en souches probiotiques constitue une piste prometteuse pour la prise en charge de l'endométriose

Context and objective. Endometriosis is a gynecological disease which is characterized by the presence of endometrial glands and stroma outside the uterine cavity and might be influenced by nutrition. It affects 10 to 15 % of women of childbearing age and has chronic inflammation as an essential component. The most common symptoms are pain and infertility. Current literature reports the beneficial effects of antiinflammatory and antioxidant foods on endometriosis. The present paper reviews the benefits of nutritional supplementation in endometriosis. Methods. A search was performed using the Pubmed, Cinahl, Cochrane Library and Embase database engines to identify articles and randomized clinical trials, of which seven were selected for analysis. Results. Supplementation with probiotic strains, vitamin E and vitamin C has a positive influence on the symptoms associated with endometriosis. In addition, a set of compounds containing vitamins, minerals, lactic ferments and omega 3 and 6 as well as an antiinflammatory type diet and foods low in fermentable carbohydrates would also have a positive influence on the symptoms. In contrast, vitamin D did not have any significant effect. Conclusion. Nutritional management, in particular focusing on supplementation with antioxidants, anti-inflammatory drugs and probiotic strains, is a promising avenue for the management of endometriosis.

Voiding recovery after radical parametrectomy in cervical cancer patients: An international prospective multicentre trial - SENTIX.

OBJECTIVE: Voiding dysfunctions represent a leading morbidity after radical hysterectomy performed in patients with early-stage cervical cancer. The aim of this study was to perform ad hoc analysis of factors influencing voiding recovery in SENTIX (SENTinel lymph node biopsy in cervIX cancer) trial. METHODS: The SENTIX trial (47 sites, 18 countries) is a prospective study on sentinel lymph node biopsy without pelvic lymphadenectomy in patients with early-stage cervical cancer. Overall, the data of 300 patients were analysed. Voiding recovery was defined as the number of days from surgery to bladder catheter/epicystostomy removal or to post-voiding urine residuum ≤50 mL. RESULTS: The median voiding recovery time was three days (5th-95th percentile: 0-21): 235 (78.3%) patients recovered in <7 days and 293 (97.7%) in <30 days. Only seven (2.3%) patients recovered after >30 days. In the multivariate analysis, only previous pregnancy (p = 0.033) and type of parametrectomy (p < 0.001) significantly influenced voiding recovery >7 days post-surgery. Type-B parametrectomy was associated with a higher risk of delayed voiding recovery than type-C1 (OR = 4.69; p = 0.023 vs. OR = 3.62; p = 0.052, respectively), followed by type-C2 (OR = 5.84; p = 0.011). Both previous pregnancy and type C2 parametrectomy independently prolonged time to voiding recovery by two days. CONCLUSIONS: Time to voiding recovery is significantly related to previous pregnancy and type of parametrectomy but it is not influenced by surgical approach (open vs minimally invasive), age, or BMI. Type B parametrectomy, without direct visualisation of nerves, was associated with longer recovery than nerve-sparing type C1. Importantly, voiding dysfunctions after radical surgery are temporary, and the majority of the patients recover in less than 30 days, including patients after C2 parametrectomy.

Suspension of ulipristal acetate for uterine fibroids during ongoing EMA's review of liver injury risk: Unfortunate timing during the Covid-19 pandemic!

OBJECTIVE: EMA decided that with ulipristal acetate (UPA) treatment for uterine fibroids, should be discontinued due to the associated risk of hepatic failure, We analyzed whether the risk of recurrent symptoms due to fibroids may lead to an increased risk of Covid -19 infection and death, that would exceed the former risk of hepatic failure and transplantation. STUDY DESIGN, SIZE, DURATION: We used a Markov model to generate probabilities. PARTICIPANTS/MATERIALS, SETTING, METHODS: There are currently about 36,250 treated patients in Europe. We estimated bleeding probabilities, while using or discontinuing UPA, which may induce a need of medical or surgical management in symptomatic patients, and increase the risk of acquiring a Covid-19 infection, and die from it. We also estimated the risk of suffering a hepatic failure and hepatic transplantation. MAIN RESULTS AND THE ROLE OF CHANCE: Based on our assumptions, ceasing UPA during a Covid 19 pandemic may be associated with a fatality ratio between 4 and 18, due to the Pandemic, whereas pursuing UPA would be associated with a fatality rate due to the pandemic between 1-2, and an added fatality rate due to hepatic impairment of 1. The added risk of stopping UPA may range between 2 and 15 additional deaths. Our calculations suggest that the decision to stop UPA in the middle of the Covid- 19 pandemic may be untimely, since it may result in an increased risk of Covid-19 infection, due to the recurrence of symptoms and the need for medical and surgical treatment. WIDER IMPLICATIONS OF THE FINDINGS: A decision, like the one EMA took need to be taken in a wider health context of a population, than simply analyzing its role as regulating agent for medications.

Central Pathology Review in SENTIX, A Prospective Observational International Study on Sentinel Lymph Node Biopsy in Patients with Early-Stage Cervical Cancer (ENGOT-CX2).

The quality of pathological assessment is crucial for the safety of patients with cervical cancer if pelvic lymph node dissection is to be replaced by sentinel lymph node (SLN) biopsy. Central pathology review of SLN pathological ultrastaging was conducted in the prospective SENTIX/European Network of Gynaecological Oncological Trial (ENGOT)-CX2 study. All specimens from at least two patients per site were submitted for the central review. For cases with major or critical deviations, the sites were requested to submit all samples from all additional patients for second-round assessment. From the group of 300 patients, samples from 83 cases from 37 sites were reviewed in the first round. Minor, major, critical, and no deviations were identified in 28%, 19%, 14%, and 39% of cases, respectively. Samples from 26 patients were submitted for the second-round review, with only two major deviations found. In conclusion, a high rate of major or critical deviations was identified in the first round of the central pathology review (28% of samples). This reflects a substantial heterogeneity in current practice, despite trial protocol requirements. The importance of the central review conducted prospectively at the early phase of the trial is demonstrated by a substantial improvement of SLN ultrastaging quality in the second-round review.

Added value of para-aortic surgical staging compared to 18F-FDG PET/CT on the external beam radiation field for patients with locally advanced cervical cancer: An ONCO-GF study.

OBJECTIVE: Extended field chemoradiation is recommended for patients with locally advanced cervical cancer (LACC) and para-aortic lymph node (PALN) metastases. The radiation planning may be based on PET/CT while others recommend to rely on surgical staging. We report the rate of patients for whom the radiation field defined on PET/CT was modified by the histological PALN status. METHODS: Between March 2010 and December 2016, 168 consecutive patients with LACC underwent a pre-therapeutic PET/CT and PALN dissection. The data were reviewed retrospectively. The diagnostic performance of the PET/CT for definition of PALN status was calculated. We determined the percentage of patients for whom PALN dissection altered the external beam radiotherapy (EBRT) field defined on the PET/CT basis. RESULTS: Of 151 patients with negative PALNs on PET/CT, 26 had histological PALN metastases. Of 17 patients with positive PALNs on PET/CT, 9 were negative on histology of which 7 were located in the common iliac region. Sensitivity, specificity, positive and negative predictive value of PET/CT were 23.5, 93.3, 47.1 and 82.8% respectively. In total, 35 out of 168 patients underwent EBRT - field adaptation (pelvic vs extended field). The rate of radiation field modification (27,7%) was particularly high in the subgroup of patients with metastatic pelvic lymph nodes (PLNs) on PET/CT. CONCLUSION: Para-aortic surgical staging contributes significantly to individualize the radiation treatment of patients with LACC, particularly for those with positive PLNs at PET/CT. Indication of surgical staging deserves particular attention when the PET/CT suggests positive LNs in the common iliac region.

Immunohistochemical Analysis of Somatostatin Receptors in Endometriosis Tissue Samples: A Retrospective Study.

Three types of endometriosis are described: superficial peritoneal endometriosis (SPE), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). The expression of somatostatin receptors (SSTR1, 2, and 5) in human endometrial tissue and its ectopic form has been previously studied and may be different in each type of endometriosis. The aim of this study was to assess the immunohistochemical expression of SSTR1, 2, and 5 in tissue samples of SPE, OMA, and DIE. We performed a retrospective analysis in the pathology department database. Patients aged <50 yr and diagnosed with endometriosis have been identified and sorted into 3 groups according to their endometriosis type: SPE, OMA, and DIE. For each selected patient, formalin-fixed paraffin-embedded blocks were retrieved in order to make new sections to be incubated with polyclonal rabbit antibodies anti-SSTR1, 2, and 5. Receptor status was considered as positive on the sections when >50% of the cells showed immunostaining. Seventy-six patients were included in the analysis. SSTR1 and 5 were expressed in 95.4% and 77.2% of SPE, respectively, in 95.8% and 83.3% of OMA, respectively, and in 100% and 80% of DIE, respectively. There was no significant difference between SPE, OMA, and DIE with regard to the SSTR1 (P=0.5) and SSTR5 (P=0.9) expression. We observed a significant difference between SPE (9.0%), OMA (16.6%), and DIE (63.3%) with regard to SSTR2 expression (P<0.05). The present study identifies 2 different immunohistochemical patterns of endometriosis lesions with regard to their SSTR expression: SSTR1+/SSTR2-/SSTR5+ for SPE and OMA, and SSTR1+/SSTR2+/SSTR5+ for DIE.

Fluorescence of Deep Infiltrating Endometriosis During Laparoscopic Surgery: A Preliminary Report on 6 Cases.

BACKGROUND: The standard treatment of rectovaginal deep infiltrating endometriosis nodules (RVDIEN) consists in their surgical removal. RVDIEN are anatomically neovascularized. Indocyanine green (ICG) reveals vascularized structures when becoming fluorescent after exposure to near-infrared (NIR) light. This study aims to evaluate if fluorescence-guided surgery can improve the laparoscopic resection of RVDIEN, thus avoiding a rectal perforation. MATERIALS AND METHODS: Patients with a symptomatic RVDIEN, scheduled for a laparoscopic rectal shaving, were enrolled in the study. Technically, the RVDIEN was targeted and removed with the help of the NIR imager device Image 1 Spies (Karl Storz GmBH & Co KG, Tuttlingen, Germany) or Visera Elite II (Olympus Europe SE & Co KG, Hamburg, Germany), after an intraoperative, intravenous injection of ICG (0.25 mg/kg). RESULTS: Six patients underwent a fluorescence-guided laparoscopic shaving procedure for the treatment of a nonobstructive RVDIEN. Fluorescence of the RVDIEN was observed in all the patients. In one patient, once the main lesion was removed, the posterior vaginal fornix still appeared fluorescent and was removed. No intraoperative rectal perforation occurred. The postoperative hospital stay was 2 days. No postoperative rectovaginal fistula occurred within a median follow-up of 16 months (range = 2-23 months). CONCLUSION: In this preliminary study, fluorescence-guided laparoscopy appeared to help in separating the RVDIEN from the healthy rectal tissue, without rectal perforation. Moreover, this technique was helpful in deciding if the resection needed to be enlarged to the posterior vaginal fornix.

Robotically assisted para-aortic lymphadenectomy: surgical results: a cohort study of 487 patients.

OBJECTIVES: The aim of this study was to evaluate perioperative outcomes of robotic-assisted laparoscopic para-aortic lymphadenectomy (PAL) in patients with gynecologic cancers during the learning phases of robotic surgery programs and to compare results of extraperitoneal versus transperitoneal approaches of PAL. MATERIALS AND METHODS: This study is a retrospective multicentric study of patients who underwent robotically assisted laparoscopic PAL (N = 487). Eleven European centers and 1 US center participated in the study. Abstracted data included age, body mass index, indication, type of surgical approach (transperitoneal or extraperitoneal), associated surgical procedures, operative time, estimated blood loss, lymph node count, hospital length of stay (LOS), and complications. Para-aortic lymphadenectomy was performed by an extraperitoneal approach in 58 cases (12%) and transperitoneal in 429 cases (88%). RESULTS: The mean (SD) para-aortic lymph node count was 12.6 (8.1), operative time was 217 (85) minutes, estimated blood loss was 105 (110) mL, and LOS was 2.8 (3.2) days. Four (0.8%) conversions to open and 2 (0.4%) conversions to laparoscopy were described. There were 32 lymphocysts (6.6%), 3 deep venous thromboses (0.6%), and 10 transfusions (2.1%). For transperitoneal approach, the average number of lymph nodes removed was higher in isolated PAL group than the hysterectomy combined group (report node counts 95% confidence interval, -7.29 to -3.52, P = 1.5 × 10⁻6). For isolated PAL, the LOS was shorter in the extraperitoneal group than in the transperitoneal group (report data 95% CI, -1.35 to -0.35, P = 0.001). CONCLUSIONS: Robotic-assisted PAL seems safe and feasible. More lymph nodes were removed during an isolated transperitoneal PAL dissection compared with a combined procedure with hysterectomy. Extraperitoneal approach seems attractive relative to transperitoneal dissection, but the superiority of one or the other way is not demonstrated by our study.

Multi-center experience of robot-assisted laparoscopic para-aortic lymphadenectomy for staging of locally advanced cervical carcinoma.

OBJECTIVES: FIGO classification is commonly used for staging of locally advanced cervical cancer. Laparoscopic para-aortic lymphadenectomy is currently used as a diagnostic tool, since we know that presence of para-aortic lymph node metastases identifies patients with poor prognosis. The application of robotics during this procedure needs to be investigated. DESIGN: Retrospective multi-center study. SETTING: Three centers participated in building one database. POPULATION: Thirty-seven patients with locally advanced cervical cancer underwent a robot-assisted laparoscopic para-aortic lymphadenectomy. METHODS: Patients were prospectively enrolled in one register. Retrospective analysis of the whole database was performed. MAIN OUTCOME MEASURES: Surgical outcomes of the robot-assisted procedure and follow-up data. RESULTS: Median number of lymph nodes collected was 27.5 (1-54) per patient. Five of 37 patients had para-aortic node metastases. The false negative rate for PET-CT diagnosing para-aortic node metastases was 11.4% (4/35). Two major intra-operative complications occurred (5.4%). Postoperative morbidity was low (13.5%). Median follow-up was 27 months [95% confidence interval (95% CI) was 24-30]. Median disease-free survival was 16 months (95% CI 2.4-29.6). Patients with negative nodes had a median disease-free survival of 24 months (not assessable), although patients with positive nodes had a median disease-free survival of 9 months (95% CI 6.9-11.9). CONCLUSIONS: In this series we report that robot-assisted laparoscopic para-aortic lymphadencetomy provided the surgeon with useful information, diagnosing 11.4% of occult para-aortic lymph node metastases in women with locally advanced cervical cancer. Intra-operative and postoperative morbidity were low. The presence of para-aortic lymph node metastases correlated with shorter disease-free survival.

Determinants of the decision to perform prophylactic oophorectomy in association with a hysterectomy for a benign condition.

BACKGROUND: The decision to perform an elective bilateral salpingo-oophorectomy (BSO) at the time of a hysterectomy for a benign condition is complex. AIM: To assess the determinants of the decision to proceed to a prophylactic BSO during a hysterectomy for a benign condition. MATERIALS AND METHODS: We collected demographic and clinical data, including age, menopausal status and risk of ovarian cancer. Using a regression model we analysed the decision perform a prophylactic BSO in women successively admitted for a hysterectomy for a benign condition, in relation to the collected demographic and clinical data. RESULTS: Data were collected for 43 women, aged between 37 and 65 years (mean age 48.6 years, SD 6.9), on the day before their hysterectomy. Thirty-six (84%) had a total hysterectomy and 7 (16%) a subtotal hysterectomy; 40 (93%) had a laparoscopic procedure. Prophylactic BSO was significantly associated with age: none of the women aged under 40 years had the procedure, compared with 8% of those aged 41-45 years, 29% of those aged 46-50 years and 83% of those aged 51 years or more (χ(2)=23; P<0.001). Of the postmenopausal women, 67% had a prophylactic BSO, compared with 24% of the premenopausal women (χ(2)=6; P<0.047). In this small series of patients no relationship was found between the decision to perform a BSO and the risk of ovarian cancer. Age was the only significant variable in the regression model (pseudo R(2) Nagelkerke=0.6, P<0.05). CONCLUSION: The physician's recommendation to perform an elective BSO at the time of a hysterectomy for a benign condition is strongly influenced by the patients' age.

Factors affecting gynaecologists' decision to perform prophylactic oophorectomy concomitantly with hysterectomy: a Belgian survey.

BACKGROUND: The recommendation to perform an elective bilateral salpingo-oophorectomy (BSO) at the time of a hysterectomy for a benign condition is complex. AIM: This survey evaluated the effect of three factors on BSO: the patient's age, her menopausal status, and the presence of a family history of breast cancer. MATERIALS AND METHOD: We conducted an anonymous written survey, sent to 1513 gynaecologists, evaluating their attitude towards performing a prophylactic BSO concomitantly with a hysterectomy. We used a clinical vignette of a patient presenting a large and painful fibroid. We modified three factors: her age (either 44 or 49 years old), menopausal status (pre-menopausal or peri-menopausal), the absence or presence of a breast cancer family history. We randomly sent one case to each gynaecologist, who was asked whether he/she would perform a BSO. RESULTS: The recommendation to perform a BSO varied between 2% and 81%, in relation to the different cases (χ(2): 151; p<0.001). On average, a five year difference in the patients' age (44 years vs 49 years) was associated with a 40% increase in proceeding a BSO. Being peri-menopausal vs being pre-menopausal, was associated with a 20% increase in suggesting a BSO. Having had a mother, diagnosed with breast cancer, was associated with a 10% increase of BSO. CONCLUSION: The physicians' recommendation to perform an elective bilateral salpingo-oophorectomy at the time of a hysterectomy, is strongly influenced by the patients' age, and to a lesser extent by her menopausal status, or a family history of breast cancer.

Evaluation of 18FDG PET-CT in the diagnosis of endometriosis: a prospective study.

BACKGROUND: Noninvasive techniques have poor sensitivity and specificity in diagnosing endometriosis, which is often associated with an inflammatory process. In several benign diseases, measurement of hypermetabolism using fluorodeoxyglucose (18F 18FDG) reflects the degree of inflammation and aggressiveness of the disease. This prospective study evaluated the value of (18)FDG positron emission tomography (PET)-computed tomography (CT) in assessing the presence of endometriosis. METHODS: Ten consecutive patients suspected with endometriosis were prospectively included in this study. A preoperative 18FDG PET-CT was performed in all the patients during the follicular phase of their cycle, which preceded laparoscopic surgery. Surgical endometriosis staging and histopathological analysis of removed tissue were confronted with the results from 18FDG PET-CT. RESULTS: Of the 10 patients, 9 had endometriosis confirmed by laparoscopy; 6 had advanced stage of the disease and 5 had histologically proven lesions. Nevertheless, none of the patients had 18FDG-demonstrated hypermetabolism at PET-CT. CONCLUSIONS: In this preliminary series, we did not observe hypermetabolic activity in relation to endometriosis using 18FDG PET-CT. This study's most important limitation is the use of 18FDG as an isotopic tracer, which is not specific to endometrial tissue.

Robot assisted laparoscopic transperitoneal para-aortic lymphadenectomy in the management of advanced cervical carcinoma.

OBJECTIVES: Adequate staging of advanced cervical cancer is essential in order to optimally treat the patient. FIGO clinical staging, imaging techniques such as CT scan, MRI and PET sometimes underestimate the extension of tumors. The presence of para-aortic lymph node metastases in advanced cervical cancer identifies patients with poor prognosis who need to be treated aggressively. Laparoscopic para-aortic lymph node dissection is now proposed as a diagnostic tool in many guidelines. We evaluated the feasibility and safety of a robot assisted laparoscopic transperitoneal approach to para-aortic lymph node dissection. STUDY DESIGN: Eight patients with advanced cervical carcinoma who were eligible for primary pelvic radiotherapy combined with concurrent cisplatin chemotherapy or pelvic exenteration underwent a pre-treatment robot assisted transperitoneal laparoscopic para-aortic lymphadenectomy. RESULTS: We isolated from 1 to 38 para-aortic nodes per patient and had one para-aortic node positive patient who was treated with extended doses of pelvic radiotherapy. We did not encounter any major complications and post-operative morbidity was low. CONCLUSIONS: Robot assisted transperitoneal laparoscopic para-aortic lymphadenectomy is feasible and provides the surgeon with greater precision than classical laparoscopy. Larger prospective multicentric trials are needed to validate the generalised usefulness of this technique.

Breast cancer seeding associated with core needle biopsies: a systematic review.

BACKGROUND: Preoperative diagnosis has become the standard in breast cancer (BC) management. Recently, ultrasound guided core needle biopsy (CNB) and stereotactic needle core biopsy have replaced fine needle aspiration cytology. Epithelial cell displacement (DE) occurs frequently after core needle biopsy (CNB) for breast cancer diagnosis. AIM: Systematically review (between 1900 and 2008) the clinical significance of DE after CNB in BC patients, and associated risk factors (delay between biopsy and surgery, needle passes, duration of the procedure, tumor size, histological type, tumor grade, margins, type of surgery, and of adjuvant treatment). MATERIALS AND METHODS: We selected 15 studies: 9 assessed the rate of DE after CNB and 6 the impact of CNB on outcome endpoints. RESULTS: We found 3 prospective and 12 retrospective studies. However these had numerous biases such as insufficient power, confounding factors, selection of cases and controls, surrogate endpoints, heterogeneity of measured displacement. Malignant DE on surgical specimens occurred in 22% of the patients. A short interval between CNB and surgical excision increased the risk of detecting displaced cells. No increase in local recurrence was reported after CNB. Contradictory results were found in terms of sentinel node metastases. Only one study evaluated overall survival data and reported no worse survival in patients with preoperative CNB. CONCLUSION: Although data are limited, no increased morbidity has been associated with iatrogenic seeding after CNB.

Host response after reconstruction of abdominal wall defects with porcine dermal collagen in a rat model.

OBJECTIVE: The purpose of this study was to compare the inflammatory response after implantation of Pelvicol with Prolene in a rat model. STUDY DESIGN: Full-thickness abdominal wall defects were created in 64 Wistar rats, and reconstructed with either Pelvicol or Prolene. Animals were sacrificed on days 7, 14, 30, and 90 to evaluate the presence of herniation, infection, adhesions, and changes in thickness and tensile strength of the implants. Histopathology and immunohistochemistry were performed to evaluate the collagen deposition and the inflammatory response. Statistics were done with unpaired t test and Mann-Whitney rank test. RESULTS: Pelvicol implantation induced infiltration of granulocytes, macrophages, and NK cells, which showed up-regulated expression of surface activation markers ICAM-1 and CD11b. This inflammatory response was significantly milder, and declined faster than in Prolene-implanted rats, and was also associated with fewer adhesions. Moreover, Pelvicol induced a slower, but more orderly collagen deposition, paralleling the surface of the implant. Pelvicol implants showed a slower increase in thickness and tensile strength early on, but this difference disappeared by day 90. CONCLUSION: Pelvicol induces a milder inflammatory response, less adhesion formation, more orderly collagen deposition than Prolene, and reaches a comparable tensile strength only after 90 days.