Atypical vaginal location of endometriosis following repeated urogynaecological surgery.

We outline a case of vaginal endometriosis in scar tissue located in the distal part of the anterior vaginal wall close to the urethra following repeated urogynaecological surgery. Our case presents a 45-year-old woman diagnosed with pelvic endometriosis in her youth. She underwent several vaginal surgeries due to pelvic organ prolapse, symptoms of stress incontinence and decreased urinary flow. One year after her most recent vaginal surgery, she developed a tender lump in the lower part of the anterior vaginal wall. A urethral diverticulum was suspected, but a diagnostic puncture and biopsy unexpectedly showed histologically verified endometriosis. As the cyst recurred, surgical excision of all visible endometriosis tissue was performed. After 3 years of follow-up, the patient remained without recurrence. This case illustrates the risk of atypical implantation of endometriosis related to repeated urogynaecological surgery and that treatment requires surgery with thorough removal of all visible tissues.

Primary umbilical endometriosis (PUE).

Primary endometriosis of the umbilicus, Villars nodule, rarely occurs. It is characterized by a discolored change in the umbilicus which manifests itself with cyclic menstrual-related symptoms such as pain, swelling and bleeding. Often the diagnosis is based on objective findings, but imaging and histology predicts and verify the diagnosis. Radical excision is performed with good results. We present ten cases with primary umbilical endometriosis and present the referral pattern dominated by primary referral to the gastro-surgeon reflecting difficulties in finding the right diagnosis.

Full-thickness endometriosis of the bladder: report of 31 cases.

OBJECTIVE: To draw attention to the rare condition of endometriosis in the bladder. This is correlated with symptoms not normally connected to endometriosis and therefore often remains underdiagnosed for years. DESIGN AND SETTING: Retrospective study in a university teaching hospital, one of two referral centres in Denmark for surgical treatment of stage III and IV endometriosis. POPULATION: Thirty-one women with deep infiltrating bladder endometriosis. METHODS: All women presenting in the Department of Obstetrics and Gynaecology with deep infiltrating bladder endometriosis between March 2002 and March 2011. We included only patients with symptomatic full-thickness bladder detrusor endometriosis and mucosal involvement. All patients had had bladder symptoms for two to seven years. MAIN OUTCOME MEASURES: Symptoms after surgery and recurrence rate. RESULTS: The main preoperative symptom was urinary frequency. All patients had significant relief of symptoms after operation, and none had recurrence of the bladder endometriosis judged by ultrasound or reported symptoms. Twenty-six (87%) patients had endometriosis in another location as well. Eight had nodules in the recto-vaginal septum. Complete surgical excision of all associated endometriotic lesions was carried out during the same surgical procedure. During the mean follow-up period of 59 months no long-term complications were diagnosed. CONCLUSION: Bladder endometriosis should be considered in patients who present with irritative urological symptoms with aggravation during menstruation or in patients with a history of endometriosis. When patients have symptoms we recommend surgical treatment in cases where medical treatment fails.

Well-leg compartment syndrome after gynecological laparoscopic surgery.

Well-leg compartment syndrome in the lower extremities after surgery in the lithotomy position is a rare but severe complication requiring early diagnosis and intervention. Several circumstances predispose to this condition as a consequence of increased intra-compartmental pressure, such as positioning of the legs during operation (lithotomy and Lloyd-Davies positions), a prolonged operation, external compression and vascular insults, both pre- and intra-operatively. To prevent well-leg compartment syndrome it is important to improve knowledge of the condition among surgeons and nursing staff. Potential risk factors and preventive initiatives are listed to reduce the risk in future patients. We describe two patients who underwent gynecologic laparoscopic surgery and postoperatively developed well-leg compartment syndrome.

The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres.

BACKGROUND: This study aimed to calculate costs and health-related quality of life of women with endometriosis-associated symptoms treated in referral centres. METHODS: A prospective, multi-centre, questionnaire-based survey measured costs and quality of life in ambulatory care and in 12 tertiary care centres in 10 countries. The study enrolled women with a diagnosis of endometriosis and with at least one centre-specific contact related to endometriosis-associated symptoms in 2008. The main outcome measures were health care costs, costs of productivity loss, total costs and quality-adjusted life years. Predictors of costs were identified using regression analysis. RESULTS: Data analysis of 909 women demonstrated that the average annual total cost per woman was €9579 (95% confidence interval €8559-€10 599). Costs of productivity loss of €6298 per woman were double the health care costs of €3113 per woman. Health care costs were mainly due to surgery (29%), monitoring tests (19%) and hospitalization (18%) and physician visits (16%). Endometriosis-associated symptoms generated 0.809 quality-adjusted life years per woman. Decreased quality of life was the most important predictor of direct health care and total costs. Costs were greater with increasing severity of endometriosis, presence of pelvic pain, presence of infertility and a higher number of years since diagnosis. CONCLUSIONS: Our study invited women to report resource use based on endometriosis-associated symptoms only, rather than drawing on a control population of women without endometriosis. Our study showed that the economic burden associated with endometriosis treated in referral centres is high and is similar to other chronic diseases (diabetes, Crohn's disease, rheumatoid arthritis). It arises predominantly from productivity loss, and is predicted by decreased quality of life.

[Inguinal endometriosis]. / Ingvinal endometriose.

Inguinal endometriosis is a rare manifestation of endometriosis. Four cases are presented. In three of these cases proper diagnosis was delayed due to differential diagnostic difficulties as the symptoms in these cases were interpreted as hernia. In two cases the patient underwent hernia surgery. In inguinal lump cases in fertile women, endometriosis should be considered if accompanied by dysmenorrhoea or deep dyspareunia. In such cases MRI (magnetic resonance imaging) scans often yield further diagnostic information. If surgery is needed, it should be performed in a gynaecological setting to facilitate full surgical intervention including abdominal laparoscopy and excision.

[Treatment of endometriosis in Danish hospitals]. / Behandling af endometriose på danske hospitaler.

UNLABELLED: Endometriosis is a chronic disease. The prevalence is difficult to define, but is estimated to be around 10%. Among women with chronic pelvic pain and infertility, the prevalence is considerably higher. MATERIALS AND METHODS: All patients registered by the National Board of Health with the diagnosis of endometriosis treated in Danish Hospitals in the period 1997-2005 were evaluated. RESULTS: The number of women referred to Danish hospitals with endometriosis almost doubled during the period 1997-2005, probably reflecting the increased focus on the disease. The number of patients with endometriosis in the rectovaginal septum more than tripled from 2000-2005 and 2/3 of these patients were treated at the two Danish centres of excellence. The number of patients with ovarian endometriosis has been relatively stable over the years. The risk of laparotomy in surgery for endometriosis was 6% 2005 in the two centres of excellence and 14.4% in other Danish hospitals. CONCLUSION: Increased focus on endometriosis reflected by more patients referred to Danish hospitals. An increasing number of patients with severe endometriosis are referred to the centres of excellence although 1/3 of patients with endometriosis in the rectovaginal septum are still treated outside the centres with special surgical skills in endometriosis. Internationally, it is generally agreed that surgery for endometriosis should be done by laparoscopy and in Denmark the risk for laparotomy in the centres of excellence is only 6%.

Laparoscopic laser resection of rectovaginal pouch and rectovaginal septum endometriosis: the impact on pelvic pain and quality of life.

BACKGROUND: The aim of this study was to assess the impact on pelvic pain and quality of life of laparoscopic resection of the rectovaginal pouch (RV) and RV septum in patients with endometriosis. METHODS: The design was a descriptive retrospective study. The study included 48 women presenting to the Department of Obstetrics and Gynaecology with RV pouch and RV septum endometriosis, between 1 January 2003 and 1 January 2006. The setting was a university teaching hospital, one of two referral centres in Denmark for the surgical treatment of stage III and IV endometriosis. Questionnaires and Visual Analogue Scale (VAS) scores for a number of different symptoms associated with endometriosis were used. The main outcome measures were: effect of laparoscopic excision on pain scores and quality of life, operative findings, type of surgery, duration of surgery, and incidence of intra- and postoperative complications. RESULTS: Significant statistical differences were found between preoperative and postoperative pain scores, quality of life, frequency of sexual activity, percentage taking analgesics or non-steroidal anti-inflammatory drugs, percentage having work difficulties due to pain, and percentage of women having sick-leave. CONCLUSION: Endometriosis in the RV pouch and RV septum can be effectively treated with laser laparoscopy performed by experienced endoscopic gynaecologists.

Laparoscopic-assisted vaginal vs. abdominal surgery in patients with endometrial cancer stage 1.

BACKGROUND: The development of new diagnostic and surgical methods has brought a differentiated approach to the surgery of endometrial cancer. The aim of this study was to verify the peri- and postoperative differences between laparoscopic and open procedures. METHODS: In the period from January 1995 to August 2001 a total of 86 patients were treated for endometrial cancer stage 1. Of these, 28 patients were treated by laparoscopic-assisted vaginal hysterectomy (LAVH) and bilateral salpingo-oophorectomy (BSO), while 58 patients were treated by total abdominal hysterectomy (TAH) and BSO. The two patient groups were comparable in all aspects. RESULTS: The average hospital stay in the LAVH group was 2.7 days compared to 5.4 days for the TAH group. There were fewer complications in the LAVH group (7%) compared to the laparotomy group (14%). CONCLUSIONS: Laparoscopic-assisted vaginal hysterectomy seems to be acceptable in the treatment of stage 1 endometrial carcinoma.