Performance of peripheral (serum and molecular) blood markers for diagnosis of endometriosis.

PURPOSE: To quantify the mRNA levels of MMP-3, MMP-9, VEGF and Survivin in peripheral blood and the serum levels of CA-125 and Ca19-9 in women with and without endometriosis and to investigate the performance of these markers to differentiate between deep and ovarian endometriosis. METHODS: A case control study enrolled a series of 60 patients. Twenty controls have been matched with 20 cases of ovarian and 20 cases of deep endometriosis. Univariable and multivariable performance of serum CA125 and CA19-9, mRNA for Survivin, MMP9, MMP3 and VEGF genes have been evaluated by means of ROC curves and logistic regression, respectively. RESULTS: No difference in markers' concentration was detected between ovarian and deep endometriosis. In comparison with controls, serum CA125 and CA19 yielded the better sensitivity followed by mRNA for Survivin gene (81.5, 51.9 and 7.5% at 10% false positive rate, respectively). Multivariable estimated odds of endometriosis yielded a sensitivity of 87% at the same false positive rate. CONCLUSIONS: A combination of serum and molecular markers could allow a better diagnosis of endometriosis.

Matrix metalloproteinase-3 mRNA: a promising peripheral blood marker for diagnosis of endometriosis.

BACKGROUND/AIMS: Endometriosis is an invasive disease. Its diagnosis depends on laparoscopy, which is traumatic and associated with potential complications. The aim of this study was to develop a rapid, reliable, and less invasive diagnostic test for endometriosis. We hypothesized that genes related to cell invasion would be transcriptionally upregulated in endometriosis, and tested whether blood levels of their transcripts might be used as biomarkers of endometriosis. METHODS: We used quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) to quantify the mRNA levels of vascular endothelial growth factor A (VEGFA), matrix metalloproteinase-3 (MMP-3), and MMP-9 in peripheral blood from 20 patients with mild/intermediate endometriosis, 20 patients with severe endometriosis and 20 endometriosis-free subjects. RESULTS: Our results indicate that circulating mRNA for MMP-3 is significantly higher in patients with endometriosis than in control patients, regardless of the degree of severity. Conversely, the level of circulating mRNA for VEGFA and MMP-9 did not distinguish patients from controls. CONCLUSION: MMP-3 mRNA is a promising peripheral blood marker that discriminates between patients with endometriosis and healthy subjects. Our results support the possibility of finding genes suitable for diagnostic qRT-PCR for endometriosis in peripheral blood and should be explored further.

A multidisciplinary, minimally invasive approach for complicated deep infiltrating endometriosis.

OBJECTIVE: To present a case of complicated deep infiltrating endometriosis managed by a multidisciplinary minimally invasive approach. DESIGN: Case report. SETTING: Tertiary care university hospital. PATIENT: A 32-year-old woman with deep infiltrating endometriosis involving the rectovaginal septum, the rectum, and the left ureter, complicated by silent left renal function loss. INTERVENTION(S): Laparoscopic left nephrectomy, ureterectomy, excision of a left ovarian endometrioma, removal of a large rectovaginal nodule, and segmental bowel resection with minilaparotomic end-to-end anastomosis. MAIN OUTCOME MEASURE(S): Multidisciplinary diagnosis and minimally invasive surgical approach to deep infiltrating endometriosis involving the rectum and the urinary tract. RESULT(S): Collaboration between gynecologists, urologists, and colorectal surgeons enabled a successful management of the case in one surgical intervention providing minor risk of complications, shorter hospital stay, and faster functional recovery. CONCLUSION(S): Deep infiltrating endometriosis is a global pathology that may involve different structures. A multidisciplinary, minimally invasive approach should be recommended to achieve appropriate disease management.

Conservative laparoscopic management of urinary tract endometriosis (UTE): surgical outcome and long-term follow-up.

OBJECTIVE: To evaluate surgical outcome and long-term follow-up of conservative laparoscopic management of urinary tract endometriosis (UTE). DESIGN: Prospective study. SETTING: Tertiary-care university hospital. PATIENT(S): Women with laparoscopic diagnosis and histologic confirmation of urinary bladder or ureteral endometriosis who agreed to undergo long-term follow-up after laparoscopic management. INTERVENTION(S): (1) Laparoscopic partial cystectomy for bladder endometriosis. (2) Uretric endometriosis laparoscopically managed by: uretrolysis only; segmental ureterectomy and terminoterminal anastomosis; or segmental ureterectomy and uretrocystoneostomy. MAIN OUTCOME MEASURE(S): Variables assessed were: preoperative findings, operative details (type and site of UTE, type of intervention, perioperative complications), and long-term follow-up (persistence/recurrence of preoperative urinary symptoms, if present, and anatomic relapse of the disease). RESULT(S): Mean operating time was 152.8+/-41.7 minutes. Mean drop in hemoglobin was 1.9+/-1.6 g/dL. Average hospital stay was 6 days. After surgery, 11 women had fever>38 degrees C and four presented transient urinary retention. During a follow-up period of 36 months, endometriosis recurred in eight patients with no evidence of bladder or ureteral reinvolvement, and there was a significant reduction in the mean score of dysuria and suprapubic pain maintained during the whole follow-up period. CONCLUSION(S): Results of long-term follow-up demonstrate significant reduction in preoperative symptoms with no anatomic relapse.

Long-term oral contraceptive pills and postoperative pain management after laparoscopic excision of ovarian endometrioma: a randomized controlled trial.

OBJECTIVE: To evaluate postoperative long-term cyclic and continuous administration of combined oral contraceptive (OC) pills in preventing endometriosis-related pain recurrence. DESIGN: Prospective, randomized, controlled trial. SETTING: Tertiary care university hospital. PATIENT(S): Three hundred eleven women who underwent laparoscopic excision for symptomatic ovarian endometrioma. INTERVENTION(S): Patients were randomly divided into three groups: nonuser group receiving no therapy, and cyclic user group and continuous user group receiving low-dose, monophasic OC pills for 24 months in either cyclic or continuous administration. MAIN OUTCOME MEASURE(S): Presence and intensity of dysmenorrhea, dyspareunia, and chronic pelvic pain were assessed by a 10-point visual analogue scale (VAS) at 6, 12, 18, and 24 months postoperatively. RESULT(S): A significant reduction in recurrence rate and VAS scores for dysmenorrhea was evident in the continuous users versus the other groups at 6 months, and in cyclic users versus nonusers at 18 months postoperatively. No significant differences in recurrence rate and VAS scores for dyspareunia and chronic pelvic pain were demonstrated among the groups. The increase of VAS scores from 6-24 months during the study period for dysmenorrhea, dyspareunia, and chronic pelvic pain was significantly higher in nonusers than in the other groups. CONCLUSION(S): Long-term postoperative use of OC pills can reduce the frequency and the severity of recurrent endometriosis-related dysmenorrhea.

Long-term cyclic and continuous oral contraceptive therapy and endometrioma recurrence: a randomized controlled trial.

OBJECTIVE: To evaluate long-term cyclic and continuous administration of oral contraceptive pills (OCP) in preventing ovarian endometrioma recurrence after laparoscopic cystectomy. DESIGN: Prospective, randomized, controlled trial. SETTING: Tertiary care University Hospital. PATIENT(S): Two hundred thirty-nine women who underwent laparoscopic excision of ovarian endometriomas. INTERVENTION(S): Patients were divided randomly into three groups: nonusers receiving no therapy and cyclic and continuous users receiving low-dose, monophasic OCP for 24 months in cyclic or continuous administration, respectively. MAIN OUTCOME MEASURE(S): Endometrioma recurrence, size of recurrent endometrioma, and growth rate during at least 2 years follow-up evaluated by transvaginal ultrasonography. RESULT(S): The crude recurrence rate within 24 months was significantly lower in cyclic (14.7%) and continuous users (8.2%) compared with nonusers (29%). The recurrence-free survival was significantly lower in nonusers compared with cyclic and continuous users. The mean recurrent endometrioma diameter at first observation was significantly lower in cyclic (2.17 +/- 0.45 cm) and continuous users (1.71 +/- 0.19 cm) compared with nonusers (2.73 +/- 0.56 cm). The mean diameter increase every 6 months of follow-up was significantly reduced in cyclic users (0.31 +/- 0.18 cm) and continuous users (0.25 +/- 0.09 cm) versus nonusers (0.48 +/- 0.3 cm). No significant differences between cyclic users and continuous users in terms of endometrioma recurrence were demonstrated. CONCLUSION(S): Long-term cyclic and continuous postoperative use of OCP can effectively reduce and delay endometrioma recurrence.

Tolerability, side effects, and complications of hysterosalpingocontrast sonography (HyCoSy).

OBJECTIVE: To evaluate the tolerability, side effects and complications of hysterosalpingocontrast sonography (HyCoSy). DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): 669 infertile women. INTERVENTION(S): All patients were examined with HyCoSy and monitored for 30 minutes after the procedure. A telephone interview was subsequently carried out to record possible late side effects and postprocedural complications. MAIN OUTCOME MEASURE(S): Tolerability to the procedure was evaluated by means of an 11-point (0 to 10) numeric rating scale of the pain experienced. Postprocedural fever, pelvic infections, peritonitis, hemorrhage were recorded. RESULT(S): Of 660 patients who completed the examination, 483 (73.2%) completed the telephone follow-up after a period of 14.7 +/- 9.9 months from the procedure. The mean patient age was 34.5 +/- 4.3 years, and mean infertility duration was 28.1 +/- 23.2 months. The mean numeric rating scale was 2.7 +/- 2.5, and 10 patients (2.0%) required postprocedural drug treatment for pain relief. Mild vasovagal reactions were experienced in 20 cases (4.1%), and four patients (0.8%) had a severe vasovagal reaction. No late complications were reported. No patients required hospital admission after the procedure. CONCLUSION(S): In our series, HyCoSy was a well-tolerated examination with a very low rate of side effects and no late complications that required no atropine or anti-inflammatory drugs. These data support the safety of HyCoSy when performed as described, but further work is needed to estimate the rate of late complications and side effects in other settings.

Dyschezia and posterior deep infiltrating endometriosis: analysis of 360 cases.

STUDY OBJECTIVE: To evaluate the relationship between anatomic locations and diameter of endometriotic lesions with severity of perimenstrual dyschezia (pain with defecation) as a possible location-indicating pain symptom for posterior deep infiltrating endometriosis (DIE). DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: Tertiary care university hospital. PATIENTS: We reviewed hospital records of patients who underwent laparoscopic treatment for pelvic endometriosis in our center between 2001 and 2006. In all, 360 patients with posterior DIE (endometrial glands and stroma infiltrated excised tissues of the specified organs) were included for whom preoperative scoring of perimenstrual dyschezia was performed using a 10-point visual analog scale (VAS). Data about anatomic location and diameter of excised nodules were retrieved from operative and pathological records. INTERVENTIONS: Laparoscopic excision of suspected endometriotic lesions. MEASUREMENTS AND MAIN RESULTS: Mean VAS score of dyschezia for patients with overall posterior DIE was 3.9 +/- 3.8, whereas in unaffected patients it was 1.9 +/- 3.3 (Mann-Whitney test p <.0005). Rectovaginal involvement (posterior vaginal wall, rectovaginal septum, and anterior rectal wall) was found in 240 of 360 women. Mean VAS score for dyschezia was 4.1 +/- 4 and 2.1 +/- 3.3 in affected and nonaffected patients, respectively (p <.0005). Mean lesion diameter in affected patients was significantly correlated with mean VAS score (Spearman rho = 0.21). Patients with anterior rectal wall endometriosis (71/240) had a mean VAS score of 4.2 +/- 4 and in nonaffected patients it was 2.7 +/- 3.6 (p <.05). Mean lesion diameter in affected patients was not significantly correlated with mean VAS score of dyschezia (Spearman rho = 0.16). CONCLUSION: Severity of dyschezia was significantly correlated with posterior DIE. A positive correlation occurred between severity of dyschezia and lesion diameter with rectovaginal endometriosis but not with anterior rectal wall involvement.

Importance of retroperitoneal ureteric evaluation in cases of deep infiltrating endometriosis.

STUDY OBJECTIVE: To discuss our clinical and surgical experience with 30 cases of ureteral endometriosis. DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: Tertiary care university hospital. PATIENTS: Records were assessed for all patients who underwent laparoscopic surgery for deep infiltrating endometriosis (DIE) from June 2002 through June 2006. Thirty patients were laparoscopically given a diagnosis that was histologically confirmed of ureteral involvement by endometriosis. INTERVENTIONS: Laparoscopic retroperitoneal examination and management of ureteral endometriosis. MEASUREMENTS AND MAIN RESULTS: Variables assessed were: preoperative findings (patient characteristics, clinical symptoms, preoperative workup), operative details (type and site of ureteral involvement, associated endometriotic lesions, type of intervention, intraoperative complications), and postoperative follow-up (short- and long-term outcomes). We recorded details of 30 patients with a median age of 33.33 years and a median body mass index of 21.96. Symptoms reported were: none in 20 (66.7%) of 30 patients, specific in 10 (33.3%) of 30, dysuria (30%), renal angle pain (10%), hematuria (3.3%), and hydroureteronephrosis (33.3%). Ureteral endometriosis was presumptively diagnosed before surgery in 40% of patients. Ureteric involvement was on the left side in 46.7%, on the right side in 26.7%, and bilaterally in 26.7%. It was extrinsic in 86.7% and intrinsic in 13.3%. It was associated with endometriosis of homolateral uterosacral ligament in all (100%) of 30, the bladder in 50%, rectovaginal septum in 80%, ovaries in 53.3%, and bowel in 36.7%. Laparoscopic intervention was: only ureterolysis in 73.3%, segmental ureteral resection and terminoterminal anastomosis in 16.7%, and segmental ureterectomy and ureterocystoneostomy in 10%. Early postoperative complications were: fever greater than 38 degrees C requiring medical therapy for 7 days in 7 patients and 1 patient had transient urinary retention requiring catheterization that resolved without further treatment. During a mean follow-up period of 14.6 months, endometriosis recurred in 3 patients with no evidence of ureteral reinvolvement. CONCLUSION: Ureteral involvement is a silent, serious complication that must be suspected in all cases of DIE. Retroperitoneal laparoscopic isolation and inspection of both ureters helps to diagnose silent ureteral involvement. Conservative laparoscopic surgery provides a safe, feasible modality for management of ureteral endometriosis.

Role of laparoscopic hysterectomy in the management of endometrial cancer.

PURPOSE OF REVIEW: By the current review we aim to describe different options for laparoscopic hysterectomy in patients with endometrial cancer and discuss the reported risk factors and limitations of laparoscopic hysterectomy in surgical staging of endometrial cancer. RECENT FINDINGS: Laparoscopic techniques and equipment have matured over the last 15 years and are now widely used to treat patients with endometrial cancer, thereby potentially reducing perioperative morbidity and postoperative pain, and providing shorter hospital stay, faster recovery and improved quality of life compared with the corresponding open procedures. However, some risk factors are postulated to limit the use of laparoscopic hysterectomy in staging of endometrial cancer. SUMMARY: Surgical staging of endometrial cancer by laparoscopic hysterectomy is feasible and well tolerated. This surgical approach does not seem to affect recurrence and overall survival rates. Limitations of laparoscopic hysterectomy in management of endometrial cancer need to be evaluated.

Obstetric and delivery outcome of pregnancies achieved after laparoscopic myomectomy.

OBJECTIVE: To assess the risks and outcome of pregnancies and deliveries after laparoscopic myomectomy (LM). DESIGN: Retrospective study. SETTING: Center of Reconstructive Pelvic Endosurgery, Reproductive Medicine Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy. PATIENT(S): A total of 514 patients of fertile age that underwent LM at the Center were selected. INTERVENTION(S): All the surgical procedures were performed using the same technique employing a vertical uterine incision and avoiding the use of electrosurgery. MAIN OUTCOME MEASURE(S): Number and outcome of pregnancies achieved after surgery, abortion rate, preterm delivery, gestational age, malpresentation, spontaneous or cesarean delivery, and postpartum hemorrhage. We also paid particular attention to the occurrence of uterine rupture. RESULT(S): A total of 158 pregnancies were achieved. There were 43 (27.2%) spontaneous abortions, 4 (2.6%) ectopic pregnancies, and 1 (0.6%) therapeutic abortion. Only 27 patients (25.5%) had vaginal deliveries, whereas 79 (74.5%) underwent cesarean section. No instances of uterine rupture were recorded. CONCLUSION(S): Our preliminary results confirmed that LM, performed by an expert surgeon, can restore reproductive capacity, allowing patients to have a successful pregnancy.