Surgical management of endometriosis.

A systematic literature review of the last two decades was performed to evaluate the effect of pelvic denervations in addition to conservative surgery on dysmenorrhoea and deep dyspareunia associated with endometriosis. Chronic pelvic pain relief after hysterectomy or adhesiolysis was also assessed. In the five non-comparative studies on the effect of pre-sacral neurectomy, the frequency of dysmenorrhoea recurrence or persistence after treatment ranged from 4 to 40%. The pooled frequency of non-responders at the end of follow-up was 23% (95% confidence interval (CI), 19 to 27%). Only two of the three comparative, non-randomized trials demonstrated a significant treatment benefit of pre-sacral neurectomy, and the results of the two identified randomized controlled trials are discordant. Significant quantitative heterogeneity among studies prevented pooling of data on dysmenorrhoea. The common odds ratio of deep dyspareunia persistence was 0.69 (95% CI, 0.31 to 1.54). In the 10 non-comparative studies on the effect of uterosacral ligament resection, the frequency of dysmenorrhoea and deep dyspareunia persistence after treatment ranged, respectively, from 0 to 50% and from 6 to 42%. The pooled frequency of non-responders at the end of follow-up was 23% (95% CI, 20 to 27%) and 13% (95% CI, 8 to 18%), respectively. Routine performance of complementary denervating procedures cannot be recommended based on the quality of the evidence available. The results of the five studies on the effect of hysterectomy on chronic pelvic pain of presumed uterine origin consistently demonstrated that 83-97% of operated women reported pain relief or improvement 1 year after surgery. There is no consensus on the outcome of adhesiolysis in patients with chronic pain, and the role of pelvic adhesions in causing symptoms is under scrutiny.

Lateral distribution of nonendometriotic benign ovarian cysts.

To investigate the left- and right-sided distribution of nonendometriotic benign ovarian cysts, data were collected on 406 women undergoing first-line surgery for tumours with various histotypes. Considering the unilateral cysts, the observed proportion of left lesions was 65/129 (50.4%) in the serous, 38/79 (48.1%) in the mucinous, 59/134 (44.0%) in the dermoid, 11/21 (52.4%) in the parovarian, and 3/7 (42.9%) in the miscellaneous cysts group, without significant differences from the expected 50%. This contrasts with the finding of a significantly more frequent development of endometriomas on the left ovary, and suggests that the pathogenesis of endometriotic and nonendometriotic cysts is different.

Is ureteral endometriosis an asymmetric disease?

Six cases of endometriosis obstructing the left ureter were observed among 1,054 consecutive patients undergoing surgery in an eight-year period. In addition, 125 women with ureteral endometriosis (left-sided, n = 66; right-sided, n = 40; bilateral, n = 19) were described in 62 articles identified in a systematic review of the English language literature between 1980 and 1998. Considering only the patients with unilateral ureteral endometriosis and combining the published figures with those of our surgical series, the observed proportion of left lesions (72/112, 64%; 95% CI 55% to 73%) was significantly different from the expected proportion of 50% (chi2(1), 9.14, P = 0.002). The lateral asymmetry found in the location of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomical differences of the left and right hemipelvis.

A levonorgestrel-releasing intrauterine system for the treatment of dysmenorrhea associated with endometriosis: a pilot study.

OBJECTIVE: To evaluate the efficacy and safety of an intrauterine system releasing 20 microg of levonorgestrel per 24 hours in the long-term treatment of recurrent dysmenorrhea in women already operated on conservatively for endometriosis. DESIGN: A prospective noncomparative pilot study. SETTING: A tertiary care and referral academic center for patients with endometriosis. PATIENT(S): Twenty parous women with recurrent moderate or severe dysmenorrhea after conservative surgery for endometriosis who did not want further children. INTERVENTION(S): A levonorgestrel-releasing intrauterine system was inserted in each woman within 7 days of the start of a menstrual cycle. MAIN OUTCOME MEASURE(S): Variations in severity of dysmenorrhea during treatment according to a 100-mm visual analogue scale and a 0-3-point verbal rating scale, modification of a pictorial blood-loss assessment chart devised to evaluate the amount of menstrual flow, and degree of satisfaction after 12 months of therapy. RESULT(S): One woman was lost to follow-up after achieving amenorrhea and expressing satisfaction, and 1 requested system removal because of weight gain and abdominal bloating. In another subject, the levonorgestrel intrauterine system was expelled 3 months after insertion. The menstrual patterns in the remaining 17 women were characterized by amenorrhea in 4 cases, hypomenorrhea or spotting in 8, and normal flow in 5. Baseline and 12-month follow-up mean +/- SD blood loss scores were 111+/-36 and 27+/-26, respectively. At the same time, mean +/- SD visual analogue and verbal rating scale scores dropped, respectively, from 76+/-12 to 34+/-23 points and from 2.5+/-0.5 to 1.2+/-0.5 points. Four women were very satisfied with treatment, 11 were satisfied, 2 were uncertain, and 3 were dissatisfied at 12-month follow-up. CONCLUSION(S): Because of the amenorrhea or hypomenorrhea induced in most women, a levonorgestrel intrauterine system greatly reduced menstrual pain associated with endometriosis and achieved a high degree of patient satisfaction.

Determinants of reproductive outcome after abdominal myomectomy for infertility.

OBJECTIVE: To determine the effect of myomectomy as a therapy for infertility and to define the factors that influence reproductive outcome. DESIGN: Retrospective study of a case series. SETTING: An academic department specializing in conservative surgery. PATIENT(S): A total of 138 infertile women who underwent first-line conservative surgical treatment at laparotomy for uterine leiomyomas over an 8-year period. INTERVENTION(S): Data were collected on baseline clinical characteristics, surgical details, and subsequent reproductive history. MAIN OUTCOME MEASURE(S): Cumulative pregnancy rates at 24 months according to selected clinical and fibroid characteristics. RESULT(S): Pregnancy occurred in 76 women. The 24-month cumulative probability of conception according to the Kaplan-Meier method was 87% in patients <30 years of age, 66% in patients 30-35 years of age, and 47% in patients >35 years of age. The pregnancy rates in women with and without minor infertility factors in addition to myomas were 56% and 71%, respectively, and those in women with <2 years versus > or =2 years of infertility were 84% and 51%, respectively. The size and site of the largest myoma and the total number of tumors removed did not influence the outcome. CONCLUSION(S): Our results suggest a benefit of myomectomy in infertile patients. However, women should be counseled carefully before surgery because the determinants of outcome appear to be independent of treatment.

Efficacy of preoperative medical treatment in facilitating hysteroscopic endometrial resection, myomectomy and metroplasty: literature review.

The evidence of the efficacy of preoperative medical treatment with danazol, gonadotrophin releasing-hormone agonists (GnRHa) or progestins in facilitating surgery and improving the long-term results of myomectomy, hysteroscopic metroplasty and endometrial resection has been reviewed. Sixteen randomized and non-randomized controlled clinical trials, published in the English literature between 1990 and 1996, were identified. In all studies comparing GnRHa or danazol versus no treatment, fluid absorption during surgery was less in subjects who underwent medical treatment independently of the drug used and the type of intervention, the reduction ranging from 142 to 572 ml. A reduction in operating time (between 2 and 25 min) was observed in both the danazol and GnRHa-treated groups in comparison with untreated controls, regardless of the type of operation (endometrial resection, myomectomy or metroplasty). With regard to long-term results, amenorrhoea tended to be more frequent in patients who received GnRHa: the pooled odds ratio (OR) of amenorrhoea for GnRHa-treated women compared with untreated controls was 2.0 [95% confidence interval (CI), 1.1-3.8]. In studies comparing GnRHa with danazol, no marked differences were observed in mean operating time, but the OR of amenorrhoea at 6-12 months after surgery was 1.9 (95% CI 1.0-3.3).