J Minim Invasive Gynecol. 2009 Mar-Apr;16(2):142-8.

Endometrioma excision and ovarian reserve: a dangerous relation.

Busacca M, Vignali M.

Department of Obstetrics and Gynecology, University of Milano, Macedonio Melloni Hospital, Italy. mauro.busacca@unimi.it

Endometrioma is one of the most frequent pathologies in gynecologic surgery. Laparoscopic cyst excision is considered the best treatment in terms of lower recurrence and improved fertility. However, it was recently questioned whether the excision of the endometrioma could decrease the function of the operated ovary and if it could affect the subsequent fertility. Even if a consistent amount of ovarian tissue is unintentionally removed together with the capsule of the cyst, resulting in does not show the follicular pattern observed in working ovaries. Currently, no definitive data clarify whether the damage to the ovarian reserve, observed in patient with endometrioma, is related to the surgical procedure, to the previous presence of the cyst, or both. Electrosurgial coagulation during hemostasis could play an important role in terms of damage to ovarian stroma and vascularization. Particular attention must be paid in presence of bilateral endometriotic cysts. In fact, an increase in premature ovarian failure rate was reported when both the ovaries are involved in surgery. Incase of assisted reproductive techniques, no clear evidence indicates which is the best approach for concomitant endometriotic cyst. On the base of these considerations endometriomas Should be treated only in case of pain, infertility, and in asymptomatic patients if the cyst diameter is greater than 4 cm.

Publication Types:

J Minim Invasive Gynecol. 2009 Mar-Apr;16(2):128-9.

 

Vaginoscopy to identify vaginal endometriosis.

Di Spiezio Sardo A, Di Iorio P, Guida M, Pellicano M, Bettocchi S, Nappi C.

Department of Gynaecology and Obstetrics, University of Naples, Italy. cdispie@tin.it

Fertil Steril. 2009 Feb 25. [Epub ahead of print]

 

Analysis of the transforming growth factor beta1 gene -509 C/T polymorphism in patients with advanced-stage endometriosis.

Kim JJ, Choi YM, Choung SH, Yoon SH, Lee KS, Ku SY, Kim JG, Moon SY.

Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea; Healthcare System Gangnam Center, Seoul, Korea.

OBJECTIVE: To investigate whether the transforming growth factor beta (TGF-beta) gene -509 C/T polymorphism is associated with susceptibility to advanced-stage endometriosis. DESIGN: Case-control study. SETTING: University department of obstetrics and gynecology. PATIENT(S): Women with advanced-stage endometriosis (n = 485) and without endometriosis (n = 352). INTERVENTION(S): Genotyping by real-time polymerase chain reaction using a Taqman assay. MAIN OUTCOME MEASURE(S): Genotype distribution and allele frequency of the -509 C/T polymorphism in the TGF-beta1 gene. RESULT(S): The genotype distribution of the TGF-beta1 gene -509 C/T polymorphism in the endometriosis group was not different from that of the control group (CC/CT/TT rates were 29.3%/48.2%/22.5% and 27.3%/50.3%/22.4% for the endometriosis and control groups, respectively). Further subgroup analyses according to the stage of endometriosis or bilaterality of ovarian endometrioma also revealed no significant differences in the genotype distribution between each of the subgroups and the control group. CONCLUSION(S): These results suggest that the TGF-beta1 -509 C/T polymorphism may not be associated with an increased risk for advanced-stage endometriosis.

Hum Reprod. 2009 Jun;24(6):1402-6. Epub 2009 Feb 26.

 

Analysis of risk factors for the removal of normal ovarian tissue during laparoscopic cystectomy for ovarian endometriosis.

Matsuzaki S, Houlle C, Darcha C, Pouly JL, Mage G, Canis M.

CHU Clermont-Ferrand, Polyclinique-Hôtel-Dieu, Gynécologie Obstétrique et Médecine de la Reproduction, Boulevard Léon Malfreyt, 63058 Clermont-Ferrand, France. sachikoma@aol.com

BACKGROUND: The aim of this study was to identify risk factors for the removal of normal ovarian tissue during laparoscopic cystectomy for endometriosis. METHODS: A total of 121 patients who had histologically confirmed ovarian endometriosis and 56 control patients who had other histologically confirmed benign cysts were included for the present analysis. The blocks of removed tissue were sectioned at 120 microm intervals and a total of five sections were analyzed for each ovarian cyst. Eight variables (age, pre-operative medical treatment, previous surgery for ovarian endometriosis, single or multiple cysts, size of the largest cyst, side of cyst, co-existence of deep endometriosis, revised American Society for Reproductive Medicine classification) were evaluated using a generalized linear modeling analysis to identify major factors associated with the removal of normal ovarian tissue. RESULTS: Normal ovarian tissue adjacent to the cyst wall was detected in 71 patients (58.7%) with endometriosis, whereas normal ovarian tissue was removed from only three patients (5.4%) with other benign cysts. A significant factor that was independently associated with the removal of normal ovarian tissue with ovarian endometriosis was pre-operative medical treatment. CONCLUSIONS: The present retrospective, controlled study suggests that pre-operative medical treatment might be a risk factor for the removal of normal ovarian tissue during laparoscopic cystectomy for ovarian endometriosis.

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Gynecol Obstet Fertil. 2009 Mar;37(3):240-5. Epub 2009 Feb 25.

 

Relevance of quality of life questionnaires in women with endometriosis

[Article in French]

Daraï E, Coutant C, Bazot M, Dubernard G, Rouzier R, Ballester M.

Service de gynécologie-obstétrique, hôpital Tenon, Assistance publique des Hôpitaux de Paris, université Pierre-et-Marie-Curie Paris-VI, Paris, France. emile.darai@tnn.aphp.fr

High recurrence rates have been reported in women treated for endometriosis despite advances in medical and surgical treatments improving both fertility and symptoms. It should therefore be considered a chronic disorder. In this particular setting, the main objectives for practitioners are to limit disease progression, recurrence and to improve quality of life (QOL). Previous studies have demonstrated a relation between an increase in pain intensity and a decrease in QOL. However, visual analogue scales to measure general well-being are insufficient to quantify the impact of endometriosis on QOL. Several generic questionnaires, mainly the SF-36, are available in various languages but are not specific of women with endometriosis. Some specific questionnaires are available but have been validated in English population for the most part rending comparison between countries difficult. Despite these limits, QOL should be systematically monitored over time by a validated questionnaire for this chronic disorder and could be a criterion for therapeutic strategy.

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J Ultrasound Med. 2009 Mar;28(3):410-1.

Comment on:

The sonographic diagnosis of deep endometriosis.

Cosmi E, Saccardi C, Litta P.

Publication Types:

J Ultrasound Med. 2009 Mar;28(3):408-9; author reply 409-10.

 

Comment on:

The sonographic diagnosis of deep endometriosis.

Abrão MS, Gonçalves MO, Ajossa S, Melis GB, Guerriero S.

Publication Types:

Fertil Steril. 2009 May;91(5):1957.e13-5. Epub 2009 Feb 24.

 

Horizontal uterine torsion in the setting of complete cervical and partial vaginal agenesis: a case report.

Omurtag K, Session D, Brahma P, Matlack A, Roberts C.

Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA. komurta@emory.edu

OBJECTIVE: To report a case in which uterine torsion in a nulligravid female adolescent was noted upon surgical management of complete cervical and partial vaginal agenesis. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 13-year-old nulligravid adolescent female. INTERVENTION(S): Ultrasound-guided vaginal exploration, diagnostic laparoscopy, and hysterectomy. MAIN OUTCOME MEASURE(S): Uterine torsion as complication of cervical agenesis and its management. RESULT(S): Complete cervical agenesis, hematometra, and resultant 180-degree horizontal uterine torsion and sacral entrapment. CONCLUSION(S): Cervical agenesis can be a risk factor for uterine torsion. Hysterectomy is a common treatment due to resultant hematometra, pelvic pain, and severe endometriosis, although rare case reports show success with uterovaginal recanalization in cases with cervical dysgenesis.

Publication Types:

Arch Gynecol Obstet. 2009 Jul;280(1):161-5. Epub 2009 Feb 24.

 

Laparoscopic ovarian cystectomy without bipolar coagulation or sutures using a gelantine-thrombin matrix sealant (FloSeal): first support of a promising technique.

Ebert AD, Hollauer A, Fuhr N, Langolf O, Papadopoulos T.

Department of Obstetrics and Gynecology, German Endometriosis Research Center Berlin Level III, Vivantes, Network for Health, Campus Humboldt, Am Nordgraben 2, Berlin 13509, Germany. andreas.ebert@vivantes.de

As a important part of endocrine surgery, laparoscopic surgery has become the gold standard for the treatment of benign symptomatic ovarian cysts refractory to medical treatment. In fact, the stripping technique seems to be the most common technique used for ovarian cyst surgery. After stripping the cystic wall, the subsequent bleeding of the ovarian stromal wound ground is usually controlled by bipolar coagulation or/and by suturing. Potentially, the surgery-induced ovarian tissue damage will be increased by heat and/or by sutures. In respect to intraovarian hemostasis, the use of gelantine-thrombin-matrix might protect from additional ovarian tissue damage, which is of great importance for the ovarian reproductive function in woman. For the first time, our data do support a promising laparoscopic technique demonstrating ovarian cystectomy without any bipolar coagulation and/or suturing of ovarian tissue using a gelantine-thrombin-matrix sealant (FloSeal) as a new tool to control post-cystectomy ovarian wound bleeding.

Publication Types:

J Reprod Immunol. 2009 Jan;79(2):196-200. Epub 2009 Feb 23.

 

PTPN22/LYP 1858C>T gene polymorphism and susceptibility to endometriosis in a Polish population.

Płoski R, Dziunycz P, Kostrzewa G, Roszkowski PI, Barcz E, Zabek J, Milewski Ł, Kamiński P, Malejczyk J.

Department of Medical Genetics, Centre of Biostructure Research, Warsaw Medical University,

Warsaw, Poland.

Endometriosis is a common gynaecological disorder due to ectopic implantation of endometrial tissue. It is manifested by pelvic inflammation and abrogation of cell-mediated immunity and may be also characterised by autoantibody production, thus suggesting that endometriosis might be an autoimmune disorder. Genetic factors also play a role in the aetiopathogenesis of this disease. Therefore, the present study was aimed at testing the association of endometriosis with the PTPN22/LYP 1858C> T gene polymorphism, which appears to be related to the development of a variety of autoimmune disorders. The study included 171 Polish patients of Caucasian origin with laparoscopically and histopathologically confirmed endometriosis and 310 unrelated, ethnically matched control individuals. DNA and serum were isolated from the peripheral blood. The PTPN22/LYP 1858C> T polymorphism was typed using a PCR-RFLP method. Anti-nuclear (ANA) and anti-cardiolipin (ACA) autoantibodies were detected by the Hep-2 indirect immunofluorescence test and a specific ELISA respectively. No statistically significant differences were found in distribution of C and T PTPN22/LYP alleles and genotypes in patients with endometriosis compared with the control population. However, on exploratory analyses we noted that the PTPN22/LYB T allele and the TT genotype may be associated with the prevalence of double positivity for ANA and ACA (p=0.003 by chi(2) test for trend and p=0.009 by Fisher’s exact test respectively). The results of the present study show that endometriosis in a Polish population is not associated with the PTPN22/LYP 1858C> T gene polymorphism. The putative effect of the PTPN22/LYP genotype on the development of autoantibodies is potentially interesting, but it should be verified in further studies.

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Histopathology. 2009 Feb;54(3):365-73.

 

Endometrial stromal sarcomas with extensive endometrioid glandular differentiation: report of a series with emphasis on the potential for misdiagnosis and discussion of the differential diagnosis.

McCluggage WG, Ganesan R, Herrington CS.

Department of Pathology, Royal Group of Hospitals Trust, Belfast, Northern Ireland, UK. glenn.mccluggage@belfasttrust.hscni.net

AIMS: To describe a series of endometrial stromal sarcomas with large numbers of endometrioid-type glands. METHODS AND RESULTS: The eight tumours occurred in patients aged 42-74 years. In three cases, the neoplasm arose in the uterine corpus and in the others there was either an extrauterine origin or the origin could not be determined since multiple sites were involved. In four cases, glands were present throughout the neoplasm and in the others there were areas of typical endometrial stromal sarcoma without glands. In one case, glands were present only in the recurrent neoplasm. The malignant stromal component comprised, for the most part, typical endometrial stromal sarcoma. In two patients, repeated biopsy specimens from the vagina or cervix were initially diagnosed as endometriosis, and in some cases there was a significant delay in diagnosis. Apart from endometriosis, other diagnostic considerations, depending on the tumour location and exact morphology, included adenomyosis, adenosarcoma and carcinosarcoma. CONCLUSIONS: Endometrial stromal sarcoma with extensive endometrioid glandular differentiation is rare. The presence of glands often results in diagnostic difficulty with a significant risk of misdiagnosis or delay in diagnosis. It is likely that some cases reported in the literature as aggressive endometriosis represent this entity.

Publication Types:

Acta Radiol. 2009 Apr;50(3):340-7.

 

Quantitative diffusion-weighted magnetic resonance imaging of normal and diseased uterine zones.

 

Kilickesmez O, Bayramoglu S, Inci E, Cimilli T, Kayhan A.

Department of Radiology, School of Medicine, Yeditepe University, Istanbul, Turkey. okilickesmez@yahoo.com

BACKGROUND: Magnetic resonance (MR) imaging has been established as the best imaging modality for the detection, localization, and staging of uterine cancers. Recently, the usefulness of diffusion-weighted imaging (DWI) in the diagnosis of cancers has been reported in several studies. PURPOSE: To calculate the apparent diffusion coefficient (ADC) values of normal uterine zones as well as benign and malignant uterine diseases, and to determine a cut-off ADC value for the quantitative detection of uterine malignancies with DWI. MATERIAL AND METHODS: Eighty-seven patients (mean age 53 years) with 107 benign and malignant uterine pathologies and 50 healthy controls (mean age 38 years) were enrolled in the study. DWI was performed with b factors of 0, 500, and 1000 s/mm(2). RESULTS: The ADC values of benign and malignant lesions were compared using Student’s t test. The mean and the standard deviation of the ADC values of the control group were as follows: myometrium 1.76+/-0.19 x 10(-3) mm(2)/s, junctional zone 0.99+/-0.18 x 10(-3) mm(2)/s, endometrium 1.65+/-0.33 x 10(-3) mm(2)/s, and cervix 1.71+/-0.17 x 10(-3) mm(2)/s. There was a statistically significant difference among the ADC values of normal myometrium and leiomyomas (1.47+/-0.36 x 10(-3) mm(2)/s; P<0.009), endometrium and endometrial carcinomas (0.86+/-0.13 x 10(-3) mm(2)/s; P<0.001), myometrium-junctional zone and adenomyosis (1.24+/-0.20 x 10(-3) mm(2)/s; P<0.001), and cervix and cervical carcinomas (0.91+/-0.14 x 10(-3) mm(2)/s; P<0.001). The ADC values differed significantly between malignant (0.88+/-0.11) and benign lesions (1.55+/-0.33; P<0.01). A cut-off value for malignant lesions of 1.05 x 10(-3) mm(2)/s yielded a sensitivity, specificity, and accuracy of 95.83%, 94.55%, and 94.94%, respectively. CONCLUSION: The present study shows that ADC measurements have the potential to quantitatively differentiate between normal and cancerous tissues of the uterine zones. We propose adding DWI as an adjunct sequence in the MR protocol for the assessment of uterine lesions.

Eur J Obstet Gynecol Reprod Biol. 2009 Apr;143(2):112-5. Epub 2009 Feb 23.

 

Successful treatment of refractory endometriosis-related chronic pelvic pain with aromatase inhibitors in premenopausal patients.

Verma A, Konje JC.

Women’s Hospital, Leicester Royal Infirmary, Leicester LE1 5WW, UK.

OBJECTIVE: Not every patient with endometriosis responds to currently recommended conventional medical treatment regimens. The objective of this study was to determine the efficacy and side effects of aromatase inhibitors in the treatment of premenopausal patients with endometriosis associated with chronic pelvic pain refractory to conventional treatment. STUDY DESIGN: Four premenopausal patients with documented refractory endometriosis and chronic pelvic pain were treated with aromatase inhibitors, either anastrazole (3) or letrozole (1), for 6 months. The treatment was combined with calcium 1.5 g per day and vitamin D 800 U per day. The main outcome measure was reduction in pelvic pain assessed by visual analogue scale. Side effects were documented and changes in serum LH, FSH and 17-beta estradiol and bone density (Dexa scan) were measured before, during and after treatment. RESULTS: There was marked improvement in pelvic pain in the four patients. Their mean pain score fell from 9 prior to treatment to 4.5 at the end of treatment. One patient with infertility conceived immediately after completing the treatment. There were no changes in the hormone levels and bone scan scores. The most common side effect was irregular bleeding with anastrazole and joint pains with letrozole. CONCLUSIONS: Aromatase inhibitors are beneficial in premenopausal women with chronic pelvic pain secondary to refractory endometriosis without compromising fertility and with minimal side effects. Further cohort and comparative studies are needed to confirm these observations.

Publication Types:

J Urol. 2009 Apr;181(4):1732-6. Epub 2009 Feb 23.

 

Laparoscopic management of endopelvic etiologies of pudendal pain in 134 consecutive patients.

Possover M.

Department and Gynecology and Neuropelviology, Hirslanden Clinic, Zürich, Switzerland.

PURPOSE: The feasibility of the laparoscopic transperitoneal approach to the pelvic somatic nerves was determined for the diagnosis and treatment of anogenital pain caused by pudendal and/or sacral nerve root lesions. MATERIALS AND METHODS: The records of 134 consecutive patients who underwent laparoscopy for refractory anogenital pain were retrospectively reviewed. All neurosurgical procedures, such as neurolysis/decompression of the pudendal nerve and the sacral nerve roots or neuroelectrode implantation to the sacral plexus for postoperative neuromodulation, were done via the laparoscopic transperitoneal approach to the pelvic nerves. RESULTS: A total of 18 patients had Alcock’s canal syndrome and decompression was successful in 15. Due to failed decompression 3 patients underwent secondary sacral laparoscopic neuroprosthesis implantation with a decrease of at least 50% on the pain visual analog scale. Sacral plexus lesions or radiculopathies, most commonly postoperative lesions and retroperitoneal endometriosis, were found in 109 patients who underwent laparoscopic neurolysis of the sacral plexus. The final outcome depended on the etiology. Of patients with postoperative nerve damage 62% had a decrease in the mean +/- SD preoperative visual analog scale score of from 8.9 +/- 2.9 (range 7 to 10) to 2.4 +/- 2.3 points (range 0 to 4) at the time of article submission at a mean followup of 17 months (range 3 to 39). Because of failed decompression, 8 patients underwent secondary sacral laparoscopic neuroprosthesis implantation and a decrease in the pain visual analog scale score was achieved in 5. Of patients with an endometriosis lesion of the sacral plexus 78% had a decrease in the mean preoperative visual analog scale score of 8.7 +/- 1.9 (range 8 to 10) to 1.1 +/- 0.7 points (range 0 to 2) at the time of article submission at a mean followup of 21 months (range 2 to 42). All 6 patients with vascular entrapment of pelvic nerves achieved complete relief. The last 7 patients underwent primary sacral laparoscopic neuroprosthesis implantation with at least a 50% decrease in the pain visual analog scale score in 4. CONCLUSIONS: Our findings emphasize that in patients with seemingly inexplicable anogenital pain, especially after failed treatment for Alcock’s canal syndrome, laparoscopic exploration of the pelvic nerves must be done for further diagnosis and therapy before prematurely labeling the patients as refractory to treatment.

Eur J Obstet Gynecol Reprod Biol. 2009 Apr;143(2):103-6. Epub 2009 Feb 18.

 

Determinants of adenomyosis in women who underwent hysterectomy for benign gynecological conditions: results from a prospective multicentric study in Italy.

Parazzini F, Mais V, Cipriani S, Busacca M, Venturini P; GISE.Collaborators (46)

Ciavattini A, Baiocchi R, Goteri G, Bertivagni E, Biggio A, Muriana, Palomba S, Zullo F, Bianchi A, Martinello R, Bracco GL, Rizzitello F, Coccia E, Meroni N, Radaelli U, Spreafico C, Odorizzi MP, Bertazzoli E, Cannata L, Pieroni G, Vizza E, Cosmaggioni I, Pittino M, Del Frate G, Trossarelli GF, Chiapparo F, Beretta P, Ghezzi F, Cromi A, Uccella S, Piccione E, Di Ciacci S, Petropolli A, Sesti F, Micalef S, Pecori E, Cobellis L, Palermo MR, Surico N, Leo L, Surico D, Boninfante G, Negri, Noci, Rosales, Noci.

Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli, Regina Elena, Milano, Clinica ostetrico ginecologica università di Milano, Italy. parazzini@marionegri.it

OBJECTIVE: We conducted a cross-sectional study on the frequency and risk factors for adenomyosis in women who underwent hysterectomy for benign gynecological conditions. STUDY DESIGN: All women who consecutively underwent hysterectomy during the study period for benign gynecological conditions at 18 gynecological departments were eligible for the study. A total of 820 women entered the study. Pathological data were collected prospectically. RESULTS: Adenomyosis was identified in 231 women (28.2%, 95% confidence interval, CI, 24.6-32.5). The frequency of adenomyosis was similar in women with indication for surgery fibroids/menorrhagia (143 cases, 28.5%) or genital prolapse (69 cases, 28.2%). The rate ratio (RR) of adenomyosis was 1.9 (95% CI 1.2-2.8) in women reporting one or more induced abortions, in comparison with those reporting no induced abortion. Women with adenomyosis reported more frequently dysmenorrhoea and chronic pelvic pain, but not dyspareunia. CONCLUSIONS: This study shows that adenomyosis is common in women who undergo hysterectomy and that it is more frequent among women reporting induced abortions dysmenorrhoea and chronic pelvic pain.

Publication Types:

Fertil Steril. 2009 Feb 14. [Epub ahead of print]

 

Evaluation of high-sensitivity C-reactive protein in comparison with C-reactive protein as biochemical serum markers in women with endometriosis.

Lermann J, Mueller A, Körber F, Oppelt P, Beckmann MW, Dittrich R, Renner SP.

Department of Obstetrics and Gynecology, Erlangen University Hospital, Erlangen, Germany.

OBJECTIVE: To compare high-sensitivity C-reactive protein (hs-CRP) with CRP as a soluble serum marker for the diagnosis of women with endometriosis. DESIGN: Prospective nonrandomized controlled trial (Canadian Task Force classification II-1). SETTING: University hospital. PATIENT(S): Eighty-two women were laparoscopically evaluated. No endometriosis was diagnosed in 34 women (the non-E group). Endometriosis was confirmed by histology in 48 women (the E group). Eighty-two women did not undergo laparoscopic evaluation (the unknown-E group). Afterward, the women were staged according to the revised American Society for Reproductive Medicine criteria (r-ASRM). INTERVENTION(S): CRP and hs-CRP were measured initially before laparoscopy. MAIN OUTCOME MEASURE(S): The hs-CRP and CRP levels and the correlation of those parameters with the stage of the disease. RESULT(S): There was a trend toward higher CRP levels and higher hs-CRP levels in the E group, while the lowest levels of both markers were found in the non-E group. There was a significantly lower hs-CRP level in the non-E group in comparison with the CRP level in this group. No differences between the different stages of the disease were found with either marker. CONCLUSION(S): Measurement of the two markers did not appear to be advantageous for the diagnosis of endometriosis independent of the stage of the disease. Nevertheless, a very low hs-CRP level might serve as a marker for an absence of endometriosis.

Fertil Steril. 2009 Feb 19. [Epub ahead of print]

 

Proteomic analysis of serum yields six candidate proteins that are differentially regulated in a subset of women with endometriosis.

Seeber B, Sammel MD, Fan X, Gerton GL, Shaunik A, Chittams J, Barnhart KT.

Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology,, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics,, University of Pennsylvania, Philadelphia, Pennsylvania; Present address: Department of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Innsbruck, Innsbruck, Austria.

OBJECTIVE: To identify potential novel biomarkers that differ between subjects with and without endometriosis and that might aid in developing a noninvasive, serum-based diagnostic test. DESIGN: Case-control evaluation of a diagnostic test. SETTING: University medical center. PATIENT(S): Consenting women of reproductive age undergoing laparoscopy for indications of pain, infertility, elective tubal ligation, tubal reanastomosis, or other benign indication. INTERVENTION(S): Diagnostic laparoscopy and peripheral venipuncture. MAIN OUTCOME MEASURE(S): Concentrations of low-molecular-weight proteins in serum; surgical staging of endometriosis. RESULT(S): Six proteins were found that were differentially expressed between those with and without disease and that had good diagnostic properties. Taken together in a two-step diagnostic algorithm, we were able to diagnose 55% of subjects, with 99% accuracy as to the status of disease. Further combining this algorithm with that derived by our previous study of serum putative markers (monocyte chemoattractant protein-1, migration inhibitory factor, leptin, and CA-125) improved our diagnostic capability to 73% of subjects, with 94% overall accuracy. CONCLUSION(S): This study is the critical first step in the identification of potential novel biomarkers of endometriosis. Future identification of the proteins and further validation in a second population is needed before applying these findings in clinical practice.

Arch Gynecol Obstet. 2009 Nov;280(5):713-8. Epub 2009 Feb 20.

 

Bowel preparation before laparoscopic gynaecological surgery in benign conditions using a 1-week low fibre diet: a surgeon blind, randomized and controlled trial.

Lijoi D, Ferrero S, Mistrangelo E, Casa ID, Crosa M, Remorgida V, Alessandri F.

Division of Obstetrics and Gynaecology, Department of Women and Children, Imperia Hospital, Via Sant’ Agata, 57, 18100 Imperia, Italy. davide.lijoi@libero.it

PURPOSE: The aim of this randomized, surgeon-blind, controlled study was to evaluate the role of a 7 days minimal-residue (low fibre intake) pre-operative diet compared with a mechanical bowel preparation in laparoscopic benign gynaecological surgery. METHODS: This was a randomized, surgeon-blind, controlled study. The study included 83 women scheduled to undergo diagnostic or operative laparoscopy for various gynaecological benign conditions. Exclusion criteria were suspicion of malignancy, associated non-gynaecological surgical pathologies, severe endometriosis, and history of previous abdominal surgery. Study group had a total daily fibre intake inferior to 10 g for a week before the operation (n = 42). Control group had a mechanical bowel preparation the day before the operation (n = 41). The principal measures of outcome were the quality of bowel preparation, the acceptability of the preoperative diet and of the mechanical bowel preparation. Secondary outcomes included postoperative pain, time of ambulation, length of postoperative ileus, and length of postoperative hospital stay. RESULTS: The two treatment groups were comparable with respect to demographic characteristics and indications for surgery. Preoperatively, abdominal distension and overall discomfort were significantly more frequent in the control group (P = 0.061 and 0.034 respectively). There was no significant difference in the small and large bowel preparation between the two groups. Postoperatively, no significant difference was observed between the two groups in pain, nausea, abdominal swelling, length of ileus, and of postoperative stay. CONCLUSIONS: This study shows that preoperative low fibre diet and mechanical bowel preparation provide similar quality of surgical field exposure. However, when compared with mechanical bowel preparation, preoperative low fibre diet may be better tolerated by the patients, thus increasing compliance. Moreover, a 7 days preoperative low fibre diet allow the patient to continue working and social activities until the day of surgery without requiring admission to the hospital or home bowel preparation on the day before surgery.

Biol Reprod. 2009 Jun;80(6):1136-45. Epub 2009 Feb 18.

 

Isolation and culture of epithelial progenitors and mesenchymal stem cells from human endometrium.

Gargett CE, Schwab KE, Zillwood RM, Nguyen HP, Wu D.

Department of Obstetrics and Gynaecology and Centre for Women’s Health Research, Monash Institute of Medical Research, Monash University, Victoria, Australia. caroline.garget@med.monash.edu.au

Human endometrium is a highly regenerative tissue undergoing more than 400 cycles of growth, differentiation, and shedding during a woman’s reproductive years. Endometrial regeneration is likely mediated by adult stem/progenitor cells. This study investigated key stem cell properties of individual clonogenic epithelial and stromal cells obtained from human endometrium. Single-cell suspensions of endometrial epithelial or stromal cells were obtained from hysterectomy tissues from 15 women experiencing normal menstrual cycles, and were cultured at clonal density (10 cells/cm(2)) or limiting dilution. The adult stem cell properties-self-renewal, high proliferative potential, and differentiation of single epithelial and stromal cells-were assessed by harvesting individual colonies and undertaking serial clonal culture, serial passaging, and culture in differentiation-induction media, respectively. Lineage differentiation markers were examined by RT-PCR, immunocytochemistry, and flow cytometry. Rare single human endometrial EpCAM(+) epithelial cells and EpCAM(-) stromal cells demonstrated self-renewal by serially cloning >3 times and underwent >30 population doublings over 4 mo in culture. Clonally derived epithelial cells differentiated into cytokeratin(+) gland-like structures in three dimensional culture. Single stromal cells were multipotent, as their progeny differentiated into smooth muscle cells, adipocytes, chondrocytes, and osteoblasts. Stromal clones expressed mesenchymal stem cell (MSC) markers ITGB1 (CD29), CD44, NT5E (CD73), THY1 (CD90), ENG (CD105), PDGFRB (CD140B), MCAM (CD146) but not endothelial or hemopoietic markers PECAM1 (CD31), CD34, PTPRC (CD45). Adult human endometrium contains rare epithelial progenitors and MSCs, likely responsible for its immense regenerative capacity, which may also have critical roles in the development of endometriosis and endometrial cancer. Human endometrium may provide a readily available source of MSCs for cell-based therapies.

Publication Types:

Stem Cells. 2009 Jan;27(1):210-9.

 

The multipotency of luteinizing granulosa cells collected from mature ovarian follicles.

Kossowska-Tomaszczuk K, De Geyter C, De Geyter M, Martin I, Holzgreve W, Scherberich A, Zhang H.

Woman’s Hospital, University of Basel, Switzerland.

Graafian ovarian follicles consist of follicular fluid, one single mature oocyte, and several hundred thousands of granulosa cells (GCs). Until now, luteinizing GCs have been considered to be terminally differentiated, destined to undergo death after ovulation. Present concepts of luteal function, endocrine regulation of early pregnancy, and the recruitment of new ovarian follicles are all based on the cyclical renewal of the entire population of GCs. We now demonstrate that luteinizing GCs isolated from the ovarian follicles of infertile patients and sorted with flow cytometry based upon the presence of their specific marker, the follicle-stimulating hormone receptor (FSHR), can be maintained in culture over prolonged periods of time in the presence of the leukemia-inhibiting factor (LIF). Under those conditions the markers of GC function such as FSHR and aromatase gradually disappeared. POU5F1 (POU domain, class 5, homeobox 1), a typical stem cell marker, was expressed throughout the culture, but germ line cell markers such as nanog, vasa, and stellar were not. Mesenchymal lineage markers such as CD29, CD44, CD90, CD105, CD117, and CD166, but not CD73, were expressed by substantial subpopulations of GCs. The multipotency of a subset of GCs was established by in vitro differentiation into other cell types, otherwise not present within ovarian follicles, such as neurons, chondrocytes, and osteoblasts. Follicle-derived stem cells were also able to survive when transplanted into the backs of immunoincompetent mice, in vivo generating tissues of mesenchymal origin. The unexpected findings of multipotency of cells with prolonged lifespans originating from ovarian follicles are likely to have a significant impact on evolving theories in ovarian pathophysiology, particularly with reference to ovarian endometriosis and ovarian cancer.

Publication Types:

Hum Reprod. 2009 Jun;24(6):1407-13. Epub 2009 Feb 16.

 

Treatment of endometriosis of uterosacral ligament and rectum through the vagina: description of a modified technique.

Camara O, Herrmann J, Egbe A, Kavallaris A, Diebolder H, Gajda M, Runnebaum IB.

Department of Gynaecology, Friedrich-Schiller-University, Bachstrasse 18, 07743 Jena, Germany.

BACKGROUND: Endometriosis is common in women of childbearing age, whereas involvement of the rectosigmoid requiring resection is rare. Laparoscopy has become a standard procedure in the management of endometriosis. The optimum way to diagnose endometriosis is by direct visualization of the implants. Usually for the removal of the specimen, an additional larger abdominal incision is needed. METHODS: Here we report on cases of four patients with a uterosacral ligament and rectal endometriosis who were successfully treated with combined laparovaginal resection, using a modification of an existing technique. They had been complaining of rectal bleeding and lower abdominal pain in relation to their menstrual cycle. The aim of this technique is to achieve a careful and margin-free resection of the area involved. This can be done without any large incisions of the abdominal wall. The hypogastric nerves remain preserved on both sides. RESULTS: The intra- and post-operative courses were uneventful. No blood transfusions were needed. Haemoglobin decrease was usually < or =1 mmol/l. The average tumour diameter was 3.5 cm. CONCLUSIONS: Our technique circumvents a larger abdominal incision. This combined laparoscopic-transvaginal approach, avoiding the extension of port-site incisions, represents a viable option for the treatment of bowel endometriosis.

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Hum Reprod. 2009 May;24(5):1012-7. Epub 2009 Feb 15.

 

Can transvaginal sonography predict infiltration depth in patients with deep infiltrating endometriosis of the rectum?

Hudelist G, Tuttlies F, Rauter G, Pucher S, Keckstein J.

Department of Obstetrics and Gynaecology Centre for Endometriosis, Villach General Hospital Nikolaigasse 43, 9500 Villach, Austria. gernot_hudelist@yahoo.de

BACKGROUND: Patients with deep infiltrating endometriosis (DIE) of the rectum often benefit from surgical treatment, including disc or segmental bowel resection, in terms of pain relief and treatment of infertility. The aim of the present study was to evaluate the diagnostic accuracy of transvaginal sonography (TVS) for preoperative detection of rectal DIE. Furthermore, we aimed to investigate whether TVS can predict infiltration depth based on the distortion of characteristic sonomorphologic features of the rectal wall. METHODS: Two-hundred patients with symptoms of endometriosis were prospectively assessed by TVS for the presence of rectal DIE before undergoing laparoscopic radical resection of endometriosis including segmental resection of the bowel in affected cases. Sensitivities, specificities, positive and negative predictive values (PPV and NPV), positive and negative likelihood ratios (LHR) and test accuracies were then calculated for the presence of infiltration of the serosal/smooth muscle (S/M) layer and submucosal/mucosal (MUC) layer as demonstrated by TVS and confirmed by histopathological analysis. RESULTS: Rectal endometriosis was confirmed in 43 out of 195 (22%) cases. The sensitivity, specificity, PPV, NPV, test accuracy and positive and negative LHR of TVS on S/M infiltration were 98%, 99%, 98%, 99%, 99%,150.24 and 0.02, respectively, whereas respective data on MUC involvement were 62%, 96%, 53%, 97%, 93.8%, 16 and 0.4. CONCLUSIONS: TVS is a highly valuable tool in detecting rectal endometriosis preoperatively. Within this, S/M endometriotic infiltration can be accurately predicted, whereas TVS is less valuable for detection of MUC involvement.

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Ann R Coll Surg Engl. 2009 Apr;91(3):259-60. Epub 2009 Feb 13.

Endometriosis-associated intestinal tumours: a consequence of long-term unopposed oestrogen?

Efthymiou CA.

Department of Thoracic Surgery, St James’s University Hospital, Leeds, UK. c_efthymiou@hotmail.com

A case of malignant transformation in an extra-ovarian site, 13 years after total abdominal hysterectomy and bilateral salpingo-oophorectomy, is discussed in a patient on long-term oestrogen implants, which highlights the potential risks surrounding the use of long-term oestrogen replacement therapy.

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BJOG. 2009 Apr;116(5):612-25. Epub 2009 Feb 10.

 

The value of medical history taking as risk indicator for tuboperitoneal pathology: a systematic review.

Luttjeboer FY, Verhoeve HR, van Dessel HJ, van der Veen F, Mol BW, Coppus SF.

Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, The Netherlands.

BACKGROUND: Guidelines recommend diagnostic laparoscopy in subfertile women with known co-morbidities in their medical history. Aggregated evidence underpinning these recommendations is, however, currently lacking. OBJECTIVE: The objective of this study was to perform a systematic review and meta-analysis of the available evidence on the association between items reported during medical history taking and tuboperitoneal pathology. SEARCH STRATEGY: MEDLINE (from 1966 to May 2007), EMBASE (from 1960 to January 2007) and bibliographies of retrieved primary articles. SELECTION CRITERIA: All relevant studies that compared medical history with the presence or absence of tubal pathology. DATA COLLECTION AND ANALYSIS: Studies comparing medical history with the presence or absence of tubal pathology were included. A diagnosis of tubal pathology had to be made by hysterosalpingography, laparoscopy or a combination of both. In the absence of invasive tubal testing, tuboperitoneal pathology was considered to be absent in case of intrauterine pregnancy. Homogeneity between studies was assessed, and the association between medical history and tubal pathology was expressed as a common odds ratio with a 95% CI. No language restriction was applied. MAIN RESULTS: We included 32 studies. In cohort studies, strong associations were found for a history of complicated appendicitis (OR 7.2, 95% CI 2.2-22.8), pelvic surgery (OR 3.6, 95% CI 1.4-9.0) and pelvic inflammatory disease (PID) (OR 3.2, 95% CI 1.6-6.6), and in case-control studies, for a history of complicated appendicitis (OR 3.3, 95% CI 1.8-6.3), PID (OR 5.5, 95% CI 2.7-11.0), ectopic pregnancy (OR 16.0, 95% CI 12.5-20.4), endometriosis (OR 5.9, 95% CI 3.2-10.8) and sexually transmitted disease (OR 11.9, 95% CI 4.3-33.3). AUTHOR’S CONCLUSIONS: Subfertile women reporting a history of PID, complicated appendicitis, pelvic surgery, ectopic pregnancy and endometriosis are at increased risk of having tuboperitoneal pathology. In these women, diagnostic laparoscopy should be offered early in the fertility work-up.

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Arch Gynecol Obstet. 2009 Oct;280(4):637-41. Epub 2009 Feb 15.

 

Primary peritoneal clear cell adenocarcinoma arising in previous abdominal scar for endometriosis surgery.

Matsuo K, Alonsozana EL, Eno ML, Rosenshein NB, Im DD.

Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland Medical Center, University of Maryland School of Medicine, 22 South Greene Street, Box 290, Baltimore, MD 21201, USA. koji.matsuo@gmail.com

BACKGROUND: Endometriosis-associated ovarian cancer arising from the surgical incision site is an unusual clinical entity. CASE: A 37-year-old woman presented with a chief complaint of progressive swelling of the mons pubis. The patient was status post laparotomy for endometrioma/endometriosis 10 years ago. MRI showed a heterogeneous multiseptated large cystic mass within the mons pubis measuring 14 x 13.4 x 10.6 cm. Initial cytoreductive surgery revealed no evidence of tumor in the peritoneal cavity. The surgery was suboptimal due to severe adhesions to the symphysis pubis. The secondary cytoreductive surgery performed after six cycles of taxotere and carboplatin was optimal. Macroscopically, the tumor was a dusky pink-purple and contained a dense white-gray to light yellow gelatinous area. The tumor was a malignant cystic and glandular neoplasm. Immunohistochemical stains included CK7(+), CK5/6(-), EMA(+), Ber-Ep4(+), Calretinin(-), ER(-), and PR(-). CONCLUSION: Primary peritoneal clear cell adenocarcinoma arising from an abdominal scar associated with prior endometrioma/endometriosis surgery was first reported.

Fertil Steril. 2009 Feb 11. [Epub ahead of print]

 

Estrogen and progesterone receptors in smooth muscle component of deep infiltrating endometriosis.

Noël JC, Chapron C, Bucella D, Buxant F, Peny MO, Fayt I, Borghese B, Anaf V.

Department of Pathology, Erasme University Hospital, Free University of Brussels, Belgium.

OBJECTIVE: To analyze the expression of estrogen (ER) and progesterone (PR) receptors in the smooth muscle component (SMC) of deep infiltrating endometriosis (DIE). DESIGN: A prospective clinical and pathologic study of 60 cases of DIE. SETTING: University Hospital Department of Gynacology. PATIENT(S): Sixty patients with symptomatic DIE (uterosacral endometriosis n = 14; bladder endometriosis n = 10; colonic endometriosis n = 16; rectovaginal endometriosis n = 20). INTERVENTION(S): Laparoscopic surgery. MAIN OUTCOME MEASURE(S): The expression of ER and PR was studied by immunohistochemistry in the SMC directly around endometriotic foci and at distance (at least >1.5 cm) from them in correlation with proliferative and secretory phases of cycle. RESULTS: The ER and PR were present in the SMC of DEI in each location excepting colonic endometriosis where ER were absent. Independently of cycle’s phases the PR were more abundant than ER. With the exception of rectovaginal endometriosis, where the ER and PR were more abundant in the proliferative than in the secretory phase, in other locations the ER and PR did not differ significantly with cycle’s phases. Last, if ER and PR were more abundant in SMC around endometriotic foci than at a distance from them. However, the difference was not significant. CONCLUSIONS: Our data substantially confirm for the first time that in various forms of DIE, ER and PR are present not only in glands and stroma but also in the smooth muscle major histologic component of this disease.

Diagn Cytopathol. 2009 May;37(5):373-6.

 

Decidualized endometrioma diagnosed by fine needle aspiration cytology: a case report with immunocytochemical confirmation.

El-Gohary YM, Garcia MT, Ganjei-Azar P.

Department of Pathology, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida 33136, USA.

Endometriosis is defined as ectopic endometrial tissue which can respond to hormonal stimulation. Cutaneous endometriosis is a rare pathologic entity that can represent a clinical diagnostic challenge. We report a case of a decidualized endometrioma in a 24-year old pregnant African American woman diagnosed by fine needle aspiration cytology and confirmed by immunocytochemistry using CD10, ER, and Calretinin. The awareness of the pathologist of the cytologic characteristics of this uncommon entity is important to avoid diagnostic pitfalls and unnecessary diagnostic interventions during pregnancy. (c) 2009 Wiley-Liss, Inc.

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J Assist Reprod Genet. 2009 Mar;26(2-3):69-73. Epub 2009 Feb 12.

 

Embryo quality before and after surgical treatment of endometriosis in infertile patients.

Shahine LK, Burney RO, Behr B, Milki AA, Westphal LM, Lathi RB.

Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Stanford University, 900 Welch Road, Suite 350, Stanford, CA 94304, USA. Ishahine@stanford.edu

PURPOSE: To investigate the hypothesis that surgical treatment of endometriosis in infertile patients may improve pregnancy rates by improving embryo quality. METHODS: We conducted a retrospective evaluation of 30 infertile patients treated with in vitro fertilization (IVF) before and after surgery for endometriosis. Patients served as their own controls and only cycles with similar stimulation protocols were compared. RESULTS: Using standard visual evaluation, embryo quality on day 3 was similar before and after surgical treatment of endometriosis. Fifty seven percent of patients had stage I-II endometriosis and 43% had stage III-IV disease. No patients had a live birth after the first IVF cycle and 43% of patients had a live birth with the IVF cycle after surgery. CONCLUSIONS: Surgical treatment of endometriosis does not alter embryo quality in patients with infertility treated with IVF.

Arch Gynecol Obstet. 2009 Jun;279(6):941-3. Epub 2009 Feb 12.

 

Scar endometriosis after a laparotomy for uterine perforation as a complication of dilatation and curettage.

Kurotsuchi S, Iwase A, Goto M, Hariyama Y, Kikkawa F.

Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Tsurumai-cho, Showa-ku, Japan.

BACKGROUND: Ectopic endometriosis is an uncommon disease. Abdominal scar endometriosis is especially rare. CASE: A 38-year-old gravid 1, para 1 woman underwent dilatation and curettage due to an intrauterine infection. During the procedure, uterine perforation occurred and an emergency laparotomy was performed to provide hemostasis and suturing. Three years later, she complained of pain and swelling at the lower end of her abdominal scar during menstruation. A biopsy of the abdominal scar demonstrated endometriosis. The patient elected to receive conservative management rather than a surgical procedure. Therefore, hormonal therapy was initiated. The hormonal therapy provided symptomatic relief and reduced the size of the lesion. CONCLUSION: We reported an extremely rare case of scar endometriosis after a laparotomy for a uterine perforation that occurred as a complication of dilatation and curettage. We suggest that hormonal therapy using gonadotropin-releasing hormone agonist might be an alternative to surgical treatment for ectopic endometriosis.

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Spine J. 2009 Jun;9(6):e16-8. Epub 2009 Feb 12.

 

An unusual cause of sciatic pain as a result of the dynamic motion of the obturator internus muscle.

Murata Y, Ogata S, Ikeda Y, Yamagata M.

Department of Orthopaedic Surgery, Tokyo Women’s Medical University, 8-1 Kawadacho, Shinjuku ku, Tokyo 162-8666, Japan. yasuaki.murata@ort.twmu.ac.jp

BACKGROUND CONTEXT: It has been reported that compression of the sciatic nerve because of any cause, including endometriosis, piriformis syndrome, abscess, tumor, adjoining uterus provoke sciatic pain. Some of these pathophysiologies have been diagnosed clinically and sometimes by exclusion. PURPOSE: To discuss the clinical features of sciatic neuropathy under the belief that dynamic motion of the obturator internus muscle and tendon should be included in the differential diagnosis of sciatic neuropathy. STUDY DESIGN: Sciatic neuropathy, which was because of compression of the sciatic nerve caused by dynamic motion of the tendon and muscle of the obturator internus, was reported. METHODS: We performed surgery to confirm the outlet of the pelvis. RESULTS: Although no compression was provoked by the piriformis muscle, obvious compression was observed on the sciatic nerve by the stretched obturator internus muscle. CONCLUSIONS: Although it may not be common, compression of the sacral plexus caused by dynamic motion of the obturator internus muscle should be included as a possible diagnosis for sciatic pain.

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