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J Minim Invasive Gynecol. 2007 May-Jun;14(3):356-61.

Laparoscopic ureteral injury and repair: case reviews and clinical update.

Cholkeri-Singh A, Narepalem N, Miller CE.

Department of Obstetrics and Gynecology, Advocate Lutheran General Hospital, Park Ridge, IL 60068, USA. acholkeri@gmail.com

Ureteral injuries are known complications of pelvic surgery. The incidence is 0.5% to 3%, and approximately one-third of these cases are not identified or corrected intraoperatively. It is critical to recognize and repair these injuries intraoperatively to decrease morbidity and prevent further complications, such as ureteral stricture, fistula formation, or loss of renal function. Traditionally, laparotomy has been the method of choice for ureteral injuries even when the injury is identified during a laparoscopic procedure. Laparoscopy has been shown to result in decreased infection rate, fewer incisional hernias, shorter hospital stay, and quicker recovery compared with laparotomy. Several articles were reviewed of successful laparoscopic ureteral injury repair, in addition to the 2 cases presented in this article. We conclude that laparoscopic ureteral injury repair is feasible, safe, and effective.

J Minim Invasive Gynecol. 2007 May-Jun;14(3):339-44.

Major complications arising from 1265 operative laparoscopic cases: a prospective review from a single center.

Johnston K, Rosen D, Cario G, Chou D, Carlton M, Cooper M, Reid G.

Sydney Women’s Endosurgery Centre, St George Private Hospital, Kogarah, New South Wales, Sydney, Australia. keithjohnston@bigpond.com

STUDY OBJECTIVE: To identify the volume and type of laparoscopic surgery being performed. To review the incidence, nature of associated complications, and reasons for conversion to laparotomy. DESIGN: A multicenter, prospective case load analysis and chart review, identifying operations performed by 6 advanced laparoscopic surgeons over a 12-month period (1/1/05 to 12/31/05). SETTING: Surgical cases were performed in 5 hospitals in Sydney, New South Wales. PATIENTS: One thousand two hundred sixty-five women underwent a variety of major and advanced operative procedures. MEASUREMENTS AND MAIN RESULTS: A total of 1265 major and advanced laparoscopic procedures were performed. Laparoscopic hysterectomy accounted for 364 cases (28.8%), pelvic floor repair and Burch colposuspension 280 cases (22.2%), excisional endometriosis surgery 354 cases (28%), adnexal surgery 177 cases (13.9%), adhesiolysis 75 cases (5.9%), and miscellaneous cases 15 (1.2%). Overall major complications in terms of bowel, urologic, or major vessel injuries accounted for 8 cases (0.6%). There were 4 injuries of the bowel, 2 injuries to the bladder, and 2 injuries to ureters. There were no major vessel injuries. There were no injuries associated with primary trocar or Veres needle insertion. The most common perioperative morbidity reported was the requirement for blood transfusion (11 cases [0.9%]), and the second most common was venous thromboembolism (4 patients [0.3%]). Six (0.5%) cases were converted to laparotomy, 2 as a result of a complication and 4 for technical reasons. Six of the 8 complications were managed laparoscopically, and a multidisciplinary input was sought only in 4 of the 8 complications. CONCLUSIONS: Despite the advanced nature of laparoscopic procedures performed by our group, the complication rate and conversion to laparotomy remain low. There is an increasing feasibility to perform traditional open operations laparoscopically. An increasing number of these complications are now being managed laparoscopically by the gynecologist.

J Minim Invasive Gynecol. 2007 May-Jun;14(3):334-8.

What is the value of preoperative bimanual pelvic examination in women undergoing laparoscopic total hysterectomy?

Condous G, Van Calster B, Van Huffel S, Lam A.

Centre for Advanced Reproductive Endosurgery, Royal North Shore Hospital, University of Sydney, Sydney, Australia. gcondous@hotmail.com

OBJECTIVE STUDY: To estimate the value of preoperative bimanual examination of the pelvis in women undergoing total laparoscopic hysterectomy (TLH). DESIGN: Prospective observational cohort study. SETTING: Private hospitals and centre. PATIENTS: One hundred fourteen consecutive women undergoing TLH. INTERVENTION: All women who were scheduled to undergo TLH from May 2005 through June 2006 had a bimanual examination of the pelvis performed before surgery and the size of the uterus clinically estimated and recorded as gestational equivalents. The operating time, the estimated blood loss (EBL) during TLH, and the final weight of the uterus at histologic study were recorded. Spearman correlation coefficient analysis was used to determine whether there was a correlation between the estimated uterine size before surgery and actual uterine weight, operating time, and EBL. MEASUREMENTS AND MAIN RESULTS: Of the one hundred fourteen consecutive women eligible for the study, 75 had complete data and therefore were included in the final analysis. The median age was 46 years (range 34-71 years); 22.7% (17/75) had a clinically estimated normal uterus, 10.7% (8/75) had an 8-10/40 uterus, 12% (9/75) had a 10-12/40 uterus, 14.6% (11/75) had a 12-14/40 uterus, 20.0% (15/75) had a 14-16/40 uterus, 9.3% (7/75) had a 16-18/40 uterus, and 10.7% (8/75) had an 18-20/40 uterus. The median operating time was 110 minutes (range 59-240 minutes); the median EBL was 80 mL (range 20-1000 mL); and the median weight of the uterus was 181 g (range 52-1080 g). Histologic diagnoses included leiomyomata in 64.0% (48/75), adenomyosis in 44.0% (33/75), endometriosis in 22.7% (17/75), endocervical polyp in 4.0% (3/75), and normal uterus in 8.0% (6/75). The Spearman correlations between clinical size of the uterus and the weight of the uterus, the EBL, and the operating time were 0.81, 0.33, and 0.29, respectively; that is, the 2 variables tended to increase together. These correlations were all significant (p <.0001, .0044, and .0114, respectively). CONCLUSIONS: This study showed significant correlation between clinical estimate of uterine size and histologic weight of the uterus, operating time, and EBL in women undergoing laparoscopic hysterectomy. These findings are of great value in preoperative counseling in relation to the risk of bleeding and the potential need for blood transfusion, and in operating room planning.

Fertil Steril. 2007 May;87(5):1180-99.

Molecular profiling of experimental endometriosis identified gene expression patterns in common with human disease.

Flores I, Rivera E, Ruiz LA, Santiago OI, Vernon MW, Appleyard CB.

Department of Microbiology, Ponce School of Medicine, Ponce, Puerto Rico. iflores@psm.edu <iflores@psm.edu>

OBJECTIVE: To validate a rat model of endometriosis using complimentary DNA (cDNA) microarrays by identifying common gene expression patterns between experimental and natural disease. DESIGN: Autotransplantation rat model. SETTING: Medical school department. ANIMALS: Female Sprague-Dawley rats. INTERVENTION(S): Endometriosis was surgically induced by suturing uterine horn implants next to the small intestine’s mesentery. Control rats received sutures with no implants. After 60 days, endometriotic implants and uterine horn were obtained. MAIN OUTCOME MEASURE(S): Gene expression levels determined by cDNA microarrays and real-time quantitative polymerase chain reaction (qPCR). The Cy5-labeled cDNA was synthesized from total RNA obtained from endometriotic implants. The Cy3-labeled cDNA was synthesized using uterine RNA from a control rat. Gene expression levels were analyzed after hybridizing experimental and control labeled cDNA to PIQOR (Parallel Identification and Quantification of RNAs) Toxicology Rat Microarrays (Miltenyi Biotec, Cologne, Germany) containing 1,252 known genes. The Cy5/Cy3 ratios were determined, and genes with >2-fold higher or <0.5-fold lower expression levels were selected. Microarray results were validated by QRT-PCR. RESULT(S): We observed differential expression of genes previously shown to be up-regulated in patients, including growth factors, inflammatory cytokines/receptors, tumor invasion/metastasis factors, adhesion molecules, and antiapoptotic factors. CONCLUSION(S): This study presents evidence in support of using this rat model to study the natural history of endometriosis and to test novel therapeutics for this incurable disease.

Fertil Steril. 2007 May;87(5):1005-9.

Pathologic findings and outcomes of a minimally invasive approach to ovarian remnant syndrome.

Kho RM, Magrina JF, Magtibay PM.

Department of Obstetrics and Gynecology, Mayo Clinic, Scottsdale, Arizona 85259, USA. kho.rosanne@mayo.edu

OBJECTIVE: To review outcomes and pathologic findings of a primarily minimally invasive approach to ovarian remnant syndrome. DESIGN: Data were abstracted from medical records documenting bilateral salpingo-oophorectomy and subsequent treatment between 1996 and 2006 for pathologically confirmed ovarian remnant tissue. Follow-up was by mailed questionnaires and telephone interviews. SETTING: Tertiary care academic medical institution. PATIENT(S): Twenty patients (mean age, 48 years) receiving treatment for ovarian remnant tissue after prior bilateral salpingo-oophorectomy. INTERVENTION(S): Primarily minimally invasive approach (conventional laparoscopy and robot-assisted laparoscopy) for removal of ovarian remnant tissue. MAIN OUTCOME MEASURE(S): Postoperative complications and recurrence. RESULT(S): The 20 patients had a mean follow-up of 30 months. Indications were endometriosis in 8 and ovarian neoplasm in 6. Eighteen patients presented with pain, and 2 presented with a pelvic mass. Nineteen had laparoscopy (14 conventional; 5 robotic), and 1 had laparotomy. Remnant ovarian tissue was associated with endometriosis in 5 and corpus luteum in 3. Two patients had malignancy in remnant ovarian tissue. Postoperative complications included pneumonia (1 case). Follow-up identified no recurrence. CONCLUSION(S): Ovarian remnant syndrome can be managed safely and successfully with minimally invasive surgery. Risk of carcinoma mandates surgical resection.

Menopause. 2007 May-Jun;14(3 Pt 2):592-7; quiz 598-9.

Options for hormone therapy in women who have had a hysterectomy.

Haney AF, Wild RA.

Department of Obstetrics and Gynecology, The University of Chicago, Chicago, IL, USA.

OBJECTIVE: To review postmenopausal hormone therapy for women who have undergone hysterectomy with or without bilateral oophorectomy and to make clinical recommendations regarding changes in regimens compared with those for women with their uterus in place. DESIGN: We conducted a literature review, including a review of current guidelines. RESULTS: When the uterus is absent, estrogen treatment is all that is needed when hot flashes and/or genital atrophic symptoms are associated with surgical or natural menopause. Reasons to add a progestogen to an estrogen-only therapy regimen after hysterectomy include the need to reduce the risk for unopposed estrogen-dependent conditions, chief among which are endometriosis or endometrial neoplasia. Multiple lines of evidence suggest that regimens containing both estrogen and progestogen versus estrogen alone are associated with a greater relative risk of breast cancer without additional improvement in relief of hot flashes or vaginal symptoms. When a bilateral oophorectomy is performed before natural menopause, the onset of menopausal symptoms, primarily vasomotor symptoms, genital tract atrophy, and/or a decline in sexual function, is rapid, and the symptoms are more severe. Thus, the need for a decision on the use of hormone therapy is accelerated. CONCLUSIONS: The decision to use or not use menopausal hormone therapy in women without a uterus should involve an individualized risk/benefit analysis just as it should when the uterus is present. After hysterectomy, for most patients, current literature results favor not including a progestogen. Data suggest an attenuation of the potential cardiovascular benefit of estrogen therapy in this situation, yet no better protection against bone fractures and an increase in the risk for breast cancer when both estrogen and progestogen are used.

Epidemiology. 2007 May;18(3):402-8.

Effect of soy isoflavones on endometriosis: interaction with estrogen receptor 2 gene polymorphism.

Tsuchiya M, Miura T, Hanaoka T, Iwasaki M, Sasaki H, Tanaka T, Nakao H, Katoh T, Ikenoue T, Kabuto M, Tsugane S.

Epidemiology and Prevention Division, Research Center for Cancer Prevention and Screening, National Cancer Center, Tokyo, Japan.

BACKGROUND: Progression of endometriosis is considered estrogen-dependent. Dietary soy isoflavones may affect the risk of endometriosis, and polymorphisms in estrogen receptor genes may modify this association. We examined associations among soy isoflavone intake, estrogen receptor 2 (ESR2) gene polymorphisms and risk of endometriosis. METHODS: We recruited women age 20-45 years old who had consulted a university hospital for infertility in Tokyo, Japan in 1999 or 2000. A total of 138 eligible women were diagnosed laparoscopically and classified into 3 subgroups: control (no endometriosis), early endometriosis (stage I-II) and advanced endometriosis (stage III-IV). We measured urinary levels of genistein and daidzein as markers for dietary intake of soy isoflavones, and genotyped ESR2 gene RsaI polymorphisms. RESULTS: Higher levels of urinary genistein and daidzein were associated with decreased risk of advanced endometriosis (P for trend = 0.01 and 0.06, respectively) but not early endometriosis. For advanced endometriosis, the adjusted odds ratio for the highest quartile group was 0.21 (95% confidence interval = 0.06-0.76) for genistein and 0.29 (0.08-1.03) for daidzein, when compared with the lowest group. Inverse associations were also noted between urinary isoflavones and the severity of endometriosis (P for trend = 0.01 for genistein and 0.07 for daidzein). For advanced endometriosis, ESR2 gene RsaI polymorphism appeared to modify the effects of genistein (P for interaction = 0.03). CONCLUSIONS: Dietary isoflavones may reduce the risk of endometriosis among Japanese women.

Ned Tijdschr Geneeskd. 2007 Mar 31;151(13):725-9.

Erratum in:

Ned Tijdschr Geneeskd. 2007 Apr 28;151(17):996.

Comment on:

Ned Tijdschr Geneeskd. 2007 Mar 31;151(13):730-1.

Ned Tijdschr Geneeskd. 2007 Mar 31;151(13):732-4.

Ned Tijdschr Geneeskd. 2007 Mar 31;151(13):753-6.

[Pelvic inflammatory disease and an abscessed endometriosis cyst: a diagnostic problem and a therapeutic dilemma]

[Article in Dutch]

van Weering HG, Mijatovic V, Groot J, Hompes PG, Brölmann HA.

Medisch Centrum Alkmaar, afd. Verloskunde en Gynaecologie, Alkmaar. h.vanweering@vumc.nl

A 52-year-old woman with known endometriosis was treated with a levonorgestrel-containing IUD for irregular vaginal blood loss. Two weeks later she was admitted with signs ofpelvic inflammatory disease (PID) and was treated with antibiotics. As no clinical improvement ensued, laparoscopy was performed which demonstrated an infected endometriosis cyst in her right ovary. Ovariectomy was performed. In a 29-year-old woman with a symptomatic endometriosis cyst in the right ovary, PID was also suspected. After an initially good response to antibiotic therapy her condition deteriorated. Laparotomy revealed an infected endometriosis cyst. It was drained with subsequent cystectomy. A third, 43-year-old, woman with known endometriosis was admitted with signs of PID. Although she had a good clinical response to antibiotic therapy, her C-reactive protein (CRP) level remained elevated. Diagnostic laparoscopy demonstrated a large abscess in the right ovary. Ovariectomy was performed. Histology showed signs of an infected endometriosis cyst. All these women presented with PID and, in addition, a cystic adnexal mass on ultrasonography. The incidence oftubo-ovarian and ovarian abscesses is higher in the presence of an endometriosis cyst. Irrespective of the presence of an endometriosis cyst, antibiotics should be the first line of treatment. Reduction in the size of the abscess is not a useful parameter for monitoring conservative treatment when an infected endometriosis cyst is present. If it is decided to perform surgery on the infected endometriosis cyst, drainage of the abscess is usually not sufficient: excision of the endometriosis cyst is the only adequate therapy.

Am J Obstet Gynecol. 2007 May;196(5):494.e1-3.

Erratum in:

Am J Obstet Gynecol. 2007 Jun;196(6):613. Magos, Adam [added].

A new technique for temporary ovarian suspension: temporarily displacing the ovaries anterior to the uterus facilitates pelvic side wall access in the laparoscopic treatment of endometriosis.

Chapman L, Sharma M, Papalampros P, Gambadauro P, Polyzos D, Papadopoulos N, Magos A.

Minimally Invasive Therapy Unit and Endoscopy Training Center, Royal Free Hospital, London, England. lynnechapman2000@yahoo.co.uk

The adnexa frequently hinder access to the pelvic side wall during laparoscopic surgery for endometriosis. An innovative tactic can facilitate dissection.

J Reprod Med. 2007 Mar;52(3):207-13.

Expression of CD44s, vascular endothelial growth factor, matrix metalloproteinase-2 and Ki-67 in peritoneal, rectovaginal and ovarian endometriosis.

Kim HO, Yang KM, Kang IS, Koong MK, Kim HS, Zhang X, Kim I.

Department of Obstetrics and Gynecology, Samsung Cheil Hospital and Women’s Healthcare Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

OBJECTIVE: To understand the pathogenetic mechanisms of endometriosis by examining the expression of adhesion molecules (CD44s), angiogenic factor (VEGF) and matrix protease and to perform Ki-67 labeling for evaluation of proliferative activity. STUDY DESIGN: Twenty-nine peritoneal endometriosis lesions (9 red, 12 black and 8 white), 11 rectovaginal and 22 ovarian were obtained. Immunohistochemical staining was performed with antibodies for CD44, VEGF, MMP-2 and Ki-67. RESULTS: CD44s were expressed mainly in stroma and showed higher expression in glandular epithelium of peritoneal endometriosis than in rectovaginal and ovarian endometriosis. The stroma in red and white lesions showed higher MMP-2 expression than in black lesions. The stromal cells in rectovaginal endometriosis showed significantly lower expression of Ki-67 (p = 0.002) than in peritoneal and ovarian endometriosis. When endometriosis was analyzed according to the revised American Fertility Society classification, Ki-67 expression was high in glandular epithelium in stages I and II (p = 0.025), whereas MMP-2 expression in stromal cells was significantly high (p < 0.001) in stages III and IV. CONCLUSION: CD44, VEGF and MMP-2 were consistently expressed in endometriotic epithelial and stromal cells. White lesions of peritoneal endometriosis should not be regarded as an inactive state, and MMP-2 in stromal cells may be responsible for the progression of endometriosis. The macroscopic appearance of endometriotic lesions should not be used as a criterion to define the degree of activity.

J Reprod Med. 2007 Mar;52(3):177-93.

Comment in:

J Reprod Med. 2008 Apr;53(4):311-2; author reply 312.

Diagnosis of adenomyosis: a review.

Levgur M.

Department of Obstetrics and Gynecology, Maimonides Medical Center and State University of New York, Health Science Center, Brooklyn 11219, USA. mlevgur@maimonidesmed.org

This article reviews the various preoperative diagnostic methods for uterine adenomyosis. MEDLINE and PubMed were searched using the keywords adenomyosis and adenomyosis diagnosis. Reviews, case-controlled studies and reports published from 1949 through March 2005 and written, or at least abstracted, in English were analyzed. Transvaginal sonography is superior to the transabdominal route, but its diagnostic sensitivity is still suboptimal, ranging from 50% to 87%. Magnetic resonance imaging is most effective for both diffuse and focal adenomyosis, with sensitivity and specificity that are comparable to or even better than those of sonography as it depicts contrasts between low-intensity lesions and surrounding tissue. Computed tomography has poor diagnostic value due to similar images portrayed by foci and normal myometrium. Myometrial biopsy of the posterior uterine wall, as pursued by some authorities in recent years, is superior to sonography, but its routine use is not recommended. Although various methods were added to the clinician’s armamentarium over the last 2 decades, the preoperative diagnosis of adenomyosis remains challenging.

Br J Hosp Med (Lond). 2007 Apr;68(4):218-9.

Immunohistochemical characterization of primary urinary bladder endometriosis.

Atiemo K, Kumaravel MM, Shafaque S, Nabi G, McClinton S.

Department of Urology, Aberdeen Royal Infirmary Hospital.

J Obstet Gynaecol. 2007 Apr;27(3):328-9.

Spontaneous ovarian abscess associated with an endometrioma.

El-Toukhy T, Hanna L.

Queen Mary’s University Hospital, Sidcup NHS Trust, Kent, UK. tarekeltoukhy@hotmail.com

J Obstet Gynaecol. 2007 Apr;27(3):287-91.

Uterine innervation in adenomyosis.

Quinn M.

Department of Gynaecology, Hope Hospital, Manchester, UK. mjquinn001@btinternet.com

This study describes the innervation of the uterus with a histopathological diagnosis of adenomyosis in a retrospective survey of two groups of uteri. Group 1 consisted of 17 histologically-normal, parous uteri and eight nulliparous uteri. Group 2 consisted of 23 parous uteri with the histopathological diagnosis of adenomyosis. Tissue sections from the uterine isthmus were stained for nerves with PGP 9.5 using a standard immunohistochemical regimen. In group 1 (n = 25, normal histological report), normal innervation of the uterine isthmus included concentrations of nerves in the subserosal layers and at the endometrial-myometrial interface with sparse, neurovascular bundles distributed throughout the myometrial stroma. In group 2, (n = 23 with adenomyosis), there were no nerves in areas of adenomyosis and absence of nerves at the endometrial-myometrial nerve plexus. Focal proliferation of small-diameter nerve fibres was observed at the margins of adenomyosis in some uteri. Subserosal nerve fibres were still present in those sections that extended to include this region. Adenomyosis is associated with loss of nerve fibres at the endometrial-myometrial interface and absence of nerve fibres in the adenomyosis.

Stem Cells. 2007 Aug;25(8):2082-6. Epub 2007 Apr 26.

Contribution of bone marrow-derived stem cells to endometrium and endometriosis.

Du H, Taylor HS.

Division of Reproductive Endocrinology, Department of Medicine, Cellular and Developmental Biology, Yale University School of Medicine, New Haven, CT 06520-8063, USA.

Bone marrow-derived cells (BMDCs) can differentiate into nonhematopoietic cells, suggesting that BMDCs may contribute to the maintenance of multiple tissues. Donor-derived bone marrow cells have been identified in human uterine endometrium. Here, two murine models were used to investigate the contribution of nonendometrial stem cells to endometrium. We investigate whether BMDCs can localize to uterine endometrium and to endometriosis. After bone marrow transplantation, male donor-derived bone marrow cells were found in the uterine endometrium of female mice. Although uncommon (<0.01%), these cells can differentiate into epithelial cells. After generation of experimental endometriosis by ectopic endometrial implantation in the peritoneal cavity, bone marrow from LacZ transgenic mice was used for transplantation. LacZ expressing cells were found in the wild-type ectopic endometrium implanted in the peritoneal cavity of hysterectomized LacZ transgenic mice. The repopulation of endometrium with bone marrow-derived stem cells may be important to normal endometrial physiology and also may help to explain the cellular basis for the high long-term failure of conservative alternatives to hysterectomy. The examination of a sexually dimorphic organ such as the uterus demonstrates the ability of male bone marrow, which cannot harbor circulating endometrial cells, to generate endometrium de novo and proves their mesenchymal stem cell origin. Finding Y chromosome bearing endometrial cells demonstrates the potential to recapitulate embryonic developmental pathways that were never activated in males; BMDCs may have vast regenerative capacity. Additionally, the ability of stem cells to engraft endometriosis has implications for the origin and progression of this disease. Ectopic differentiation of stem cells may be a novel mechanism of disease. Disclosure of potential conflicts of interest is found at the end of this article.

Fertil Steril. 2007 Dec;88(6):1505-33. Epub 2007 Apr 26.

Whole genome deoxyribonucleic acid microarray analysis of gene expression in ectopic versus eutopic endometrium.

Eyster KM, Klinkova O, Kennedy V, Hansen KA.

Division of Basic Biomedical Sciences, Sanford School of Medicine of the University of South Dakota, Vermillion, South Dakota 57069, USA. Kathleen.Eyster@usd.edu

OBJECTIVE: To use DNA microarrays to identify differentially expressed genes in eutopic endometrium compared with ectopic endometrium. DESIGN: Prospective, cross-sectional, observational study. SETTING: University Medical Center and Research Laboratory. PATIENT(S): Eleven women with endometriosis. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Differential gene expression. RESULT(S): Seven hundred seventeen of the 53,000 probes on the whole human DNA microarrays were changed by twofold or greater in ectopic versus eutopic endometrium. Families of genes that were expressed differentially include genes that code for proteins associated with the immune system and inflammatory pathways, cell adhesion, cell-cell junctions, the extracellular matrix and its remodeling, cytoskeletal proteins, and signal transduction pathway components, among others. CONCLUSION(S): The altered immune environment may allow survival of endometriotic cells that enter the abdominal cavity. Alterations of cell adhesion-associated genes may contribute to the adhesive and invasive properties of ectopic endometrium, and changes in signal transduction pathways support a change in the communication among cells of the endometrial explant compared with eutopic endometrium. These families of differentially expressed genes provide multiple opportunities for the development and testing of new hypotheses regarding endometriosis.

Urology. 2007 Apr;69(4 Suppl):53-9.

The emerging presence of interstitial cystitis in gynecologic patients with chronic pelvic pain.

Stanford EJ, Dell JR, Parsons CL.

Center for Advanced Pelvic Surgery and Medicine, Belleville Memorial Hospital, Belleville, Illinois 62801, USA. ejs222@aol.com

Emerging data are changing the pelvic pain paradigm for gynecologic patients. Historically, interstitial cystitis (IC) was rarely considered as a cause of chronic pelvic pain (CPP), but recent data suggest that IC is a common cause of CPP in gynecologic patients and perhaps is even the most common cause. It is important to consider the bladder as a generator of symptoms early in the evaluation of the gynecologic patient with CPP. New tools have been developed to aid the gynecologist in ruling out IC in patients with CPP, including a new IC symptom questionnaire and the Potassium Sensitivity Test (PST). By determining whether the pain is of bladder origin, the physician can more successfully treat the patient with CPP.

J Coll Physicians Surg Pak. 2007 Apr;17(4):228-9.

Acute small bowel obstruction secondary to ileal endometrioma.

Riaz N, Khurshaidi N.

Department of Surgery, The Aga Khan University Hospital, Stadium Road, Karachi-74800, Pakistan.

Pelvic endometriosis, a common disease of the female genital tract, may also affect the bowel, especially the rectosigmoid colon. Involvement of small intestine occurs very infrequently. A case of small bowel obstruction caused by ileal endometriosis is reported.

J Coll Physicians Surg Pak. 2007 Apr;17(4):199-202.

Endometriosis: frequency and correlation between symptomatology and disease stage.

Mehmud G, Akhtar T, Sadia S.

Department of Obstetrics and Gynecology, Mother and Child Health Center, Pakistan Institute of Medical Sciences, Islamabad.

Objective: To determine the frequency of endometriosis in general gynecological and infertile women presenting to hospital and to correlate symptomatology and stage of disease. Design: Cross-sectional study. Place and Duration of Study: Gynecology Department of Mother and Child Health Center, Pakistan Institute of Medical Sciences, Islamabad, from March 2000 to March 2002. Patients and Methods: Fifty patients with diagnosis of endometriosis on laparoscopy were included in the study. The degree of pain symptoms was graded according to 1-4 point verbal rating scale designed by Biberoglu and Behrman. Endometriosis was staged according to Revised American Fertility Society (R-AFS) scoring on laparoscopy. Correlation coefficient-Spearman rank order correlation test was applied to analyze data. Results: The frequency of endometriosis in infertile women was 24% (33) and in women with general gynecological complaints, it was 23% (17). There was a significant positive correlation between chronic pelvic pain and R-AFS scoring. Increasing severity of pelvic pain was also positively correlated with presence of endometrioma and complete obliteration of pouch of Douglas. No correlation between dysmenorrhoea and R-AFS scoring could be detected. Dysmenorrhoea was strongly and positively correlated with the presence of superficial implants. Dyspareunia was found to have positive correlation with R-AFS score and also with complete obliteration of pouch of Douglas. Conclusion: The frequency of endometriosis in infertile women was 24% (33) and in women with general gynecological complaints, it was 23% (17). Chronic pelvic pain and dyspareunia had strong positive correlation with R-AFS score while dysmenorrhoea had no such correlation.

Pharmacogenet Genomics. 2007 Mar;17(3):181-8.

Description of a novel polymorphic gene encoding for arylamine N-acetyltransferase in the rhesus macaque (Macaca mulatta), a model animal for endometriosis.

Fakis G, Boukouvala S, Kawamura A, Kennedy S.

Nuffield Department of Obstetrics and Gynecology, John Radcliffe Hospital, University of Oxford, Oxford, UK. gfakis@mbg.duth.gr

OBJECTIVES: Case-control studies have previously associated polymorphisms in the gene encoding the xenobiotic metabolizing enzyme arylamine N-acetyltransferase 2 (NAT2) with endometriosis, a common multifactorial disease in women. These studies, however, have been problematic on methodological grounds and their results are inconclusive. To better understand the possible relationship between the NAT2 gene and endometriosis, we characterized its homologue in the rhesus macaque, an animal model for the disease. METHODS: Human NAT2-specific primers were used to isolate orthologous gene sequences from four unrelated rhesus macaques of the same colony. Recombinant proteins were expressed in mammalian cells and analysed for their ability to acetylate NAT substrates and bind anti-NAT antibodies. RESULTS: A polymorphic gene, showing 94% identity to human NAT2, was identified in the rhesus macaque. Its two characterized alleles, designated (MACMU)NAT2*1 and (MACMU)NAT2*2, were differentiated by one synonymous (C(624)T) and one nonsynonymous (G(691)A) polymorphism, the latter causing a Val(231)Ile substitution. The recombinant (MACMU)NAT2 protein was not recognized by anti-(HUMAN)NAT1 antibody, but reacted with antibodies against (HUMAN)NAT2 or the active site of NAT. Rhesus NAT2 provided relatively high acetylation activity with p-anisidine, lower activity with procainamide, sulphamethazine or 5-aminosalicylate and poor activity with p-aminobenzoic acid. Differences in the activities of the two allozymes were evident with most substrates. CONCLUSIONS: A polymorphic homologue of human NAT2 was characterized in the rhesus macaque, to facilitate investigations of the postulated involvement of this isoenzyme in the toxicogenetics of endometriosis.

Pathology. 2007 Apr;39(2):285-7.

Unilateral pelvic endometriosis and congenital unilateral ovarian agenesis.

Johnston K, Russell P, Shukla A, Reid G, Cooper M.

Gynecol Endocrinol. 2007 Feb;23(2):105-11.

Expression analysis of the genes involved in estradiol and progesterone action in human ovarian endometriosis.

Smuc T, Pucelj MR, Sinkovec J, Husen B, Thole H, Lanisnik Rizner T.

Institute of Biochemistry, Faculty of Medicine, University of Ljubljana, Vrasov trg. 2, 1000 Ljubljana, Slovenia.

Endometriosis is defined as the presence of endometrial glands and stroma within extrauterine sites, and it is well known that endometriosis is an estrogen-dependent disease. The defective formation and metabolism of steroid hormones is responsible for the promotion and development of endometriosis. In the present study we examined the mRNA levels of six enzymes that are involved in the metabolism of estrogen and progesterone–aromatase, 17beta-hydroxysteroid dehydrogenase (17beta-HSD) types 1, 2 and 7, sulfatase and sulfotransferase–and of the steroid receptors–estrogen receptors alpha and beta (ERalpha, ERbeta) and progesterone receptors A and B (PRAB)–implicated in human ovarian endometriosis. We analyzed 16 samples of ovarian endometriosis and 9 of normal endometrium. The real-time polymerase chain reaction analyses revealed that six of the nine genes investigated are differentially regulated. Aromatase, 17beta-HSD types 1 and 7, sulfatase and ERbeta were statistically significantly upregulated, while ERalpha was significantly downregulated, in the endometriosis group compared with the control group. There were no significant differences in 17beta-HSD type 2, sulfotransferase and PRAB gene expression. Our results indicate that, in addition to the previously reported upregulation of aromatase, upregulation of 17beta-HSD types 1 and 7 and sulfatase can also increase the local estradiol concentration. This could thus be responsible for the estrogen-dependent growth of endometriotic tissue. Surprisingly ERalpha was downregulated.

Hum Reprod. 2007 Jun;22(6):1714-7. Epub 2007 Apr 23.

Spontaneous adenomyosis in the chimpanzee (Pan troglodytes): a first report and review of the primate literature: case report.

Barrier BF, Allison J, Hubbard GB, Dick EJ Jr, Brasky KM, Schust DJ.

Department of Obstetrics, Gynecology and Women’s Health, University of Missouri, Columbia, MO 65212, USA. barrierb@health.missouri.edu

Adenomyosis is a non-neoplastic condition characterized by the presence of ectopic endometrium in the myometrium with hyperplasia of adjacent smooth muscle. Common symptoms in women include debilitating pelvic pain and abnormal uterine bleeding, and the condition has been paradoxically associated with both multiparity and subfertility. Adenomyosis spontaneously occurs in humans and some non-human primates, including the baboon and macaque, where it has been associated with primary infertility and the presence of endometriosis. No cases of adenomyosis have been previously reported in Pongidae such as gorilla, orangutan or chimpanzee. We here describe two cases of naturally occurring adenomyosis in the chimpanzee (Pan troglodytes) and briefly review the literature regarding the presence of adenomyosis in non-human primate species.

Hum Reprod. 2007 Jun;22(6):1725-9. Epub 2007 Apr 23.

Endometriosis is associated with a decreased risk of pre-eclampsia.

Brosens IA, De Sutter P, Hamerlynck T, Imeraj L, Yao Z, Cloke B, Brosens JJ, Dhont M.

Leuven Institute for Fertility and Embryology, Tiensevest 168, B-3000 Leuven, Belgium. ivo.brosens@med.kuleuven.ac.be

BACKGROUND: We postulated that impaired endometrial differentiation in women with pelvic endometriosis predisposes for pre-eclampsia. METHODS: A retrospective case-control study set at the University of Ghent IVF centre. The incidence of pre-eclampsia and pregnancy-induced hypertension (PIH) following the clinical and/or laparoscopic diagnosis of endometriosis-associated infertility (case group; n = 245 pregnancies) was compared with the incidence of these obstetric complications in pregnancies following treatment for male-factor infertility (control group; n = 274 pregnancies). Pregnancy data were obtained by searching electronic databases and postal questionnaires. The case and control groups were matched for age, parity and multiple pregnancies. RESULTS: The incidence of pre-eclampsia was significantly lower in the case group (0.8%) when compared with control group (5.8%) (P = 0.002; odds ratio (OR) = 7.5, 95% confidence interval (CI): 1.7-33.3). Analysis of obstetric outcome in the subgroup of patients with laparoscopic data confirmed the lower risk of pre-eclampsia in the case (1.2%) versus control (7.4%) groups (P = 0.032; OR = 6.6, 95% CI: 1.2-37). PIH occurred in 3.5% and 8.7% of case and control pregnancies, respectively (P = 0.018; OR = 2.6, 95% CI: 1.2-6.0). The odds of developing pre-eclampsia were 5.67 times higher in the control group than in pregnancies following endometriosis-associated infertility. In multiple pregnancies, the odds of developing pre-eclampsia increased 1.93 times per additional child, with or without endometriosis. CONCLUSIONS: We found no evidence that endometriosis predisposes for pre-eclampsia. Instead, the risk of hypertensive disorder in pregnancy is significantly reduced in women with endometriosis-associated infertility.

Fertil Steril. 2007 Oct;88(4):795-803. Epub 2007 Apr 23.

Different types of small nerve fibers in eutopic endometrium and myometrium in women with endometriosis.

Tokushige N, Markham R, Russell P, Fraser IS.

Department of Obstetrics and Gynaecology, Queen Elizabeth II Research Institute for Mothers and Infants, University of Sydney, Sydney, Australia. ntokushige@med.usyd.edu.au

OBJECTIVE: To investigate types of nerve fibers in endometrium and myometrium in women with endometriosis. DESIGN: Laboratory study using human tissue. SETTING: University-based laboratory. PATIENT(S): Women with and without endometriosis undergoing hysterectomy. INTERVENTION(S): Histologic sections of contiguous endometrial and myometrial tissues were prepared from hysterectomies performed on women with and without endometriosis. MAIN OUTCOME MEASURE(S): Types and density of nerve fibers in endometrium and myometrium in women with and without endometriosis were determined using a series of specific markers for neuronal structure and function: PGP9.5, NF, SP, CGRP, TH, VAChT, VIP, and NPY. RESULT(S): Nerve fibers stained with PGP9.5 and NF in endometrium and myometrium were significantly increased in women with endometriosis compared with women without endometriosis. Nerve fibers in the functional layer of endometrium in women with endometriosis were likely to be sensory C, a mixture of sensory A delta, sensory C, and adrenergic fibers in the basal layer of the endometrium, a mixture of sensory A delta, sensory C, adrenergic and cholinergic fibers in the myometrium. CONCLUSION(S): Increased nerve fiber density in endometrium and myometrium, and sensory C fibers and adrenergic nerve fibers in the endometrium in women with endometriosis may play an important role in the mechanisms of pain generation in this condition.

J Endourol. 2007 Apr;21(4):437-40.

Laparoscopic retroperitoneal nephrectomy for giant hydronephrosis: when simple nephrectomy isn’t simple.

Challacombe B, Sahai A, Murphy D, Dasgupta P.

Department of Urology, Guy’s Hospital and GKT School of Medicine, London, UK.

BACKGROUND AND PURPOSE: Retroperitoneoscopic nephrectomy (RN) for giant hydronephrosis (GH) is regarded as a more challenging procedure than RN for small nonfunctioning kidneys (SNFK). We describe specific technical modifications to facilitate surgery in the GH group and compare outcomes in the two groups. PATIENTS AND METHODS: Data were collected in a prospective fashion on all patients undergoing upper urinary-tract laparoscopy at a single institution. Eleven patients (eight women, three men; mean age 41 years) underwent RN for GH. The etiologies were congenital ureteropelvic junction obstruction in 10 and obstruction secondary to endometriosis in 1. Technical modifications to facilitate surgery included initial fingerplasty, balloon dissection in two directions, initial intact dissection, subsequent pelvic puncture and aspiration, and extracorporeal retraction if required. The results were compared with those of a matched group of 19 patients who had RN for SNFK. RESULTS: All procedures were completed without open conversion. In the GH group, the mean operating time was 126 minutes (range 65-240 minutes) and the estimated blood loss 101 mL (range 5-450 mL). No patient required transfusion, and the mean length of the hospital stay was 2.9 days (range 1.5-6 days). In the group undergoing RN for SNFK, the mean operating time was 116 minutes (range 55-270 minutes), the estimated blood loss 46 mL (range 5-400 mL), and the mean length of stay 2.8 days (range 1-5 days). In the GH group, the estimated blood loss was significantly greater (P = 0.042), and the operative time was longer, although this difference did not reach statistical significance. CONCLUSION: An RN for GH is not as simple as laparoscopic simple nephrectomy for other benign lesions. Operative duration and blood loss are greater. Technical modifications have been vital to our success with this procedure.

Surgeon. 2007 Apr;5(2):125; author reply 125.

Comment on:

Surgeon. 2006 Feb;4(1):55-6.

Re: Post caesarean incisional hernia or scar endometrioma? Rao et al. Surgeon 2006: 1; 55-56.

Sagar J, Kumar V.

Mol Hum Reprod. 2007 Jun;13(6):399-404. Epub 2007 Apr 20.

Interaction between cytochrome P450 gene polymorphisms and serum organochlorine TEQ levels in the risk of endometriosis.

Tsuchiya M, Tsukino H, Iwasaki M, Sasaki H, Tanaka T, Katoh T, Patterson DG Jr, Turner W, Needham L, Tsugane S.

Epidemiology and Prevention Division, Research Center for Cancer prevention and Screening, National Cancer Center, 5-1-1 Tsukiji, Tokyo, 104-0045, Japan.

Exposure to dioxins and polychlorinated biphenyls (PCBs) has been suggested as a possible etiologic factor for endometriosis, but the association remains highly controversial. To assess whether cytochrome P450 (CYP) gene polymorphisms modulate the effect of dioxins and/or PCBs in endometriosis risk, we conducted a case-control study among infertile Japanese women. A total of 138 eligible women aged 20-45 were diagnosed laparoscopically and classified into three subgroups: control (no endometriosis), early endometriosis (stages I-II) and advanced endometriosis (stages III-IV). Neither CYP1A1 Ile462Val and CYP1B1 Leu432Val polymorphisms (genotypes with versus genotypes without the minor allele) nor serum dioxin and PCB toxic equivalency (TEQ) levels (low versus high) were independently associated with either early or advanced endometriosis risk. However, genotypes with the CYP1A1 462Val allele showed a statistically significant reduced risk of advanced endometriosis in combination with high serum dioxin TEQ levels (adjusted odds ratio = 0.13, 95% confidence interval: 0.02-0.76) (P for interaction = 0.08). Although no association was found between serum PCB TEQ level and advanced endometriosis in any stratum of CYP1B1 Leu432Val polymorphism, a statistically significant interaction was found (P for interaction = 0.05). CYP1A1 and CYP1B1 polymorphisms may modify the relation between environmental exposure to organochlorine and advanced endometriosis risk.

Ann Epidemiol. 2007 Jul;17(7):503-10. Epub 2007 Apr 19.

Endometriosis among women exposed to polybrominated biphenyls.

Hoffman CS, Small CM, Blanck HM, Tolbert P, Rubin C, Marcus M.

Department of Epidemiology, University of North Carolina at Chapel Hill, USA.

PURPOSE: We examined the association between endometriosis and exposure to polybrominated biphenyls (PBBs) and polychlorinated biphenyls (PCBs) among women inadvertently exposed to PBBs in 1973. METHODS: Serum PBBs and PCBs were measured in the late 1970s. Women self-reported endometriosis at interview in 1997. We constructed Cox models to estimate the relative incidence of endometriosis in relation to PBB and PCB levels. RESULTS: Seventy-nine of 943 women (9%) reported endometriosis. Compared with women with low PBB exposure (<or=1 parts per billion [ppb]), women with moderate PBB (1-4 ppb) (hazard ratio [HR] = 0.72; 95% confidence interval [CI], 0.39-1.31) and high PBB (>or=4 ppb) (HR = 0.90; 95% CI, 0.51-1.59) exposure did not have increased incidence of endometriosis. Increased incidence of endometriosis was suggested among women exposed to moderate PCB (5-8 ppb) (HR = 1.67; 95% CI, 0.91-3.10) and high PCB (>or=8 ppb) (HR = 1.68; 95% CI, 0.95-2.98) levels compared with low PCB exposure (<or=5 ppb). CONCLUSIONS: Our study does not support an association between PBB exposure and endometriosis. Findings for serum PCB level are consistent with an emerging body of literature suggesting an association between PCB exposure and endometriosis.

Clin Exp Obstet Gynecol. 2007;34(1):63-4.

Endometriosis of ureter-induced recurrent urinary tract infections in a premenopausal woman–case report.

Stamatiou K, Petrakos G, Alevizos A, Bovis K, Economou A, Panagopoulos P, Mariolis A.

Department of Urology, Tzaneion General Hospital, Piraeus, Greece.

Endometriosis of the urinary tract is infrequent. The ureters and kidneys are the least usual place of localization. Endometriosis of the ureter often leads to silent loss of renal function due to delayed diagnosis. We report a case of a premenopausal female with endometriosis of the left distal ureter, presenting an infection of the urinary tract and having reported previous incidents of menorrhagia and left flank renal pain with automatic recession. Pharmacological treatment was applied with a satisfactory outcome. A short review of the literature is presented.

Ultraschall Med. 2007 Apr;28(2):212-5.

Spontaneous bleeding from the uterine arteries during pregnancy–problems in diagnosis and therapy–bleeding from uterine arteries during pregnancy.

Kirkinen P, Keski-Nisula L, Kuoppala T, Tommola S, Uotila J.

Department of Obstetrics and Gynecology, University Hospital of Tampere, Finland. pertti.kirkinen@pshp.fi

Arterial bleeding, initially negative on MRI, ultrasonography and radiographic angiography, complicated the course of pregnancy with severe and recurrent vaginal and pelvic haemorrhage in the second trimester. Bleeding from the left uterine artery was successfully terminated by angiographic embolisation. No harmful effects on the fetal well-being were recorded after the embolisation. Massive haemorrhage, most probably from the right uterine artery, recurred some days later, and Caesarean section was performed. At postpartal ultrasonography and catheter angiography, massive arterial bleeding from a pseudoaneurysmatic vessel was clearly imaged on the right side of the cervical myometrium and could successfully be treated by radiographic embolisation. Though the primary aetiology of bleeding remains uncertain, it is possible that cervical endometriosis could have been associated with this complication.

Phys Ther. 2007 Jun;87(6):801-10. Epub 2007 Apr 18.

Differential diagnosis of endometriosis in a young adult woman with nonspecific low back pain.

Troyer MR.

mtroyer1@msn.com

BACKGROUND AND PURPOSE: Endometriosis is a common gynecological disorder that can cause musculoskeletal symptoms and manifest as nonspecific low back pain. CASE DESCRIPTION: The patient was a 25-year-old woman who reported the sudden onset of severe left-sided lumbosacral, lower quadrant, buttock, and thigh pain. The physical therapist examination revealed findings suggestive of a pelvic visceral disorder during the diagnostic process. The physical therapist referred the patient for medical consultation, and she was later diagnosed by a gynecologist with endometriosis and a left ovarian cyst. OUTCOMES: The patient underwent laser laparoscopy and excision of the ovarian cyst followed by a regimen of gonadotropin-releasing hormone agonists. The intervention resulted in abolition of the lower quadrant pain and a significant reduction of the back and leg pain that enabled the patient to return to her normal activities. DISCUSSION: A thorough physical therapist examination that considers all of the musculoskeletal, visceral, and psychosocial components is essential to identify pelvic disorders such as endometriosis and other disease processes during the differential diagnosis of nonspecific low back pain. Medical consultation is necessary to provide proper diagnosis and intervention of endometriosis, but physical therapists also may have an important role in the identification of endometriosis and the management of the musculoskeletal aspects of the disorder.

Zhonghua Fu Chan Ke Za Zhi. 2007 Feb;42(2):120-3.

[Modified tubo-uterine implantations for proximal tubal occlusive infertility after femal sterilization with mucilago phenol]

[Article in Chinese]

Zhang DK, Li YQ, Li XY, Di N, Luo Y, Yang DZ, Kuang JQ.

Department of Obstetrics and Gynecology, Second Affiliated Hospital of Sun Yat-sen University, Guangzhou 510120, China.

OBJECTIVE: To explore the effects of modified tubo-uterine implantations performed on women with proximal tubal occlusive infertility after femal sterilization with mucilago phenol. METHODS: Two hundred and eight infertile women who were admitted to the Second Affiliated Hospital of Sun Yat-sen University between 1986 and 2004 were included. They all accepted modified tubo-uterine implantation after occlusion of fallopian tubes with mucilago phenol. RESULTS: It was found that the occlusions were all located in the interstitial portion or isthmic portion of the fallopian tubes. Different degrees of pelvic adhesions were found in 65 cases. Fifty-seven cases were slightly adhesive, seven cases were of moderate degree and one case was severe. One hundred and ninety-nine cases were followed up after operations (95.7%). One hundred and ninety-three women accepted hydrotubation in the following month just after the operation and 185 women were found to be unobstructed (95.8%). One hundred and forty-three women became pregnant, the pregnant rate being 71.9% (143/199). One hundred and twenty-five women had term deliveries (87.4%), three women were in early pregnancy and two in midtrimester pregnancy. Eleven women had spontaneous abortion (7.7%). Two women had tubal pregnancy (1.0%). None of the 199 cases had any signs of endometriosis. CONCLUSIONS: Modified tubo-uterine implantations are quite effective for proximal tubal occlusive infertility. It may be a favorable method for such kind of tubal occlusions.

Zhonghua Fu Chan Ke Za Zhi. 2007 Feb;42(2):92-5.

[Outcome analysis of stage III – IV endometriosis after conservative surgery]

[Article in Chinese]

Li Y, Zhu HL, Liang XD, Zhang C, Wang ZH, Cui H.

Gynecologic Oncology Center, People’s Hospital, Peking University, Beijing 100044, China.

OBJECTIVE: To analyze the recurrence and fertility outcome of stage III – IV endometriosis after conservative surgery. METHODS: A retrospective study was performed on 90 women with stage III – IV endometriosis who had been diagnosed by pathology after conservative surgery. They were divided into three groups: 16 without endocrine therapy (Group A), 52 treated with gestrinone (Group B), 22 treated with gonadotropin releasing hormone agonist (GnRHa) (Group C). The number of infertile patients in the three groups was 10, 15 and 10, respectively. The recurrent and pregnant outcomes were compared after a median follow-up of 48.5 months (2 – 7 years). RESULTS: The recurrent rate of groups A, B, and C was 18.8% (3/16), 30.8% (16/52) and 13.6% (3/22), respectively (P = 0.247); the recurrent time in the three groups were Group A: 63.8 months, Group B: 63.3 months, and Group C: 47.6 months (P = 0.376). There were no significant differences in pregnant outcome among the three groups. The cumulative pregnant rates were 70.0% (7/10), 66.7% (10/15) and 60.0% (6/10), respectively (P = 0.890). There was also no difference in the first pregnant interval after surgery (P = 0.092) and 65.2% of the patients acquired pregnancy spontaneously in the first year after surgery. CONCLUSIONS: Neither gestrinone nor GnRHa can prolong the recurrent time or reduce the recurrent rate after conservative surgery. Surgery can improve the fertility ability of stage III and IV endometriosis patients; however, the pregnant rate cannot be improved with endocrine therapy after conservative surgery.

J Obstet Gynaecol Res. 2007 Apr;33(2):207-10.

Clinical pitfalls of pain recurrence in endometriosis arising in the posterior vaginal fornix.

Tachibana M, Murakami T, Utsunomiya H, Terada Y, Yaegashi N, Okamura K.

Department of Obstetrics and Gynecology, Tohoku University School of Medicine, Sendai, Japan. masahito@mail.tains.tohoku.ac.jp

Endometriotic nodules in the lower genital tract often cause dysmenorrhea and dyspareunia. We report here a case of posterior vaginal fornix endometriosis that was overlooked for several years. We performed a trans-vaginal resection after the associated pain was not relieved by repetitive gonadotropin-releasing hormone agonist (GnRHa) therapy or abdominal surgery. After the resection, the patient’s symptoms disappeared. The patient subsequently conceived and proceeded to a full-term delivery. The pathological diagnosis was ‘endometriosis of the vagina.’ Immunohistochemical staining revealed that the progesterone receptor-positive cells outnumbered the estrogen receptor-positive cells. We emphasize that the existence of vaginal lesions should be considered in cases in which pain has not improved despite long-term GnRHa administration, or in cases involving dyspareunia. To provide appropriate treatment, attentive evaluation and careful examination of the disease are necessary for a patient with prolonged unsatisfactory progress.

Practitioner. 2007 Mar;251(1692):36, 39-40, 43-6.

Tailor treatment to the patient in endometriosis.

Fladjoe PK, Overton CE.

St Michael’s University Hospital.

Ann N Y Acad Sci. 2007 Apr;1101:49-61. Epub 2007 Apr 13.

Uterine contractility: visualization of synchronization measures in two simultaneously recorded signals.

Oczeretko E, Kitlas A, Borowska M, Swiatecka J, Laudanski T.

Institute of Computer Science, University of Białystok, Sosnowa 64, 15-887 Białystok, Poland. eddoczer@ii.uwb.edu.pl

The analysis of the uterine contraction signals in nonpregnant states gives information about physiological changes during the menstrual cycle. Spontaneous uterine activity was recorded directly by a dual microtip catheter. The device consisted of two ultra-miniature pressure sensors. One sensor was placed in the fundus, the other in the cervix. It was important to identify time delays between contractions in two topographic locations, which may be of potential diagnostic significance in various pathologies: dysmenorrhea, endometriosis, and fecundity disorders. In this study the following synchronization measures-the cross-correlation, the semblance, the mutual information-were used to visualize the time delay changes over time. These measures were computed in a moving window with a width corresponding to approximately two or three contractions. As a result, the running synchronization functions were obtained. The running synchronization functions visualize changes in the propagation of the two simultaneously recorded signals. The propagation% parameter assessed from these functions allows for quantitative description of synchronization. Finally, we illustrate the use of running synchronization functions to investigate the effect of treatment with tamoxifen on primary dysmenorrhea.

Fertil Steril. 2007 Dec;88(6):1541-7. Epub 2007 Apr 16.

Hormonal suppression treatment or dietary therapy versus placebo in the control of painful symptoms after conservative surgery for endometriosis stage III-IV. A randomized comparative trial.

Sesti F, Pietropolli A, Capozzolo T, Broccoli P, Pierangeli S, Bollea MR, Piccione E.

Endometriosis Center, Section of Gynecology & Obstetrics, Department of Surgery, Tor Vergata University Hospital, Rome, Italy. Francesco.Sesti@uniroma2.it

OBJECTIVE: To evaluate the effectiveness for the outcomes of endometriosis-related pain and quality of life of conservative surgery plus placebo compared with conservative surgery plus hormonal suppression treatment or dietary therapy. DESIGN: Randomized comparative trial. SETTING: University hospital. PATIENT(S): Two hundred twenty-two consecutive women who underwent conservative pelvic surgery for symptomatic endometriosis stage III-IV (r-AFS). INTERVENTION(S): Six months of placebo (n = 110) versus GnRH-a (tryptorelin or leuprorelin, 3.75 mg every 28 days) (n = 39) or continuous estroprogestin (ethynilestradiol, 0.03 mg plus gestoden, 0.75 mg) (n = 38) versus dietary therapy (vitamins, minerals salts, lactic ferments, fish oil) (n = 35). MAIN OUTCOME MEASURE(S): Painful symptoms (visual analogue scale score) and quality-of-life endometriosis-related symptoms (SF-36 score) at 12 months’ follow-up. RESULT(S): Patients treated with postoperative hormonal suppression therapy showed less visual analogue scale scores for dysmenorrhoea than patients of the other groups. Hormonal suppression therapy and dietary supplementation were equally effective in reducing nonmenstrual pelvic pain. Surgery plus placebo showed significative decrease in dyspareunia scores. Postoperative medical and dietary therapy allowed a better quality of life than placebo. CONCLUSION(S): Postoperative hormonal suppression treatment or dietary therapy are more effective than surgery plus placebo to obtain relief of pain associated with endometriosis stage III-IV and improvement of quality of life.

Fertil Steril. 2007 Aug;88(2):507-9. Epub 2007 Apr 11.

A comparison of follicular response of ovaries to ovulation induction after laparoscopic ovarian cystectomy or fenestration and coagulation versus normal ovaries in patients with endometrioma.

Alborzi S, Ravanbakhsh R, Parsanezhad ME, Alborzi M, Alborzi S, Dehbashi S.

Shiraz University of Medical Sciences, Shiraz, Iran. Alborzis@sums.ac.ir <Alborzis@sums.ac.ir>

In a comparison of follicular responses to controlled ovarian hyperstimulation (COH) between normal ovaries and ovaries previously treated by different laparoscopic techniques for ovarian endometrioma in 65 patients with unilateral endometrioma, laparoscopic ovarian fenestration and coagulation was performed in 24 cases (group 1) and laparoscopic ovarian cystectomy in the other 41 (group 2). In 16 patients with bilateral endometrioma (group 3), cystectomy was done in one ovary and fenestration and coagulation in the contralateral side. The results indicate that the response of ovaries to COH after laparoscopic ovarian cystectomy or fenestration and coagulation was the same and that there was no difference in response to COH between normal ovaries and those operated on by the laparoscopic techniques mentioned above.

Surg Technol Int. 2007;16:137-41.

Laparoscopic treatment of bowel endometriosis.

Lewis LA, Nezhat C.

Center for Special Minimally Invasive Surgery, Stanford University Medical Center, Palo Alto, California, USA.

The most common site of extragenital endometriosis is the intestinal tract, which accounts for approximately 80% of all extragenital endometriosis. The symptoms of intestinal endometriosis are crampy pain, flatulence, painful tenesmus, hyper-peristalsis, progressive constipation, diarrhea alternating with constipation, and occasionally rectal bleeding. As endometriosis in this location often undergoes fibrotic changes, it can be resistant to hormonal therapy, which makes surgical therapy the only option for many women. Until recently, laparoscopic treatment of bowel endometriosis was thought to be impossible. Development of several safe and effective techniques for laparoscopic treatment of intestinal endometriosis has made such treatment possible. In this chapter, the authors describe five proven techniques for treatment of intestinal endometriosis: shaving, disk excision, anterior rectal wall excision, segmental resection, and appendectomy.

Hum Reprod. 2007 Jul;22(7):2016-9. Epub 2007 Apr 11.

Laparoscopy-guided myometrial biopsy in the definite diagnosis of diffuse adenomyosis.

Jeng CJ, Huang SH, Shen J, Chou CS, Tzeng CR.

Department of Obstetrics and Gynecology, School of Medicine, Taipei Medical University, and Department of Pathology, Cathay General Hospital, Taipei 110, Taiwan. drcjjeng@tmu.edu.tw

BACKGROUND: The purpose of this study was to investigate the usefulness of laparoscopy-guided myometrial biopsy in the diagnosis of diffuse adenomyosis. METHODS: This prospective non-randomized study (Canadian Task Force classification II-1) was conducted in a tertiary medical center. One hundred patients who had clinical signs and symptoms strongly suggestive of adenomyosis were included as the study sample. Transvaginal sonography, serum CA-125 determination and laparoscopy-guided myometrial biopsy were performed. RESULTS: The mean largest myometrial thickness was 3.10+/-0.56 cm (range 2.30-4.50). The mean serum CA-125 level was 49.64+/-38.30 U/ml (range 10.90-205.28). Of these 100 patients, adenomyosis was pathologically proven in 92 patients, small leiomyoma in four patients and myometrial hypertrophy in four patients. The sensitivity of myometrial biopsy was 98% and the specificity 100%; the positive predictive value was 100% and the negative predictive value 80%, which were superior to those of transvaginal sonography, serum CA-125 determination or the combination of both. CONCLUSION: Laparoscopy-guided myometrial biopsy is a valuable tool for obtaining a definite diagnosis of diffuse adenomyosis with preservation of the uterus in infertility workup or in the evaluation of dysmenorrhea or chronic pelvic pain.

Fertil Steril. 2007 Oct;88(4):832-9. Epub 2007 Apr 10.

GnRH agonist and antagonist protocols for stage I-II endometriosis and endometrioma in in vitro fertilization/intracytoplasmic sperm injection cycles.

Pabuccu R, Onalan G, Kaya C.

Ufuk University School of Medicine, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Ankara, Turkey.

OBJECTIVE: To investigate the outcomes of intracytoplasmic sperm injection (ICSI) cycles after controlled ovarian hyperstimulation (COH) with GnRH antagonist or GnRH agonist (GnRH-a) in mild-to-moderate endometriosis and endometrioma. DESIGN: Prospective randomize trial. SETTING: A private IVF center. PATIENT(S): A total of 246 ICSI cycles in 246 patients were divided into three groups: women with mild-to-moderate endometriosis (n = 98); women who had ovarian surgery for endometrioma (n = 81); women with endometrioma and no history of previous surgery (n = 67). INTERVENTION(S): Patients in each group were randomized to COH with either triptrolein or cetrorelix. MAIN OUTCOME MEASURE(S): Clinical parameters, characteristics of COH, and ICSI results were analyzed. RESULT(S): Outcomes of COH with both GnRH antagonist and GnRH-a were similar in patients with mild-to-moderate endometriosis. Implantation rates were 15.9% vs. 22.6% and clinical pregnancy rates were 27.5% vs. 39% with GnRH antagonist and GnRH-a protocols, respectively, in patients who had ovarian surgery for endometrioma. Implantation rates were 12.5% vs. 14.8% and clinical pregnancy rates were 20.5% vs. 24.2% with GnRH antagonist and GnRH-a protocols, respectively, in patients with endometrioma and no history of ovarian surgery. CONCLUSION(S): Considering the implantation and clinical pregnancy rates, COH with both GnRH antagonist and GnRH-a protocols may be equally effective in patients with mild-to-moderate endometriosis and endometrioma who did and did not undergo ovarian surgery.

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