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Ovarian Endometrioma in Subfertile Women: The Need for a New Surgical Staging
Abstracts / Journal of Minimally Invasive Gynecology 17 (2010) S69–S89 Intervention: Preoperative: transvagynal ultrasound, abdominal pelvic MRI, barium enema, Rectocolonoscopy, cystoscopy and isotope renogram. The assessment was conducted jointly by Gynecologists, Surgeons and Urologists integrated into our unit Endometriosis. Was diagnosed: rectovaginal septum nodule in 4 cm that penetrated the posterior vaginal fornix, several disease rectosigmoid wall and grade IV ureteral loss of function of the left kidney. Measurements and Main Results: Laparoscopic Procedure Liberation rectovaginal septum and resection of the nodule (leg trapped distal left ureter), vaginal opening and rebuilding, TT intestinal resection and laparoscopic left nephrectomy. The surgery lasted ten hours without complications. The patient was discharged at 7 days after the intervention. In its first objectively review we see a remarkable improvement in their quality of life, and yet IVF program. Conclusion: We present this case for its uniqueness and few references in the literature where all these procedures are collected in a single laparoscopic surgery. The multidisciplinary management of these patients is essential to optimize results. It is important to keep in mind the possible silent renal functional impairment in cases of deep endometriosis, given the few symptoms that usually present.
291
Open Communications 17dEndometriosis (4:38 PM d 4:43 PM)
Ovarian Endometrioma in Subfertile Women: The Need for a New Surgical Staging Zayed MA, Setohy KA, El Anany HG. Obstetrics and Gynecology, Cairo University, Cairo, Egypt; Obstetrics and Gynecology, Women’s Medical Center, Cairo, Egypt Study Objective: To present a new surgical staging for ovarian endometriomas at the time of laparoscopy in infertile women to help the clinician to standardize the plan of management and formulate the prognosis of infertility. Design: Prospective clinical trial. Setting: Private sector and University teaching hospital- Cairo- Egypt. Patients: Seventy eight infertile patients with ovarian endometrioma. Intervention: Laparoscopic management of ovarian endometrioma and staging using a new simple surgical staging system of endometrioma in infertile patient. Four surgical stages for ovarian endometrioma were developed for classification of infertile patients designed to simplify management protocol of infertile patients with enometriomas. Patients were followed for one year for results of management. Measurements and Main Results: Seventy eight women were diagnosed as having endometriomas distributed as follow according to rAFS classification: stage I: 3 cases (9.6%), Stage II 4 cases (12.9%), Stage III 31 cases (38.7%) and finally stage IV 30 (38.7%). After management according to the proposed surgical staging, recurrence rate over one year was relatively low (12.7%), 52.2% of participants got pregnant within one year whether spontaneous pregnancy or after IVF. Results of surgery and prognosis of infertility according to our new staging system shows better correlation by stage than with rA.
292
Open Communications 17dEndometriosis (4:44 PM d 4:49 PM)
Influence of GnRHa on the Expression of NGF, TrkA and P75 mRNA in Eutopic Endometrium in Patients with Endometriosis Li X, Leng J, Lang J. Gynecology and Obstetrics, Peking Union Medical College Hospital, Beijing, China Study Objective: To evaluate the effect of GnRHa on NGF, TrkA and P75 mRNA expression in normal and eutopic endometrial stromal cells. Design: Endometriosis-related pain can be successfully managed with GnRH agonists. However, the precise molecular mechanism remains unclear. Some studies showed perineurial and intraneurial invasion by stromal cells which mediated by neurotrophins such as NGF (nerve growth factor) and its two receptors, TrkA (tyrosine kinase receptor A)
S87
and P75, was associated with pain symptoms in endometriosis. As previous research suggested endometriosis was determined by eutopic endometrium, in this study, NGF, trkA and P75 mRNA in endometrial stromal cells were evaluated by reverse transcription polymerase chain reaction. Setting: Gynecological laboratory in a tertiary hospital. Patients: 5 women with endometriosis compared to 5 women without endometriosis. Intervention: The eutopic endometria were obtained from the patients with endometriosis and the control women during surgery. Endometrial stromal cells were treated with different concentrations of GnRHa (5!1011g/ ml,5!1010g/ml,5!109g/ml,5!108g/ml,5!107g/ml) for 24 hours, and collected for the measurement of NGF, TrkA and p75 mRNA. Measurements and Main Results: NGF, TrkA and P75 mRNA were expressed in endometrial stromal cells. The levels of these neurotrophins mRNA in eutopic endometrial stromal cells of patients with endometriosis were all higher than the control group, and significantly reduced by every concentrations of GnRHa after 24 hours compared with untreated cells, while this did not happen to the control group. Conclusion: Eutopic endometrial stromal cells from endometriosis patients express more NGF, TrkA and P75 mRNA than normal endometrium. This may be involved in endometriosis-associated pain mediated by neurotrophins. The suppression of NGF, TrkA and P75 mRNA by GnRHa may be a hint of further mechanisms of treating endometriosis-associated pain.
293
Open Communications 18dNew Concepts in MIG (3:20 PM d 3:25 PM)
A Novel Approach to Total Laparoscopic Hysterectomy Using Only Two 5mm Ports: Initial Clinical Experience Lii SJ, Becker SF, Danilyants NE, Mackoul PJ. Obstetrics and Gynecology, George Washington University Hospital, Washington, District of Columbia Study Objective: To demonstrate the feasibility of performing laparoscopic hysterectomy (LH) using only two 5mm ports. Design: Retrospective study of 44 consecutive laparoscopic hysterectomies performed by two surgeons using two 5mm ports and traditional laparoscopic equipment. Setting: Three suburban community hospitals. Patients: 44 women ages 26-72 scheduled to undergo LH. Intervention: LH with or without salpingo-oophorectomy via a two-port technique, with a 5-mm port placed supraumbilically and a 5-mm port placed suprapubically. All procedures were performed using a Harmonic ACEÒ, a 5-mm laparoscope, and conventional laparoscopic equipment. A Stryker MiniLap device was used in 5 cases. Uterine artery ligation in the retroperitoneal space was accomplished in all cases. Measurements and Main Results: 44 women underwent two-port LH. Average BMI was 28.0 kg/m2 (18.9-40.4 kg/m2), 11 of which were greater than 30. They averaged 1 prior abdominal surgery each; 12 patients had 2 or more prior abdominal surgeries. Median operative time was 46 min (26-79 min), median blood loss was 100ml (10-400ml), and median weight of resected uteri was 123g (41-1152g). All patients were discharged home on the same day. There was one bladder perforation that presented on postoperative day 5 with abdominal pain and intraabdominal fluid on ultrasound. This was repaired laparoscopically and the patient went home the following day. There were no injuries to ureter or bowel. There were no transfusions or other readmissions. Conclusion: Laparoscopic hysterectomy with retroperitoneal dissection using two traditional 5mm and the Harmonic ACEÒ, is a safe and feasible approach in terms of operative time, estimated blood loss, complication rates and cosmetic results. It can be done in women with prior abdominal surgery as well as in obese women. With decreased overall incision size compared to single port procedures, this 2-port approach affords patients better cosmesis and lower risk of herniation. Possible benefits for reduced pain and improved patient satisfaction should be evaluated in prospective studies.
291
Open Communications 17dEndometriosis (4:38 PM d 4:43 PM)
Ovarian Endometrioma in Subfertile Women: The Need for a New Surgical Staging Zayed MA, Setohy KA, El Anany HG. Obstetrics and Gynecology, Cairo University, Cairo, Egypt; Obstetrics and Gynecology, Women’s Medical Center, Cairo, Egypt Study Objective: To present a new surgical staging for ovarian endometriomas at the time of laparoscopy in infertile women to help the clinician to standardize the plan of management and formulate the prognosis of infertility. Design: Prospective clinical trial. Setting: Private sector and University teaching hospital- Cairo- Egypt. Patients: Seventy eight infertile patients with ovarian endometrioma. Intervention: Laparoscopic management of ovarian endometrioma and staging using a new simple surgical staging system of endometrioma in infertile patient. Four surgical stages for ovarian endometrioma were developed for classification of infertile patients designed to simplify management protocol of infertile patients with enometriomas. Patients were followed for one year for results of management. Measurements and Main Results: Seventy eight women were diagnosed as having endometriomas distributed as follow according to rAFS classification: stage I: 3 cases (9.6%), Stage II 4 cases (12.9%), Stage III 31 cases (38.7%) and finally stage IV 30 (38.7%). After management according to the proposed surgical staging, recurrence rate over one year was relatively low (12.7%), 52.2% of participants got pregnant within one year whether spontaneous pregnancy or after IVF. Results of surgery and prognosis of infertility according to our new staging system shows better correlation by stage than with rA.
292
Open Communications 17dEndometriosis (4:44 PM d 4:49 PM)
Influence of GnRHa on the Expression of NGF, TrkA and P75 mRNA in Eutopic Endometrium in Patients with Endometriosis Li X, Leng J, Lang J. Gynecology and Obstetrics, Peking Union Medical College Hospital, Beijing, China Study Objective: To evaluate the effect of GnRHa on NGF, TrkA and P75 mRNA expression in normal and eutopic endometrial stromal cells. Design: Endometriosis-related pain can be successfully managed with GnRH agonists. However, the precise molecular mechanism remains unclear. Some studies showed perineurial and intraneurial invasion by stromal cells which mediated by neurotrophins such as NGF (nerve growth factor) and its two receptors, TrkA (tyrosine kinase receptor A)
S87
and P75, was associated with pain symptoms in endometriosis. As previous research suggested endometriosis was determined by eutopic endometrium, in this study, NGF, trkA and P75 mRNA in endometrial stromal cells were evaluated by reverse transcription polymerase chain reaction. Setting: Gynecological laboratory in a tertiary hospital. Patients: 5 women with endometriosis compared to 5 women without endometriosis. Intervention: The eutopic endometria were obtained from the patients with endometriosis and the control women during surgery. Endometrial stromal cells were treated with different concentrations of GnRHa (5!1011g/ ml,5!1010g/ml,5!109g/ml,5!108g/ml,5!107g/ml) for 24 hours, and collected for the measurement of NGF, TrkA and p75 mRNA. Measurements and Main Results: NGF, TrkA and P75 mRNA were expressed in endometrial stromal cells. The levels of these neurotrophins mRNA in eutopic endometrial stromal cells of patients with endometriosis were all higher than the control group, and significantly reduced by every concentrations of GnRHa after 24 hours compared with untreated cells, while this did not happen to the control group. Conclusion: Eutopic endometrial stromal cells from endometriosis patients express more NGF, TrkA and P75 mRNA than normal endometrium. This may be involved in endometriosis-associated pain mediated by neurotrophins. The suppression of NGF, TrkA and P75 mRNA by GnRHa may be a hint of further mechanisms of treating endometriosis-associated pain.
293
Open Communications 18dNew Concepts in MIG (3:20 PM d 3:25 PM)
A Novel Approach to Total Laparoscopic Hysterectomy Using Only Two 5mm Ports: Initial Clinical Experience Lii SJ, Becker SF, Danilyants NE, Mackoul PJ. Obstetrics and Gynecology, George Washington University Hospital, Washington, District of Columbia Study Objective: To demonstrate the feasibility of performing laparoscopic hysterectomy (LH) using only two 5mm ports. Design: Retrospective study of 44 consecutive laparoscopic hysterectomies performed by two surgeons using two 5mm ports and traditional laparoscopic equipment. Setting: Three suburban community hospitals. Patients: 44 women ages 26-72 scheduled to undergo LH. Intervention: LH with or without salpingo-oophorectomy via a two-port technique, with a 5-mm port placed supraumbilically and a 5-mm port placed suprapubically. All procedures were performed using a Harmonic ACEÒ, a 5-mm laparoscope, and conventional laparoscopic equipment. A Stryker MiniLap device was used in 5 cases. Uterine artery ligation in the retroperitoneal space was accomplished in all cases. Measurements and Main Results: 44 women underwent two-port LH. Average BMI was 28.0 kg/m2 (18.9-40.4 kg/m2), 11 of which were greater than 30. They averaged 1 prior abdominal surgery each; 12 patients had 2 or more prior abdominal surgeries. Median operative time was 46 min (26-79 min), median blood loss was 100ml (10-400ml), and median weight of resected uteri was 123g (41-1152g). All patients were discharged home on the same day. There was one bladder perforation that presented on postoperative day 5 with abdominal pain and intraabdominal fluid on ultrasound. This was repaired laparoscopically and the patient went home the following day. There were no injuries to ureter or bowel. There were no transfusions or other readmissions. Conclusion: Laparoscopic hysterectomy with retroperitoneal dissection using two traditional 5mm and the Harmonic ACEÒ, is a safe and feasible approach in terms of operative time, estimated blood loss, complication rates and cosmetic results. It can be done in women with prior abdominal surgery as well as in obese women. With decreased overall incision size compared to single port procedures, this 2-port approach affords patients better cosmesis and lower risk of herniation. Possible benefits for reduced pain and improved patient satisfaction should be evaluated in prospective studies.