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Endometriosis of the urinary tract
Abstracts
Measurements and Main Results. Of 400 patients who completed surgery and follow-up, 10 were converted to laparotomy, 7 in the first group of 100, 1 in the second group, 1 in the third, and none in the fourth. Nine women were readmitted for fever, one for partial bowel obstruction and one for continued postoperative bleeding. Three of the first 200 patients experienced cervical prolapse, and none in the second group. Eight patients returned to surgery; one for a partial bowel obstruction, two for mild bleeding, three to correct cervical prolapse, one for a_numbilical hernia, and one for a staging procedure after the unexpected finding of stage Ib ovarian cancer in the pathologic specimen. Returns to surgery decreased as the surgeon's experience progressed and management was altered. There were no bowel or bladder injuries, postoperative hemorrhages, or significant hematomas. Operating room time decreased steadily as the study progressed. Conclusion. The surgeon's learning curve is a significant factor in successful completion of laparoscopic hysterectomy, reduction of operating room time, and avoidance of postoperative complications.
ceral peritoneum appears more sensitive to dry gas than parietal peritoneum. Mesothelial damage is attenuated when gas is humidified and warmed. 208. Bimodal Energy Sources for Laparoscopic Hysterectomy M Wynn-Williarns, A Larn. Centre for Advanced Reproductive Endosurgery, North Shore Private Hospital, Sydney, Australia.
Objective. To describe concurrent use of bipolar diathermy and ultrasonic energy (laparoscopic coagulating shears, harmonic scalpel) to increase the safety and efficiency of TLH. Measurements and Main Results. The records of 114 women undergoing laparoscopic hysterectomy (LAVH 20%, TLH 80%) in which bipolar diathermy was combined with harmonic scalpel were reviewed. The main indication for surgery was menorrhagia (39%). Mean anesthesia time was 143 minutes (range 65-255 min). Additional surgery was performed in 76% of patients (BSO 34%, McCall culdoplasty 21%, colposuspension 15 %, resection of endometriosis 11%, pelvic floor repair 13 %, resection of endometriosis 11%). Two patients had blood loss greater than 500 ml; one required blood transfusion. One patient required admission to intensive care for postoperative chest pain. The mean hospital stay was 3 days (range 1-11 days). Conclusion. Combined laparoscopic coagulating shears and bipolar diathermy is safe and increases the efficiency of laparoscopic hysterectomy.
207. Humidity and Temperature of Insufflation Gas on Intact Peritoneum DM Wisernan. Synechion Inc., Dallas, Texas.
Objective. To determine the effect of insufflation gas humidity and temperature on intact peritoneum. Measurements and Main Results. Standard CO2 was painted onto 2 x 2-cm areas of peritoneum covering either large bowel or parietal peritoneum at a standard pressure (5 psi), distance (2 cm), and time (30 sec) of dogs sacrificed for other reasons. Gas was passed through an Insufflow (Lexion Medical, St. Paul, MN) device with or without conditioning. During conditioning, gas was humidified and warmed to 37 ~ C. Tissues were dissected, processed for histology, and stained with hematoxylin and eosin or trichrome stains. Appearance of the mesothelial layer was determined by light microscopy. Few mesothelial changes were observed in sidewall tissues. For intestinal tissues, damage consisting of mesothelial denudation was evident after cold, dry gas. Mesothelial damage was greatly attenuated when gas was warmed and humidified. Tissue exposed to conditioned CO2 appeared comparable with control tissue. Conclusion. Mesothelial damage due to dry gas exposure can be detected by simple light microscopy. Vis-
209. Endometriosis of the Urinary Tract M Wynn-Williarns, A Larn, A Yazdani, MC Cooper, G Reid, PJ Maher, G Cario, J Tsaltas, R O'Sullivan. Centre for Advanced Reproductive Endosurgery, North Shore Private Hospital, Sydney, Australia.
Objective. To study the prevalence, features, management, and outcome of urinary tract endometriosis managed at tertiary referral centers in Australia. Measurements and Main Results. Data on 26 patients were collected (mean age 36.8 yrs, range 26-53 yrs; 61.5% nulliparous; 69% with previous surgery). Complaints were pelvic-abdominal pain (92%), dysuria (34%), cyclic dysuria-stranguria (17%), urgency (13%), hematuria (8%), and pelvic mass (4%). Preoperative investigations were ultrasound (39%), cystoscopy (43%), IVP (13%), and CT scan (8%). Operative findings were bladder lesions (86%), ureteric
$62
August 2002, Vol. 9, No. 3 Supplement The Journal of the American Association of Gynecologic Laparoscopists
211. Failure of Laparoscopic Instrument Insulation
lesions (22%), concomitant pelvic disease (52%), and concomitant bowel disease (26%). Procedures performed were laparotomy (26%), laparoscopic partial cystectomy (56%), laparoscopic nephrectomy (4%), and ureteric steuts (34%). An indwelling catheter was used for an average of 8.5 postoperative days. Followup ranged from 3 to 16 months. Medical suppression was administered in 8% of patients. Three women underwent further surgery. Conclusion. Urinary tract endometriosis occurs in 1 to 45 of patients. Many women have concomitant pelvic, ovarian, or bowel disease. Diagnosis is often delayed, with serious consequences. There are no randomized trials to guide management. A multidisciplinary approach is required. Surgery is indicated in the presence of ureteric obstruction, severe pelvic fibrosis, or deep nodules. Medical therapy requires careful follow-up.
in the Tertiary Institution 1A Yazdani, 2H Krause. 1Centre for Advanced Reproductive Endosurgery, Woolloongabba, Australia; 2Herston, Australia.
Objective. To determine the prevalence of insulation failure in gynecologic laparoscopic instruments. Measurements and Main Results. All laparoscopic instruments in two tertiary institutions were tested in accordance with biomedical engineering guidelines. They were visually inspected and subjected to standard analysis. Defects were defined and quaaatified. We found an overall rate of insulation failure of 25%, with up to 66% in specific subanalysis. These defects affected up to 100% of all operative equipment sets. Defects were visually predictable in 16%, but 67% of faulty instruments had no identifiable defect on close inspection. Conclusion. Failure of laparoscopic instrument insulation is much higher than previously documented, and has major practice implications for nondisposable electrosurgical instrumentation.
210. Outcome of Pregnancy after Transcervical Resection of Endometrium E Xia, H Duan, H Duan, XW Huang, D Yu, M Zhang, J Zheng. Fuxing Hospital, Beijing, China.
Objective. To evaluate the outcome and management of pregnancy after transcervical resection of endometrium (TCRE). Measurements and Main Results. There were two cases of spontaneous abortion; in one of the women cervical pregnancy was combined with a lot of bleeding when the gestational sac was extracted. There were 27 cases of artificial abortion. Among them one case of intrauterine adhesion was resected by resectoscope and the gestational sac was removed by suction. One woman experienced profuse arterial bleeding (~700 ml) just after suction ended and was unresponsive to general treatment. Bleeding was stopped with pressure from an intrauterine balloon. One pregnancy in the right uterine cornu was managed with subtotal hysterectomy because suction abortion failed. Two women had tubal pregnancy. In one woman with term pregnancy and placenta increta, delivery of a lowbirthweight infant and subtotal hysterectomy were performed simultaneously. Conclusion. Pregnancy after TCRE can be complicated by abortion, abnormal insertion of placenta, fetal growth retardation, and abnormal third-stage labor. Therefore these high-risk women have to be monitored intensively and treated appropriately.
212. The Efficacy of Laparoscopic Uterosacral Ligaments Colpopexy in Management of Vaginal Vault Prolapse CF Yen, CL Lee, YK Soong, CJ Wang, M.D. Chang Gung Memorial Hospital, Tao-Yuan, Taiwan.
Objective. To evaluate the efficacy of laparoscopic uterosacral ligament colpopexy, derived from the high McCall colpopexy, in management of vaginal vault prolapse during LAVH. Measurements and Main Results. Women with grade 2 uterine prolapse underwent LAVH. After LAVH, the intervention group had uterosacral ligament shortening, plication, and repair of paracervical ring concomitantly. The control group had only standard LAVH. Total vaginal length was measured before, immediately after, and 1 month after surgery. At 1month examination, vaginal length in the intervention group increase 1.5 + 2.5 cm, whereas in the control group it increased only 0 + 1.5 cm. All patients in both groups had no discomfort. Conclusion. Uterosacral ligament colpopexy may significautly increase total vaginal length.
$63
Measurements and Main Results. Of 400 patients who completed surgery and follow-up, 10 were converted to laparotomy, 7 in the first group of 100, 1 in the second group, 1 in the third, and none in the fourth. Nine women were readmitted for fever, one for partial bowel obstruction and one for continued postoperative bleeding. Three of the first 200 patients experienced cervical prolapse, and none in the second group. Eight patients returned to surgery; one for a partial bowel obstruction, two for mild bleeding, three to correct cervical prolapse, one for a_numbilical hernia, and one for a staging procedure after the unexpected finding of stage Ib ovarian cancer in the pathologic specimen. Returns to surgery decreased as the surgeon's experience progressed and management was altered. There were no bowel or bladder injuries, postoperative hemorrhages, or significant hematomas. Operating room time decreased steadily as the study progressed. Conclusion. The surgeon's learning curve is a significant factor in successful completion of laparoscopic hysterectomy, reduction of operating room time, and avoidance of postoperative complications.
ceral peritoneum appears more sensitive to dry gas than parietal peritoneum. Mesothelial damage is attenuated when gas is humidified and warmed. 208. Bimodal Energy Sources for Laparoscopic Hysterectomy M Wynn-Williarns, A Larn. Centre for Advanced Reproductive Endosurgery, North Shore Private Hospital, Sydney, Australia.
Objective. To describe concurrent use of bipolar diathermy and ultrasonic energy (laparoscopic coagulating shears, harmonic scalpel) to increase the safety and efficiency of TLH. Measurements and Main Results. The records of 114 women undergoing laparoscopic hysterectomy (LAVH 20%, TLH 80%) in which bipolar diathermy was combined with harmonic scalpel were reviewed. The main indication for surgery was menorrhagia (39%). Mean anesthesia time was 143 minutes (range 65-255 min). Additional surgery was performed in 76% of patients (BSO 34%, McCall culdoplasty 21%, colposuspension 15 %, resection of endometriosis 11%, pelvic floor repair 13 %, resection of endometriosis 11%). Two patients had blood loss greater than 500 ml; one required blood transfusion. One patient required admission to intensive care for postoperative chest pain. The mean hospital stay was 3 days (range 1-11 days). Conclusion. Combined laparoscopic coagulating shears and bipolar diathermy is safe and increases the efficiency of laparoscopic hysterectomy.
207. Humidity and Temperature of Insufflation Gas on Intact Peritoneum DM Wisernan. Synechion Inc., Dallas, Texas.
Objective. To determine the effect of insufflation gas humidity and temperature on intact peritoneum. Measurements and Main Results. Standard CO2 was painted onto 2 x 2-cm areas of peritoneum covering either large bowel or parietal peritoneum at a standard pressure (5 psi), distance (2 cm), and time (30 sec) of dogs sacrificed for other reasons. Gas was passed through an Insufflow (Lexion Medical, St. Paul, MN) device with or without conditioning. During conditioning, gas was humidified and warmed to 37 ~ C. Tissues were dissected, processed for histology, and stained with hematoxylin and eosin or trichrome stains. Appearance of the mesothelial layer was determined by light microscopy. Few mesothelial changes were observed in sidewall tissues. For intestinal tissues, damage consisting of mesothelial denudation was evident after cold, dry gas. Mesothelial damage was greatly attenuated when gas was warmed and humidified. Tissue exposed to conditioned CO2 appeared comparable with control tissue. Conclusion. Mesothelial damage due to dry gas exposure can be detected by simple light microscopy. Vis-
209. Endometriosis of the Urinary Tract M Wynn-Williarns, A Larn, A Yazdani, MC Cooper, G Reid, PJ Maher, G Cario, J Tsaltas, R O'Sullivan. Centre for Advanced Reproductive Endosurgery, North Shore Private Hospital, Sydney, Australia.
Objective. To study the prevalence, features, management, and outcome of urinary tract endometriosis managed at tertiary referral centers in Australia. Measurements and Main Results. Data on 26 patients were collected (mean age 36.8 yrs, range 26-53 yrs; 61.5% nulliparous; 69% with previous surgery). Complaints were pelvic-abdominal pain (92%), dysuria (34%), cyclic dysuria-stranguria (17%), urgency (13%), hematuria (8%), and pelvic mass (4%). Preoperative investigations were ultrasound (39%), cystoscopy (43%), IVP (13%), and CT scan (8%). Operative findings were bladder lesions (86%), ureteric
$62
August 2002, Vol. 9, No. 3 Supplement The Journal of the American Association of Gynecologic Laparoscopists
211. Failure of Laparoscopic Instrument Insulation
lesions (22%), concomitant pelvic disease (52%), and concomitant bowel disease (26%). Procedures performed were laparotomy (26%), laparoscopic partial cystectomy (56%), laparoscopic nephrectomy (4%), and ureteric steuts (34%). An indwelling catheter was used for an average of 8.5 postoperative days. Followup ranged from 3 to 16 months. Medical suppression was administered in 8% of patients. Three women underwent further surgery. Conclusion. Urinary tract endometriosis occurs in 1 to 45 of patients. Many women have concomitant pelvic, ovarian, or bowel disease. Diagnosis is often delayed, with serious consequences. There are no randomized trials to guide management. A multidisciplinary approach is required. Surgery is indicated in the presence of ureteric obstruction, severe pelvic fibrosis, or deep nodules. Medical therapy requires careful follow-up.
in the Tertiary Institution 1A Yazdani, 2H Krause. 1Centre for Advanced Reproductive Endosurgery, Woolloongabba, Australia; 2Herston, Australia.
Objective. To determine the prevalence of insulation failure in gynecologic laparoscopic instruments. Measurements and Main Results. All laparoscopic instruments in two tertiary institutions were tested in accordance with biomedical engineering guidelines. They were visually inspected and subjected to standard analysis. Defects were defined and quaaatified. We found an overall rate of insulation failure of 25%, with up to 66% in specific subanalysis. These defects affected up to 100% of all operative equipment sets. Defects were visually predictable in 16%, but 67% of faulty instruments had no identifiable defect on close inspection. Conclusion. Failure of laparoscopic instrument insulation is much higher than previously documented, and has major practice implications for nondisposable electrosurgical instrumentation.
210. Outcome of Pregnancy after Transcervical Resection of Endometrium E Xia, H Duan, H Duan, XW Huang, D Yu, M Zhang, J Zheng. Fuxing Hospital, Beijing, China.
Objective. To evaluate the outcome and management of pregnancy after transcervical resection of endometrium (TCRE). Measurements and Main Results. There were two cases of spontaneous abortion; in one of the women cervical pregnancy was combined with a lot of bleeding when the gestational sac was extracted. There were 27 cases of artificial abortion. Among them one case of intrauterine adhesion was resected by resectoscope and the gestational sac was removed by suction. One woman experienced profuse arterial bleeding (~700 ml) just after suction ended and was unresponsive to general treatment. Bleeding was stopped with pressure from an intrauterine balloon. One pregnancy in the right uterine cornu was managed with subtotal hysterectomy because suction abortion failed. Two women had tubal pregnancy. In one woman with term pregnancy and placenta increta, delivery of a lowbirthweight infant and subtotal hysterectomy were performed simultaneously. Conclusion. Pregnancy after TCRE can be complicated by abortion, abnormal insertion of placenta, fetal growth retardation, and abnormal third-stage labor. Therefore these high-risk women have to be monitored intensively and treated appropriately.
212. The Efficacy of Laparoscopic Uterosacral Ligaments Colpopexy in Management of Vaginal Vault Prolapse CF Yen, CL Lee, YK Soong, CJ Wang, M.D. Chang Gung Memorial Hospital, Tao-Yuan, Taiwan.
Objective. To evaluate the efficacy of laparoscopic uterosacral ligament colpopexy, derived from the high McCall colpopexy, in management of vaginal vault prolapse during LAVH. Measurements and Main Results. Women with grade 2 uterine prolapse underwent LAVH. After LAVH, the intervention group had uterosacral ligament shortening, plication, and repair of paracervical ring concomitantly. The control group had only standard LAVH. Total vaginal length was measured before, immediately after, and 1 month after surgery. At 1month examination, vaginal length in the intervention group increase 1.5 + 2.5 cm, whereas in the control group it increased only 0 + 1.5 cm. All patients in both groups had no discomfort. Conclusion. Uterosacral ligament colpopexy may significautly increase total vaginal length.
$63