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Laparoscopic excision of recurrent endometriomas: Long-term outcome and comparison with primary surgery
492
Journal of Minimally Invasive Gynecology, Vol 13, No 5, September/October 2006
ination in 18/67 (27%), and in women with a gynecologic presentation in the remaining 25/67 (37%). Four women had removal of the uterine septum; 1 by abdominal approach and 3 hysteroscopically; 36/67 (54%) had the vaginal septum removed. Fifty of 67 (75%) women had at least 1 pregnancy either before or after treatment of their Müllerian variation. Eight of 50 women had primary infertility and required assistance to become pregnant. For women who had a first pregnancy without correction of the variation, 13/49 (27%) miscarried, 5/49 (10%) had a preterm delivery, and 31 (63%) had a term delivery. For women who had metroplasty, there were 8 pregnancies before correction with a live birth rate of 13% (1/8), and 8 pregnancies after correction, for a live birth rate of 75% (6/8). For all pregnancies in these women, there was a live birth rate of 72% (83/115). This is a rare abnormality of the reproductive tract, and the figures for pregnancy outcome are similar to other studies of septate uterus. The figures presented do not support the hypothesis that the more complete the septum, the worse the reproductive outcome. For women who have recurrent miscarriage with this abnormality, treatment of the abnormality is likely to give them a high chance of live birth. The author comments that this abnormality is not associated with endometriosis and genital malignancy. There is no evidence to support routine surgical correction of this abnormality. Editorial note: Given the rarity of this abnormality, there is unlikely to be randomized trials to assess reproductive outcome. Given the information presented, the desire of the patient for delivery should be taken into consideration, since caesarean delivery rate was 61% due to malpresentation. For women desiring vaginal delivery, possible excision of vaginal septum with or without hysteroscopic metroplasty should be discussed and patient desire should drive intervention or conservative management. Summarized by Jason Abbott, PhD, FRANZCOG, MRCOG
Laparoscopic excision of recurrent endometriomas: Long-term outcome and comparison with primary surgery By Fedele L, Bianchi S, Zanconato G, Berlanda N, Raffaelli R, and Fontana E Fertil Steril 2006;85:694 – 699 This is a retrospective study comparing 305 women undergoing primary surgery for ovarian endometriomas with 54 women having repeat surgery for recurrent ovarian endometriomas in the same ovary. The ovaries were treated in all cases by stripping the cyst out. Follow-up was by ultrasound scanning and assessment of pain symptoms and the need for repeat intervention and reproductive outcome are reported. Women with recurrence in a contralateral ovary, disease of gastrointestinal or urinary tracts, loss of
follow-up, indications to remove an ovary, or surgical complication were reasons for 99 exclusions from the study. Women who had recurrent disease were more likely to have Stage IV disease (35% vs 20% p ⫽ .05) and had a higher adhesions score. They were also more likely to be infertile (44% vs 29%, p ⫽ .01). A 5-year recurrence of at least 1 moderate or severe pain symptom was not different between primary and recurrent surgical groups (21% vs 14%). Similarly, 5-year sonographic recurrence rates were not different (19% vs 15%). For primary and recurrent groups, cumulative pregnancy rates were 41% vs 32%, assisted reproductive technologies 32% vs 50%. Elevated follicle-stimulating hormone levels in the earlier follicular phase are reported in the recurrent group (5.5%) versus the primary group (1.3%). These data support the fact that the recurrence rate for pain and the sonographic recurrence of ipsilateral endometriomas is about 20% for both primary and recurrent surgery. Repetitive surgery may deplete the ovary through volume reduction. Editorial note: These data support conservative surgery for ovarian endometriosis and offers valuable information for counseling regarding pregnancy. The possibility of reduced ovarian function needs to be discussed with the patient having recurrent surgery. Summarized by Jason Abbott, PhD, FRANZCOG, MRCOG
Effects of tamoxifen vs raloxifene on the risk of developing invasive breast cancer and other disease outcomes By Vogel VG, Costantino JP, Wickerham DL, et al for the National Surgical Adjuvant Breast and Bowel Project JAMA 2006;295:2727–2741 The long-awaited results of the STAR trial, matching tamoxifen 20 mg/d versus raloxifene 60 mg/d for prevention of breast cancer, are now starting to appear. The study encompassed 19 747 women at least 35 years of age (mean 58.5) who were postmenopausal and with a Gail model prediction of at least 1.66% increase in breast cancer risk (at least a 4% risk of breast cancer within 5 years). This was, of course, a prospective, randomized, double-blind study in almost 200 centers with a mean observation interval of 3.9 years. The invasive cancer incidence was 4.30/1000 versus 4.41/1000 for tamoxifen and raloxifene, respectively, RR 1.02 and CI 0.82–1.28, obviously showing no difference. For noninvasive breast cancer, the results were 1.51/1000 versus 2.11/1000 for RR 1.40, CI 0.98 –2.00, which is closer to significance, with p ⫽ 0.052. No differences were found for other invasive cancers, stroke, or ischemic heart disease events. Thromboembolic events were, however, less for raloxifene (RR, 0.70; CI,
Journal of Minimally Invasive Gynecology, Vol 13, No 5, September/October 2006
ination in 18/67 (27%), and in women with a gynecologic presentation in the remaining 25/67 (37%). Four women had removal of the uterine septum; 1 by abdominal approach and 3 hysteroscopically; 36/67 (54%) had the vaginal septum removed. Fifty of 67 (75%) women had at least 1 pregnancy either before or after treatment of their Müllerian variation. Eight of 50 women had primary infertility and required assistance to become pregnant. For women who had a first pregnancy without correction of the variation, 13/49 (27%) miscarried, 5/49 (10%) had a preterm delivery, and 31 (63%) had a term delivery. For women who had metroplasty, there were 8 pregnancies before correction with a live birth rate of 13% (1/8), and 8 pregnancies after correction, for a live birth rate of 75% (6/8). For all pregnancies in these women, there was a live birth rate of 72% (83/115). This is a rare abnormality of the reproductive tract, and the figures for pregnancy outcome are similar to other studies of septate uterus. The figures presented do not support the hypothesis that the more complete the septum, the worse the reproductive outcome. For women who have recurrent miscarriage with this abnormality, treatment of the abnormality is likely to give them a high chance of live birth. The author comments that this abnormality is not associated with endometriosis and genital malignancy. There is no evidence to support routine surgical correction of this abnormality. Editorial note: Given the rarity of this abnormality, there is unlikely to be randomized trials to assess reproductive outcome. Given the information presented, the desire of the patient for delivery should be taken into consideration, since caesarean delivery rate was 61% due to malpresentation. For women desiring vaginal delivery, possible excision of vaginal septum with or without hysteroscopic metroplasty should be discussed and patient desire should drive intervention or conservative management. Summarized by Jason Abbott, PhD, FRANZCOG, MRCOG
Laparoscopic excision of recurrent endometriomas: Long-term outcome and comparison with primary surgery By Fedele L, Bianchi S, Zanconato G, Berlanda N, Raffaelli R, and Fontana E Fertil Steril 2006;85:694 – 699 This is a retrospective study comparing 305 women undergoing primary surgery for ovarian endometriomas with 54 women having repeat surgery for recurrent ovarian endometriomas in the same ovary. The ovaries were treated in all cases by stripping the cyst out. Follow-up was by ultrasound scanning and assessment of pain symptoms and the need for repeat intervention and reproductive outcome are reported. Women with recurrence in a contralateral ovary, disease of gastrointestinal or urinary tracts, loss of
follow-up, indications to remove an ovary, or surgical complication were reasons for 99 exclusions from the study. Women who had recurrent disease were more likely to have Stage IV disease (35% vs 20% p ⫽ .05) and had a higher adhesions score. They were also more likely to be infertile (44% vs 29%, p ⫽ .01). A 5-year recurrence of at least 1 moderate or severe pain symptom was not different between primary and recurrent surgical groups (21% vs 14%). Similarly, 5-year sonographic recurrence rates were not different (19% vs 15%). For primary and recurrent groups, cumulative pregnancy rates were 41% vs 32%, assisted reproductive technologies 32% vs 50%. Elevated follicle-stimulating hormone levels in the earlier follicular phase are reported in the recurrent group (5.5%) versus the primary group (1.3%). These data support the fact that the recurrence rate for pain and the sonographic recurrence of ipsilateral endometriomas is about 20% for both primary and recurrent surgery. Repetitive surgery may deplete the ovary through volume reduction. Editorial note: These data support conservative surgery for ovarian endometriosis and offers valuable information for counseling regarding pregnancy. The possibility of reduced ovarian function needs to be discussed with the patient having recurrent surgery. Summarized by Jason Abbott, PhD, FRANZCOG, MRCOG
Effects of tamoxifen vs raloxifene on the risk of developing invasive breast cancer and other disease outcomes By Vogel VG, Costantino JP, Wickerham DL, et al for the National Surgical Adjuvant Breast and Bowel Project JAMA 2006;295:2727–2741 The long-awaited results of the STAR trial, matching tamoxifen 20 mg/d versus raloxifene 60 mg/d for prevention of breast cancer, are now starting to appear. The study encompassed 19 747 women at least 35 years of age (mean 58.5) who were postmenopausal and with a Gail model prediction of at least 1.66% increase in breast cancer risk (at least a 4% risk of breast cancer within 5 years). This was, of course, a prospective, randomized, double-blind study in almost 200 centers with a mean observation interval of 3.9 years. The invasive cancer incidence was 4.30/1000 versus 4.41/1000 for tamoxifen and raloxifene, respectively, RR 1.02 and CI 0.82–1.28, obviously showing no difference. For noninvasive breast cancer, the results were 1.51/1000 versus 2.11/1000 for RR 1.40, CI 0.98 –2.00, which is closer to significance, with p ⫽ 0.052. No differences were found for other invasive cancers, stroke, or ischemic heart disease events. Thromboembolic events were, however, less for raloxifene (RR, 0.70; CI,