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Primary Infertility Associated with Abdominal Wall, Bowel and Pelvic Endometriosis: A Case Report
Abstracts / Journal of Minimally Invasive Gynecology 16 (2009) S103eS157
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clear cell and endometrioid subtypes. However, there is no current evidence to help definitively answer whether this relationship is an association or a causal relationship. Conclusion: Ovarian clear cell carcinoma and endometrioid adenocarcinoma may arise from endometriosis and malignant transformation of endometriosis can occur at any age including prior to menopause. Clinicians should consider routinely performing biopsies in all patients undergoing laparoscopy for endometriosis, as well as performing ovarian cystectomy or possibly oopherectomy in postmenopausal women with endometriomas.
analysis, the following variables remain associated with each other: intestinal involvement with severe dysmenorrhea (Odds Ratio 5 3.9; 95% Confidence Interval: 1.8-8.3) and gastro-intestinal symptoms (OR 5 15.3; 95% CI: 5.5-42.3), vaginal involvement with dyspareunia (OR 5 2.6; 95%CI: 1.2-5.6). Conclusion: In the context of an endometrioma, severe pelvic pain symptoms (VAS >7) are significantly associated with deep infiltrating lesions. The report of an endometrioma at transvaginal ultrasonography should prompt the practitioner to perform an appropriate work-up in order to diagnose deep endometriotic lesions.
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Primary Infertility Associated with Abdominal Wall, Bowel and Pelvic Endometriosis: A Case Report Avellanet YR, Koh CH. Reproductive Specialty Center, Milwaukee, WI Study Objective: A case of abdominal wall, bowel and pelvic endometriosis associated with primary infertility is reported. Design: Case Report. Setting: Private Office. Patients: A 38-year-old nulligravid female with no prior abdomino-pelvic surgical history and a history of primary infertility, dysmenorrhea, right upper quadrant and periumbilical pain associated with her menstrual cycle was evaluated with findings of a palpable and movable right upper quadrant mass to the right of the umbilicus of approximately 3 cm. Intervention: An MRI and ultrasonography revealed the presence of a mass consistent with an abdominal wall endometrioma. Laparoscopy revealed multifocal endometriosis including areas of the right abdominal wall, ileum, appendix, cecum, perirectum, anterior rectum, periureter, bladder, distal vagina, and ovarian endometrioma. Patient underwent radical excision of all endometriosis identified including abdominal wall endometrioma with mesh repair, bowel resection with anastomosis and ovarian cystectomy. Measurements and Main Results: The patient was discharged from the hospital on the 6th post-operative day uneventfully. Five weeks after the surgery, the patient is pain free. Conclusion: Since the diagnosis of subcutaneous endometriosis without any prior surgical procedures has never been reported, endometriosis should be included in the differential diagnosis of masses of the abdominal wall in patients reporting endometriosis-specific symptoms and infertility.
391 Painful Endometrioma Must Make Aware of Deep Endometriotic Lesions Borghese B,1,2 Santulli P,1 Chopin N,1 de Ziegler D,1 Chapron C.1,2 1 Department of Obstetrics and Gynecology and Reproductive Medicine, Cochin University Hospital, Paris Descartes University, Paris, France; 2 Team 21, Department of Genetics and Development, Cochin Institute, Paris, France Study Objective: To assess the risk of concomitant discovery of deep infiltrating endometriosis (DIE) in women afflicted with endometrioma (OMA) and to correlate it with the intensity of painful symptoms. Design: Prospective observational study between January 2004 and March 2008. Setting: University tertiary referral center. Patients: Two-hundred and twelve consecutive patients with histologically proven OMA. Intervention: Complete surgical exeresis of endometriotic lesions. Measurements and Main Results: The intensity of painful symptoms was assessed with a 10-cm visual analog scale (VAS). Pain was considered to be severe when VAS was above 7. Correlations were sought with a multiple regression logistic model. According to univariate analysis, DIE was related to severe dysmenorrhea (p ! 0.001), severe dyspareunia (p 5 0.001), severe non-cyclic chronic pelvic pain (p 5 0.032) and severe gastro-intestinal symptoms (p ! 0.001). According to multivariate
Severe Ureteral Endometriosis: An Excellent Example, Which Demonstrates That Deep Endometriosis Must Be Managed with a Global Approach Chapron C,1,2 Borghese B,1,2 Leconte M,3 Chiodo I,1 de Ziegler D1 Dousset B.3 1Department of Obstetrics and Gynecology and Reproductive Medicine, Cochin University Hospital, Paris Descartes University, France; 2Team 21, Department of Genetics and Development, Cochin Institute, France; 3Department of Colorectal and Endocrine Surgery, Cochin University Hospital, Paris Descartes University, France Study Objective: To evaluate the distribution of deep infiltrating endometriosis (DIE) lesions in patients presenting with severe ureteral endometriosis (SUE). Design: Observational study between June 1992 and December 2007. Setting: University tertiary referral center. Patients: Twenty-nine patients presenting DIE with SUE. Severe ureteral endometriosis was defined as DIE lesions causing significant obstruction to the urinary flow with ureteral stenosis. Intervention: Complete surgical exeresis of DIE lesions. Measurements and Main Results: During the study period, 627 patients underwent complete surgical exeresis of DIE lesions. Twenty-nine patients (4.6%) with SUE were observed. Thirteen patients (44.8%) had an associated ovarian endometrioma. The endometrioma was right-sided in 2 patients (15.4%), left-sided in 5 patients (38.5%) and bilateral in 6 patients (46.1%). SUE was never isolated. All patients presented with associated histologically proven DIE lesions. Anatomic distribution of DIE lesions was the following: Utero-sacral ligaments (USL) (20 patients; 68.9%); vagina (20 patients; 68.9%); bladder (7 patients; 24.1%); intestine (28 patients; 96.5%). Taking into account the bilaterality of certain DIE lesions (USL: 12 patients; ureter: 5 patients) and the multifocality of intestinal DIE (11 patients), 139 histologically proven DIE lesions were observed after complete DIE lesion exeresis. For these 29 patients with SUE, the anatomic distribution of the DIE lesions was the following: USL (32 DIE lesions); vagina (20 DIE lesions); bladder (7 DIE lesions); intestine (46 DIE lesions); ureter (34 DIE lesions). The mean number of histologically proven DIE lesions for patients presenting with SUE was 4.8 1.9 (range 2 e 9). Conclusion: These results confirm that SUE must be considered as a multifocal pathology. It is essential to bear this DIE multifocality in mind when deciding on the surgical modalities. In this context an interdisciplinary diagnostic (radiologist) and surgical approach (gynecologist, urologist, and intestinal surgeons) is necessary in order to excise all the DIE lesions in a single operation.
393 Retrospective Analysis of the Follicle Loss after Laparoscopic Excision of Endometriomas Compared to Benign Non-Endometriotic Ovarian Cysts Dogan E,1 Ulukus C,2 Okyay E,1 Ertugrul C,1 Saygili U,1 Koyuncuoglu M.2 1Obstetrics and Gynecology, Dokuz Eylul University, Turkey; 2Pathology, Dokuz Eylul University, Turkey Study Objective: To evaluate the functional ovarian tissue loss during ovarian endometrioma excision by stripping technique compared with benign non-endometrioma cysts.
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clear cell and endometrioid subtypes. However, there is no current evidence to help definitively answer whether this relationship is an association or a causal relationship. Conclusion: Ovarian clear cell carcinoma and endometrioid adenocarcinoma may arise from endometriosis and malignant transformation of endometriosis can occur at any age including prior to menopause. Clinicians should consider routinely performing biopsies in all patients undergoing laparoscopy for endometriosis, as well as performing ovarian cystectomy or possibly oopherectomy in postmenopausal women with endometriomas.
analysis, the following variables remain associated with each other: intestinal involvement with severe dysmenorrhea (Odds Ratio 5 3.9; 95% Confidence Interval: 1.8-8.3) and gastro-intestinal symptoms (OR 5 15.3; 95% CI: 5.5-42.3), vaginal involvement with dyspareunia (OR 5 2.6; 95%CI: 1.2-5.6). Conclusion: In the context of an endometrioma, severe pelvic pain symptoms (VAS >7) are significantly associated with deep infiltrating lesions. The report of an endometrioma at transvaginal ultrasonography should prompt the practitioner to perform an appropriate work-up in order to diagnose deep endometriotic lesions.
390
392
Primary Infertility Associated with Abdominal Wall, Bowel and Pelvic Endometriosis: A Case Report Avellanet YR, Koh CH. Reproductive Specialty Center, Milwaukee, WI Study Objective: A case of abdominal wall, bowel and pelvic endometriosis associated with primary infertility is reported. Design: Case Report. Setting: Private Office. Patients: A 38-year-old nulligravid female with no prior abdomino-pelvic surgical history and a history of primary infertility, dysmenorrhea, right upper quadrant and periumbilical pain associated with her menstrual cycle was evaluated with findings of a palpable and movable right upper quadrant mass to the right of the umbilicus of approximately 3 cm. Intervention: An MRI and ultrasonography revealed the presence of a mass consistent with an abdominal wall endometrioma. Laparoscopy revealed multifocal endometriosis including areas of the right abdominal wall, ileum, appendix, cecum, perirectum, anterior rectum, periureter, bladder, distal vagina, and ovarian endometrioma. Patient underwent radical excision of all endometriosis identified including abdominal wall endometrioma with mesh repair, bowel resection with anastomosis and ovarian cystectomy. Measurements and Main Results: The patient was discharged from the hospital on the 6th post-operative day uneventfully. Five weeks after the surgery, the patient is pain free. Conclusion: Since the diagnosis of subcutaneous endometriosis without any prior surgical procedures has never been reported, endometriosis should be included in the differential diagnosis of masses of the abdominal wall in patients reporting endometriosis-specific symptoms and infertility.
391 Painful Endometrioma Must Make Aware of Deep Endometriotic Lesions Borghese B,1,2 Santulli P,1 Chopin N,1 de Ziegler D,1 Chapron C.1,2 1 Department of Obstetrics and Gynecology and Reproductive Medicine, Cochin University Hospital, Paris Descartes University, Paris, France; 2 Team 21, Department of Genetics and Development, Cochin Institute, Paris, France Study Objective: To assess the risk of concomitant discovery of deep infiltrating endometriosis (DIE) in women afflicted with endometrioma (OMA) and to correlate it with the intensity of painful symptoms. Design: Prospective observational study between January 2004 and March 2008. Setting: University tertiary referral center. Patients: Two-hundred and twelve consecutive patients with histologically proven OMA. Intervention: Complete surgical exeresis of endometriotic lesions. Measurements and Main Results: The intensity of painful symptoms was assessed with a 10-cm visual analog scale (VAS). Pain was considered to be severe when VAS was above 7. Correlations were sought with a multiple regression logistic model. According to univariate analysis, DIE was related to severe dysmenorrhea (p ! 0.001), severe dyspareunia (p 5 0.001), severe non-cyclic chronic pelvic pain (p 5 0.032) and severe gastro-intestinal symptoms (p ! 0.001). According to multivariate
Severe Ureteral Endometriosis: An Excellent Example, Which Demonstrates That Deep Endometriosis Must Be Managed with a Global Approach Chapron C,1,2 Borghese B,1,2 Leconte M,3 Chiodo I,1 de Ziegler D1 Dousset B.3 1Department of Obstetrics and Gynecology and Reproductive Medicine, Cochin University Hospital, Paris Descartes University, France; 2Team 21, Department of Genetics and Development, Cochin Institute, France; 3Department of Colorectal and Endocrine Surgery, Cochin University Hospital, Paris Descartes University, France Study Objective: To evaluate the distribution of deep infiltrating endometriosis (DIE) lesions in patients presenting with severe ureteral endometriosis (SUE). Design: Observational study between June 1992 and December 2007. Setting: University tertiary referral center. Patients: Twenty-nine patients presenting DIE with SUE. Severe ureteral endometriosis was defined as DIE lesions causing significant obstruction to the urinary flow with ureteral stenosis. Intervention: Complete surgical exeresis of DIE lesions. Measurements and Main Results: During the study period, 627 patients underwent complete surgical exeresis of DIE lesions. Twenty-nine patients (4.6%) with SUE were observed. Thirteen patients (44.8%) had an associated ovarian endometrioma. The endometrioma was right-sided in 2 patients (15.4%), left-sided in 5 patients (38.5%) and bilateral in 6 patients (46.1%). SUE was never isolated. All patients presented with associated histologically proven DIE lesions. Anatomic distribution of DIE lesions was the following: Utero-sacral ligaments (USL) (20 patients; 68.9%); vagina (20 patients; 68.9%); bladder (7 patients; 24.1%); intestine (28 patients; 96.5%). Taking into account the bilaterality of certain DIE lesions (USL: 12 patients; ureter: 5 patients) and the multifocality of intestinal DIE (11 patients), 139 histologically proven DIE lesions were observed after complete DIE lesion exeresis. For these 29 patients with SUE, the anatomic distribution of the DIE lesions was the following: USL (32 DIE lesions); vagina (20 DIE lesions); bladder (7 DIE lesions); intestine (46 DIE lesions); ureter (34 DIE lesions). The mean number of histologically proven DIE lesions for patients presenting with SUE was 4.8 1.9 (range 2 e 9). Conclusion: These results confirm that SUE must be considered as a multifocal pathology. It is essential to bear this DIE multifocality in mind when deciding on the surgical modalities. In this context an interdisciplinary diagnostic (radiologist) and surgical approach (gynecologist, urologist, and intestinal surgeons) is necessary in order to excise all the DIE lesions in a single operation.
393 Retrospective Analysis of the Follicle Loss after Laparoscopic Excision of Endometriomas Compared to Benign Non-Endometriotic Ovarian Cysts Dogan E,1 Ulukus C,2 Okyay E,1 Ertugrul C,1 Saygili U,1 Koyuncuoglu M.2 1Obstetrics and Gynecology, Dokuz Eylul University, Turkey; 2Pathology, Dokuz Eylul University, Turkey Study Objective: To evaluate the functional ovarian tissue loss during ovarian endometrioma excision by stripping technique compared with benign non-endometrioma cysts.