Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis

International Journal of Gynecology & Obstetrics 49 (1995) 359-368

Citations from the literature This is a selection of abstracts taken from the field of gynecology and obstetrics which the Journal’s editors feel may be of interest to our readers’ Where are we going?

Kempers R.D. USA

FERTIL STERIL 1994624 (686-689) Searching for answers to ‘Where are we going?’ 10 predictions for the coming decade follow: I. Recombinant agents. 2. Preimplantation genetic diagnosis and gene therapy. 3. Advances in basic science research. 4. Disappearance of gynecologic surgery for infertility. 5. Development of artificial organs: tubes, womb, and spermatoceles. 6. Investigation of male factors: identification of specific defects in spermatogenesisand functions of the epididymis. 7. Central nervous systemmanipulation through drugs. 8. Computer systems to diagnoseand treat infertility. 9. Ethical issueswill be resolved and managed more readily. 10. The electronic journal. I have speculatedbroadly and humbly apologize for my myopia, which will be far more evident with the inevitable arrival of many other important advances in the coming decade.

MINIMAL Endoscopic

INVASIVE

versus lnparotomy

SURGERY management

of endometriomas

Bateman B.G.; Kolp L.A.; Mills S. USA

FERTIL STERIL 19946U4 (690-695) Objective: To compare the surgical managementand followup of patients with endometriomas managed by endoscopic surgery versus laparotomy using a retrospective case control formal. Design: Endoscopic oophorocystectomies were performed on 36 patients. Chart review of laparotomy oophorocystectomiesfrom 21 patients was conducted. Six-week and 12month follow-up for evaluation of symptoms, evidence of recurrence, and fertility was available on all subjects. Results: In the endoscopygroup, 39 patients had screeninglaparoscopy for possible endoscopic surgery. Three of this group required laparotomy and 36 patients underwent endoscopic surgery. Chart review identified 21 patients who had undergone primary lap’ Generated by the Excerpta Medica Database, EMBASE. SSDI 0020-7292(94)02317-X

arotomy for endometriomas. Patient groups were matched for age, severity of disease,presenceof other infertility factors, and absence of perioperative medical suppression. Outcome parameters for each group were: operating time-endoscopy 2.8 h ( f 1.2), laparotomy 3.1 h (f 1.8); estimated blood lossendoscopy 40 cc (~45); laparotomy, 240 cc ( * 107); recovery time-endoscopy,6.2 days (*2.5), laparotomy 30 days ( k6.8); endometrioma recurrence rate-endoscopy 1I. l%, laparotomy 19%;and pregnancy rate-endoscopy42.8%,laparotomy 46.6%. Conclusion: A high percentageof patients with endometriomas associatedwith advanced endometriosis can be managed effectively by endoscopic surgery. Prospective,

raodomized,

double-blind,

controlled

laparoscopy in the treatment of pelvic pain minimal, mild, and moderate endometriosis

trial

of laser

associated

with

Sutton C.J.G.; Ewen S.P.; Whitelaw N.; Haines P. GBR

FERTIL STERIL 19946U4 (696-700) Objective: To assessthe efficacy of laser laparoscopic surgery in the treatment of pain associated with minimal, mild, and moderate endometriosis. Design: A prospective, randomized, double-blind, and controlled clinical study. Setting: Royal Surrey County Hospital, Guildford, United Kingdom, a referral center for the laser laparoscopic treatment of endometriosis. Patients: Sixty-three patients with pain (dysmenorrhoea,pelvic pain, or dyspareunia) and minimal to moderate endometriosis. Interventions: The patients were randomized at the time of laparoscopy to laser ablation of endometriotic deposits and laparoscopic uterine nerve ablation or expectant management. Pain symptoms were recorded subjectively and by visual analogue scale. The women were unaware of the treatment allocated as was the nurse who assessedthem at 3 and 6 months after surgery. Main Outcome Measure: Improvement or resolution of pain symptoms assessedsubjectively and by visual analogue score. Results: Laser laparoscopy results in statistically significant pain relief compared with expectant managementat 6 months after surgery. Sixty-two and a half percent of the lasered patients reported improvement or resolution of symptoms compared with 22.6% in the expectant group. Results were poorest for minimal diseaseand, if patients with mild and

360

Citations from the literature /International

Journal of Gynecology & Obstetrics 49 (I 995) 359-368

moderate diseaseonly are included, 73.7%of patients achieved pain relief. There were no operative or laser complications. Conclusions: Laser laparoscopy is a safe, simple, and effective treatment in alleviating pain symptoms in women with stagesI, II, and III endometriosis. Randomisedtrial of hysterectomy, endometrial laser ablation, and tranvcervical endometrial resectionfor dysfunctional uterine bleeding Pinion S.B.; Parkin D.E.; Abramovich D.R.; Naji A.; Alexander D.A.; Russell LT.; Kitchener H.C. GBR

BR MED J 1994309/6960(979-983) Objective - To evaluate the effectivenessand safety of endometrial laser ablation and transcervical resection of the endometrium compared with hysterectomy in the surgical treatment of women with dysfunctional uterine bleeding. Design Prospective randomised controlled trial. Setting Gynaecology department of a large teaching hospital. Subjects - 204 women who would otherwise have been undergoing hysterectomy for menorrhagia were recruited between August 1990and March 1992and randomly allocated to hysterectomy (n = 99) or conservative (hysteroscopic) surgery (transcervical resection (n = 52) and laser ablation (n = 53)). Main outcome measures- Operative complications, postoperative recovery, relief of menstrual and other symptoms, patient satisfaction with treatment after six and 12 months. Results - Women treated by hysteroscopic surgery had less early morbidity and a significantly shorter recovery period than those treated by hysterectomy (median time to full recovery 2-4 weeks v 2-3 months, P < 0 001). Twelve months later 17women in the hysteroscopy group had had a hysterectomy, 11 for continuing symptoms; 11 women had had a repeat hysteroscopic procedure; 45 were amenorrhoeic or had only a brown discharge; and 35 had light periods. Dysmenorrhoea and premenstrual symptoms improved in most women in both groups. After 12 months 89%(79/89)in the hysterectomy group and 78% (75196) in the hysteroscopy group were very satisfied with the effect of surgery (P < 0.05); 95% (85/89) and 90% (86/96) thought that there had been an acceptable improvement in symptoms, and 72% (64/89)and 71% (68196)would recommendthe sameoperation to others. Conclusions - Hysteroscopic endometrial ablation was superior to hysterectomy in terms of operative complications and postoperative recovery. Satisfaction after hysterectomy was significantly higher, but between 70% and 90% of the women were satisfied with the outcome of hysteroscopic surgery. Hysteroscopic surgery can be recommended as an alternative to hysterectomy for dysfunctional uterine bleeding.

GYNECOLOGICAL

ENDOCRINOLOGY

lmmunobistochemical analysis of estrogen and progesterone receptors in endometrium and peritoneal endometriosis:A new quantitative method

Nisolle M.; Casanas-Roux F.; Wyns C.; De Menten Y.; Mathieu P.-E.; Donnez J. BEL

FERTIL STERIL 199462/4 (751-759) Objective: To evaluate estrogen receptors (ER) and progesteronereceptors (PR) content in glandular and stromal cells of eutopic and ectopic endometrium. Design: A recently advanced stereographic computer technology was applied for the investigation of steroid receptors. Setting: University hospital department of gynecology. Patients: Biopsies of endometrium and typical peritoneal endometriotic lesionswere taken from 19 infertile patients with laparoscopically proved endometriosis. Endometrial biopsies were also taken from 15patients without endometriosis. All of them were untreated. Results: In normal endometrium, the highest concentrations of ER and PR occurred in the epithelial and stromal cells during the late proliferative phase of the menstrual cycle. Estrogen receptor and PR content declined throughout the secretory phase. Progesterone receptor content was found not to be significantly decreasedin the stroma during the early secretory phase and quite high in the late secretory phase. In peritoneal endometriotic lesions, the highestconcentrations of ER and PR were found during the late proliferative phase.When compared with normal endometrium, a lower ER content and a similar PR content were observed,and the cyclic changesin peritoneal endometriosis lesions were also similar. Conclusion: A new computerized technology for the evaluation of ER and PR in eutopic and ectopic endometrium. Although the ER content was found to be lower in endometriotic tissue when compared with endometrium, the cyclic pattern was similar in both eutopic and ectopic endometrium. Progesteronereceptor content was similar in both tissues, except during the late secretory phase in ectopic glandular epithelium in which a high persistent PR content was observed. Alterations in androgenconjugatelevels in womenand men with alopecia Legro R.S.; Carmina E.; Stanczyk F.Z.; Gentzschein E.; Lobo R.A. us‘4 FERTIL STERIL 19946214(744-750) Objective: To assesslevels of androgen metabolites thought to reflect, at least in part, peripheral androgen activity in women with androgenic alopecia and men with premature balding in an effort to determine if a common abnormality exists. Design: Prospective study in various groups of women and men. Setting: Reproductive Endocrine Clinic at our university medical center. Patients: Ten normal ovulatory female controls and 50 hyperandrogenic women divided on the basis of hirsutism and alopecia as follows: [I] 8 hirsute women with androgenic alopecia; [2] 12 nonhirsute women with androgenic alopecia; [3] 18 hirsute women without androgenic alopecia; and [4] 12nonhirsute women without androgenic alopecia. Ten normal men and 10young premature balding men matched for age and weight also were compared. Intervention: Blood was obtained from all subjects. Main Outcome Measure: Com-