Faculty Bibliography

OBJECTIVE:The purpose of this study was to examine our experience with laparoscopic and laparoscopically assisted management of bowel endometriosis and to recommend treatment approaches, considering patient goals for both pain mitigation or fertility, or both. METHODS:The medical records of 187 women treated laparoscopically for intestinal endometriosis were reviewed retrospectively for presenting symptoms, methods of surgical treatment, complications, and efficacy of treating pain and infertility. The extent of resection was determined by the severity of the endometriotic lesion, tempered by the patient's fertility goals. RESULTS:The most common patient complaint preceding surgery was pelvic pain. In addition, 58 (31%) patients experienced impaired fertility. Of the patients available for long-term follow-up, 152 (85%) reported complete or significant long-term pain relief. Complete pain relief in the immediate postoperative period was significantly more likely with partial bowel resection compared with shaving only, 92% vs 80%, respectively, P<0.04. The least invasive procedure, shaving, was associated with a significantly lower complication rate, 6%, compared with 23% for disc excision (P<0.007) and 38% for segmental resection (P<0.001), and higher pregnancy rates. The incidence of pregnancy in patients with a history of infertility was 34% during the follow-up period.

Ovarian remnant syndrome has become increasingly recognized as a cause of pelvic pain after extirpative surgery. Surgical removal of the ovarian remnant is the optimal treatment. Laparoscopy is safe and effective in managing ovarian remnant syndrome when performed by an experienced laparoscopist.

The role of operative laparoscopy in the management of patients with adnexal masses is expanding, offering distinct advantages of lower morbidity, improved postoperative recovery, and reduced cost. Although clinical examination and the results of preoperative work-up often indicate the benign or malignant nature of the cyst, only histology can provide the absolute diagnosis. Advanced operative laparoscopy for management of ovarian cysts, when performed by experienced endoscopic surgeons, is as safe and effective as open techniques.

BACKGROUND:Advanced abdominal pregnancy is a rare, life-threatening condition that presents a number of challenges. CASE/METHODS:A 29-year-old primigravida with 10 years of secondary infertility and a previous tuboplasty had a 21-week abdominal pregnancy treated with preoperative arterial embolization before laparoscopically assisted fetal delivery. Postoperatively, 4 cycles of methotrexate were administered at 50 mg/m2 intramuscularly every 3 weeks for the retained abdominal placenta. Subsequent spontaneous conception occurred, and a live, full-term infant was delivered by cesarean delivery 17 months later. No adverse sequelae were found during long-term follow-up. CONCLUSION/CONCLUSIONS:This report demonstrates successful minimally invasive management of an advanced abdominal pregnancy with a multimodal approach that included preoperative arterial embolization, laparoscopically assisted delivery, and judicious use of postoperative methotrexate.

OBJECTIVES: Bryostatin-1 is a macrocyclic lactone that has been shown to regulate protein kinase C (PKC) activity and thereby potentially inhibit tumor invasion, angiogenesis, cell adhesion, and multidrug resistance. In preclinical experiments, bryostatin-1 induces tumor growth inhibition and enhances cytotoxicity when combined with other agents including cisplatin in cervical cancer cells. It was therefore anticipated that combination bryostatin-1-cisplatin therapy would be effective in patients with cervical cancer. The current study was conducted to evaluate this therapeutic approach in patients with recurrent or advanced-stage cervical carcinoma. METHODS: An IRB-approved New York Gynecologic Oncology Group (NYGOG) trial was activated for patients with a histological diagnosis of metastatic cervical cancer or in patients with recurrent disease not eligible for surgery or radiation. Enrolled patients received bryostatin-1 (50-65 microg/m(2)) as a 1-h infusion followed by cisplatin (50 mg/m(2)). The combined treatment was administered every 21 days. RESULTS: Fourteen patients were enrolled. The majority of patients had squamous cell carcinoma. Ten out of fourteen patients had recurrent disease. Fifty percent of the patients received bryostatin at 50 microg/m(2) and 50% received bryostatin at 65 microg/m(2). Seventy-one percent completed two cycles of treatment. The most common grade II-III toxicities were myalgia, anemia, and nausea or vomiting. One patient developed a hypersensitivity reaction and one developed grade III nephrotoxicity. Seventy-one percent (10/14) of patients were evaluated for tumor response. Eight out of ten (80%) of patients had progressive disease and 2/10 (20%) had stable disease. There were no treatment responses. CONCLUSIONS: Despite promising preclinical data, this clinical trial indicates that the combination of cisplatin and bryostatin-1 at the doses and schedule used is not effective in patients with advanced-stage or recurrent cervical cancer. There is even the possibility of therapeutic antagonism. The development of a serum assay for bryostatin-1 and additional mechanistic studies would be useful for future bryostatin clinical trials

OBJECTIVES: To determine the incidence of port-site metastases in patients undergoing laparoscopic procedures for gynecologic cancers. METHODS: The charts of patients treated by laparoscopy for diagnosis, treatment, or staging of gynecologic cancers by the academic faculty attending physicians were studied from July 1, 1997 to June 30, 2001. No patient without a histological or cytological diagnosis of cancer from the index procedure were included. Fisher's exact test was used for statistical analysis. RESULTS: Eighty-three patients were identified accounting for 87 procedures. Types of cancer treated included endometrial (39), ovarian (29), and cervical (14). Twenty procedures were performed for recurrence of ovarian or peritoneal cancer, and ascites was present in 10 cases. Port-site metastases occurred in 2 patients accounting for 8 sites. Five sites were diagnosed in a single patient 13 days after a second-look laparoscopy for stage IIIB ovarian cancer, and 3 sites were diagnosed in a patient 46 days after an interval laparoscopy for stage IIIC primary peritoneal cancer. Ascites was present in both patients. The overall incidences of port-site metastases per procedure and per port placed were 2.3% (2/87) and 2.4% (8/330), respectively. In patients with a recurrence of ovarian or peritoneal cancer, no port-site metastases (0/16) occurred in the absence of ascites, whereas 50% (2/4) of patients with ascites developed port-site metastases (P < .035). CONCLUSIONS: The overall incidence of port-site metastases in gynecologic cancers in our study was 2.3%. The risk of port-site metastases is highest (5%) in patients with recurrence of ovarian or primary peritoneal malignancies undergoing procedures in the presence of ascites.

STUDY OBJECTIVE/OBJECTIVE:To report the outcome of rigid sigmoidoscopy during operative laparoscopy in patients at high risk for rectosigmoid and large bowel injury. DESIGN/METHODS:Prospective patient database with retrospective chart review (Canadian Task Force classification II-3). SETTING/METHODS:Referral practice and tertiary medical center. PATIENTS/METHODS:Two hundred sixty-two women with rectosigmoid endometriosis and adhesions. INTERVENTIONS/METHODS:Rigid sigmoidoscopy during laparoscopy. At the end of surgery, proctosigmoidoscopy was performed to evaluate intraluminal abnormality or rectosigmoid injury. The pelvis was then filled with isotonic fluid to observe laparoscopically for air leakage. MEASUREMENTS AND MAIN RESULTS/RESULTS:Sigmoidoscopy was performed due to a lesion involving the rectum or sigmoid in 60.7%, large bowel in 11.1%, and posterior cul-de-sac in 28.2% of patients. During laparoscopy, endometriosis was found in 30.5%, adhesions in 20.2%, and both in 43.5%. Four women (1.5%) had bowel injury identified during sigmoidoscopy; all bowel injuries were treated by intracorporeal laparoscopic suturing. One incomplete repair was detected by sigmoidoscopy. In one woman (0.4%) a rectal polyp was detected. CONCLUSION/CONCLUSIONS:Bowel injury is one of the most serious complications of laparoscopy. Early detection and prompt intraoperative management are essential to prevent a potentially catastrophic outcome. Sigmoidoscopy is a relatively easy procedure and aids during laparoscopy in the diagnosis of bowel perforation and in assessment of bowel wall invasion and potential stricture caused by endometriosis. It is a safe procedure even when performed immediately after extensive laparoscopic surgical treatment of rectosigmoid endometriosis and adhesions.

OBJECTIVE:To report a series of laparoscopic vesicopsoas hitch procedures performed for the treatment of infiltrative ureteral endometriosis. METHODS:A retrospective chart review of 6 women with severe endometriosis and ureteral obstruction caused by infiltrative disease of the distal ureter was performed. The patients underwent successful laparoscopic ureteroneocystostomy and vesicopsoas hitch. RESULTS:Five of the 6 patients had a history of endometriosis, and their obstructions were diagnosed during prior surgeries. The other patient was diagnosed with severe endometriosis of the rectum, bladder, and ureter at the time of the procedure. She was referred for evaluation of an incidental finding of hydroureter and hydronephrosis. Three patients were treated with gonadotrophin-releasing hormone (GnRH) analog for at least 3 months preoperatively. Five patients had ureteral stents in place prior to the psoas hitch surgery. No intra- or postoperative complications occurred. All patients had a normal cystogram performed 10 to 14 days postoperatively prior to Foley catheter removal. Stents were kept in place for 6 to 8 weeks, and an intravenous pyelogram (IVP) was done 2 weeks after removal. All patients had a normal renal ultrasound, computer tomography, or intravenous pyelogram at least 1 year postoperatively. CONCLUSION/CONCLUSIONS:Laparoscopic vesicopsoas hitch can be a safe and effective alternative to the laparotomy with the known benefits of laparoscopy.

OBJECTIVE:To compare immunohistochemical staining patterns in noncystic and cystic endometriosis lesions. DESIGN/METHODS:Experimental. SETTING/METHODS:Archived pathology material in an academic research environment. PATIENT(S)/METHODS:Endometriosis tissues from the pathology archives including slide tissue sections and blocks. INTERVENTION(S)/METHODS:None; this was a retrospective study. MAIN OUTCOME MEASURE(S)/METHODS:Immunohistochemical staining of the tissues was performed using anti-bcl-2, anti-p53, anti-matrix metalloproteinase IX, and anti-collagen VI antibodies. Staining was qualitatively assessed in terms of extent and intensity. RESULT(S)/RESULTS:p53 showed no staining in both groups. Anti-bcl-2 stained 100% (30/30) of endometriosis lesions compared with only 23% (7/30) of endometriotic cysts (P<.0001), and anti-matrix metalloproteinase IX stained 85% (23/27) of endometriosis lesions and only 39% (14/36) of endometriotic cysts (P=.0003). Anti-collagen VI, however, stained only 6% (2/35) of endometriosis lesions and 75% (21/28) of endometriotic cysts (P<.0001). CONCLUSION(S)/CONCLUSIONS:Compared with endometriosis lesions, endometriotic cysts display different expression of proteins with relative overexpression of collagen VI and underexpression of bcl-2 and metalloproteinase IX. This report is the first comparative immunohistochemical study showing these differences.