Faculty Bibliography

OBJECTIVE:To report laparoscopic management of 15 patients with infiltrative bladder wall endometriosis and to report a case of endometrioid adenosarcoma. DESIGN/METHODS:Prospective chart review. SETTING/METHODS:Referral center for endometriosis. PATIENT(S)/METHODS:Fifteen women with infiltrating endometriosis of the bladder. INTERVENTION(S)/METHODS:Laparoscopic segmental cystectomy and pathologic review of endometriotic bladder nodules in 15 patients. MAIN OUTCOME MEASURE(S)/METHODS:Location and characteristics of endometriotic bladder nodules. RESULT(S)/RESULTS:Laparoscopic and cystoscopic evaluation confirmed that the endometriotic lesions were penetrating through the bladder wall. In 8 patients, the lesions were located in the dome of the bladder. In the remaining 7, the lesions were in the posterior wall, above the trigone. It was possible to treat all the lesions by performing a laparoscopic partial cystectomy. No intraoperative complications occurred. Deeply infiltrating endometriosis was confirmed on histologic evaluation in 14 cases. One patient was diagnosed with endometriosis on frozen section, but the final pathology revealed an adenosarcoma of the bladder. CONCLUSION(S)/CONCLUSIONS:Surgical excision of deeply infiltrating endometriosis of the bladder wall can be performed laparoscopically and offers the benefit of a definitive pathologic diagnosis to rule out an occult malignancy.

BACKGROUND: A number of histologic and epidemiologic studies have suggested an association between endometriosis and ovarian carcinoma. Some reports have described a transition from endometriosis to atypical endometriosis to carcinoma. Using immunohistochemistry, the authors compared staining patterns in benign endometriotic cysts with ovarian tumors and the endometriotic cyst lining from which they arose, in an attempt to identify sequential or etiologic correlations. METHODS: One hundred thirteen formalin-fixed, paraffin-embedded sections were studied (30 benign ovarian endometriotic cysts, 24 endometriotic cysts containing endometrioid carcinomas, 19 endometriotic cysts harboring clear cell carcinomas, and 40 ovarian papillary serous cystadenocarcinomas). All sections were immunostained with anti-bcl-2 and anti-p53 antibodies using the streptavidin-biotin method. RESULTS: bcl-2 was reported to stain 23% of benign endometriotic cysts, 67% of endometrioid carcinomas, 73% of clear cell carcinomas, and 50% of papillary serous carcinomas. Approximately 42% of benign endometriotic lesions adjacent to the endometrioid carcinoma and 73% adjacent to clear cell carcinomas were found to stain for bcl-2 (p = 0.274 [not significant (NS)] and P = 0.008, respectively). p53 staining was negative in the benign endometriotic cyst group and was positive in 37-55% of the group with tumors. p53 staining was positive in 25% of the benign endometriotic lesions next to the endometrioid carcinoma and in 9% of the benign endometriotic lesions next to clear cell carcinoma (P = 0.014 and P = 0.239 [NS], respectively). CONCLUSIONS: The results of the current study suggest that alterations in bcl-2 and p53 may be associated with the malignant transformation of endometriotic cysts.

BACKGROUND: Complex wound failures are a source of significant morbidity and mortality. They are costly and time consuming to treat, and may evolve into chronic, debilitating conditions. Vacuum-assisted closure is a novel wound healing technique applying subatmospheric pressure to wounds to expedite healing. CASES: We report the successful use of vacuum-assisted closure therapy on three patients on a gynecologic oncology service with complex wound failures of various chronicity. In all cases, vacuum-assisted closure therapy was well tolerated and demonstrated efficacy within 48 hours of initiation. CONCLUSION: We conclude that vacuum-assisted closure therapy should be included in the armamentarium of the gynecologist addressing complex wound failures.

BACKGROUND:Ovarian neoplasms, other than sex cord--stromal tumors, are rare causes of hyperandrogenism. Only two cases of primary mucinous carcinomas associated with virilization have been reported. CASE/METHODS:A 50-year-old female was referred to our clinic with a large pelvic mass. On examination she had significant facial hirsutism, clitoromegaly, and male pattern pubic hair growth. Serum levels of testosterone and dihydroepiandrosterone sulfate were elevated. A 30-cm, multilocular, solid and cystic, left ovarian mass was resected. Histology revealed moderately to poorly differentiated mucinous cystadenocarcinoma. The ovarian stroma contained florid proliferation of luteinized cells. The right ovary showed cortical stromal hyperplasia. Abnormal hormone values normalized 10 days postoperatively. CONCLUSION/CONCLUSIONS:We report a rare case of mucinous cystadenocarcinoma with virilization, review the literature, and discuss the mechanisms of hormone production by these tumors.

OBJECTIVE:To report the surgical history, clinical characteristics, and operative technique used in patients with ovarian remnant syndrome after laparoscopic oophorectomy. DESIGN/METHODS:Observational study. SETTING/METHODS:Teaching hospital and private practice office. PATIENT(S)/METHODS:Nineteen patients with documented history of unilateral or bilateral laparoscopic oophorectomies with histologic confirmation of ovarian remnants. INTERVENTION(S)/METHODS:Operative laparoscopy for resection of ovarian remnants. MAIN OUTCOME MEASURE(S)/METHODS:Risk factors and surgical technique contributing to ovarian remnant syndrome. RESULT(S)/RESULTS:The patients underwent a mean of 4.7 previous surgical procedures (range, two to nine): 12 had bilateral oophorectomy, and seven had unilateral oophorectomy. The infundibulopelvic ligament had been secured with bipolar desiccation in 11 patients, pretied surgical loops in six, and a linear stapler in two. Cystic ovarian remnants were identified by pelvic sonography in 12 women and by computed tomography (CT) scan in one. Six women underwent reoperation, two for ovarian remnants in different sites. CONCLUSION(S)/CONCLUSIONS:With laparoscopic oophorectomy there is risk of ovarian remnant due to improper tissue extraction or misapplication or improper use of pretied surgical loops, linear stapler, or bipolar electrodesiccation on the infundibulopelvic ligament, especially in women with a history of multiple pelvic surgeries, adhesions, or endometriosis.

OBJECTIVE:To evaluate the short- and long-term results of laparoscopic enterolysis in patients with chronic pelvic pain following hysterectomy. METHODS:Forty-eight patients were evaluated at time intervals from 2 weeks to 5 years after laparoscopic enterolysis. Patients were asked to rate postoperative relief of their pelvic pain as complete/near complete relief (80-100% pain relief), significant relief (50-80% pain relief), or less than 50% or no pain relief. RESULTS:We found that after 2 to 8 weeks, 39% of patients reported complete/near complete pain relief, 33% reported significant pain relief, and 28% reported less than 50% or no pain relief. Six months to one year postlaparoscopy, 49% of patients reported complete/near complete pain relief, 15% reported significant pain relief, and 36% reported less than 50% or no pain relief. Two to five years after laparoscopic enterolysis, 37% of patients reported complete/near complete pain relief, 30% reported significant pain relief, and 33% reported less than 50% or no pain relief. Some patients required between 1 and 3 subsequent laparoscopic adhesiolysis. A total of 3 enterotomies and 2 cystotomies occurred, all of which were repaired laparoscopically. CONCLUSION/CONCLUSIONS:We conclude that laparoscopic enterolysis may offer significant long-term relief of chronic pelvic pain in some patients.

OBJECTIVE:To report the technique and outcome of a laparoscopic vesicopsoas hitch used for the treatment of infiltrative ureteral endometriosis. DESIGN/METHODS:Case report. SETTING/METHODS:A tertiary care center. PATIENT(S)/METHODS:A 36-year-old woman with infiltrative endometriosis of the ureter. INTERVENTION(S)/METHODS:A laparoscopic vesicopsoas hitch. MAIN OUTCOME MEASURE(S)/METHODS:The return of normal ureteral function as measured by IV pyelography and ultrasonography. RESULT(S)/RESULTS:After partial ureteral resection, it was noted that a tension-free anastomosis to the bladder was not possible. Thus, a laparoscopic vesicopsoas hitch was performed. CONCLUSION(S)/CONCLUSIONS:A vesicopsoas hitch can be performed successfully by laparoscopy.

Fistulas between the anorectum and vagina may arise from several causes. Treatment depends on their etiology and location, as well as the surgeon's experience. Operative laparoscopy was successful in two women with type IV (mid)rectovaginal fistula in whom previous surgical attempts failed. Our experience suggests that mid and high rectovaginal fistulas can be effectively treated by laparoscopy in the hands of experienced endoscopic surgeons.

STUDY OBJECTIVE/OBJECTIVE:To determine the recurrence rate of myomas after laparoscopic myomectomy. DESIGN/METHODS:Retrospective review (Canadian Task Force classification II-2). SETTING/METHODS:Tertiary referral center. PATIENTS/METHODS:One hundred fourteen women (age 25-51 yrs, median 38 yrs) who were followed for an average of 37 months (range 6-120 mo). INTERVENTION/METHODS:Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS/RESULTS:Follow-up data were obtained by chart review and from returned questionnaires. Variables were date of surgery, first diagnosis of recurrence, and last follow-up visit. There were 38 (33.3%) recurrences after an average interval of 27 months. Twenty-four of these women did not require treatment. Eight underwent a second laparoscopic myomectomy, and one had a third. One patient had myomectomy and then hysterectomy, and six patients chose hysterectomy to treat the first recurrence. Cumulative risk of recurrence (Kaplan-Meier curve) was 10.6% after 1 year, 31.7% after 3 years, and 51.4% after 5 years. CONCLUSION/CONCLUSIONS:Although laparoscopic myomectomy is associated with less morbidity than removal by laparotomy, our results suggest that recurrence of myomas may be higher with the laparoscopic approach. Of 38 women with recurrent myoma, however, only 14 (36.8%) required additional surgery.

OBJECTIVE:To evaluate the long-term pain reduction achieved by laparoscopic presacral neurectomy. METHODS:One hundred seventy-six women with median (range) age 30 (18-45) years underwent presacral neurectomy combined with excision and vaporization of endometriotic lesions and were observed, using structured questionnaires, for up to 72 months postoperatively. The study included a convenience sample of the first 100 questionnaires returned. Forty of the women were studied for 12-23 months, and 60 for 24-72 months. The main outcome measures were reduction of pelvic pain, dysmenorrhea, and dyspareunia after surgery. RESULTS:Pelvic pain, dysmenorrhea, and dyspareunia were reportedly reduced by more than 50% in 74, 61, and 55 patients, respectively, more than 12 months after laparoscopic presacral neurectomy. More than 50% reduction in pelvic pain was reported by 69.8%, 77.3%, 71.4%, and 84.6% of the patients, respectively, with endometriosis stages I-IV, using the revised classification of the American Fertility Society. Comparatively, more than 50% reduction in dysmenorrhea was reported by 52.8% of the patients with stage I endometriosis, 68.2% with stage II, 71.4% with stage III, and 69.2% with stage IV. Reduction of dyspareunia by more than 50% was reported by 54.7% of the patients with stage I endometriosis, 50.0% with stage II, 28.6% with stage III, and 61.5% with stage IV. CONCLUSION/CONCLUSIONS:Long-term outcome of laparoscopic presacral neurectomy is satisfactory in the majority of patients. The stage of endometriosis is not related directly to the degree of pain improvement achieved.