Faculty Bibliography

We randomly assigned 95 women, age 17-55 (mean 36.5) with unilateral or bilateral ovarian cysts measuring 1.1 to 6.1 cm in greatest diameter, to four groups to determine the efficacy of hormonal suppression. Eleven did not complete the study, and 9 did not follow up, for a study population of 75. Of these 75, 29 women had a history of endometriosis and 12 were treated with ovulation induction within 6 months of inclusion. Group I (24), received no treatment and served as a control; Group II (15) took oral contraceptives (OCP) containing 35 &mgr;g ethinyl estradiol and 1 mg norethindrone; Group III (23) received OCP's with 50 &mgr;g ethinyl estradiol and 1 mg norethindrone; and Group IV (13) took danazol 800 mg/day. All medications were taken continuously for 6 weeks. Patients were then re-evaluated by pelvic examination and transvaginal ultrasound. If the cysts persisted, the patient was scheduled for diagnostic and possible operative laparoscopy. Complete resolution of cysts was found in: Group I - 14 (58%), Group II - 6 (40%), Group III - 15 (65%), and Group IV - 7 (54%). Of the 33 women with persistent cysts, 28 underwent videolaparoscopy. The results were as follows: Group I (42%) - five functional, two endometriomas, one hydrosalpinx, and one benign paraovarian serous cyst; Group II (60%) - three functional, one endometrioma, and one benign simple cyst; Group III (35%) - two functional, five endometriomas, and one loop of bowel; and Group IV (46%) - four functional and two endometriomas. The results, analyzed using the chi2 test, indicated that there is no significant difference between expectant management and hormonal suppression in treating functional ovarian cysts. A CA 125 was obtained on 48 women. Using the t-test, we compared values for cysts which persisted and those which did not. There was no correlation between CA 125 levels and persistence or resolution.

To determine the usefulness of noninvasive clinical tests to diagnose symptomatic endometriosis, we retrospectively reviewed the medical records of 91 patients with chronic pelvic pain and laparoscopically confirmed endometriosis. Thirty-seven women (41%) had pelvic peritoneal endometrial implants with adhesions; in 44 (48%) the ovaries were also affected, and in 10 (11%) the disease involved both the uterus and ovaries. Seventy-nine (87%) women had dysmenorrhea, dyspareunia, or both. Forty-three (47%) had a normal bimanual pelvic examination and 37 (41%) an unremarkable transvaginal sonographic evaluation (no significant difference). The women were divided into two groups: group 1, in whom the disease extended to the ovaries and uterus, and group 2, those in whom only peritoneal implants and adhesions were present. In group 1, 48 women (89%) had an abnormal ultrasonographic evaluation compared with only 4 (11%) in group 2 (p <0.001). Our findings indicate that bimanual pelvic examination and transvaginal sonography are equally accurate in detecting endometriosis; however, when the uterine surface and ovaries are involved, the latter is more informative. Therefore, patients with chronic pelvic pain, especially pain related to menstruation or coitus, should be evaluated laparoscopically to diagnose mild endometriosis adequately.

BACKGROUND:The proper treatment of bladder endometriosis is unknown. CASE/METHODS:Two women with endometriosis involving the full thickness of the bladder wall experienced persistent hematuria during menstruation. They had not responded to previous conservative medical or surgical therapy, so we performed laparoscopic segmental resection, with satisfactory results. CONCLUSION/CONCLUSIONS:Hematuria during menstruation due to endometriosis of the bladder is uncommon. In the two cases presented, good results followed laparoscopic segmental resection.

Nineteen women underwent laparoscopic radical hysterectomy or laparoscopically assisted vaginal radical hysterectomy, with pelvic node dissection and paraaortic node dissection when indicated. One procedure was converted to laparotomy due to equipment failure (at The University of Puerto Rico). There were two minor postoperative complications. The first, febrile morbidity resulting from a urinary tract infection, responded to medical therapy. The second was incisional bleeding, which was controlled with sutures applied using a local anesthetic. No major postoperative complications were noted, there have been no incidents of recurrence, and the follow-up results are encouraging.

We report the first case of a laparoscopic radical hysterectomy and paraaortic and pelvic lymphadenectomy to treat a stage IA2 carcinoma of the cervix. To our knowledge, a laparoscopic radical hysterectomy with laparoscopic paraaortic lymphadenectomy has not been previously described.

A specific technique of advanced operative laparoscopy, known as videolaseroscopy, using the CO2 laser and videomonitor, is described. Operating room setup, anesthesia considerations, and specific applications to pelvic disease are elaborated.

A randomized prospective study was conducted to evaluate the ease of use and safety of direct insertion of laparoscopic trocars. Comparison of previous pneumoperitoneum by Veress needle insertion with direct insertion of the reusable conventional laparoscopic trocar and direct insertion of the disposable shielded trocar revealed minor complication rates of 22, 6 and 0%, respectively. No major complications occurred in this series of 200 patients.

After initial videolaseroscopy for the treatment of endometriosis-associated infertility, 157 patients underwent a second-look laparoscopy to evaluate and treat recurrence of disease and/or adhesions. The patients were divided into two groups. Group 1 consisted of 135 patients who underwent second-look laparoscopy for persistent infertility and/or recurrence of pain. Group 2 consisted of 22 patients who achieved pregnancy after initial surgery and underwent second-look laparoscopy for evaluation of ectopic pregnancy or in association with uterine evacuation for first trimester spontaneous abortion. Both groups of patients demonstrated a significant reduction in adhesion scores involving the ovaries, tubes, posterior cul-de-sac, anterior cul-de-sac, and omentum/bowel. Although the initial mean adhesion scores were similar for both groups, at second-look laparoscopy the mean adhesion scores were significantly lower for group 2, particularly for ovarian and tubal adhesions. None of the patients formed de novo adhesions. From these results we may conclude that videolaseroscopy: (1) is effective in reducing peritoneal adhesions; (2) is associated with a low frequency of postoperative adhesion recurrence; and (3) appears to completely avoid de novo adhesion formation.

In using laser laparoscopy for the treatment of endometriosis, protecting patients from inadvertent injury to pelvic structures adjacent to diseased tissue has been a major concern. In many cases, because of this risk, surgeons have stopped short of effecting thorough treatment of endometrial implants on the bowel, bladder, ureters, or great vessels. In a large series of patients, we have used hydrodissection successfully with few complications. We believe that the technique of hydrodissection is a safe and efficient method, permitting more thorough treatment of endometriosis that otherwise might be deemed untreatable by laser laparoscopy.