LA CONSULTA SEMANAL

OCTUBRE 2000

CONSULTA

Obstet Gynecol 2000 Apr 1;95(4 Suppl 1):S35
Disseminated leiomyomatosis and endometriosis following laparoscopic supracervical hysterectomy.
Kung R, Lie KI
Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
Objective: To describe cases of disseminated leiomyomatosis and diffuse endometriosis following laparoscopic supracervical hysterectomies.Methods: Using an administrative hospital-based database, all cases of laparoscopic supracervical hysterectomies performed between 1992 and 1998 were identified. Any cases requiring subsequent pelvic surgery (laparoscopic or open technique) were reviewed.Results: A total of 146 laparoscopic hysterectomies were performed in this time period. The indications were symptomatic leiomyomata (83), endometriosis (29), or both (24). Other diagnoses were responsible for the remaining 10 cases. The mean age of the patient at the time of hysterectomy was 41. Seven patients had subsequent surgery: removal of cervical stump for low-grade endometrial stromal sarcoma (final pathology was negative) and recurrent pain (6 cases) (final pathology revealed disseminated leiomyomatosis, endometriosis [2], giant cell reaction, connective tissue, and incidental Brenner tumor). The mean time interval between surgeries was 39 months. Of those 7 cases, 4 were completed laparoscopically.Conclusions: Disseminated leiomyomatosis and diffuse endometriosis may occur following laparoscopic supracervical hysterectomy. Presumably small, even microscopic, fragments of smooth muscle or endometrium dispersed during morcellation can proliferate and ultimately result in pelvic pain and masses.

Baillieres Best Pract Res Clin Obstet Gynaecol 2000 Jun;14(3):501-23
Surgical management of endometriosis.
Vercellini P, De Giorgi O, Pisacreta A, Pesole AP, Vicentini S, Crosignani PG
First Department of Obstetrics and Gynaecology, University of Milan, Italy.
A systematic literature review of the last two decades was performed to evaluate the effect of pelvic denervations in addition to conservative surgery on dysmenorrhoea and deep dyspareunia associated with endometriosis. Chronic pelvic pain relief after hysterectomy or adhesiolysis was also assessed. In the five non-comparative studies on the effect of pre-sacral neurectomy, the frequency of dysmenorrhoea recurrence or persistence after treatment ranged from 4 to 40%. The pooled frequency of non-responders at the end of follow-up was 23% (95% confidence interval (CI), 19 to 27%). Only two of the three comparative, non-randomized trials demonstrated a significant treatment benefit of pre-sacral neurectomy, and the results of the two identified randomized controlled trials are discordant. Significant quantitative heterogeneity among studies prevented pooling of data on dysmenorrhoea. The common odds ratio of deep dyspareunia persistence was 0.69 (95% CI, 0.31 to 1.54). In the 10 non-comparative studies on the effect of uterosacral ligament resection, the frequency of dysmenorrhoea and deep dyspareunia persistence after treatment ranged, respectively, from 0 to 50% and from 6 to 42%. The pooled frequency of non-responders at the end of follow-up was 23% (95% CI, 20 to 27%) and 13% (95% CI, 8 to 18%), respectively. Routine performance of complementary denervating procedures cannot be recommended based on the quality of the evidence available. The results of the five studies on the effect of hysterectomy on chronic pelvic pain of presumed uterine origin consistently demonstrated that 83-97% of operated women reported pain relief or improvement 1 year after surgery. There is no consensus on the outcome of adhesiolysis in patients with chronic pain, and the role of pelvic adhesions in causing symptoms is under scrutiny.
Publication Types:
  Review
  Review, academic

BMJ 2000 May 27;320(7247):1449-52 [Texto completo]
Extracts from the "clinical evidence". Endometriosis.
Farquhar CM
Department of Obstetrics and Gynaecology, National Women's Hospital, Private Bag 92 189, Auckland 3, New Zealand. c.farquhar@auckland.ac.nz
DEFINITION: Endometriosis is characterised by ectopic endometrial tissue, which can cause dysmenorrhoea, dyspareunia, non-cyclical pelvic pain, and subfertility. Diagnosis is made by laparoscopy. Most endometrial deposits are found in the pelvis (ovaries, peritoneum, uterosacral ligaments, pouch of Douglas, and rectovaginal septum). Extrapelvic deposits, including those in the umbilicus and diaphragm, are rare. Endometriomas are cysts of endometriosis within the ovary. INCIDENCE/PREVALENCE: In asymptomatic women, the prevalence ranges from 2% to 22%, depending on the diagnostic criteria used and the populations studied. In women with dysmenorrhoea, the incidence of endometriosis ranges from 40% to 60%, and in women with subfertility it ranges from 20% to 30%. The severity of symptoms and the probability of diagnosis increase with age. Incidence peaks at about age 40. Symptoms and laparoscopic appearance do not always correlate. AETIOLOGY: The cause is unknown. Risk factors include early menarche and late menopause. Embryonic cells may give rise to deposits in the umbilicus, while retrograde menstruation may deposit endometrial cells in the diaphragm. Oral contraceptives reduce the risk of endometriosis, and this protective effect persists for up to a year after their discontinuation. PROGNOSIS: We found one small randomised controlled trial (RCT) in which repeat laparoscopy was performed in the women treated with placebo. Over 12 months, endometrial deposits resolved spontaneously in a quarter, deteriorated in nearly half, and were unchanged in the remainder. AIMS: To relieve pain (dysmenorrhoea, dyspareunia, and other pelvic pain) and to improve fertility, with minimal adverse effects. OUTCOMES: American Fertility Society scores for size and number of deposits; recurrence rates; time between stopping treatment and recurrence; rate of adverse effects of treatment. In women with pain: relief of pain, assessed by visual analogue scale and subjective improvement. In women with subfertility: cumulative pregnancy rate, live birth rate. In women undergoing surgery: ease of surgical intervention (rated as easy, average, difficult, or very difficult).
Publication Types:
  Review
  Review, tutorial

Am Fam Physician 1999 Oct 15;60(6):1753-62, 1767-8 [Texto completo]
Published erratum appears in Am Fam Physician 2000 May 1;61(9):2614
Diagnosis and treatment of endometriosis.
Wellbery C
Department of Family Medicine, Georgetown University School of Medicine, Washington, DC, USA.
Endometriosis is a progressive disease affecting 5 to 10 percent of women. It can cause dyspareunia, dysmenorrhea, low back pain and infertility. A definitive diagnosis can be made only by means of laparoscopy. Medical treatment designed to interfere with ovulation generally provides effective pain relief, but the recurrence rate following cessation of therapy is high, and this type of treatment will not resolve infertility. Surgical treatment improves pregnancy rates and is the preferred initial treatment for infertility caused by endometriosis. Surgery also appears to provide better long-term pain relief than medical treatment. Bilateral oophorectomy and hysterectomy are treatment options for patients with intractable pain, if childbearing is no longer desired.

Publication Types:
  Review
  Review, tutorial

Clin Obstet Gynecol 1999 Sep;42(3):633-44
Surgical treatment options for endometriosis.
Kim AH, Adamson GD
Fertility Physicians of Northern California, Palo Alto, USA.
Publication Types:
  Review
  Review, tutorial

Br J Obstet Gynaecol 1999 Jul;106(7):740-4
Recurrent pain after hysterectomy and bilateral salpingo-oophorectomy for endometriosis: evaluation of laparoscopic excision of residual endometriosis.
Clayton RD, Hawe JA, Love JC, Wilkinson N, Garry R
The Northern Endometriosis Centre, St James's University Hospital, Leeds, UK.
Endometriosis can represent with a variety of symptoms including pelvic pain, dyspareunia and pain with defaecation, up to several years after hysterectomy and bilateral salpingo-oophorectomy. This may occur when all endometriotic tissue is not excised at the time of the initial procedure. Although excision of endometriosis at this time would be preferable, we have found laparoscopic excision of residual endometriosis to be effective in relieving endometriosis associated pain.

Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1360-3
Long-term outcome of nonconservative surgery (hysterectomy) for endometriosis-associated pain in women <30 years old.
MacDonald SR, Klock SC, Milad MP
Section of Reproductive Endocrinology and Infertility, Department of Obstetrics
and Gynecology, Northwestern University Medical School, Chicago, Illinois, USA.
OBJECTIVE: This study was undertaken to evaluate the effect that a patient's age at the time of hysterectomy for endometriosis-associated pain has on long-term improvement in symptoms. STUDY DESIGN: An investigation of women who underwent hysterectomy for pelvic pain and endometriosis at <30 or >40 years of age was performed by means of medical records review and mailed questionnaires. Participants were asked to complete 2 standardized surveys, the Disruption of Functioning Index and the Beck Depression Inventory. RESULTS: Sixteen women in the study group (<30 years old) and 27 women in the control group returned completed questionnaires. Although similar proportions reported overall alleviation of pain, the study group was significantly more likely to report residual symptoms, such as dyspareunia and dysuria. This younger group also more often reported a sense of loss after hysterectomy and reported more overall disruption in different aspects of life. CONCLUSION: Women who undergo hysterectomy for pelvic pain and endometriosis at <30 years old are more likely than older women to have residual symptoms, to report a sense of loss, and to report more disruption from pain in different aspects of their lives.

Arch Gynecol Obstet 1998;262(1-2):69-73
Comparison of complications of vaginal hysterectomy in patients with leiomyomas and in patients with adenomyosis.
Furuhashi M, Miyabe Y, Katsumata Y, Oda H, Imai N
Department of Obstetrics and Gynecology, Handa City Hospital, Aichi, Japan.
We reviewed 1246 vaginal hysterectomies performed at Handa City Hospital between January 1984 and December 1996. We divided the patients into 2 groups: those with leiomyomas (n = 893) and those with adenomyosis (n = 353). There was no difference in operative time and estimated blood loss between the 2 groups when analyzed by uterine weight. However, adenomyosis was associated with an increased risk of bladder injury.

Obstet Gynecol 1998 May;91(5 Pt 1):673-7
Timing of estrogen replacement therapy following hysterectomy with oophorectomy for endometriosis.
Hickman TN, Namnoum AB, Hinton EL, Zacur HA, Rock JA
Division of Reproductive Endocrinology and Infertility, Johns Hopkins School of Medicine, Baltimore, Maryland, USA. timothy.hickman@mailzone.com
OBJECTIVE: To determine whether the immediate initiation of estrogen replacement therapy (ERT) in the postoperative period increases the incidence of symptom recurrence following total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) for the treatment of endometriosis. METHODS: In a retrospective cohort study, 95 women who underwent TAH with BSO for endometriosis at the Johns Hopkins Hospital during 1979-1991 and who subsequently received ERT were identified by computer search. Follow-up information was obtained from medical records, outpatient charts, and telephone surveys. Pain recurrence in patients who started ERT within 6 weeks after surgery and in those who delayed ERT for more than 6 weeks was compared and adjusted for length of patient follow-up and other covariates. RESULTS: Sixty women began ERT within the immediate postoperative period, and four (7%) of them had recurrent pain; 35 women began ERT more than 6 weeks after surgery, and seven (20%) of them had recurrent pain. The mean length of follow-up was 57 months. The difference in the crude rate of symptom recurrence following early and delayed initiation of ERT after TAH with BSO was not statistically significant (P = .09). Controlling for length of patient follow-up, no significant differences were observed between the two groups. Adjusting for covariates of stage, age, and postoperative adjunct medroxyprogesterone therapy, those who started ERT more than 6 weeks after surgery had a relative risk of 5.7 (95% confidence interval 1.3, 25.2) for pain recurrence. CONCLUSION: Although the number of patients in the study was too small to reach statistical significance in all analyses, these findings suggest that patients who begin ERT immediately after TAH with BSO are at no greater risk of recurrent pain than those who delay ERT for more than 6 weeks.

Int J Gynaecol Obstet 1998 Jan;60(1):92-3
ACOG criteria set. Quality evaluation and improvement in practice: Abdominal hysterectomy with or without adnexectomy for endometriosis. Number 27, October 1997. Committee on Quality Assessment. American College of Obstetricians and Gynecologists.
Publication Types:
  Guideline
  Practice guideline

Clin Obstet Gynecol 1998 Jun;41(2):387-92
Treatment of endometriosis.
Reddy S, Rock JA
Emory University, Department of Obstetrics and Gynecology, Atlanta, Georgia,
USA.
Publication Types:
  Review
  Review, tutorial

Obstet Gynecol Clin North Am 1997 Jun;24(2):375-409
Surgical treatment of endometriosis.
Adamson GD, Nelson HP
Department of Gynecology and Obstetrics, Stanford University School of Medicine, Palo Alto, California, USA.
Surgical resection of endometriosis, previously possible only by means of laparotomy, can now be accomplished through laparoscopic techniques. The requirements for surgery, surgical principles, operative techniques, and results are summarized in this article, with emphasis on the laparoscopic approach.
Publication Types:
  Review
  Review, academic

Am Fam Physician 1997 Feb 15;55(3):827-34 [Texto completo]
Published erratum appears in Am Fam Physician 1997 Apr;55(5):1586
Hysterectomy: indications, alternatives and predictors.
Kramer MG, Reiter RC
University of Iowa College of Medicine, Iowa City, USA.
Hysterectomy, the most common major nonobstetric operation, is performed in more than 570,000 women in the United States each year. Although the number of hysterectomies has decreased in recent years, many authorities believe that hysterectomy is often unnecessary and unjustified. There is no universally accepted set of criteria regarding the appropriate indications for hysterectomy. The main indications for hysterectomy include the following conditions: uterine leiomyomas, dysfunctional uterine bleeding, endometriosis/adenomyosis, chronic pelvic pain and genital prolapse. Current literature, however, routinely recommends conservative management of most nonmalignant gynecologic conditions, with hysterectomy reserved for refractory cases. Several nonmedical factors, such as patient race, age, geographic location, medical history and background, as well as health care provider characteristics, such as time since completion of training, gender, and affiliation with teaching hospitals, are also associated with hysterectomy rates.
Publication Types:
  Review
  Review, tutorial
Comments:
  Comment in: Am Fam Physician 1997 Feb 15;55(3):774-6
  Comment in: Am Fam Physician 1997 Sep 15;56(4):1064, 1067-8

Fertil Steril 1997 Jun;67(6):1185-7
Subtotal hysterectomy in patients with endometriosis--an option.
Nisolle M, Donnez J
Publication Types:
  Comment
  Letter
Comments:
  Comment on: Fertil Steril 1996 Dec;66(6):925-8

Postgrad Med 1996 Dec;100(6):133-40
Hysterectomy for benign gynecologic disorders: when and why?
Crosignani PG, Aimi G, Vercellini P, Meschia M
Luigi Mangialli Clinic of Obstetrics and Gynecology, University of Milan, Italy.
Controversy continues to swirl around hysterectomy-particularly about when and why it is appropriate for benign disorders. In the United States, one woman in three undergoes hysterectomy by age 65. The rate in the European Union nations ranges from 6% to 20%. In this review, the most recent epidemiologic data on hysterectomy are summarized, and the generally accepted indications for this procedure for benign gynecologic diseases are presented and discussed.
Publication Types:
  Review
  Review, tutorial

Fertil Steril 1996 Dec;66(6):925-8
Laparoscopic trachelectomy for persistent pelvic pain and endometriosis after supracervical hysterectomy.
Nezhat CH, Nezhat F, Roemisch M, Seidman DS, Nezhat C
Department of Gynecology and Obstetrics, Stanford University School of Medicine, California, USA.
OBJECTIVES: To discuss the safety of laparoscopic removal of the cervical stump after supracervical hysterectomy. DESIGN: Retrospective review of six cases. SETTING: Center for Special Pelvic Surgery, a tertiary referral center. PATIENT(S): Between August 1993 and December 1995, six patients underwent laparoscopic removal of the cervical stump. Their mean age was 43.1 years (range 32 to 56 years). All women had pelvic pain, and one had abnormal bleeding. Three patients had histories of severe endometriosis only, one had extensive endometriosis with adhesions, one had severe adhesions and leiomyomas, and one had all three conditions at hysterectomy. INTERVENTION(S): Laparoscopic trachelectomy. MAIN OUTCOME MEASURE(S): Laparoscopic findings and intraoperative and postoperative complications. RESULT(S): The mean blood loss was 100 mL (range 50 to 200 mL). There were no major intraoperative or postoperative complications. CONCLUSION(S): Cervical stump removal can be accomplished laparoscopically by an experienced surgeon.
Comments:
  Comment in: Fertil Steril 1997 Jun;67(6):1185-7

Fertil Steril 1995 Nov;64(5):898-902
Incidence of symptom recurrence after hysterectomy for endometriosis.
Namnoum AB, Hickman TN, Goodman SB, Gehlbach DL, Rock JA
Johns Hopkins Hospital, Department of Gynecology and Obstetrics, Baltimore, Maryland 21287-1247, USA.
OBJECTIVES: To determine the relative risk of symptom recurrence and/or reoperation after hysterectomy with ovarian preservation for the treatment of endometriosis. DESIGN: Historical prospective study of patients with endometriosis who underwent hysterectomy with or without ovarian preservation. PATIENTS: One hundred thirty-eight women who underwent hysterectomy with the diagnosis of endometriosis. METHODS: A computer search identified 138 women who underwent hysterectomy with the diagnosis of endometriosis at Johns Hopkins Hospital from 1979 to 1991. Follow-up information was obtained from medical records, outpatient charts, and telephone surveys. RESULTS: Twenty-nine women had hysterectomy with some ovarian tissue preserved; 109 had all ovarian tissue removed. Of those with ovarian preservation, 18 of 29 (62%) had recurrent pain and 9 of 29 (31%) required reoperation. Of those who had no ovarian preservation, 11 of 109 (10%) had recurrent symptoms and 4 of 109 (3.7%) required reoperation. Ovarian conservation was associated with a relative risk for pain recurrence of 6.1 (95% confidence interval [CI] 2.5 to 14.6) compared with patients with oophorectomy in a Cox proportional hazards model. The relative risk for reoperation in patients with ovarian conservation was 8.1 (95% CI 2.1 to 31.3). CONCLUSION: Compared with women who had oophorectomy for endometriosis, patients who underwent hysterectomy with ovarian conservation had 6.1 times greater risk of developing recurrent pain and 8.1 times greater risk of reoperation.

Chest 1994 Dec;106(6):1894-6
Thoracic endometriosis. Recurrence following hysterectomy with bilateral salpingo-oophorectomy and successful treatment with talc pleurodesis.
Joseph J, Reed CE, Sahn SA
Department of Medicine, Medical University of South Carolina, Charleston 29425.
This is a report of an unusual patient who had four of the five manifestations of thoracic endometriosis, including right pneumothorax, left hemothorax, chest pain, and hemoptysis. This patient shows that recurrence of symptoms can occur while a patient is receiving hormonal replacement therapy even after hysterectomy and bilateral salpingo-oophorectomy; estrogen replacement should probably be delayed for several months to allow complete regression of the ectopic endometrial tissue. Alternatively, chemical pleurodesis can be effective in treating recurrent pneumothorax or hemothorax while the patient is receiving hormonal replacement. Bilateral pleural involvement and hemoptysis suggest microembolization of endometrial tissue as the pathogenic mechanism for thoracic endometriosis.

J Am Assoc Gynecol Laparosc 1994 Aug;1(4, Part 2):S30
Ovarian Preservation at Hysterectomy for Endometriosis.
Reich H, McGlynn F
210 Division Street, Kingston, PA 18704.
Traditionally, definitive treatment for symptomatic endometriosis has been total abdominal hysterectomy with bilateral salpingo-oophorectomy. However, aggressive excision of all endometriotic implants at the time of hysterectomy with preservation of one or both ovaries may be an acceptable alternative. All hysterectomies performed between 1988 and 1993 were retrospectively reviewed. Fifty-two women underwent laparoscopic hysterectomy for pelvic pain from advanced stage endometriosis with preservation of at least one ovary. The majority of women had significant to total relief of pelvic pain postoperatively. Average follow-up was 36 months. This series suggests that ovarian preservation at the time of hysterectomy can be considered in women with endometriosis. Patient benefits include avoidance of symptoms of surgical castration and subsequent exogenous hormone replacement.

J Am Assoc Gynecol Laparosc 1994 Aug;1(4, Part 2):S24-5
The Incidence of Endometriosis in Posthysterectomy Women.
Nezhat FR, Admon D, Seidman D, Nezhat CH, Nezhat C
Center for Special Pelvic Surgery, 5555 Peachtree-Dunwoody Road, Suite 276, Atlanta, GA 30342.
One hundred consecutive patients, age 24-62, status post total hysterectomy with and without bilateral oophorectomy (BSO), presented with chronic pelvic pain. All underwent laparoscopy. Of those who did not have BSO, 30 had definite endometriosis found at laparoscopy and five had questionable endometriosis. Of the 30 patients found to have definite endometriosis, 24 had a positive history of endometriosis, five had a negative history and one had a questionable history. Sixty-four underwent total hysterectomy with BSO. Of these 64, definite endometriosis was found in 22 at laparoscopy, questionable endometriosis was noted in 3, and findings for 39 were negative. Of the 22 women with positive endometriosis, 19 had a positive history of endometriosis, 2 had a negative history and 1 had a questionable history. Of these 22 patients, 13 were on estrogen replacement therapy, 2 were on estrogen and progesterone, 2 were on testosterone estradiol pellets, 2 were on GnRH analogs, 1 was on danazol and 2 received no medication. In this group, the time between hysterectomy and our laparoscopy was eight months to 15 years. Twenty-four of the 100 patients had a positive history of endometriosis with negative findings at laparoscopy. Our findings support the view that endometriosis will be found at laparoscopy in a significant number of women with chronic pelvic pain status post hysterectomy with or without BSO, especially if the woman has a positive history of endometriosis.