Gynecol 2000 Apr 1;95(4 Suppl 1):S35
Disseminated leiomyomatosis and endometriosis following laparoscopic
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 , 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,
First Department of Obstetrics and Gynaecology, University of Milan,
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.
BMJ 2000 May 27;320(7247):1449-52 [Texto
Extracts from the "clinical evidence". Endometriosis.
Department of Obstetrics and Gynaecology, National Women's Hospital,
Private Bag 92 189, Auckland 3, New Zealand. firstname.lastname@example.org
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).
Am Fam Physician 1999 Oct 15;60(6):1753-62, 1767-8 [Texto
Published erratum appears in Am Fam Physician 2000 May 1;61(9):2614
Diagnosis and treatment of endometriosis.
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.
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.
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
Clayton RD, Hawe JA, Love JC, Wilkinson N, Garry R
The Northern Endometriosis Centre, St James's University Hospital, Leeds,
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
and Gynecology, Northwestern University Medical School, Chicago, Illinois,
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,
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. email@example.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.
Clin Obstet Gynecol 1998 Jun;41(2):387-92
Treatment of endometriosis.
Reddy S, Rock JA
Emory University, Department of Obstetrics and Gynecology, Atlanta,
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
Am Fam Physician 1997 Feb 15;55(3):827-34 [Texto
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.
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
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,
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.
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.
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
Joseph J, Reed CE, Sahn SA
Department of Medicine, Medical University of South Carolina, Charleston
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
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