116 Questions
What is the primary goal of endometriosis treatment?
To alleviate pain and infertility
What percentage of patients with endometriosis experience disease progression within a year of diagnosis?
30% to 60%
What is a key consideration in choosing an endometriosis treatment approach?
Least invasive and least expensive approach
What is defined by the World Health Organization (WHO) as 'all surgical procedures carried out to diagnose, conserve, correct and/or improve reproductive function'?
Reproductive surgery
Why is treatment of endometriosis often justified?
All of the above
What is a common consequence of eliminating endometriotic implants by surgical or medical treatment?
Temporary relief from symptoms
What is a key aspect of managing endometriosis?
Treating the disease and its sequelae
What is a key challenge in treating endometriosis?
The disease is chronic and has a high recurrence rate
What cellular components are typically found in endometriotic implants?
Endometrial glands and stromal cells
What is a limitation of using histologic criteria to diagnose endometriosis?
It results in underdiagnosis of endometriosis
What is characteristic of stromal endometriosis?
Presence of endometrial stroma with hemosiderin-laden macrophages or hemorrhage
What is a type of lesion that may have different degrees of proliferative or secretory glandular activity?
Different types of endometriosis lesions
What is a characteristic of deep endometriosis?
Presence of proliferative strands of glands and stroma in dense fibrous and smooth muscle tissue
What is the significance of smooth muscle cells in endometriotic lesions?
They are frequent components of endometriotic lesions
What is defined as the presence of endometrial glands and stroma in macroscopically normal pelvic peritoneum?
Microscopic endometriosis
What is the significance of microscopic endometriosis?
It is important in the histogenesis of endometriosis and its recurrence after treatment
What is the proposed mechanism for the origin of endometriosis?
Coelomic metaplasia
What is the treatment of choice for endometriosis when complete excision is possible?
Complete excision
Which of the following structures are associated with endometriosis?
Bowel, lungs and pleural cavity, skin, lymph glands, and brain
What is the percentage of risk associated with germline variants in endometriosis?
50%
When is referral to a center with advanced laparoscopic surgery and laparotomy recommended?
When disease severity is suspected or diagnosed
What is the goal of surgical treatment for endometriosis?
To excise all visible endometriotic lesions and associated adhesions
What is the induction theory an extension of?
Coelomic metaplasia theory
What is the role of somatic genetic variants in endometriosis?
They possibly play a role in the pathophysiology of endometriosis
Why is laparoscopy preferred over laparotomy?
It is associated with quicker recovery, better cosmesis, and less postoperative pain
What should be considered early in the treatment plan for endometriosis-associated pain?
Multidisciplinary approach involving a pain clinic and counseling
What is the result of a study involving the genetic induction of endometriosis in mice?
Ovarian endometriotic lesions may arise directly from the ovarian surface epithelium through a metaplastic differentiation process
What is the term for the transformation of coelomic epithelium into endometrial tissue?
Metaplasia
What is the recommended approach when medical or surgical treatment does not alleviate pain?
Consider a multidisciplinary approach
When is laparotomy indicated for endometriosis treatment?
When laparoscopy is impossible
What is the relationship between endometriosis and ovarian surface epithelium?
Little commonality between endometriosis and ovarian surface epithelium
What is an important aspect of managing severe or deep endometriosis?
Involving the patient in all decisions
What is the purpose of surgical excision of peritoneal endometriosis lesions?
To allow histologic analysis and confirmation of endometriosis
Which laser method is claimed to be superior for removing endometriosis lesions?
CO2 laser
What is the purpose of ovarian cystoscopy during drainage and ablation of ovarian endometriomas?
To inspect the intracystic lesions
What is the advantage of excisional surgery for endometriomas with a diameter of 3 cm?
It provides a more favorable outcome with regard to the recurrence of the endometrioma
What is the difference between surgical excision and surgical ablation of peritoneal endometriosis?
Surgical excision allows histologic analysis and confirmation of endometriosis
What is the goal of maximal preservation of normal ovarian tissue during excision of ovarian endometriomas?
To improve fertility outcomes
What is the advantage of excisional surgery over drainage and ablation for ovarian endometriomas?
It has a lower recurrence of pain symptoms
What is the purpose of aspirating the ovarian endometrioma during drainage and ablation?
To irrigate the cyst
What is the primary factor that increases the incidence of fibroids?
Early menarche
What is the effect of progesterone on fibroid growth?
It increases the growth of fibroids
What is the role of aromatase in fibroids?
It increases the production of estradiol
What is the effect of GnRH agonists on fibroid size?
They decrease the size of fibroids
What is the role of growth factors in fibroid growth?
They stimulate fibroid growth
What is the effect of estradiol on fibroid growth?
It induces the expression of progesterone receptors
What is the effect of progesterone withdrawal on fibroid growth?
It decreases the size of fibroids
What is the role of antiprogestin RU486 in fibroid growth?
It blocks the growth of fibroids
What was the percentage decrease in uterine volume in women with large fibroids and urinary symptoms after treatment with GnRH agonist?
55%
What was the median growth rate of fibroids in a prospective, longitudinal study of 72 premenopausal women?
9% over 12 months
What percentage of fibroids regressed over the study period in a prospective, longitudinal study of 72 premenopausal women?
7%
What is the likelihood of finding a uterine sarcoma in premenopausal women with rapid uterine growth?
0.26%
What is a common symptom of women with uterine sarcoma?
Abdominal pain and vaginal bleeding
What is the age group in which women with uterine sarcoma are often found?
Postmenopausal women
What is the effect of GnRH treatment on urge and stress incontinence in women with fibroids?
It has no effect on urge and stress incontinence
What is the type of fibroid that is entirely within the cavity?
Type 0
What was the mean age of patients diagnosed with uterine sarcoma according to the SEER database?
68 years
What is the significance of the study finding that growth rates declined with age for white women but not for African American women?
It explains why African American women have more fibroid-related symptoms
What type of examination is often required for a definite diagnosis of submucous fibroids?
Saline-infusion sonography (SIS)
What percentage of the fibroid diameter must be within the myometrium for it to be classified as a Type 2 fibroid?
50% or more
What type of fibroid is entirely within the myometrium, without extension to either the endometrial surface or to the serosa?
Type 4
What is the name of the system that categorizes submucous, intramural, subserosal, and transmural fibroids?
FIGO classification system
How many patients were diagnosed with uterine sarcoma in the period from 2000 to 2012 according to the SEER database?
13,089
What is the classification of fibroids that abut the endometrium without any intracavitary component?
Type 3
What type of fibroid is subserosal and attached to the serosa by a stalk?
Type 7
What is the mean age of women who underwent myomectomy according to a literature review?
36 years
What type of fibroid has no involvement of the myometrium?
Type 8
What type of fibroids can usually be diagnosed by pelvic examination?
Clinically significant subserosal and intramural fibroids
What is the average increase in the diameter of fibroid after using transdermal estrogen patches plus oral progesterone for 12 months?
0.5-cm
What is a possible reason for the incidence of fibroids decreasing with increasing parity?
The vessels supplying fibroids regress during involution of the uterus
What is the effect of smoking on the incidence of fibroids?
Decreases the incidence of fibroids
What is a proposed mechanism for the initiation of fibroid formation?
Cellular injury or inflammation
What is the effect of taking oral estrogen and progesterone on fibroid size?
No change in fibroid size
What is the percentage of treated women who had any increase in fibroid volume over baseline after three years?
8%
What is the effect of pregnancy on the incidence and number of clinically apparent fibroids?
Decreases the incidence and number of fibroids
What is the effect of nicotine on the bioavailability of estrogen?
Decreases the bioavailability of estrogen
What is the benefit of laparoscopic ablation of minimal and mild endometriosis?
Slight fecundity benefit
What is the role of laser-based instruments in adhesiolysis?
Offer no additional value over less expensive techniques
What is the significance of adhesions in endometriosis?
They can create dense adhesions in the pelvis
What is the significance of fistula in endometriosis?
It is a common postoperative complication
What is the role of assisted reproductive technologies in endometriosis?
They are necessary in cases with extensive adhesions
What is the relationship between visible disease and symptoms in endometriosis?
The extent of visible disease is frequently unrelated to the severity of symptoms
What is the role of electrosurgery in adhesiolysis?
It is a less expensive technique for adhesiolysis
What is the significance of laparoscopic operations for mechanical infertility?
They are probably equally effective to similar procedures performed by laparotomy
What is the typical range of watts used to achieve the best available output in endoscopy?
250-300 watts
What type of cables are used to transmit light from the source to the endoscope?
Fiberoptic cables
What is the purpose of creating a pneumoperitoneum in laparoscopy?
To create a working space
What is the gas typically used to create a pneumoperitoneum?
Carbon dioxide
What is the primary mechanism of laparoscopic scissors in cutting tissue?
Cutting mechanically
What is the function of an insufflator in laparoscopy?
To deliver CO2 from a gas cylinder to the patient
Which laser is the most efficient in cutting tissue?
CO2 laser
What is the term for the technique of using mechanical lifting systems to create a working space?
Gasless laparoscopy
What is the advantage of the 'gasless' or 'isobaric' technique?
It has some advantages over pneumoperitoneum, particularly in patients with cardiopulmonary disease
What is the frequency of oscillation in ultrasonic cutting?
55,000 times per second
What is the process that occurs in low-density tissue during ultrasonic cutting?
Cavitation
What is the purpose of intraperitoneal retractors in laparoscopy?
To create an intraperitoneal space
What is the purpose of the tip of the ultrasonic cutting device?
To cut mechanically
What is the drawback of using KTP and Nd:YAG lasers?
They have a slightly greater degree of collateral thermal injury
What is the purpose of the vibrating element in the handle of the ultrasonic cutting device?
To oscillate the blade
What is the significance of the distance of oscillation in ultrasonic cutting?
It determines the efficiency of the cutting process
What is the primary advantage of using a posterior colpotomy incision for manual morcellation?
It is a more cosmetically acceptable approach
What is the main concern associated with the use of electromechanical morcellators in gynecologic surgery?
The potential for disseminating tumor cells in cases of undiagnosed uterine malignancy
Approximately what is the prevalence of occult malignancy, or undiagnosed uterine sarcoma, among women undergoing hysterectomy or myomectomy for presumed benign leiomyomas?
1 in 500 to 2,500
What is the name given to electromechanical morcellators, which utilize a rapidly rotating blade to quickly core and remove large solid specimens from the abdomen?
Power morcellators
What has been developed to allow electromechanical morcellation to be performed within a contained system?
Large specimen bags
What is the consequence of morcellation of a uterine sarcoma?
It worsens the patient's prognosis
What is the role of electromechanical morcellation in gynecologic surgery, according to most experts in the field?
It allows us to provide minimally invasive surgical options to women with large benign tumors
What is the purpose of the FDA warning statement regarding the use of electromechanical morcellation?
To warn surgeons about the potential risks of disseminating tumor cells with electromechanical morcellation
What is a concern related to the performance of morcellation during laparoscopic myomectomy?
The risk of unsuspected leiomyosarcomas
What is a potential benefit of microprocessor-assisted ('robotic') laparoscopic myomectomy?
More surgeons can suture effectively under laparoscopic guidance
What is a characteristic of laparoscopic approach compared to laparotomy?
Reduced postoperative pain and fever
What is a method used for morcellation of leiomyomas during laparoscopic myomectomy?
Electrosurgical morcellating system
What is NOT a concern regarding the use of laparoscopic myomectomy?
The risk of postoperative infection
What is a potential limitation of laparoscopic myomectomy?
Inability to effectively treat infertility and heavy menstrual bleeding
What is a characteristic of electromechanical morcellation?
It cuts and extracts tissue
What is NOT a benefit of the laparoscopic approach compared to laparotomy?
Improved treatment of infertility
Study Notes
Endometriosis Origins
- Endometriosis can occur in various body parts, including the bowel, lungs, pleural cavity, skin, lymph glands, nerves, and brain.
- Coelomic metaplasia is a proposed mechanism for the origin of endometriosis, where coelomic epithelium transforms into endometrial tissue.
Coelomic Metaplasia Theory
- This theory suggests that an endogenous biochemical factor can induce undifferentiated peritoneal cells to develop into endometrial tissue.
- Supported by experiments in rabbits, but not substantiated in women or nonhuman primates.
Genetic Factors
- Endometriosis is a complex disorder caused by a combination of multiple genetic and environmental factors.
- Genetic factors can be divided into germline and somatic genetic variants.
- Germline variants are inherited and confer a genetic susceptibility to develop endometriosis, representing approximately 50% of the risk associated with the disease.
Histology of Endometriosis
- Endometriotic implants consist of endometrial glands and/or stroma, with or without hemosiderin-laden macrophages.
- Endometrioid stroma may be more characteristic of endometriosis than endometrioid glands.
- Stromal endometriosis contains endometrial stroma with hemosiderin-laden macrophages or hemorrhage and may represent a very early event in the pathogenesis of endometriosis.
Principles of Treatment
- Treatment of endometriosis must be individualized, considering the clinical problem in its entirety, including the impact of the disease and the effect of its treatment on quality of life.
- The least invasive and least expensive approach that is effective with the least long-term risks should be chosen.
- Symptomatic endometriosis patients can be treated with analgesics, hormones, surgery, assisted reproduction, or a combination of these modalities.
Surgical Treatment
- The goal of surgery is to excise all visible endometriotic lesions and associated adhesions and to restore normal anatomy.
- Laparoscopy is preferred over laparotomy because it is associated with quicker recovery, better cosmesis, less postoperative pain, decreased costs, lower morbidity, and fewer postoperative adhesions.
- Laparotomy is only indicated in rare cases of advanced-stage disease where laparoscopy is impossible.
Conservative Surgery
- Peritoneal endometriosis lesions can be removed during laparoscopy by surgical excision with scissors, bipolar coagulation, or laser methods.
- Ovarian endometriomas can be treated by excision of the cyst wall or drainage and ablation of the cyst wall.
- Excisional surgery for endometriomas with a diameter of 3 cm provides a more favorable outcome than drainage and ablation with regard to the recurrence of the endometrioma, recurrence of pain symptoms, and in women who were previously subfertile or had subsequent spontaneous pregnancy.
Fibroids and Hormones
- Fibroids are rarely observed before puberty, most prevalent during reproductive years, and regress after menopause.
- Factors that increase overall lifetime exposure to estrogen, such as obesity and early menarche, increase the incidence of fibroids.
- Decreased exposure to estrogen, found with smoking, exercise, and increased parity, is protective against fibroids.
- Serum levels of estrogen and progesterone are similar in women with and without clinically detectable fibroids.
- Aromatase within fibroids increases de novo production of estradiol, higher than in normal myometrium.
Role of Progesterone
- Progesterone is important in the pathogenesis of fibroids, with increased concentrations of progesterone receptors A and B compared to normal myometrium.
- The highest mitotic counts are found in fibroids at the peak of progesterone production.
- GnRH agonists decrease the size of fibroids, but progestin given concurrently with GnRH prevents a decrease in size.
Growth Factors
- Growth factors, produced locally by smooth muscle cells and fibroblasts, stimulate fibroid growth primarily by increasing extracellular matrix.
- Many growth factors are overexpressed in fibroids, increasing smooth muscle proliferation, DNA synthesis, and mitogenesis.
Natural History of Fibroids
- Most fibroids grow slowly, with a median growth rate of 9% over 12 months.
- Multiple fibroids in the same individual have highly variable growth rates, suggesting that growth results from factors other than hormone levels.
- After age 35, growth rates decline with age for white women but not for African American women.
Rapid Fibroid Growth
- Rapid uterine growth in premenopausal women rarely indicates the presence of uterine sarcoma.
- One study found only 1 sarcoma among 371 women operated on for rapid growth of presumed fibroids.
Uterine Sarcoma
- Women found to have uterine sarcoma are often clinically suspected of having a pelvic malignancy.
- Women with pain and bleeding and who are closer to menopause or postmenopausal may have a rare sarcoma.
Diagnosis
- Clinically significant subserosal and intramural fibroids can usually be diagnosed by pelvic examination based on findings of an enlarged, irregularly shaped, firm, and nontender uterus.
- Uterine size assessed by bimanual examination correlates well with uterine size and weight at pathologic examination.
- A definite diagnosis of submucous fibroids often requires saline-infusion sonography (SIS), hysteroscopy, or magnetic resonance imaging (MRI).
Fibroid Location
- The FIGO fibroid classification system categorizes submucous, intramural, subserosal, and transmural fibroids.
- The classification system includes types 0 to 8, with different characteristics for each type.
Laparoscopic Myomectomy
- Laparoscopic myomectomy involves morcellation of leiomyoma fragments, which can be removed through laparoscopic ports or a small incision.
- Compared to laparotomy, the laparoscopic approach is associated with reduced postoperative pain and fever, and a shorter institutional stay.
- There is no convincing evidence that robotic surgery offers any benefits in measurable perioperative outcomes.
- Controversies surrounding laparoscopic myomectomy include concerns about the risks associated with intraperitoneal morcellation.
Morcellation
- Morcellation can be performed via laparotomy or laparoscopic direction using hand-held cutting instruments, electrosurgical or electromechanical morcellating systems.
- The controversy around morcellation relates to the potential impact on patients with unsuspected leiomyosarcomas, but there is no evidence that morcellation adversely affects prognosis.
- Electromechanical morcellation is a technique used to remove large solid specimens from the abdomen, but concerns have been raised about its use in cases where an undiagnosed uterine malignancy is present.
Adhesiolysis
- Adhesiolysis can be accomplished by blunt or sharp dissection with scissors, ultrasonic shears, or an RF electrosurgical electrode.
- There is no evidence that laser-based instruments provide any additional value over less expensive techniques such as electrosurgery.
- The choice of technique for adhesiolysis is likely to be equally effective in appropriately trained hands.
Endometriosis
- Endometriosis is an enigmatic disorder where the extent of visible disease is often unrelated to the severity of symptoms.
- The endometriosis-related inflammation can create dense adhesions in the pelvis, involving the uterus, fallopian tubes, ovaries, bladder, ureters, bowel, and rectum and sigmoid colon.
- Postoperative complications, such as fistula, are relatively high due to the incidence of adhesions.
Laparoscopic Instrumentation
- Light guides or cables transmit light from the source to the endoscope via a bundle of densely packed optical fibers (fiberoptic).
- Fiberoptic cables lose function over time, particularly if mishandling breaks the fibers.
- The peritoneal cavity is a potential space, requiring a gas, typically CO2, to create a working environment.
- Alternative approaches, such as mechanical lifting systems, allow room air into the peritoneal cavity, creating a "gasless" laparoscopy.
Laparoscopic Scissors and Cutting Instruments
- Laparoscopic scissors are designed to cut mechanically and can apply energy simultaneously for desiccation and hemostasis.
- Laser energy can be focused to vaporize and cut tissue, with the CO2 laser being the most efficient cutting instrument.
- Ultrasonic cutting is accomplished mechanically using a blade that oscillates back and forth in a linear fashion, with a degree of collateral thermal tissue coagulation injury.
Morcellation Techniques
- Manual morcellation can be performed using a minilaparotomy or an incision in the posterior cul-de-sac (posterior colpotomy).
- Laparoscopic morcellation can be achieved with scissors, ultrasonic equipment, or electrosurgery, with electromechanical morcellators being the most efficient technique.
- Concerns have been raised about the use of electromechanical morcellators, but experts believe they still have a role in gynecologic surgery, allowing for minimally invasive surgical options.
This quiz covers the anatomical aspects of endometriosis, including the affected body parts and the transformation of coelomic epithelium into endometrial tissue.
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