1999 was a year of evolution and stability for the ISGE. Following two very successful scientific meetings in Sun City, South Africa and in Amsterdam in 1998, we continued the pattern of both an Annual Congress and a Regional Meeting. This year's Annual Congress in Montreal was highly successful in every way. The recent Regional Meeting in Cairo in September was an opportunity for us to introduce the ISGE to a large number of potential members in Egypt, a country where there is a great and growing interest in gynaecologic endoscopy. Our Scientific Program Committee has taken a sincere interest in each meeting and this allows us to have both program continuity and to develop themes introduced at previous meetings. Now that we have entered the 21st Century, the stage is set for our continued development as a scientific surgical society.
The Board has made a careful consideration for the future venues of both the Annual Congress and the Regional Meetings to be certain there is an appropriate geographical rotation. For example, our 9th Annual Congress will be in Australia, in April 2000, scheduled in conjunction with the 10th Annual Scientific Meeting of the Australian Gynaecological Endoscopy Society. Our next Regional Meeting will be in Budapest in August/September 2000, followed by our 10th Annual Congress, in Chicago, on March 28-31, 2001, with a Regional Meeting in Sao Paulo, Brazil in the fall of that year. When one reviews the above meeting sites, there is no question that our organization is truly an international society, with a nice geographic balance.
I should like to take this opportunity to congratulate our new Vice President, Dr. L. K. Yap of Singapore and to recognize Dr. J. E. Carter, our new Newsletter Editor. Both of these dedicated individuals will bring renewed enthusiasm to the ISGE. We welcome them and their continued active participation.
The ISGE is now just over ten years old and solidly established. On occasion, it is worthwhile to review the initial goals of the Society. These are four in number. First and foremost, the ISGE was founded to provide an international forum for the exchange of information and new ideas for gynaecologic endoscopists. Secondly, our direction has been to provide leadership and unprejudiced academic excellence in endoscopy and minimally invasive surgery. Thirdly, our goal has been to provide education, to promote safety and competence in gynaecologic endoscopy; and fourthly, the ISGE has a mandate to scientifically investigate and evaluate new endoscopic techniques that may be of benefit to women, worldwide. These goals are indeed appropriate for the beginning of this new century. Gynaecologic surgery is in transition at this time in history and the ISGE is in a unique position to work with our members and colleagues worldwide to advance science and to enhance the clinical practice of endoscopy and minimally invasive surgery in our specialty.
We have many interesting issues and challenges that face us in the coming months and these will be the subjects of future correspondence within this Newsletter. These items include the role of our journal, Gynaecological Endoscopy, the location of our permanent office, the development and publication of internationally accepted guidelines for gynaecologic endoscopy and our training activities in those cities and countries where it is becoming an important part of gynaecologic practice.
Our next full Board Meeting will be in Australia, April 2000, prior to the 9th Annual Congress. If you have items or issues for consideration by the Board, please direct them to me or to our Secretary - Treasurer.
John J. Sciarra, MD, Ph.D. has served as the Thomas J. Watkins Professor and Chairman of the Department of Obstetrics and Gynecology of Northwestern University Medical School in Chicago, Illinois as well as the chairman of the Department of Obstetrics and Gynecology at the Prentice Women's Hospital and Maternity Center of Northwestern Memorial Hospital since 1974.
With Dr. Sciarra's direction, energy, and vision, Prentice rapidly achieved the highest standards of patient care and the Department of Obstetrics and Gynecology drew together an outstanding faculty, which, over the years, has earned national and international prominence in patient care, research, and teaching. Additionally, a significant number of the physicians trained in the Department have become heads of other key departments and assumed leadership roles in obstetrics and gynecology.
From 1991 to 1994, Dr. Sciarra served as president of the International Federation of Gynecology and Obstetrics (FIGO), an association representing over 100 member countries. As president, Dr. Sciarra worked on behalf of FIGO's efforts to further maternal and child health worldwide. Dr. Sciarra presently holds the office of president of the International Association of Supporters of FIGO (SOFIGO). He is one of the founding members of this fund-raising arm of FIGO. In addition, he was chairman of the Scientific Program Committee for the FIGO XVth World Congress of Obstetrics and Gynecology that was held in Copenhagen, Denmark in 1997 and is on the Scientific Program Committee for the FIGO XVIth World Congress to be held in Washington, DC from September 3-8, 2000.
Throughout his career, Dr. Sciarra has maintained a great interest in Endoscopy, both scientific and practical. Working with Prof. Robert Neuwirth he performed one of the first laparoscopic procedures in the City of New York during the mid-1960's, using room-air insufflated with a hand pump to achieve a pneumoperitineum. Dr. Neuwirth then extended this work into a live television presentation at the 1971 FIGO 6th World Congress on Obstetrics and Gynecology also held in New York.
After leaving New York, he was recruited to be Professor and Chairman of the Department of Obstetrics and Gynecology at the University of Minnesota in Minneapolis. There, he spearheaded the introduction of Laparoscopy and Hysteroscopy at the University and its affiliated hospitals. In these early years, the focus of Endoscopy was female sterilization and diagnostic assessment of pelvic pain as well as obscure but obviously palpable pelvic masses. In contrast, hysteroscopy was relatively unknown at that time and often termed "a procedure in search of an indication."
Dr. Sciarra's interest in Endoscopy was seminal in his being awarded a multi-year contract by the United States' Agency for International Development to sponsor the Program for Applied Research on Fertility Regulation (PARFR). As part of this program, a Workshop on Hysteroscopic Sterilization was held from June 22-24, 1973. The speakers included individuals whose names are well known to members of this Society and presently enjoy international reputation. Among them are Drs. Melvin Cohen, Ian Craft, Paul Dmowski, Motoyuka Hayashi, Hans Lindemann, John Marlow, Robert Neuwirth, Jordan Phillips, Rudolfo Quinones, Patrick Steptoe and Rafael Valle. Sixteen-millimeter films augmented traditional slide presentations, as video presentations were not yet popular. It was a groundbreaking workshop. Having had the distinct pleasure of sitting in the audience, I remember the profound effect the proceedings had on both my colleagues and myself.
The Workshop proceedings were subsequently published as the first in a series on fertility regulation. This volume, long out of print, became a model for publications that regularly enlightened the academic world on numerous aspects of contraceptive research and especially female sterilization. Little did I know that my casual meeting with Dr. Sciarra in 1973 would lead to a 25 year collaboration with him commencing in 1975, when he assumed the Chair at Northwestern.
Sadly, the quest for an optimal method for Hysteroscopic Sterilization, so eloquently described in the 1973 Workshop, remains as one of the unanswered endoscopic problems. At least this was the conclusion that Dr. Sciarra came to in 1996 after he and I reviewed the progress or lack thereof in this area at the Valedictory Symposium for Professor Shan Ratnam in Singapore, November of that year.
Perhaps it is the unanswered question of developing an optimal method of Hysteroscopic Sterilization that prompted Dr. Sciarra to help found the International Society for Gynecologic Endoscopy and to serve it in numerous capacities. His activities for the Society brought him the honor of the ISGE Presidency at the Montreal Annual Meeting in 1999. In this capacity, he will serve as Local Organizing Committee Chair at the 10th Annual Congress to be held in Chicago, March 28-31, 2001. In this effort, he is being assisted by an outstanding Committee, which in turn has planned a comprehensive educational program, along with spectacular activities that only Chicago can provide.
Dr. Sciarra's efforts on behalf of Obstetrics and Gynecology are truly unique. On a local level, he has put the Prentice Women's Hospital and Maternity Center on the world stage. On a national level, he has served in a leadership capacity to numerous American organizations dealing with the subject of Obstetrics and Gynecology. Internationally, he brings the ISGE valuable leadership attributes stemming from his recent Presidency of FIGO. Clearly his work brings distinction to the ISGE in the same manner that distinction was brought to Dr. Sciarra when he was asked to assume its Presidency.
Louis G. Keith, MD
Director, Undergraduate Education
Northwestern University Medical School
The Editor's Corner
James E. Carter, M.D., Ph.D., F.A.C.O.G.
Editor, ISGE Newsletter
As we embark on our New Year events for the ISGE, it is good to reflect on the accomplishments of the past. The annual congress in Montreal was a landmark event for many of us because of the breadth and depth of the programs and this issue of the Newsletter again contains a summary of some of those exciting venues. Our thanks again to Togas Tulandi and his excellent committee for their hard work. Our regional meeting in Cairo was a very educational program for all of us who attended both from a scientific and a culture perspective.
The excellent scientific sessions were well attended and the program itself very well organized. The cultural programs organized by Dr. Amman Assaf brought the attendees in close contact with the wonderful Egyptian heritage.
Now we look forward to our annual meeting in Australia followed by our regional meeting in Budapest Hungary.
As editor of our Newsletter I am very appreciative of the contributions made by each of you to the ISGE Newsletter.
In closing, I would like to pay tribute to a personal friend and a wonderful scientific colleague, Arnold J. Kresch, M.D. who died of pancreatic cancer at the age of 61. Dr. Kresch was a personal friend and colleague as well as a mentor. He was also a friend and long time supporter of the work of Mary Lou Ballweg, President of the Endometriosis Association. As Mary Lou Ballweg so eloquently stated in the Endometriosis Association Newsletter: "Dr. Kresch died in late December. He had been associated with Stanford University Medical Center, Palo Alto, California since 1970 as clinical professor and in other capacities. Medically, he was best known for his work in pelvic pain and endometriosis. He became interested in endometriosis in a most unusual way. First trained as a gynecologist, he then also trained in psychiatry. He proceeded to educate physicians that pelvic pain was a condition 'that was not in the patient's head.' He developed pain analysis and mapping tools (reprinted in the "Endometriosis Source Book" available from the Endometriosis Association international headquarters). He lead us to understand how amazingly accurate patients are in describing exactly where the source of their problem was. An energetic man with many interests, Dr. Kresch was also involved in cattle ranching and a vineyard. He invented surgical instruments for the destruction of the lining of the uterus for heavy bleeding problems as an alternative to hysterectomy. A Foundation has been established to carry on Dr. Kresch's work. Contributions can be sent to Arnold J. Kresch M.D. Medical Research Foundation for Women, Inc c/o Peter L. Dmytrk, Secretary, 333 Market Street, Suite 2300, San Francisco, CA 94105."
The loss of Dr. Kresch is a personal loss as well as a loss to our entire community of scientists and to patients afflicted with pelvic pain. As we continue our work we are all faced with the issue of our own mortality. This knowledge helps us strive to improve the world we live in.
I.A. Brosensa & J.J. Brosensb
a. Leuven Institute for Fertility and Embryology, Leuven, Belgium
b. Department of Reproductive Sciences and Medicine, Division of Paediatrics, Obstetrics and Gynaecology, ICSM at Hammersmith Hospital, London, UK
* Corresponding author. Tel.: +32-16-270190; fax: +32-16-270197. E-mail address ivo.brosens @ med.kuleuven.ac.be
For several decades laparoscopy has been the gold standard for the diagnosis of endometriosis. Indeed, the definition of endometriosis was created by the reflux concept of Sampson's (1) and consequently, visualization of hemorrhagic implants and, as final proof, biopsies showing glands and stroma have been the basis of the diagnosis. Today, there are major reasons to state that the definition and consequently the place of laparoscopy in the diagnosis should undergo a major revision.
First, the definition of endometriosis is based on the reflux concept and not on the original observation of specific endometrial activity at ectopic sites. Indeed, Sampson (2) discovered endometriosis by observing menstrual shedding in endometrial-like, tissue in ovarian chocolate cysts in two patients operated at the time of menstruation.
Secondly, the visual, mechanistic definition neglects to include the smooth muscle cell hyperplasia, which was accurately described by CuIlen (3) to occur along the Mllerian tract, primarily in the myometrium, the posterior fornix, the uterosacral ligaments and to some extent at other fibromuscular sites. It is now well recognized that smooth muscle differentiation is also a specific activity associated with basal endometrium. The present confusing terminology of deep, infiltrating and invasive endometriosis has been a consequence of restricting a disease process to a concept, which neglects the metaplastic changes of mesenchymal cells differentiating into smooth muscle cells (4). The so called deep, rectovaginal endometriosis in contrast with peritoneal and ovarian endometriosis does not correspond with the phenotype of superficial, but basal endometrium and presents all the morphological features of adenomyosis (5,6).
It is therefore logical to redefine endometriosis by the specific, functional changes associated with ectopic endometrial-like tissue. Regardless of the underlying etiology and pathogenesis, the phenotype of ectopic endometrial-like tissue is apparently determined by the surrounding microenvironment (7). Peritoneal and ovarian endometriosis have characteristics, albeit defective, of superficial endometrium and are functionally characterized by sex steroid hormone-dependent bleeding. in contrast, rectovaginal endometriosis, like diffuse uterine adenomyosis is similarly as basal endometrium characterized by inordinate smooth muscle differentiation and hyperplasia and nodule formation.
Moreover, there is increasing evidence that endometriosis is part of a pleiotropic reproductive disorder including aberrant eutopic endometrium, disruption of normal inner myometrial peristalsis, proinflammatory state of the peritoneum, abnormal ovarian steroidogenesis and impaired oocyte maturation (8). The normal sex steroid hormone response of the Mllerian tract is disrupted and the presence of endometriotic implants is only one aspect of the pleiotropic reproductive disorder. Consequently, if the visual concept of endometriosis is being replaced by a functional definition, the method of diagnosis should also undergo a major revision.
There are also clinical reasons to review the place of traditional laparoscopy in the diagnosis of endometriosis. Whilst not classified as major surgery, laparoscopy is an invasive and expensive procedure. It requires general anesthesia of the patient and full operating theatre facilities. The transabdominal approach is responsible for approximately 50% of the complications (9,10). Injury to a major blood vessel can be catastrophic with a reported mortality of 15% and the offending instrument is the Veress needle as often as the trocar (11). The diagnosis of endometriosis by laparoscopy has therefore never been practical. The delay in the diagnosis of endometriosis in patients with infertility and chronic pelvic pain Is 3.5 and 11.7 years respectively (12). The delay results in disease progression with increased risk of persistent disease and patient's anxiety and depression. Monitoring the evolution of the disease by laparoscopy has also not been routine practice. On the contrary, the role of purely diagnostic laparoscopy is being gradually eliminated from the contemporary management of endometriosis, in which suspected lesions are treated surgically when they are first seen. A recent Canadian study showed that this approach results in a modest increase in subsequent pregnancy rates (13). The results of the study remain controversial, but the most consistent finding in similar studies is that destroying visible implants fails to cure the disease.
Therefore, there are major reasons to revise the diagnostic approach of endometriosis. Alternatives to standard laparoscopy for the diagnosis of endometriosis have already been proposed or are in development. Recently, a new office procedure based on the transvaginal access and the use of saline as distension medium, called transvaginal hydrolaparoscopy (THL), has been proposed as a more suitable screening method for early diagnosis of endometriosis in patients with infertility or chronic pelvic pain (14). The safety factors include the use of local anesthesia. transvaginal access, needle technique and saline for distension. The systematic use of saline for distension makes THL a much more sensitive technique for the diagnosis of adhesions. For instance, examination of the ovaries by THL in patients with mild endometriosis revealed 50% more periovarian adhesions compared to standard laparoscopy (15). In addition, THL is likely to restore the normal decision making process of a surgical procedure which proceeds from diagnosis to evaluation of the treatment options with the patient and ultimately a planned surgical procedure. Conventional T2-weighed MR imaging, on the other hand, is an accurate technique to detect adenomyotic hyperplasia in the myometrium. posterior fornix and uterine ligaments (16). This imaging technique can also detect hemorrhagic lesions if greater than 4 mm (17). The development of ultrasensitive endocavitary uterine and rectal MR receiver coils is likely to facilitate detection of early lesions along the Mllerian tract. The technique is noninvasive, is more cost effective than laparoscopy, and can be repeated when indicated.
In conclusion, not only the definition, but also the diagnosis of endometriosis should undergo a major revision. Pelvic endoscopy remains a useful technique to visualize and document the superficial, hemorrhagic type of endometriosis and adhesions, but fails to reveal the adenomyostic, nodular type and, even more important, the pleiotropic reproductive abnormalities. If the visual concept of endometriosis is no longer tenable and endometriosis is apparently part of a pleiotropic reproductive disorder, characterized by disruption of normal sex steroid hormone dependent differentiation process in the Mllerian tract, it is more likely that in the near future a combination of techniques is desirable for the diagnosis of the disease endometriosis/adenomyosis.
1. Sampson JA (1927) Peritoneal endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity. Am J Obstet Gynecol 14: 422-69.
2. Sampson JA (1921) Perforating hemorrhagic (chocolate) cysts of the ovary. Arch Surg 1921: 245-323
3. Cullen TS (1920) The distribution of adenomyoma containing uterine mucosa. Arch Surg 1: 215-83.
4. Fujii S, Konishi I, Mon T (1989) Smooth muscle differentiation at endometrio-myometrial junction. An `ultrastructural study. Am J Obstet Gynecol 163: 105-12
5. Brosens IA (1994) New principles in the management of endometriosis. Acta Obstet Gynecol Scand Suppl 159:18-21.
6. Donnez J, Nisolle M, Smoes P. Gillet N, Beguin 5, Casanas-Roux F (1996) Peritoneal endometriosis and "endometriotic" nodules of the rectovaginal septum are two different entities. Ferti Steril 66: 362-8.
7. Tabibzadeh S. Sun XZ, Kong OF, Kasnic G, Miller J, Satyaswaroop PG (1993) Induction of a polarized micro-environment by human T cells and interferon-gamma in three dimensional spheroid cultures of human endometrial epithelial cells. Hum Reprod. 8: 182-92.
8. Brosens JJ, Brosens IA. From a visual to a functional diagnosis of endometriosis: implications for the diagnosis. Am J Obstet Gynecol (submitted for publication).
9. Chapron C, Querleu D, Bruhat M-A, Madelenat P, Fernandez H, Pierre F, Dubuisson J-B (1998) Surgical complications of diagnostic and operative gynaecological laparoscopy : a series of 29 966 cases. Hum Reprod 13: 867-72.
10. Jansen FW, Kapiteyn K, Trimbos-Kemper T, Hermans J, Trimbos JB (1997) Complications of laparoscopy: prospective multicentre observational study. Br J Obstet Gynaecol 104: 595-600.
11. Baadsgaard SE, Bille S, Egeblad K (1989) Major vascular injury during gynecologic laparoscopy. Acta Obstet Gynecol Scand 68: 283-5.
12.Dmowski WP, Lesniewicz R, Rana N, Pepping. Changing trends in the diagnosis of endometriosis: a comprehensive study of women with pelvic endometriosis presenting with chronic pelvic pain or infertility. Fertil Steril 67: 238-43.
13. Marcoux S, Maheux R, Brub S and the Canadian Collaborative Group on Endometriosis. (1997) Laparoscopic surgery in infertile women with minimal or mild endometriosis. N Eng J Med 337: 217-22.
14. Gordts S, Campos R, Rombauts L, Brosens I (1998) Transvaginal hydrolaparoscopy as an outpatient procedure for infertility investigation. Hum Reprod 13: 99-103.
15. Campo R, Gordts S, Rombauts L, Borsens I (1999) Diagnostic accuracy of transvaginal hydrolaparoscopy in infertility. Fertil Steril 71: 1157-60.
16. Mark AS, Hricak H, Heinrichs LW, Hendrickson MR, Winkler ML, Bachica JA, Stickler JE (1987) Adenomyosis and leiomyoma: differential diagnosis with MR imaging. Am J Radiology 163: 527-9
17. Takahashi K, Okada s, Oszaki T, Kitao M, Sugimuri K (1994) Diagnosis of pelvic endometriosis by magnetic resonance imaging using "fat-saturation" technique. Fertil Steril 62: 973-7.
Togas Tulandi M.D.
Professor of Obstetrics and Gynecology, McGill University
Director Division Reporductive Endocrinology and Infertility.
Our field in gynecologic endoscopy has been expanding very rapidly. Most studies in this field, however have been observational retrospective studies. In essence, an individual or a group of surgeons reported their experience of a given surgical procedure and its results. The validity of such studies is inferior to those of randomized studies. The patients are highly selected and without a comparison group of similar patients undergoing different treatment, it is impossible to assess the findings with any confidence.
Even when the value of randomized trials is appreciated, the number of suitable cases presenting at an institution could be small as to make a truly randomized design prohibitively lengthy. As a compromise, we can use historical controls (patients undergoing the standard procedure in previous years) as a comparison group. The use of a multicenter trial to supplement the number of patients is a preferable approach. Here, a society such as ISGE can play a role.
Over the years, I have been conducting research related to reproduction, and reproductive and endoscopic surgery. For the purpose of this discussion, I will limit to those of surgical/endoscopic research.
Research on Surgical Modalities
One of my first few projects was evaluation of different surgical modalities. In the mid eighties, I performed several randomized studies comparing the use of laser and electrocautery on adhesion formation and on pregnancy rates following salpingostomy and following salpingo-ovariolysis. No significant difference was found. Back then, several gynecologists stated that I was a "poor laser surgeon" and accordingly, "Tulandi could not demonstrate the superior results of laser surgery". The medical community now accepts our results. Laser, electrocautery, ultrasound scalpel and electrocautery are merely surgical modalities. The surgeon's skill and experience, his or her preference of the surgical technique and proper patient's selection play a more important role.
Research on Endometriosis
Endometriosis is another subject of my interest. In 1997, we reported the results of a randomized study of superovulation in women with endometriosis. We have also published an article demonstrating the efficacy of laparoscopic treatment of stage I and II endometriosis compared to the untreated control group of women. The study, however was not randomized. We then participated in a randomized multicenter Canadian study where the patients were randomized at the time of laparoscopy to undergo treatment or no treatment. It was a difficult study to conduct, however the results clearly showed the benefit of laparoscopic treatment of endometriosis in infertile women.
In view of the treatment of ovarian endometrioma, we and others have demonstrated the recurrence rate after laparoscopic excision is lower than that after fenestration and vaporization of the cyst wall. Currently, we are investigating the familial risk of endometriosis and continuing our study on nerve fibers in association with endometriosis and pelvic pain.
Research on Post-surgical Adhesions
This is another important subject. We and others have found that intra-abdominal adhesion is the most common cause of small bowel obstruction. Also, it plays a major factor in infertility and in chronic pelvic pain. In 1990, we reported that the pregnancy rate in infertile women with adnexal adhesions was treatment-dependent. The treatment consisted of salpingo-ovariolysis. Subsequently, we have conducted and participated in many clinical trials evaluating adhesion-preventing substances or materials. Most of the agents in the market are indeed effective, but the search for an agent that is unequivocally effective continues. Presently, we are involved in evaluating the efficacy of polymer on adhesion prevention. Other studies including the effects of growth factor on adhesion formation are also being conducted.
Our animal projects compliment the continuing effort to understand and to decrease adhesion formation.
Research on Endometrial Ablation
As endoscopists, we prefer to conduct surgery under direct vision. We have stopped doing blind procedures such as curettage. However, industries have introduced many non-hysteroscopic methods of endometrial ablation that are easy to conduct, not operator-dependent, fast and can be done in the "office". The safety and efficacy of these non-hysteroscopic methods remain to be seen. They have to be compared to the conventional hysteroscopic technique. We are presently involved in such a study. Many other devices will be invented and will need evaluation.
Research on Ectopic Pregnancy and Call for Participation
In this millennium, many of minimally invasive approaches will be introduced. This has been true for the treatment of ectopic pregnancy. In early nineties, we reported treatment of ectopic pregnancy by local methotrexate injection under ultrasound guidance. The results, however is inferior to that of systemic methotrexate treatment . Accordingly, systemic methotrexate has become our primary treatment of tubal ectopic pregnancy. For those who still require surgery, laparoscopic salpingostomy can be done. The reproductive outcome following salpingostomy with suturing of the salpingostomy opening is similar to that after spontaneous closure by secondary intention.
With the more frequent use of Assisted Reproductive Technology, there has been an increasing rate of interstitial and heterotopic pregnancies. There are many reports on medical and surgical management of these conditions. However, most studies to date are limited to case reports including our report of laparoscopic treatment of interstitial pregnancy in 5 women.
In order to evaluate the safety and efficacy of medical and surgical treatment of interstitial pregnancy, in collaboration with the Society for Reproductive Surgeons a registry has been created. ISGE members are welcome to participate in this registry. If you encounter an interstitial pregnancy, please contact me to obtain a simple and standardized form. My fax number is 1 514 843 1448 and my new e-mail address is [email protected]
Research on Ovarian Preservation
In 1998, we received a video-award for our presentation "Laparoscopic ovarian transposition prior to radiation" at the 16th World Congress on Fertility and Sterility, 16th World Congress on Fertility and Sterility, 54th Annual Meeting of the American Society for Reproductive Medicine, in San Francisco, California. Subsequently, we published the technique. Presently, we are cryo-preserving ovarian tissue from women prior to chemotherapy or radiation. This is in attempt to preserve fertility. Although, it might be farfetched, in the future we might also try to postpone menopause.
Organized projects under the auspices of ISGE
ISGE is a unique society. Most of the members are experts in endoscopic surgery and many enjoy the freedom to participate in the activities of the society. The time has come for ISGE to become an international leader in endoscopic research. We can start with a registry of some procedures and eventually conduct an organized research among its members. For example, a study evaluating sexual function following laparoscopic total vs. supracervical hysterectomy. We have started this project, but the number of cases is still small.
Research is essential if progress is to be made. Observational study reporting experience of an individual surgeon is interesting, but not sufficient. I will welcome ideas and suggestions in this regard.
Pelvic Pain and Endometriosis: New Concepts in Diagnosis and Treatment
Summarized from ISGE 8th Annual Congress
Plenary Session on Pelvic Pain
Ted L. Anderson, M.D., Ph.D.
"What is the hardest of all to do? To see with our eyes what our eyes lay before us. (Paraphrased, with apologies from Goethe) That essentially is the message of the innovative efforts of Ms. Deborah Bush, Chairperson of the New Zealand Endometriosis Foundation. She has developed an interactive Menstrual Health and Endometriosis Education Program that has been presented to over 40,000 young women (ages 15-24), educators and clinicians. There has been an overwhelmingly positive response as this population gained better knowledge of what is "normal" and how to recognize the symptoms of endometriosis. Of note, anecdotal reports show this program has resulted in increased referrals to gynecologists and increased early diagnosis and treatment. Hopefully, such early intervention will mitigate the long-term sequellae of adhesions, pain and infertility. On the other hand, it is too often that we dismiss endometriosis as a source of pelvic and rectal pain, especially in young women and after hysterectomy and salpingo-oophorectomy.
However, infiltrative endometriosis involving the apical vaginal wall, the anterior rectal wall and the soft tissues of the cul-de-sac are not uncommon. This is the advice from Dr. Ray Garry and his colleagues from WEL Foundation, South Cleveland Hospital, Middleborough, UK. Using his techniques of radical laparoscopic excision, he excises the tissue bounded by the uterosacral ligaments laterally, the anterior rectal wall posteriorly and the posterior cervix. Then he removes the tissue en bloc. This technique offers relief from dysmenorrhea, dyspareunia, rectal pain and general pelvic pain in over 80% of his patients as measured by a standardized questionnaire. They have not examined the potential added benefit of hormonal suppressive therapy pre or post-operatively. Despite excellent results in this difficult patient population, this group continues to follow long-term success, as will we, with great interest."
The patient with pelvic pain continues to be one of the greatest therapeutic challenges to gynaecologists. There have been few developments in recent years that will impact treatment success in these patients, as we will likely see with conscious laparoscopy and pain mapping. This was illustrated beautifully in an excellent workshop on pelvic pain, moderated by Dr. Christopher Sutton (The Guilford Nuffield Hospital, Surrey, UK). Our concepts of pain aetiologies were challenged by Dr. FM. Howard (Rochester General Hospital, NY, USA), who provided evidence that endometriosis lesions accounted for only 1/3 of pain described by patients during conscious pain mapping, with adhesions accounting for another 1/3. This group called into question the routine use of postoperative GnRH agonists in this patient population. Dr. John Steege (University of North Carolina, USA), demonstrated the power of pain mapping by showing a procedure without sound in a post-hysterectomy patient with adhesions involving the pelvic sidewall and vaginal cuff, as well as an ovarian remnant. After an audience poll of operative options, he replayed the tape with audio feedback from the patient during the procedure. Much to our surprise, this experience changed the opinion of appropriate operative intervention in a substantial number of participants. Dr. Lawrence Demco (University of Calgary, Canada), illustrated his techniques of pain mapping through multiple video clips. Interestingly, many patients described pain with touching of peritoneal surfaces up to 2.5 cm away from visible endometriotic lesions. Additionally, he demonstrated that the pain perceived by the patient frequently does not correlate with the position of lesions or pain elicited during mapping. For example, touching visible endometriosis on the left pelvic sidewall often correlated with right-sided pelvic pain experienced by the patient. Using these techniques to guide subsequent operative interventions, he has described greater than 80% of patients remain pain free at 6 months follow-up. Dr. Sutton presented his prospective randomized double-blinded study that demonstrated the efficacy of operative treatment for stage I-III endometriosis compared with no treatment. Not surprisingly, there was increasing benefit of surgical treatment with advancing endometriosis stage. Additionally, he presented the results of a study showing no additional benefit of LUNA when endometriosis is ablated surgically. Certainly the message we can learn from this workshop will continue to guide our ability to understand and treat pelvic pain.
Vaginal prolapse is present when the vaginal apex lies below the level of the hymenal ring. This occurs when the upper one fourth of the vagina which is suspended by the cardinal/uterosacral ligament complex breaks free from its attachments via the uterosacral ligaments to the sacrum.
(DeLancey Level I) In addition, the middle one half of the vagina, which is maintained by the lateral attachments, has frequently broken free. (DeLancey Level II) Lateral defects are often found in the anterior quadrant of these patients and these can be unilateral or bilateral (paravaginal defects or detachments of the pubocervical fascia from its lateral attachment to the fascia of the obturator interna muscle at the level of the arcus tendineus fascia of the pelvis). The arcus tendineus pelvic fascia is the tendineus aponeurosis of the obturator internus muscle internally and the levator ani complex posteriorly. The apex of vagina after hysterectomy is formed by the connection of the pubocervical fascia to the recto vaginal (Denonvilliers) septum (rectovaginal fascia). The rectovaginal fascia is a distinct fibrous tissue layer between the vagina and rectum in a diaphragm-like configuration, with its principle attachments located peripherally: cranially to the cul-de-sac peritoneum, the uterosacral ligaments and the base of the cardinal ligaments; caudally to the perineal body; and laterally to the fascia covering of the levator ani muscles. In the cul-de-sac, the rectovaginal fascia merges with the fibers of the uterosacral ligaments. In the area lateral to the upper vagina, it merges into the more lateral fibers of the cardinal/uterosacral complex. These are the DeLancey suspension of the posterior vaginal wall at Level I. An enterocele can occur if the pubocervical fascia separates from the rectovaginal fascia in the midline.
Pelvic support defects are similar to hernias. With the exception of enteroceles, pelvic support defects are not associated with protrusions of peritoneal sacs containing intra-abdominal contents; however, they do have disruptions in the continuity of their supporting connective tissue as in midline, cystocele, or rectocele defects is lateral vaginal attachments such as paravaginal defects or loss of apical suspension such as uterine and vaginal vault prolapse. These defects are visible on preoperative and intraoperative inspection. They behave just as other hernias; they either remain stable or increase in size. No hernias spontaneously cure themselves. Failure to identify accurately and repair properly each of these defects results in the failure of the operation. The operative repair of pelvic support defects should include each individual defect. By understanding this anatomy it is then possible to reconstruct the vaginal vault utilizing suture technique by re-establishing the normal anatomy of the pelvis. First the uterosacral ligaments are identified as they enter into the sacrum. These ligaments are first tagged with suture prior to performance of the remaining procedure. Then the peritoneum overlying the break between the pubocervical and rectovaginal fascia is opened. The pubocervical fascia is identified ventrally between the vagina and the bladder by sharp dissection. The rectovaginal fascia is identified posteriorly. A corner stitch is then placed on both sides approximating the edges of the pubocervical and rectovaginal fascia. This corner stitch is then incorporated into the uterosacral ligament as it courses to the sacrum and the rectovaginal pubocervical complex is sutured in this manner to the unbroken portion of the uterosacral ligament. This performed on both sides. Then the rectovaginal fascia is approximated to the pubocervical fascia with interrupted sutures. Following this a reinforcing suture from the uterosacral ligaments to the posterior rectovaginal fascia is placed bilaterally. After completion of the enterocele repair and vault suspension buy suture technique, the space of Retzius is entered and the paravaginal defect is identified and repaired bilaterally. Following this a Burch procedure is performed. If a rectocele is present this has been repaired by vaginal approach after completion of the other procedures.
1. DeLancey JOL Anatomy and biomechanics of genital prolapse. Clinical obstetrics and gynecology 1993;36:897-909.
2. DeLancey JOL Pelvic organ prolapse. In: Danforth's obstetrics and gynecology 7th edition. ed. Scott JR, DiSaia PJ, Hammond CP, Spellacy WN. JB Lippincott Co., Philadelphia 1994:803-825.
3. Richardson AC, Lyon JB, Williams NL. New look at pelvic relaxation. Am J Obstet Gynecol 1976;126:568-573.
4. Nichols DH, Randall CL. Vaginal surgery 3rd ed Williams & Wilkins, Baltimore 1989;463 pp.
5. Richardson AC. The rectovaginal septum revisited: Its relationship to rectocele and its importance in rectocele repair. Clinical Obstet & Gynecol 1993;36:976-983.
6. Richardson AC. The anatomic defects in rectocele and enterocele. Journal of pelvic surgery 1995;1:214-221.
7. Liu CY. Laparoscopic cystocele repair: Paravaginal suspension. In: Laparoscopic hysterectomy and pelvic floor construction. ed Liu CY, Blackwell Science 1996:330-340.
8. Youngblood JP. Paravaginal repair for cystourethrocele. Clinical Obstet & Gynecol 1993;36:960-966.
9. Shull BL. Pelvic organ prolapse: anterior, superior and posterior vaginal segment defects. Am J Obstet Gynecol 1991; 181:6-11.
Session 8 Microwave endometrial ablation
Claude A. Fortin described The Menu for Endometrial Ablation which is evolving towards "global ablation" very rapidly. Electrosurgical and laser ablation techniques give a high satisfaction rate but are skill dependent. The use of various energy modes for a simplified ablative technique requires that the ideal device have the following characteristics: minimal learning curve, short procedure and fast recovery, suited for office setup or outpatient, safe, efficacious, no endometrial preparation, cost effective.
The various techniques that have been described include thermal transfer energy (balloon or free circulating fluid), radio-frequency hyperthermia, cryotechnology, microwave surgery, photodynamic therapy, laser interstitial therapy. The use of these various devices will improve the treatment of abnormal uterine bleeding and some point one of these devices will in fact most likely be found to be superior to the other devices.
B. Butters described the physics of microwave endometrial ablation. Microwave endometrial ablation (MEA) uses microwaves at 9.2 GHz, in order to restrict the depth of tissue necrosis for the purpose of endometrial ablation in the treatment of treatment of menorrhagia. The MEA applicator provides a localized hemispherical zone of heating in the endometrial cavity. It achieves overall destruction of the endometrium in a progressive manner delivering minimal total energy at a minimal rate for maximum safety and effectiveness. The microwave device achieves tissue destruction even in the presence of submucosal fibroids and polyps.
C. Barn described a randomized trial comparing microwave endometrial ablation to transcervical resection of the endometrium in women with excessive menstrual loss. 263 women were randomized with 134 having transcervical resection and 129 having microwave endometrial ablation. All have now been followed for at least 1 year. Full operative and 1-year follow up data with results of 2 years from 140 women, demonstrated that there is little difference between the 2 groups. MEA appears to be an effective and simple alternative to TCRE.
T. Tulandi presented a preliminary experience of microwave endometrial ablation. Of a total of 16 patients, only I patient refused MEA. Fifteen patients underwent the procedure. The duration of the procedure was 3 to 4 minutes. Hysteroscopic examination following MEA revealed complete endometrial destruction in 14 patients. Patients experienced intermittent brownish vaginal discharge up to 3 weeks after surgery. One patient complained on mild low abdominal cramps and vaginal discharge until 4 weeks postoperatively. Patient acceptance of MEA is high. The procedure is technically simple and lasts only several minutes.
Session 9: Hormone, surgery and thermal balloon:
A. I. M. Audebert presented When to Stop Oral Contraceptive Pills Before Surgery. Dr. Audebert concluded that it is recommended to stop oral contraceptives before any type of elective surgery and that the timing should be based on the dynamic of the normalization of the hemostatic factors induced by oral contraceptives. Three to four weeks should be sufficient regarding the effects of oral contraceptives and their reversibility.
Dr. E. Zupi presented Endometrium and Tamoxifen. The use of Tamoxifen in breast cancer patients and its effect on the endometrium was evaluated. One hundred and one breast cancer patients receiving Tamoxifen 20 to 30 mg a day for at least 1 year. Those with an endometrial thickness greater than 5 mm were advised to undergo hysteroscopy and endometrial biopsy if necessary. For less than 5 mm, hysteroscopy was recommended only if irregular echotexture was observed. In the asymptomatic group (no bleeding), 31 polyps, IS atrophic endometria and 6 vases of hyperplasia were observed. Two cases of endometrial cancer, 16 polyps and 3 hyperplasias were detected in patients with vaginal bleeding.
0. Shawki presented Hydrothermal Ablation of Endometrium for Treatment of Menorrhagia. A Simplified Technique Utilizing an Economic System. Dr. Shawki pointed out that dysfunctional uterine bleeding is a leading indication for hysterectomy. Dr Shawki described a device which utilizes and intrauterine silicone-made balloon manufactured by Cook OB/GYN which is mounted on a plastic catheter for distention with fluid. Conventional curettage was performed. Then the balloon was introduced and it was filled with the aid of a 20 mm syringe using water at a temperature of 900C. The distention was sustained for 30 seconds and deflation and refill was performed 40 to 50 times. This kept the endometrial temperature constantly stable. The vagina was carefully packed with gauze to avoid thermal injury. The procedure lasted 30 minutes. AU patients were discharged within 2 hours after the procedure. Eighty-five percent of the 14 patients reported significant improvement in menorrhagia. Failure of treatment occurred in 2 cases and it was repeated and successful. This very inexpensive approach provides a very simple technique for endometrial ablation.
Session 10: Workshop Pelvic Pain:
F. M. Howard presented What's New in Pelvic Pain. Pelvic pain accounts for 10% of all referrals to a gynecologist, as many as 40% of all laparoscopies and 12% of hysterectomies in the United States. Cervical stenosis, sciatic hernias, and endosalpingiosis must be considered as etiologies of chronic pelvic pain. Laparoscopic pain mapping is a new approach to evaluation of pelvic pain. In studies using this technique, endometrioses accounts for 1/3 and adhesions account for 1/3 of tender lesions at the time of conscious pain mapping. Most endometriotic lesions do not account for the pain of women with chronic pelvic pain when the technique of conscious pain mapping is used. Surgery is indicated in the treatment of endometriosis, but routine postoperative GnRH agonist therapy is not. Interstitial cystitis can be treated with intravesical BCG. Pelvic congestion syndrome can be treated by laparoscopic ovarian vein ligation and by embolization of the ovarian veins.
J. Steege presented Conscious Pain Mapping for the Diagnosis of Chronic Pelvic Pain. Dr. Steege pointed out that the interpretation of the importance of pathology seen at the time of laparoscopy is problematic because most forms of gynecologic pathology are in some women associated with chronic pelvic pain while virtually all forms can be present asymptotically in other women. Dr. Steege presented a case in which ovarian remnants did not create pain but the pain that the patient experienced could be reproduced by palpation and traction on adhesions to the vaginal apex. This case demonstrated the importance of conscious pain mapping to identify the source of chronic pelvic pain in women.
L. Demco presented Conscious Sedation, Pain Mapping of Endometriosis using Patient-Assisted Laparoscopy. Dr. Demco demonstrated by use of patient-assisted laparoscopy (PAL) the relationship of lesions of endometriosis to pelvic pain. In lesions that did provoke a pain response, red or vascular lesions were most painful followed by clear lesions with subsequent vascular patterns, followed by white scarred lesions and the least tender were black lesions. Pain could be elicited 2.7 cm away from the edge of a visible lesion. The treatment of pain associated with the lesions of endometriosis is greatly assisted by patient-assisted laparoscopy which allows adequate clarification and treatment of a painful lesion using the input from the patient.
C. Sutton presented Treatment of Pelvic Pain. Dr. Sutton presented the results of a double-blind prospective randomized controlled trial of laparoscopic laser surgery for endometriosis. He had previously shown that he had successful pain relief in 62.5% of women compared to only 22.6% of controls. One of the problems with his previous study is that it included uterine nerve ablation. In his further prospective study, comparing laser vaporization of endometriosis alone to laser vaporization combined with LUNA, Dr. Sutton demonstrated that the LUNA did not appear to confer any benefit on the leading symptoms of dysmenorrhea, dyspareunia or pelvic pain unrelated to the menstrual cycle. From his original study, 60% still have satisfactory symptom relief, 3 have needed repeated laser laparoscopy. Of the 40% that continued to experience painful symptoms, 6 of the 22 had a hysterectomy but no sign of endometriosis was found at the time of the procedure.
Session 11: Endometriosis. laparoscopic techniques
F. Viscomi presented Laparoscopic Aspects, Depth and Histologic Findings in Peritoneal Endometriosis. Dr. Viscomi pointed out the correlation between laparoscopic aspects and histologic findings in peritoneal endometriosis. Sixty-seven women were laparoscoped for pelvic pain (41 cases), infertility (17), ovarian tumor (5), and other pathology (4). The laparoscopic aspects were classified as red, black and white lesions. The histological perimeters used were presence of hemosiderin, vascularization of the stroma, occurrence of mitosis, presence of debris, fibrotic tissue, depth of the lesion and functional characteristics of glands and stroma. There was a statistically significant association with stroma vascularization, intraluminal debris, fibrotic tissue, depth os the lesion and functional characteristics of the glands and stroma with each of the three types of lesions. There was no significant statistical association between presence of hemosiderin and mitosis in red, black and white lesions. The findings showed an agreement regarding the evolution theory from red to black and finally to white lesions in peritoneal endometriosis. Progression also occurs with depth. Red lesions are superficial and as the progression occurs to black and white lesions, the depth increases.
F. H. Loh presented Ovarian Follicular Response After Laparoscopic Cystectomy for Endometrial Ovarian Cysts. Dr. Loh pointed out that endometriotic cysts are some of the more common pathologies encountered during laparoscopic ovarian cystectomy. One hundred and eighty eight laparoscopic ovarian cystectomies were performed for endometriotic cysts. When stratified for age, for women under the age of 35 years, post-cystectomy ovaries undergoing spontaneous cycles had poor follicular response (0.3 +or - 0.47 follicles per cycle) compared to with normal ovaries (1.0 + or- 0 follicles per cycle). For women above the age of 35 years, there was no difference between the responses of post-cystectomy ovaries and normal ovaries in all of the different stimulation cycles. Dr. Loh concluded that ovarian follicular response is diminished in post-cystectomy ovaries undergoing spontaneous or Clomid stimulated cycles when compared with the normal ovaries for women under the age of 35 years.
R. Garry presented Images in Endometriosis - A Multi-Media Presentation. This work provided an atlas of every stage of endometriosis from the visualization of actual pieces of endometrium being actively extruded from the fallopian tubes to the management of complete cul-de-sac disease with rectal involvement.
C. Chapron presented Laparoscopic Partial Cystectomy for Bladder Endometriosis. Dr. Chapron pointed out that partial cystectomy is the treatment of choice for bladder endometriosis in the vast majority of cases. A retrospective study of 11 patients who underwent laparoscopic partial cystectomy was performed. The results were very satisfactory with an average follow up of 31.6 months. No pre or post operative complications were observed. The patients reported an improvement in their condition with complete disappearance of urinary symptoms in every case.
L. Mettler presented A Randomized Trial Comparing a Radially Expandable Needle System with Conventional Dr. Mettler pointed out that in previous randomized prospective studies comparing the radially expanding needle system to the cutting trocar, pain scores were significantly lower in the radially expanding group (STEP). In the present study, 49 patients were randomized to the STEP system and 51 patients were randomized to trocars. The patients were asked to rate their pain using a visual analog scale at 4, 8, 12 , 24 and 72 hours after surgery. Results showed that with the STEP system there was statistically improved patient assessment of pain. The mean postoperative pain scores were consistently lower in the STEP group, but were most apparent at 4, 8 and 12 hours (p=0.05). Differences in operative time and adverse events were not statistically significant. The STEP radially expanding needle system demonstrates statistically improved patient postoperative comfort.
Session 12: Video Session of the German Society of Gynecologic Endoscopy.
H. C. Verhoeven presented Transvaginal Hydrolaparoscopy in Infertility. Dr. Verhoeven has observed that 79% of their infertile patients without obvious pathology presented normal findings or pathology of doubtful clinical significance at the time of traditional diagnostic .laparoscopy. Traditional diagnostic laparoscopy is expensive and must be considered as a major surgical procedure and is not totally harmless. His group has performed 103 transvaginal hydrolaparoscopies. This procedure allows the exploration tubo-ovarian structures early on in infertile patient without obvious pathology. His group has found this technique to be very suitable to an outpatient setting, atraumatic, and without the need of general anesthesia.
L. Mettler presented GnRH Analogs and Myoma Therapy by Endoscopic Surgery. Dr. Mettler answered the question "Does pretreatment with GnRH analogs for hysteroscopic and laparoscopic myoma resection provide a benefit for the performance of myomectomies with a "Yes," In Dr Metller's experience it definitely helps to pre-treat for 3 months before myoma enucleation. However laparoscopic enucleation should take place no earlier than 6 weeks after the Depo injection. She pointed out that during estrogen deprivation it is more difficult to separate myoma capsule and tissue. Allowing a slight recurrent estrogen production of the body facilitates myoma enucleation. Thus the benefits of decreasing the size of the subserosal and intramural myomas is combined with the ease of separation in a slightly estroginzed environment. For submucosal myomas, enucleation can proceed within 4 weeks after the final GnRH analog treatment. GnRH antagonists may also be used prior to these procedure.
I. Semm presented Myoma Enucleation and the Motorized Macro-Morcellator Applied Using the New Horizontal Introduction Technique. Use of the serrated edged macro-morcellator (SEMM) with a battery operated motor which is available in widths 10, 15, 20 and 24 mm in diameter allows the rapid morcellation of even the largest myomas One technique for myoma resection involves splitting the capsule and exposing two thirds of the myoma. The motorized macro-morcellator is then introduced and the myoma is morcellated in-situ. The resulting morcellated tissue cylinders are up to 24 mm in width and 18 cm long and each cylinder can weigh up to 70 gm. When only the pedicle remains, it is ligated using a Roeder-Loop.
R. Felberbauin presented GnRH-Agonists ad IVF. The "Long" agonistic protocol is the gold standard for stimulation protocols for ART. The pharmacologic mode of action for GnRH-antagonists provides for competitive blockade of the GnRH-receptors on the cell membrane of the gonadotrophic cells. Without any intrinsic activity of these compounds, the "flair up" is completely avoided and gonadotrophins are suppressed almost immediately. A single administration of GnRH antagonist around day 9 abolishes any premature LH rise. The use of GnRH-antagonists allows the start of ovarian stimulation within the spontaneous cycle, shortening significantly treatment cycle lengths. Stimulation outcome and pregnancy rates of about 26% per embryo transfer are comparable to those after "Long" protocol stimulation. Combination of softer stimulation regimes like clomiphene citrate and low-dose HMG with mid cycle administration GnRH-antagonist may be the way to a cheap, safe and ovarian stimulation.
W. Kupker presented The/Benefits of GnRH-Agonist Therapy in Women with Minimal Endometriosis. The stimulation effect of steroid hormones, in particular estradiol, plays a key role in modulating the progress of endometriosis. Hypoestrogenism subsequent to application of GnRH-agonists demonstrates down-staging of endometriotic activity. The therapeutic effect of GnRH-agonists results in improved fecundity rates in spontaneous cycles and assisted reproduction as well as improvement of symptomatic endometriosis. The benefit of a GnRH-agonist therapy in cases of symptomatic minimal endometriosis has to be carefully evaluated in terms of its systemic approach and its ability to reach invisible endometriotic lesions which are not detectable at conventional surgical laparoscopy.
Session 13: New Technologies in Endoscopv.
A. I. Brill presented Understanding 3-1) Bipolar Endometrial Ablation. A dedicated electrosurgical generator is combined with a 3-D bipolar device to deliver consistent depths of ablation, irrespective of pretreatment, endometrial thickness or cavity dimensions. By entering the uterine length and cornu-to-cornu distance into the generator, ablations are tailored to the specific endometrial surface area. The device coagulates the myometrium to an average depth of 3 mm in the cornua and lower isthmus and 5 mm in mid-body and fundus. Amenorrhea rates of 80% have been achieved without endometrial pre-treatment. Total cavity coverage is obtained using this system. (NovasureTM Endometrial Ablation System).
Re: ISGE Research Committee
Dear Dr. Sciarra,
Happy New Year and Happy Millennium. As I am finishing an article for ISGE Newsletter, I realized that ISGE is a unique society. Most of the members are experts in endoscopic surgery and many enjoy the freedom to participate in the activities of the society. I feel that the time has come for ISGE to become an international leader in endoscopic research. We can start with a registry of some procedures and eventually conduct an organized research among its members. I am sure you will agree that research is essential if progress is to be made. Observational study reporting experience of an individual surgeon is interesting, but not sufficient. I will welcome your ideas and suggestions in this regard.
I was the Chair of Research and Publication Committee of the Society of Reproductive Surgeons, 1995-1998. I have some experience in this regard and will be more than happy to do it for ISGE. Thank you for your attention and I look forward to hearing from you.
Togas Tulandi M.D.
Fax: 1 514 843 1448
Dear Dr. Carter,
With a great deal of interest, I recently read the report of J.B. Dubuisson, "Laparoscopic Management of Genital Prolapse" published in the June 1999 issue. The technique described a good alternative for patients with genital prolapse who wish to keep their uterus. However, this procedure may be limited to a small population, since it has been my experience that the majority of patients with genital prolapse are either beyond the age of reproduction or have no further desire for future pregnancies. In these cases, removal of the protruding uterus is done.
While I agree that the laparoscopic alternative is better than the laparotomy sacropromontory fixation, in some cases, due to a concomitant pelvic pathology, this surgery is indicated. In cases where the relaxation of the pelvic floor is extensive, the lumen of the vagina is markedly enlarged and there is a major posterior component present. Such conditions facilitate the exposure of the right sacrospinous ligament, and as such the operation could be done vaginally. In other cases. I chose a combined vaginal and laparoscopic approach, which includes a vaginal hysterectomy, followed by a McCall culdeplasty, cystocele-rectocele repair and a laparoscopic sling supporting the uterosacral. and cardinal complex to the lateral abdominal fascia. I have followed 35 of these cases for over 1 year, and 12 of them for an additional 5 years without recurrence. I agree that the lateral suspension to the aponeurosis of the external oblique is a good alternative. I congratulate the author for presenting this optional treatment for a select group of patients With genital prolapse who wish to keep their uterus.
Daniel A. Tsin, M.D.
Associate Director of Gynecology
The Mount Sinai Hospital Of Queens
37-42 77th Street
Jackson Heights, NY 11372
(718) 898-5101 Fax (718) 898-5273
Reference: Tsin D.A, Whang G., Sequeira R. Mahmood D., Granato R. E. Journal of Laparoendoscopic Surgery 1995:5:145-149.