Laparoscopic Isthmocele Repair: Efficacy and Benefits before and after Subsequent Cesarean Section.

OBJECTIVE: To evaluate the effect of laparoscopic isthmocele repair on isthmocele-related symptoms and/or fertility-related problems. The residual myometrial thickness before and after subsequent cesarean section was also evaluated. DESIGN: Retrospective, case series. SETTING: Public university hospital. POPULATION: Women with isthmocele (residual myometrium < 5 mm) complaining of abnormal uterine bleeding, chronic pelvic pain or secondary infertility not otherwise specified. METHODS: Women's complaints and the residual myometrium were assessed pre-operatively and at three to six months post-operatively. In patients who conceived after surgery, the latter was measured at least six months after delivery by cesarean section. MAIN OUTCOME MEASURES: Resolution of the main symptom three to six months after surgery and persistence of laparoscopic repair benefits after subsequent cesarean section were considered as primary outcome measures. RESULTS: Overall, 31 women underwent laparoscopic isthmocele repair. The success rates of the surgery as improvement of abnormal uterine bleeding, chronic pelvic pain and secondary infertility were 71.4% (10 of 14), 83.3% (10 of 12) and 83.3% (10 of 12), respectively. Mean residual myometrial thickness increased significantly from 1.77 mm pre-operatively to 6.67 mm, three to six months post-operatively. Mean myometrial thickness in patients who underwent subsequent cesarean section (N = 7) was 4.49 mm. In this sub-group, there was no significant difference between the mean myometrial thickness measured after the laparoscopic isthmocele repair and that measured after the subsequent cesarean section. None of these patients reported recurrence of their symptoms after delivery. CONCLUSION: Our findings suggest that the laparoscopic isthmocele excision and repair is an appropriate approach for the treatment of isthmocele-related symptoms when done by skilled laparoscopic surgeons. The benefit of this new surgical approach seems to persist even after a subsequent cesarean section. Further investigations and prospective studies are required to confirm this finding

Efficacy, Safety and Outcomes of the Laparoscopic Management of Cesarean Scar Ectopic Pregnancy as a Single Therapeutic Approach: A Case Series.

peer reviewedA standardized consensus for the management of cesarean scar pregnancy (CSP) is lacking. The study objective is to evaluate the efficacy, safety and outcomes of the laparoscopic management of CSP as a single therapeutic surgical approach without being preceded by vascular pretreatment or vasoconstrictors injection. This is a retrospective bi-centric study, a case series. Eight patients with a future desire to conceive underwent the laparoscopic treatment of unruptured CSPs. Surgery consisted of "en bloc" excision of the deficient uterine scar with the adherent tissue of conception, followed by immediate uterine repair. The data collected for each patient was age, gestity, parity, number of previous c-sections, pre-pregnancy isthmocele-related symptoms, gestational age, fetal cardiac activity, initial β-human chorionic gonadotropin levels, intra-operative blood loss, blood transfusion, operative time and the postoperative complications, evaluated according to Clavien-Dindo classification. The CSP was successfully removed in all patients by laparoscopy. The surgical outcomes were favorable. All patients with histories of isthmocele-related symptoms reported postoperative resolution of symptoms. The median residual myometrium thickness increased significantly from 1.2 mm pre-operatively to 8 mm 3 to 6 months after surgery. The laparoscopic management seems to be an appropriate treatment of CSP when performed by skilled laparoscopic surgeons. It can be safely proposed as a single surgical therapeutic approach. Larger series and further prospective studies are needed to confirm this observation and to affirm the long-term gynecological and obstetrical outcomes of this management

Pseudotumoral Endometriotic Nodule

peer reviewedStudy Objective: To demonstrate a rare case of a pediculated endometriotic nodule that was initially diagnosed as a solid adnexal mass. Design: We present a stepwise narrated demonstration of our laparoscopic technique. Setting: We present a case report of a patient aged 44 years, gravida 2 para 2, who was diagnosed with a solid (adnexal) mass during a gynecologic examination. She presented symptoms of dyspareunia. During a bimanual examination, 2 fixed nodules were palpated in both the uterosacral ligaments, and a mobile solid mass of 5 cm could be palpated on the right adnex. A transvaginal ultrasound showed a solid (adnexal) mass of 50 mm in diameter. The tumor marker cancer antigen 125 was normal, and after application of the International Ovarian Tumor Analysis score, the risk of malignancy was up to 39%. A complementary magnetic resonance image showed a heterogeneous solid mass of 47 × 47 × 29 mm with a differential diagnosis of a pediculated fibroma in (myxoid) degeneration vs an adnexal solid mass. A laparoscopic unilateral adnexectomy was scheduled, and the patient was informed about the risk of malignancy. The laparoscopy revealed bilateral normal adnexa, the presence of a solid pediculated mass originating from the right uterosacral ligament and 2 endometriotic nodules originating from the left and right uterosacral ligaments. The rectovaginal space was dissected, and a third deep infiltrating endometriotic nodule was revealed. The operation proceeded by the sectioning of the left uterosacral ligament below the endometriotic nodule. The posterior vaginal wall was separated from the endometriotic nodule, and after further dissection of the rectovaginal space, we arrived in a disease-free area. After opening of the right medial division of the pararectal space, the right hypogastric nerve was dissected and preserved. The solid mass was separated from the uterus, the right uterosacral ligament was excised at a distance from the nodule, and the pediculated mass was removed intact en block with the right ligament. The patient was discharged 24 hours after surgery. The postoperative period was uneventful. The definitive histology report confirmed the presence of endometriotic nodules and a solid tumor classified as a pseudotumoral endometriotic mass. This was justified by the presence of conjunctival vascular stroma including multiple endometriotic foci, the presence of cytogenic stroma of variable abundance including glands lined with a columnar epithelium, and, most important, the fact that the epithelium had no cytologic atypias. Interventions: Laparoscopic excision of the pseudotumoral endometriotic nodule en block with the right and left uterosacral ligaments. Conclusion: Endometriosis is a complex multifactorial pathology in which several factors are involved: genetics, environmental factors, immunologic reactions, hormonal effects, and anatomic anomalies. All these factors may contribute to the creation of an inflammatory response related to immune cells, adhesion molecules, extracellular matrix metalloproteinase, and proinflammatory cytokines enhancing the formation of fibrotic tissue [1,2]. These changes may sometimes have an unusual presentation, as we are showing in this case report of a pseudotumoral endometriotic mass. This rare case should be included in the differential diagnosis of solid tumors before surgery for symptomatic patients and those who have a medical history of endometriosis

Laparoscopic approach for a cesarean scar pregnancy.

peer reviewed[en] OBJECTIVE: To describe a surgical technique of laparoscopic resection of a cesarean scar pregnancy (CSP) with an immediate myometrial reconstruction. The advantage of such a technique is that it is a minimally-invasive procedure that can treat the ectopic pregnancy and the defected scar at the same time with good postoperative results. DESIGN: Video article with the description of a surgical minimally-invasive technique. SETTING: Academic medical center. PATIENT(S): A 34-year-old patient, Gravida 6 Para 4 Abortus 1, with a history of 4 previous cesarean sections presented to the emergency department with abdominal pain and vaginal bleeding. The patient was hemodynamically stable. An endovaginal ultrasound revealed a viable pregnancy of 8 weeks implanted in the cesarean scar, with a residual myometrium of <1 mm. Because of increasing abdominal pain, vaginal bleeding, and a desire to preserve future fertility, an emergent laparoscopy was performed. INTERVENTION(S): Laparoscopy was performed using a CO2 AcuPulse laser device (Lumenis Inc. Salt Lake City, Utah). A continuous wave mode was used, with a power of 30 Watt and a round-shaped beam of 1.5 mm in diameter. The laser was connected to a 10-mm Hopkins endoscope 0° (Karl Storz, Tuttlingen, Germany). A complete adhesiolysis was performed, and the urinary bladder was detached from the anterior abdominal wall. The vesicouterine fold was opened to expose the isthmic part of the uterus where the ectopic pregnancy was implanted. The defected scar was resected en bloc with the pregnancy, using the laser. The limits of the resection depended on the residual myometrial thickness. We considered a myometrial thickness of >8 mm as healthy tissue. A metallic probe was introduced vaginally into the endocervix to differentiate the anterior part from the posterior part of the uterus. This probe facilitates the manipulation of the cervix and, thus, the laparoscopic intracorporeal suturing during the myometrial reconstruction. A 2-layered suturing was performed. The first layer of the suture consisted of 3 interrupted figure-of-8 sutures using a monofilament absorbable suture (Monocryl 0, ETHICON-Johnson and Johnson medical devices New Brunswick, New Jersey). A second superficial layer consisted of a continuous nonlocking suture using the same type of thread. MAIN OUTCOME MEASURE(S): Laparoscopic excision of the CSP and immediate repair of the scar defect without any postoperative complications. RESULT(S): An emergent laparoscopy was performed, with excision of the CSP and immediate reconstruction of the residual myometrium. No complications occurred, the blood loss was estimated at 200 mL, and no blood transfusion was necessary. The patient was discharged 24 hours after the intervention. Six months after surgery, the remaining myometrial thickness was between 7 mm and 9.3 mm, and no residual cesarean scar defect (isthmocele) was visualized by ultrasound. CONCLUSION(S): Cesarean scar pregnancy is a rare form of ectopic pregnancy. The incidence, however, is increasing as a consequence of the rising cesarean section rate. Different surgical and nonsurgical techniques have been described in the literature. Laparoscopic excision of a CSP is an effective and feasible technique with the advantage of an immediate myometrial reconstruction. The cesarean scar defect diminishes, and this potentially could improve the future fertility of the patient and decrease the probability of abnormal uterine bleeding and chronic pelvic pain

Impact of adenomyosis and endometriosis on chronic pelvic pain after niche repair

Objectives To determine if the laparoscopic isthmocele repair in patients with endometriosis and/or adenomyosis (AD) has an impact on the post-operative outcomes on chronic pelvic pain (CPP). Methods A retrospective study was performed on 45 patients who underwent laparoscopic niche repair surgery between 2016 and 2021 in Liege University Hospital La Citadelle at the department of Obstetrics and Gynecology. Their preoperative ultrasonography was studied using the MUSA criteria in order to determine the presence of adenomyosis. The histology results were used to detect the presence of endometriosis. According to the clinical practice, all patients were seen in a post-operative period of 3 to 6 months and afterwards at their annual check-up. Data were collected from medical records. Results: Out of the 45 patients, 80% had adenomyosis, 40% endometriosis and 33% endometriosis and concomitant adenomyosis. Out of the 36 patients with AD, 67% had diffuse type, while 19% had anterior focal AD. On the 18 patients with endometriosis, 83% show concomitant adenomyosis. In post-operative period (at 3 to 6 months), only 1 out of 18 patients (5%) with endometriosis, 5/21 (24%) with AD only, and 6/15 (40%) with both pathologies had CPP recurrence. There are more CPP recurrent patients in the group of endometriosis with concomitant AD compared to endometriosis only group (statistical significance p < 0,05). In post-operative period (at 12 months), only 1 out of 18 patients (5%) with endometriosis only has CPP recurrence , with AD only 2/21 (9,5%), and both 8/15 (53%). There are more CPP recurrent patients in the group with the presence of simultaneous pathologies compared to endometriosis (statistical significance p < 0,01) or AD only (statistical significance p < 0,02). Conclusions: Cesarean section has an important impact on adenomyosis development. In our case series, 80% of our patients treated for isthmocele present concomitant AD. Moreover, 86% of them show diffuse or anterior focal AD. To our best knowledge, it is the first long term study on the CPP outcomes for patients who have been treated for niche repair. Our results demonstrate that there is an important CPP recurrency rate in patient with AD and concomitant endometriosis after 1 year. Patients who undergo niche repair should be selected carefully as CPP does not seem to be a good indication for uterine scar repair in patients with concomitant adenomyosis and endometriosis

Impact of Adenomyosis and Endometriosis on Chronic Pelvic Pain after Niche Repair

peer reviewedChronic pelvic pain (CPP) is one of the main isthmocele symptoms, together with abnormal uterine bleeding and secondary infertility. When patients undergo a laparoscopic niche repair surgery, it is important to determine if they present associated pathologies, such as adenomyosis and/or endometriosis, which are also a cause of CPP. A retrospective study was performed on 31 patients with CPP undergoing a laparoscopic niche repair. The pre-operative ultrasound was analyzed to determine the presence of adenomyosis. Endometriosis was histologically diagnosed. CPP outcome was evaluated at early (3–6 months) and late (12 months) post-operative follow ups. In our population of 31 women presenting CPP, only six of them (19.4%) did not have any associated pathology. In the group of 25 patients with associated pathology, 10 (40%) had no benefit from the reconstructive surgery in terms of CPP at early follow-up (3–6 months) and 8 (32%) in the post-operative period at 12 months. Patients with CPP who undergo niche repair should be carefully selected as CPP does not seem to be a good indication for uterine scar repair in patients with concomitant adenomyosis and endometriosis

Nurr1:RXRα heterodimer activation as monotherapy for Parkinson’s disease

Significance In Parkinson’s disease (PD), dopamine (DA)-producing neurons gradually degenerate, leading to DA deficiency and to the main symptoms of PD. Current medications do not impede neurodegeneration, but relieve symptoms by replenishing DA; however, their chronic use causes serious side effects. We targeted a protein required for the development and function of DA neurons by designing a chemical compound that, by activating this protein, increases DA and improves symptoms without current treatment side effects while simultaneously preventing neuron loss in PD mice. Our findings point to a monotherapy that can both impede PD progression and concurrently improve symptoms of PD.</jats:p