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12 - The Future of Operative Laparoscopy for Infertility
- from PART II - INFERTILITY EVALUATION AND TREATMENT
- Edited by Botros R. M. B. Rizk, University of South Alabama, Juan A. Garcia-Velasco, Hassan N. Sallam, Antonis Makrigiannakis, University of Crete
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- Book:
- Infertility and Assisted Reproduction
- Published online:
- 04 August 2010
- Print publication:
- 15 September 2008, pp 107-114
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Summary
Laparoscopy allows for the comprehensive evaluation of the pelvis and uterus including confirmation of tubal patency and evaluation of tubo-ovarian relationships. Laparoscopy represents an effective alternative to artificial reproductive technology (ART) for women with tubal disease/hydrosalpinx, leiomyoma, endometriosis, and/or unexplained infertility. Diagnostic laparoscopy combined with operative endoscopic procedures allow prompt and complete identification of all contributory factors, helping the physician to institute appropriate therapy, and will help ensure higher conception rates over shorter intervals. In the recent era of evidence-based medicine, it is recommended that a multicentric prospective randomized study is needed to prove the efficacy of laparoscopic evaluation in predicting the fertility outcome in patients experiencing infertility. Careful selection of patients based on clinical history as well as physical examination and non-invasive laboratory techniques will identify those patients most likely to benefit from endoscopic examination for their infertility evaluation.
11 - LAPAROSCOPIC ADHESIOLYSIS AND ADHESION PREVENTION
- Camran Nezhat, Stanford University School of Medicine, California, Farr Nezhat, Mount Sinai School of Medicine, New York, Ceana Nezhat
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- Book:
- Nezhat's Operative Gynecologic Laparoscopy and Hysteroscopy
- Published online:
- 23 December 2009
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- 07 July 2008, pp 304-315
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Summary
Adhesions are defined as connections between opposing serosal and/or nonserosal surfaces of the internal organs and the abdominal wall, at sites where there should be no connection. This connection can be a band, which is vascular or avascular, and filmy/transparent or dense/opaque, or it could be a cohesive connection of surfaces without an intervening adhesion band. Adhesion formation is an almost unavoidable consequence of abdominal surgery. Although not all patients with intra-abdominal adhesions develop symptoms, the clinical implications, such as early and late bowel obstruction, infertility, and chronic abdominal pain, remain a common problem in general surgical and gynecologic practice. In addition, adhesion formation is associated with increased socioeconomic costs.
THE RISK FACTORS AND CLINICAL SIGNIFICANCE OF ADHESIONS
The risk factors for pelvic adhesions include a history of pelvic inflammatory disease (PID), prior surgery, perforated appendix, endometriosis, and inflammatory bowel diseases. Other recognized causes of adhesions include bacterial peritonitis, radiotherapy, chemical peritonitis, foreign body reaction, long-term continuous ambulatory peritoneal dialysis, endometriosis, and pelvic inflammatory disease. However, the greatest contribution of these risk factors is a previous history of an intra-abdominal operative procedure.
Adhesion formation after abdominal and pelvic operations remains extremely common and is a source of considerable morbidity. Menzies and Ellis confirmed that after an intra-abdominal operation, most patients developed adhesions.
14 - PELVIC FLOOR
- Camran Nezhat, Stanford University School of Medicine, California, Farr Nezhat, Mount Sinai School of Medicine, New York, Ceana Nezhat
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- Book:
- Nezhat's Operative Gynecologic Laparoscopy and Hysteroscopy
- Published online:
- 23 December 2009
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- 07 July 2008, pp 366-424
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Summary
Retropubic Burch colposuspension has been considered by many to be the “gold standard” procedure for the treatment of female stress urinary incontinence for almost 40 years. Vancaillie and Schuessler introduced the laparoscopic approach to retropubic colposuspension in 1991. Numerous reports followed in subsequent years describing laparoscopic colposuspensions and their efficacy. Analysis of the outcomes of these various laparoscopic “Burch” colposuspensions is difficult because many of the techniques are not true Burch procedures but rather other modified retropubic colposuspensions. In this section, we describe the laparoscopic Burch colposuspension, including patient selection, preoperative evaluation, operative technique, possible complications, and efficacy. We review the efficacy of the laparoscopic Burch colposuspension studies that use the Burch—Tanagho procedure and compare these techniques to other popular anti-incontinence procedures. The many modified laparoscopic retropubic procedures are not addressed.
BURCH COLPOSUSPENSION: THE EVOLUTION OF A PROCEDURE
In 1961, Burch published the description of a new female anti-incontinence procedure, based on a technique started in 1958. The technique involved entering the space of Retzius via a paramedian incision. After clearing the periurethral tissue of its overlying fat and areolar tissue, three 2-0 chromic sutures were placed at the mid-urethra and the bladder neck and then fixed to Cooper's ligament. Burch reported a subjective cure rate of 92% in 143 patients with 10 to 60 months of followup.
9 - MANAGEMENT OF ADNEXAL MASSES
- Camran Nezhat, Stanford University School of Medicine, California, Farr Nezhat, Mount Sinai School of Medicine, New York, Ceana Nezhat
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- Book:
- Nezhat's Operative Gynecologic Laparoscopy and Hysteroscopy
- Published online:
- 23 December 2009
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- 07 July 2008, pp 179-250
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Summary
The adnexa are in an anatomic region in the pelvis that includes the ovaries, the fallopian tubes, and the structures within the broad ligament. The differential diagnosis of an adnexal mass is complex because of the wide spectrum of disorders that involve the adnexa. Most frequently, adnexal masses involve the ovary itself because of its inherent growth properties through ovulation and thus its propensity for neoplasia. During the evaluation of an adnexal mass, the picture may be further complicated as imaging does not always clearly delineate the adnexa from other nearby organs. An estimated 5% to 10% of women in the United States will undergo a surgical procedure for a suspected ovarian neoplasm during their lifetime. Although the majority of adnexal masses are benign in nature, the primary goal of the diagnostic evaluation is the exclusion of malignancy.
ETIOLOGY
The differential diagnosis of the adnexal mass varies with age (Table 9.1.1). Age is also the most important factor in determining the potential for malignancy. In fact, the risk that an ovarian neoplasm is malignant increases 12-fold from ages 12 through 29 and 60 through 69. Although there is emerging evidence that the presence of an adnexal mass in postmenopausal women is more common than once thought, masses found in premenarchal and postmenopausal women should be considered abnormal and must be promptly evaluated.
21 - ADDITIONAL PROCEDURES FOR PELVIC SURGEONS
- Camran Nezhat, Stanford University School of Medicine, California, Farr Nezhat, Mount Sinai School of Medicine, New York, Ceana Nezhat
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- Book:
- Nezhat's Operative Gynecologic Laparoscopy and Hysteroscopy
- Published online:
- 23 December 2009
- Print publication:
- 07 July 2008, pp 537-551
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Summary
Cystoscopy, the gold standard for diagnosis of disorders and injuries of the lower urinary tract, provides another tool for prevention and active management of urologic pathology and surgical complications by allowing the surgeon to assess the integrity and function of the urethra, bladder, and ureters. At our center, we have incidentally detected bladder endometriosis, polyps, malignant lesions, diverticula, duplicated ureter, and interstitial cystitis. One case of complete ureteral obstruction and renal necrosis due to invasive endometriosis was detected during an incidental cystoscopy. Contralateral periureteral disease was treated, resulting in successful conservation of the other kidney.
Cystoscopic technique, unfortunately, is not routinely taught during obstetrics/gynecology residency training; therefore, many gynecologists do not feel comfortable performing the procedure. This is unfortunate as gynecologists deal with urogynecologic issues daily with conditions such as urinary incontinence, pelvic organ prolapse, and severe endometriosis involving the lower urinary tract. Two large multicenter studies demonstrated that 66% to 80% of patients with chronic pelvic pain had evidence of bladder-origin pain due to bladder epithelial damage or interstitial cystitis. In the gynecologic literature, chronic pelvic pain is associated with endometriosis in 30% to 87% of cases as well. The surgical treatment of pelvic pain is the most frequent indication for operative laparoscopy, although in as many as 40% of patients, no pathology is found.
10 - ENDOMETRIOSIS
- Camran Nezhat, Stanford University School of Medicine, California, Farr Nezhat, Mount Sinai School of Medicine, New York, Ceana Nezhat
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- Book:
- Nezhat's Operative Gynecologic Laparoscopy and Hysteroscopy
- Published online:
- 23 December 2009
- Print publication:
- 07 July 2008, pp 251-303
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Summary
Endometriosis is classically defined as the presence of endometrial glands and stroma in ectopic locations. Affecting from 6% to 10% of reproductive-aged women, endometriosis may result in dysmenorrhea, dyspareunia, chronic pelvic pain, and/or subfertility. The prevalence of this condition in women experiencing pain, infertility, or both is as high as 50%. Endometriosis is a debilitating condition, posing quality-of-life issues for the individual patient. The disorder represents a major cause of gynecologic hospitalization in the United States, estimated to have exceeded $3 billion in inpatient health care costs in 2004 alone. The significant individual and public health concerns associated with endometriosis underscore the importance of understanding its pathogenesis. The first recorded description of pathology consistent with endometriosis was provided by Shroen in 1690. Despite the passage of time and extensive investigation, the exact pathogenesis of this enigmatic disorder remains unknown.
THEORIES REGARDING PATHOGENESIS
Numerous theories detailing the development of endometriosis have been described. For purposes of review, these theories can generally be classified into those that propose that implants arise from tissues other than the endometrium and those that propose that implants arise from uterine endometrium (Table 10.1.1).
Nonendometrial Origin
Metaplasia of coelomic epithelium represents a distinct pathogenic mechanism for the establishment of endometriotic implants.