Blood tests for prediction of deep endometriosis:A case-control study

BACKGROUND Deep endometriosis(DE)is the most aggressive subtype of endometriosis.The diagnosis may be challenging,and no biomarkers that can discriminate women with DE from those without DE have been developed.AIM To evaluate the role of blood hemostatic parameters and inflammatory indices in the prediction of DE.METHODS This case-control study was performed at the Women’s Hospital,Zhejiang University School of Medicine between January 2015 and December 2016.Women with DE and women with benign gynecologic disease(control group)eligible for gynecological surgery were enrolled.Routine plasma hemostatic parameters and inflammatory indices were obtained before surgery.Univariate and multivariate analysis were performed.Receiver operating characteristic(ROC)curves were generated,and areas under the curve(AUC)were calculated to assess the predictive values of the selected parameters.RESULTS A total of 126 women were enrolled,including 31 with DE and 95 controls.Plasma fibrinogen(Fg,P<0.01),international normalized ratio(P<0.05),and Creactive protein levels(P<0.01)were significantly higher in women with DE compared with controls.Plasma hemoglobin(HB)levels(P<0.05)and shortened thrombin time(P<0.05)were significantly lower in women with DE than in controls.Plasma Fg levels[adjusted OR(aOR)2.12,95%confidence interval(CI):1.31-3.75]and plasma HB levels(aOR 0.48,95%CI:0.29-0.78)were significantly associated with DE(both P<0.05).ROC analysis showed that the diagnostic value of Fg or HB alone for DE was limited.The AUC of the combination of both markers as a dual marker index was 0.773 with improved sensitivity(67.7%)and specificity(78.9%)at cutoffs of 3.09 g/L and 126 g/L,respectively.CONCLUSION The combination of Fg and HB was a reliable predictor of DE.A larger study is needed to confirm the findings.

Robotic Assisted Surgery for Endometriosis—“Is the Way Forward?”

Endometriosis is a chronic and progressive gynecologic disorder that affects 10% - 50% of women of reproductive age worldwide. Chronic pain and infertility are the most debilitating problems associated with it requiring both medical and surgical treatment. Laparoscopy is considered the gold standard for diagnosis and treatment. However, a 10% rate of conversion to laparotomy has been reported when performed by skilled laparoscopic surgeons and much higher in low volume less skilled surgeons. To improve surgical outcomes, robotic assistance is the logical next step in performing minimally invasive gynecological surgeries, especially in complex endometriosis cases. Enhanced 3D visualization and 10× magnification along with Endowrist instruments with seven degrees of freedom facilitates precise and careful dissection. Firefly technology using ICG green dye can improve detection of small and invisible lesions. Robotics is useful in deep infiltrating disease manifesting as lesions deeper than the superficial tissues of rectovaginal septum, vaginal fornix, pelvic sidewalls, parametrium, bowel or ureter and bladder. Trials show no increase in surgical time, blood loss, or intra- or postoperative complications and similar clinical outcome when robotics is compared with laparoscopy. At present, it is more appropriate to compare it with laparotomy rather than laparoscopy. Robotics can be used to manage recurrence of endometriosis after hysterectomy. Surgeons experienced in conventional laparoscopy can utilize robotic platform for deep infiltrating endometriosis for performing complex surgical dissection and achieving the surgical goals in mind and reduce conversions to open surgery. Robotic assistance can bridge the gap in performance of laparoscopic surgery in advanced endometriosis.

Anatomical distribution of pelvic deep infiltrating endometriosis and its relationship with pain symptoms

Background Endometriosis is a controversial and enigmatic disease.Deep infiltrating endometriosis （DIE） is responsible for painful symptoms and is the least understood type of endometriosis.Little work has been devoted to define the location of DIE lesions and its relationships with pain.The aim of the study was to investigate the relationship between the anatomical distribution of DIE lesions and pain symptoms.Methods Clinical data from 354 patients between May 2003 and December 2007 with laparoscopically diagnosed endometriosis were collected including 177 DIE patients and 177 non-DIE patients.The pain symptoms,including dysmenorrhea （DM）,chronic pelvic pain （CPP,defined as intermittent or permanent pelvic pain,not related to the menstruation and longer than 6 months）,deep dyspareunia （pelvic pain at intercourse） and dyschezia （pelvic pain with defecation）,were recorded for every patient before operation.Endometriotic lesions were recorded by their anatomical distributions,the depth of infiltration and lesion colors.And the relationship between the anatomical distribution of DIE lesions and pain symptoms was analyzed.Pearson＇s chi-square test or Fisher＇s exact test,one-way analysis of variance （ANOVA） and linear regression and binary Logistic regression were used for statistical analysis.Results The duration （（13.79±3.94） years） of pain suffering in DIE patients was much longer than that of non-DIE patients （P 〈0.01）.In DIE patients,60.7% of the uterosacral ligament （USL） nodules were bilateral （P 〈0.01）; 44.6% of the cul-de-sacs were completely blocked.Rectum invasion was observed in 19.9% of DIE patients （P=0.03）; pelvic adhesion was also more common.Up to 98.41% of the deep infiltrative lesions were located in the posterior pelvic compartment.DIE lesions were also found in bladder （1.58%）,USL （67.08%）,cul-de-sac （12.02%）,recto-vaginal septum （12.66%）,rectum and rectosigmoid junction （2.85%） and ureter （3.80%）.The odds ratio of USL-DIE for CPP,deep dyspareunia,dyschezia were 2.52,1.29 and 2.24 respectively.And the depth of infiltration correlated with the severity of dysmenorrhea.Conclusions DIE lesions were associated with severe pain symptoms.The main distribution of DIE lesions was in the posterior pelvic compartment,and was more widespread and severe in DIE patients.Moreover,resection of these DIE lesions are very important to treat the pain symptoms.

Analysis of the Predictive Factors for the Recurrence of Deep Infiltrating Endometriosis:A 2-Year Prospective Study

Objective:To investigate factors that may be associated with the recurrence of deep infiltrating endometriosis(DIE)and DIE-related symptoms.Methods:Starting in September 2014,women with a confirmed diagnosis of DIE based on surgical and histological findings were included in the prospective study with a 2-year follow-up in our hospital.A total of 84 consecutive patients were included,all of whom underwent laparoscopic surgery.The data were obtained from the medical records of the patients.Follow-up data,including presence of pain as assessed using the visual analog scale(VAS)score and ultrasonography/magnetic resonance imaging findings,were obtained at 3,6,9,12,and 24 months postoperatively.Variables,such as age,body mass index,severity and duration of symptoms,size and location of the lesion,and pre-and postoperative medical treatment,were evaluated using univariate and multivariate analyses to identify factors correlated to recurrence.Results:A total of 11(13.1%)patients presented with recurrence,with a mean time to recurrence of 14.2 months.The univariate analysis showed that the longer duration of menstruation(7.4 vs.6.0,P=0.010),the more advanced revised American Fertility Society(rAFS)stage(Stages I and II vs.III and IV,χ^(2)=9.964,P=0.001),the higher VAS score for dysmenorrhea(9.4 vs.5.2,P=0.001),and the more severe pain during defecation(7.8 vs.4.8,P=0.016)were positively correlated to DIE recurrence.However,the multivariate analysis also revealed that a more severe dysmenorrhea and advanced rAFS stage were the independent factors associated with the recurrence of DIE,with an odds ratio of 1.895(confidence interval[CI]:1.061-3.385,P=0.031)and 4.310(CI:1.091-17.028,P=0.037),respectively.Conclusions:More than 10%of patients presented with recurrence of DIE 2 years after surgery.Recurrence of DIE was more common in patients who complained of more severe dysmenorrhea and had an advanced rAFS stage.