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Endometriosis is considered an estrogen-dependent disease of women in their reproductive age and characterized by the occurrence of stromal cells and endometrial-like glands outside the uterine cavity.
A report of a 9-year-old premenarcheal girl who was transferred to the Endometriosis Research Center Berlin-Brandenburg Level III (Academic Teaching Hospital) because of cyclic pelvic pain since her 8th year of life.
History, examination, abdominal ultrasound, laboratory tests, laparoscopic resection of visible lesions. Paraffin-embedded histology (HE staining) and immunohistochemistry.
Endometriosis, defined as the presence of stromal tissue and epithelial glands, was confirmed both by HE staining and immunohistochemistry (CD10), respectively.
Young pre- or perimenarcheal girls with chronic/cyclic pelvic pain can have endometriosis, and thus the possibility of endometriosis should be included in the differential diagnosis.
Deep-infiltrating endometriosis may affect the vagina, the rectum, and the cervicoisthmic part of the uterus, resulting in severe pain, particularly dyschezia, dysmenorrhea, dyspareunia, and diminished quality of life. Advanced surgical techniques, such as laparoscopic-assisted anterior rectum resection, are recognized as safe and effective therapeutic approaches. In some cases, a laparotomy or minilaparotomy has to be performed for technical reasons. This can be avoided in some cases by transvaginal-laparoscopic low anterior rectum resection. The technique is a 4-step procedure, which can be described as follows: step 1 (vaginal) - rectovaginal examination, preparation of the rectovaginal septum, opening of the pouch of Douglas, mobilization of the endometriotic nodule and the rectum, temporary vaginal closure; step 2 (laparoscopic) - removal of additional endometriotic lesions, adhesiolysis, final mobilization of the rectum, mobilization of the rectosigmoid, endoscopic resection using an endoscopic stapler step 3 (vaginal) - transvaginal resection of the lesion, preparation of the oral anvil, closure of the vagina; and step 4 (laparoscopic) - endoscopic transanal stapler anastomosis and underwater rectoscopy, prophylaxis of adhesions, drainage. We used this procedure to treat a 46-year-old woman (gravida 2, para 2) who was admitted to our hospital for severe lower abdominal pain, constipation, dyspareunia, dyschezia, and cyclic rectal bleedings. The symptoms were caused by an endometriotic nodule accompanied by a palpable rectum stenosis. In addition, she reported a past abdominal hysterectomy with complications caused by symptomatic myomatous uterus. As a gynecologic natural orifice surgery approach, the transvaginal-laparoscopic anterior rectum resection may be an additional useful surgical technique that could be offered by surgical gynecologists to some women with deep-infiltrating endometriosis.
As a important part of endocrine surgery, laparoscopic surgery has become the gold standard for the treatment of benign symptomatic ovarian cysts refractory to medical treatment. In fact, the stripping technique seems to be the most common technique used for ovarian cyst surgery. After stripping the cystic wall, the subsequent bleeding of the ovarian stromal wound ground is usually controlled by bipolar coagulation or/and by suturing. Potentially, the surgery-induced ovarian tissue damage will be increased by heat and/or by sutures. In respect to intraovarian hemostasis, the use of gelantine-thrombin-matrix might protect from additional ovarian tissue damage, which is of great importance for the ovarian reproductive function in woman. For the first time, our data do support a promising laparoscopic technique demonstrating ovarian cystectomy without any bipolar coagulation and/or suturing of ovarian tissue using a gelantine-thrombin-matrix sealant (FloSeal) as a new tool to control post-cystectomy ovarian wound bleeding.
For women taking tamoxifen, recent data strongly support the estrogen agonist role of tamoxifen as a causal factor for the increased risk of endometriosis, but also of leiomyomata, endometrial polyps, and endometrial hyperplasia.
A 54-year-old perimenopausal woman on tamoxifen (20 mg/day), gravida 0, with surgically treated invasive lobular breast cancer and extensive lobular carcinoma in situ (pT2 (m) pN0 (snl) pL0 G2 pTis (LCLIS) R0 M0 Ki-67 1%, ER+, PR+, Her-2-neu-negative) was referred for evaluation of a pelvic mass. The ultrasonographic examination showed a regular endometrium of less than 6 mm thickness, a uterine myoma (approximately 3 cm in diameter), a right-sided sactosalpinx (7.7 x 3.6 x 5.7 cm), an ovarian cyst on the right side (approximately 4 cm), and a left-sided ovarian cyst (approximately 3 cm in diameter) without any malignancy criteria. The CA-125 level was normal (9.4 U/ml). With the exception of a decreased serum progesterone level; the endocrine status showed no sign of ovarian insufficiency (LH 5.6 mIU/ml, FSH 9.0 mIU/ml, estradiol 103.7 pg/ml, progesterone 1.51 ng/ml, testosterone 0.11 ng/ml, DHEA-S 62.3 microg/dl, SHBG 64.39 nmol/l, free androgen index 0.6). During laparoscopy 2 uterine subserous leiomyomata, a right-sighted sactosalpinx, bilateral ovarian cysts, and an extended polypoid, vascularized endometriosis of the bladder peritoneum, the pelvic wall and Douglas pouch were found. Complete pelvic deperitonealization, bilateral adnexectomy, and also enucleation of the 2 leiomyomata were performed.
Pathological examination confirmed the sactosalpinx. In the cystic ovary (right side), a serous cystadenoma close to a hemorrhagic corpus luteum (HCL) was diagnosed. The left ovary showed another HCL. The removed leiomyomata did not show atypia or significant mitotic activity. The endometriotic lesions presented strong expression of the estrogen receptor, the progesterone receptor, and the proliferation marker MIB-1. In addition, there was no HER-2-neu expression. A switch to the aromatase inhibitor letrozol was recommended.
The possibility of tamoxifen-induced or tamoxifen-driven endometriosis in peri- or postmenopausal patients with breast cancer should be considered.
... This discovery indicates, that the smooth muscle cells were of new origin in the differentiation process. 8,18 In summary, transvaginal and inguinal ultrasound was the method of choice to investigate the extension of an inguinal endometriosis. The laparoscopy should be performed, in order to exclude or treat a pelvic endometriosis. ...
... Laparoscopically assisted rectal resection and transvaginal specimen retrieval (LARRT) for DIE patients has been originally described by Nezhat et al. [12][13][14] in 1992. Several groups have confirmed the feasibility of this approach in case series [5,[15][16][17][18][19][20][21]. Potential concerns, however, include functional postoperative problems e.g., due to scar formation or the formation of recto-vaginal fistulas as a postoperative complication. ...
... Haemostatic agents are applied to covered bleeding sites under direct vision, of which the FloSeal is widely used. The FloSeal is a novel matrix haemostatic sealant composed of collagen-derived particles and topical bovine-derived thrombin, facilitating the formation of stable clots at the bleeding site (Angioli et al. 2009, Ebert et al. 2009, Song et al. 2014. Coagulation was considered inferior to the haemostasis method of suture and the FloSeal treatment in terms of ovarian reserve protection (Fedele et al. 2004, Li et al. 2009, Coric et al. 2011, El Behery et al. 2011, Song et al. 2014, Asgari et al. 2016, Zhang et al. 2016, Sahin et al. 2017, Choi et al. 2018, Shaltout et al. 2019, Xiao et al. 2019, E. Y. Park et al. 2020, S. J. Park et al. 2020, Chung et al. 2021, Park et al. 2021, Mohamed et al. 2011. ...
... Hyperperistalsis probably develops already before menarche when estradiol levels are rising and falling during "occult anovulatory cycles", in which follicles can grow to preovulatory size [151][152][153][154][155]. It may lead to injury and Fig. 4 This is a schematic demonstration of the level of detachment of archimetral tissue in healthy women and in women with uterine hypercontractility and archimetrosis. ...
