Evaluation of the performance of fertiloscopy in 160 consecutive infertile patients with no obvious pathology.
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We have defined fertiloscopy as the combination in one investigation of transvaginal hydropelviscopy, dye-test, optional salpingoscopy, and hysteroscopy, performed on an outpatient basis under local anaesthesia or neuroleptanalgesia. We have applied this approach in a routine manner to 160 infertile patients with no obvious pathology. Fertiloscopy was achieved in 154 patients (96.2%). In five patients visualization was not satisfactory because of technical problem or adhesions in the pouch of Douglas. We had one (0.6%) rectal injury, which was treated conservatively. Sixty patients (37.5%) had normal fertiloscopic examination. Endometriosis was discovered in 21 patients (13.1%) post-pelvic inflammatory disease (PID) lesions in 58 cases (36.2%), and subtle abnormalities in 15 cases (9.3%). Salpingoscopy was completed when post-PID lesions were encountered. In 39% of cases only partial examination was possible because of external tubal adhesions, but it was nevertheless sufficient to obtain a good view of the first one-third of the ampulla. In all, 74 patients (46.2%) were referred directly to in-vitro fertilization (IVF) procedures, and so avoided a further laparoscopy. Quality of imaging, accuracy of the pelvic examination in a physiological manner, and safety of the procedure are the main advantages of this minimally invasive technique. Selection of the patients for surgery is therefore enhanced, and indication for IVF is better balanced, avoiding the performance of extensive procedures in patients who should thus benefit from this less traumatic alternative. (+info)
Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility.
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In a retrospective case report series, we evaluated the efficacy of hysteroscopic adhesiolysis in patients with severe Asherman's syndrome. In 31 patients with permanent severe adhesions, hysteroscopic treatment was performed. In all patients, uterine cavity with at least one free ostial area was restored after one (n = 16), two (n = 7), three (n = 7), and four (n = 1) surgical procedures. All previously amenorrhoeic patients (n = 16) had resumption of menses. Twenty-eight patients were followed-up with a mean time of 31 months (range 2-84). Fifteen pregnancies were obtained in 12 patients and the outcomes were the following: two first trimester missed abortions, three second trimester fetal losses, one second trimester termination of pregnancy for multiple fetal abnormalities and nine live births in nine different patients. Pregnancy rate after treatment was 12/28 (42.8%) and live birth rate was 9/28 (32.1%). In patients 35 years (P = 0. 01). Three patients were lost to follow-up and their results omitted. In nine patients with live births, one Caesarean hysterectomy for placenta accreta and one hypogastric arteries ligation for severe haemorrhage and placenta accreta were performed. Hysteroscopic treatment of severe Asherman's syndrome appeared to be effective for the reconstruction of a functional uterine cavity with a 42.8% pregnancy rate. However, these pregnancies were at risk for haemorrhage with abnormal placentation. (+info)
Expanded polytetrafluoroethylene membrane for the prevention of peridural fibrosis after spinal surgery: an experimental study.
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One of the most common complications of lumbar spine surgery is peridural fibrosis, a fibroblastic invasion of the nerve roots and the peridural sac exposed at operation. Peridural fibrosis may produce symptoms similar to those the patient experienced preoperatively and, if another spinal operation is necessary, may increase the risk of injury at reexposure. In a controlled study in dogs, we assessed the use of expanded polytetrafluoroethylene (ePTFE) as a barrier to postoperative invasion of fibrous tissue into the laminectomy defect. In 14 dogs, a two-level laminectomy was done, at L4-L5 and L6-L7. In 12 dogs, an ePTFE membrane was placed directly over the dorsal surface of the laminectomy defect at L4-L5 and within the defect (over the surface of the dura) at L6-L7. No material was implanted in two dogs (controls). Tissue for histologic studies was obtained from the controls and from ten dogs with the membrane 12 weeks postoperatively. Two dogs with the membrane underwent reoperation. The study found that there was no peridural fibrosis in seven of the ten specimens in which the ePTFE membrane had been placed directly on the dorsal surface of the laminectomy defect, some peridural fibrosis in all specimens in which the membrane had been placed within the defect, and extensive fibrosis in controls. The ePTFE membrane created an excellent plane of dissection for reoperation. No foreign-body reactions to the membrane or membrane-related infections occurred. We conclude that the ePTFE spinal membrane, when properly implanted, is an effective barrier to postsurgical fibrous invasion of the vertebral canal. Clinical studies of use of this material in spinal surgery are warranted. (+info)
Expanded polytetrafluoroethylene membrane for the prevention of peridural fibrosis after spinal surgery: a clinical study.
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Peridural fibrosis developing after laminectomy may cause pain that can necessitate reoperation. Many materials have been used as a barrier to invasion of fibrous tissue into the vertebral canal, but the ideal material has not been found. Various studies in animals have achieved favourable results with an expanded polytetrafluoroethylene (ePTFE) membrane. In a prospective, randomized study, we compared postoperative results in 33 patients who had an ePTFE membrane implanted to cover the defect caused by laminectomy during lumbar spine decompression with the results in 33 patients in whom no material was implanted. At operation, an ePTFE membrane was placed after the decompression procedure to cover the laminectomy defect completely. Systematic clinical and MRI follow-up evaluations of patients with and without the membrane were conducted 3, 6, 12, and 24 months postoperatively. The effect of ePTFE membrane implantation over laminectomy sites on postoperative peridural fibrosis, pain and neurological claudication was assessed. The ePTFE-membrane group had a significantly lower rate of epidural fibrosis on MRI (P<0.0001) and of clinical manifestations of radiculalgia (P = 0.002) compared with the no-material group. Epidural fibrosis that occurred in the ePTFE group was generally less extensive than that in the no-material group. There was no significant difference in the rate of postoperative claudication in the two groups. Significantly more seromas occurred in the ePTFE group (P = 0.0002). There were no infections or other complications in either group. The results showed that placement of an ePTFE spinal membrane over the laminectomy defect produced by lumbar spine surgery provided a physical barrier to invasion of fibrous tissue into the vertebral canal, and patients with the membrane had less postoperative radicular pain. (+info)
Adhesion preventive effect of hyaluronic acid after intraperitoneal surgery in mice.
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Prevention of intraperitoneal adhesion after gynaecological surgery is essential for maintaining postoperative fertility. In this study, the adhesion prevention effect was examined of a hyaluronic acid (HA) solution obtained from the fermentation method and having a molecular weight of 1.9x10(6) with high viscosity. Laparotomy was conducted on female mice 7 weeks old, whose menstrual periods were synchronized by pregnant mare serum gonadotrophin (PMSG) to injure the uterine horn surface. Intraperitoneal adhesions were favourably formed in 91.7% of cases induced with iodine abrasion, compared with 50% induced by electrosurgery. Intraperitoneal administration of HA was evaluated for its effect on the prevention of adhesions made by iodine abrasion. Adhesion prevention effects of HA were observed at concentrations of 0.3, 0.5, 0.75 and 1.0%, among which the most pronounced effect was with the use of a 0.3% solution (92.3% of cases). Compared with the control group adhesion score of 2.0 +/- 0. 8, significant decreases in adhesion scores were observed at all concentrations. HA with a molecular weight of 1.9x10(6) was recognized to have a definitive prevention effect on postoperative adhesions in mice after laparotomy and is considered to be a prospective material for future clinical use. (+info)
Nitric oxide modulation of focal adhesions in endothelial cells.
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A permissive role of nitric oxide (NO) in endothelial cell migration and angiogenesis promoted by vascular endothelial growth factor (VEGF), endothelin, and substance P has previously been established. The present studies were designed to examine the mechanism(s) involved in the NO effect on focal adhesions. Time-lapse videomicroscopy of human umbilical vein endothelial cells (HUVECs) plated on the silicone rubber substrate revealed that unstimulated cells were constantly remodeling the wrinkling pattern, indicative of changing tractional forces. Application of NO donors reversibly decreased the degree of wrinkling, consistent with the release of tractional forces exerted by focal adhesions and stress fibers. Morphometric and immunocytochemical analyses showed that NO inhibited adhesion and spreading of HUVECs and attenuated recruitment of paxillin to focal adhesions. NO also had a profound dose-dependent effect on the formation of stress fibers by HUVECs. De novo formation of focal adhesions in HUVECs was significantly diminished in the presence of NO donors. Migration of HUVECs showed an absolute requirement for the functional NO synthase. NO donors did not interfere with focal adhesion kinase recruitment to focal adhesions but affected the state of its tyrosine phosphorylation, as judged from the results of immunoprecipitation and immunoblotting experiments. Videomicroscopy of HUVECs presented with VEGF in a micropipette showed that the rate of cell migration was slowed down by NO synthase inhibition as well as by inhibition of tyrosine phosphorylation. Collectively, these data indicate that NO reversibly releases tractional forces exerted by spreading endothelial cells via interference with the de novo formation of focal adhesions, tyrosine phosphorylation of components of focal adhesion complexes, and assembly of stress fibers. (+info)
How long does laparoscopic surgery really take? Lessons learned from 1000 operative laparoscopies.
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The purpose of this study was to assess the operating time of the most common gynaecological laparoscopic procedures. We analysed retrospectively 1000 consecutive operative laparoscopies on a procedure-by-procedure basis. Diagnostic laparoscopy and laparoscopic sterilization were specifically excluded from the analysis. The various laparoscopic procedures were grouped and analysed under six major categories. The average operating time for all cases was 76.9 min (range 10-400). In 38 cases (3.8%) the laparoscopic procedure was converted to laparotomy. The average operating time for treating ectopic pregnancy and tubal disease was approximately 60 min (range 13-240). Surgery for endometriosis and ovarian cysts averaged 72 min (range 10-240). Laparoscopic myomectomy and hysterectomy averaged 113 and 131 min respectively (range 25-400). Our results show that while the operating time for most operative laparoscopies is less than 75 min, the range of operating times is great. The relative lack of predictability in procedure times means that the efficient utilization of fixed theatre sessions is difficult. (+info)
The role of neutrophils in the formation of peritoneal adhesions.
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The most common cause of intraperitoneal adhesions which may result in infertility and intestinal obstruction is previous abdominal surgery. Surgical trauma of the peritoneum in the absence of infection elicits a rapid and transient influx of polymorphonuclear leukocytes (PMN) into the peritoneal cavity. The role of neutrophils in intraperitoneal adhesion formation has not been studied. We aimed to study the effects of PMN counts and PMN functions on peritoneal adhesion formation. Forty peritoneal adhesion-induced rats were randomly divided into three groups; group I, receiving saline; group II, receiving cyclophosphamide; and group III, receiving granulocyte-macrophage colony-stimulating factor (GM-CSF). In all groups, peritoneal lavage was performed to determine PMN counts the day after adhesion induction. Blood neutrophil counts and neutrophil functions were also determined. Adhesions were evaluated blindly 14 days after the operation. Adhesion tissue samples were microscopically evaluated. Tissue hydroxyproline and collagen concentrations were measured. The neutrophil counts and phagocytosis significantly increased in group III and neutrophil counts decreased in group II (P < 0.05). The score of adhesion formation in group II was significantly less than that in groups I and III (P < 0.05). Hydroxyproline concentrations of adhesion tissue were significantly decreased in group II when compared with group III (P < 0.05). The present study shows that neutropenia lowers the degree of postoperative adhesion formation. It is concluded that PMN may have a role to play in modulating post-operative adhesion formation. (+info)