Laparoscopy Today

CONFERENCE REPORT: PLEASE CHECK MY BLADDER BEFORE YOU REMOVE MY FEMALE ORGANS! IT IS NOT JUST ENDOMETRIOSIS: THE NEW INSIGHT FOR TREATING LOW ABDOMINAL AND PELVIC PAIN IN WOMEN

FROM THE 15th SLS ANNUAL MEETING AND ENDO EXPO 2006, BOSTON, MASS, SEPTEMBER 6-9, 2006
GENERAL SESSION: BEST OF LAPAROSCOPY UPDATES

ABDOMINAL AND PELVIC PAIN

MAURICE K. CHUNG, MD, RPh

Chronic pelvic pain can has many causes, including ailments occurring in the pelvic region, such as endometriosis, and in the bladder, for instance interstitial cystitis. Symptoms may be similar, and more than one condition may occur at the same time. Chronic pelvic pain, therefore, should be considered a multi-organ disease and treated accordingly.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

CONFERENCE REPORT: Scoping Out New Options in Pelvic Reconstruction

FROM THE 15TH INTERNATIONAL CONGRESS AND ENDO EXPO
LAPAROSCOPY UPDATE: ABDOMINAL/PELVIC PAIN/ADHESIONS

CONRAD DUNCAN, MD

Members of SLS support both the application of minimally invasive innovations as well as the application of evidenced-based medicine in our surgical practices.

In the past 10 years, urologists and gynecologists have witnessed the introduction and widespread adoption of the use of synthetic mesh in the management of patients with stress urinary incontinence (SUI). The introduction of the Tension Free Vaginal Tape‚ essentially revolutionized the treatment of SUI. “Long term” (10 yr) data has shown the tension-free mid-urethral sling to be a relatively safe and efficacious minimally invasive treatment option for SUI.

We are now witnessing the propagation of the use of synthetic mesh in the correction of a wide range of vaginal vault defects including total uterine prolapse. Surgical application of mesh for the repair of pelvic organ prolapse has been based on theoretical principles, extrapolation from the general surgery literature, industry sponsorship and surgeon preference, as we do not yet have evidence-based data to support their widespread use. Yet, many pelvic reconstructive surgeons have embraced their application as an even more minimally invasive alternative than laparoscopic pelvic reconstruction.

We will review the anatomical and surgical principles involved in the placement of a total vaginal mesh, review the surgical technique in video and review some of the preliminary surgical outcomes data.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: J Minim Invasive Gynecol Intestinal Endometriosis

Laparoscopic Resection of Intestinal Endometriosis: A 5-Year Experience. Ribeiro PAA et al. 2006;13(5):442-446 • The authors set out to describe the clinical manifestations, surgical techniques, and observed complications in patients undergoing laparoscopic resection of intestinal deeply infiltrating endometriosis. Ribeiro PAA et al describe their evaluation of and 7-step surgical technique for treating 125 patients who underwent laparoscopic radical excision followed by resection of the rectosigmoid colon for treatment of intestinal endometriosis. The authors concluded that symptoms of intestinal endometriosis are not specific; laparoscopy is a safe and effective treatment; and special attention must be given to intestinal anastomosis and nerve preservation.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Laparoscopic Abdominal Access

EXCERPT FROM NEW TEXTBOOK
Prevention and Management of Laparoendoscopic Surgical Complications, 2nd Edition

CAMRAN NEZHAT, MD, NANETTE LASHAY, MD, JOHN MORTON, MD, MASSIMILIANO MARZIALI, MD

PATIENT PREPARATION AND POSITION

The anesthesiology team and circulating nurses coordinate the patient's transfer onto the operating table. The operative site is cleansed and shaved preoperatively. Operating tables must be designed to provide a 25-degree Trendelenburg position. After the induction of endotracheal anesthesia, an oral or nasogastric tube should be placed to deflate the stomach. Sequential compression devices are placed on the legs, which are then placed in padded stirrups to provide good support and proper position. Padding near the peroneal nerve is essential. To avoid nerve compression, no leg joint is extended more than 60 degrees for pelvic procedures. The buttocks must protrude a few centimeters from the edge of the table to allow uterine manipulation. The patient's arms are placed at the side, padded with foam troughs, and secured by a sheet. This allows the surgeon and assistants to stand unencumbered next to the patient. The anesthesiologist should have easy access to the patient's arm (Figure 1).

Once the patient is positioned, her abdomen, perineum, and vagina are prepared with a suitable bactericidal solution, and a Foley catheter is inserted. She is draped to expose the abdomen and perineum, and a pelvic examination is performed. Cystoscopy may be indicated for male or female patients and hysteroscopy may be indicated for female patients undergoing diagnostic and operative laparoscopy. After withdrawal of the hysteroscope, a uterine manipulator is inserted into the cervical os to manipulate the uterus and for chromopertubation. Rectal and vaginal probes can help separate the tissue planes of the cul-de-sac. The assistant can do a simultaneous rectal and vaginal examination for the same purposes. A sponge on a ring forceps is placed in the posterior fornix to outline the posterior cul-de-sac or anteriorly to identify the vesicouterine space. In patients who are suspected of having rectosigmoid endometriosis, a sigmoidoscopic examination is suggested. The rectum is insufflated to look for bubbles as they pass into the posterior cul-de-sac filled with irrigation fluid [1].

PLACEMENT OF THE VERESS NEEDLE

Insertion of the Veress needle, the primary trocar, and the secondary trocars is an important aspect of diagnostic and operative laparoscopy. Serious complications and injuries can occur during these procedures. The following factors increase the risk of injury:

1.   Previous abdominal and pelvic operations

2.  Body weight (whether patient is very obese or very thin)

3.  A large uterus and the presence of a large pelvic mass

4.  Failure to deflate the stomach with an oral or nasogastric tube

The optimal location for the Veress needle and primary trocar is intraumbilical because the skin is attached to the fascial layer and anterior parietal peritoneum with no intervening subcutaneous fat or muscle. The transumbilical approach accounts for the shortest distance between the skin and the peritoneal cavity even in obese patients. When a patient is morbidly obese, or her umbilicus exhibits poor hygiene, or a suspicion exists of an umbilical hernia, initial placement can be above or below the umbilicus. These sites sometimes are modified. The primary trocar is inserted above the umbilicus even subxiphoid in patients who have an enlarged uterus caused by a uterine leiomyoma, pregnancy, or sometimes for para-aortic lymph node dissection.

Before the needle is inserted, a transverse or vertical cutaneous incision is made large enough to accommodate the primary trocar. A vertical umbilical incision provides better cosmetic results.2 When one is incising the umbilicus, a skin hook is used to grasp and evert the base of the umbilicus, raising it from the abdominal structures. If needed, and especially in the case of morbidly obese patients, a Kocher clamp can be used to grasp the fascia, lift up, and further increase the distance between the fascia and underlying abdominal structures.

One should check the patency of the Veress needle before it is inserted. Traditionally, the angle of insertion is approximately 45 degrees for an intraumbilical placement while the patient is horizontal; a premature Trendelenburg position alters the usual landmarks (Figure 3). Transumbilical placement with a 90-degree angle of insertion is recommended after proper training with this technique. Palpating the abdominal aorta and the sacral promontory is performed first. The patient is completely flat, and the operating table is all the way down to maximize the surgeon's upper body control during insertion of the Veress needle. The Veress needle, held at the shaft, is directed toward the sacral promontory (Figure 4). The surgeon and assistant apply counter traction by grasping the skin and fat on each side of the umbilicus with a towel clamp [3]. In obese patients, a 90-degree angle is necessary initially to enter the peritoneal cavity. In thin individuals, vital structures are closer to the abdominal wall, so the surgeon makes certain that the abdominal wall is elevated and only a small portion of the needle is inserted into the abdominal cavity. That is rarely more than 2 cm to 3 cm of the Veress needle or trocar. A prospective study [4] involving 97 women undergoing operative laparoscopy showed that the position of the aortic bifurcation is more likely to be caudal to the umbilicus in the Trendelenburg position, compared with the supine position regardless of body mass index. Its presumed location can be misleading during Veress needle or primary trocar insertion. The physician must be careful to avoid major retroperitoneal vascular injury during this procedure.

VERIFICATION OF INTRAPERITONEAL LOCATION

Failure to achieve and maintain a suitable pneumoperitoneum predisposes the patient to complications.

“Hanging Drop” Method

Correct needle placement is verified by the “hanging drop” technique. A drop of saline is placed on the hub of the Veress needle after insertion through the abdominal wall. Lifting the abdominal wall establishes negative pressure within the abdomen, drawing the drop of fluid into the needle. Absence of this sign indicates improper placement of the Veress needle.

Additional methods of verifying proper placement of the Veress needle are summarized in Table 1.

PLACEMENT OF THE PRIMARY TROCAR

The sharp primary trocar is aimed toward the sacral promontory. Dull trocars require increased force during insertion, multiple insertions, and excessive instrument manipulation. The insertion of a disposable-shielded trocar in the presence of a pneumoperitoneum requires half the force needed for the insertion of a reusable sharp trocar. The disposable trocar shield does not completely prevent injury [11]. Using these new devices can inflict injury because of the unexpected ease of their insertion. Numerous mesenteric, bowel, and vascular injuries have been reported with the use of disposable trocars.

A pneumoperitoneum reduces the proximity of the abdominal wall to the spine and the potential for damage to bowel and vessels [12]. Whether a pneumoperitoneum is associated with a lower incidence of trocar-related injuries is unproved.

Conventional Technique

The direction of trocar insertion is 90 degrees to the abdominal wall plane toward the sacral
promontory. Control of the laparoscopic trocar is essential as it penetrates each layer of the anterior abdominal wall. The trocar is inserted with the patient in a horizontal position because viscera tend to slide away from the advancing trocar. A premature Trendelenburg position does not prevent visceral injury even if significant adhesions are present. Altering the patient's position affects the surgeon's view of important landmarks, such as the sacral promontory and hollow of the sacrum. The major anatomic landmarks include the umbilicus located at the level of L3 and L4. The abdominal aorta bifurcates between L4 and L5.

In a program for laparoscopic sterilization, Soderstrom and Butler [13] revealed that the complication rate was reduced 10-fold when a consistent operating format was used. Successful insertion depends on an adequate skin incision; trocars in good working condition (disposable trocars should be checked to be sure they are not locked); proper orientation of the trocar, sheath, and surgeon's hand; and control over the instrument's force and depth of insertion.

With all trocar insertions, the surgeon must hold the instrument properly with the patient in a supine position at the height of the surgeon's waist or slightly below it. The trocar and its sleeve are held with the index finger extended to the level of the maximal planned penetration to prevent the sharp trocar tip from thrusting too deeply. The trocar is held in the palm of the dominant hand. It is rotated in a semicircular fashion with its long axis as controlled, firm downward pressure is applied (Figure 8). As the trocar is advanced, the operator senses when the fascia is traversed; the force is reduced as the trocar is advanced slowly to enter the peritoneum. Disposable pyramidal tip trocars are preferable. Flat dilating tip trocars leave a smaller fascial defect, but require more force pressure with less control. A disposable-shielded trocar has the advantage of a sharp instrument for each operation.

Direct Insertion

Trocar insertion without creating a pneumoperitoneum initially reduces the number of preliminary procedures, saving operative time and preventing potential complications. Direct insertion is a safe alternative to initially creating a pneumoperitoneum [14-21]. Nezhat and associates [14] compared the ease and safety of creating a pneumoperitoneum with those of direct insertion of either a reusable trocar or a disposable shielded trocar in 200 patients in a randomized, prospectively controlled study (Tables 2 and 3).

The direct trocar technique as described by Nezhat [22] consists of placing the patient in the supine position with her legs in Direct OR stirrups after general anesthesia is induced. She is prepped and draped in the usual sterile fashion. A transurethral Foley catheter is placed for intraoperative bladder drainage. The stomach is decompressed with a nasogastric or orogastric tube. The operating table is lowered at or below the level of the surgeon's waist. After palpating the bifurcation of the aorta and sacral promontory, the umbilical skin is elevated with a skin hook and a 1-cm incision is made sharply with a scalpel. The anterior abdominal wall is then elevated by using 2 towel clamps placed on either side of the umbilicus. While elevating the anterior abdominal wall away from the underlying viscera, the surgeon holds a 10-mm trocar with his index finger positioned 3 cm away from the trocar tip to guard against sudden uncontrolled entry into the abdomen. The trocar is inserted at a 90-degree angle and advanced in a controlled fashion into the peritoneal cavity with a twisting semicircular motion. The laparoscope is then introduced, proper intraperitoneal placement ascertained, and pneumoperitoneum created with high-flow insufflation. The underlying structures are then carefully inspected for injury.

Open Laparoscopy

In 1971, Hasson [23] introduced the concept of open laparoscopy to eliminate the risks associated with insertion of the Veress needle and trocar. This technique involves direct trocar insertion through a small skin incision without prior pneumoperitoneum. Specially designed equipment consists of a cannula and trumpet valve fitted with a cone-shaped sleeve. A blunt obturator protrudes 1cm from the tip of the cannula. The cone sleeve seals the peritoneal and fascial gap.

A small transverse, curved, or vertical incision is made at the umbilicus. Two Allis clamps, a knife handle with a small blade, a straight scissors, a tissue forceps with teeth, a right-angle skin hook, 4 S-shaped retractors, a needle holder, 2 curved Kocher clamps, and 4 small curved hemostats are needed. As the incision is made, Allis clamps or a self-retaining retractor is used to provide adequate exposure. Once the fascia is cut, a 1-cm incision is made in the peritoneum. One suture of 0 polydioxanone (Ethicon) is passed through each peritoneal edge and fascia and tagged. The cannula carrying the blunt obturator is inserted through the opening into the peritoneal cavity. The obturator is withdrawn, and CO2 is insufflated through the cannula, which is inserted as deeply as required to prevent leakage. The previously placed sutures are used to fix the trocar sleeve so that the laparoscope can move freely within the abdominal cavity. At the end of the procedure, the abdominal wall is closed, by using the previously placed sutures.

Open laparoscopy usually takes about 5 minutes to 10 minutes longer than closed laparoscopy performed by operators with comparable expertise. In more than 1000 consecutive operations done by Hasson [23], the frequency of minor wound infection was 0.6% and that of small bowel injury was 0.1%. In a review of the laparoscopic complications, the open techniques reduced the incidence of failed procedures, inappropriate gas insufflation, gas embolism, bladder and pelvic kidney punctures, major vessel injuries, and postoperative herniations [24].

In a survey conducted by Penfield [25], intestinal lacerations are the most serious complication of open laparoscopy, and most of those lacerations occurred during the early use of this technique. In 10,840 open laparoscopies attempted by 18 board certified obstetricians/gynecologists, 6 bowel lacerations were reported, 4 were recognized and repaired, and 2 were not suspected until several days postoperatively.
To reduce the risk of bowel laceration, the surgeon should use a focus spotlight, work with an experienced assistant, make a vertical incision to facilitate exposure, grasp and elevate the fascia with small Kocher clamps, and cut between the clamps. A gynecologist who attempts open laparoscopy usually will find that the procedure is slow and cumbersome because of difficulty in exposing and identifying each layer of the abdominal wall.

ACCESSORY TROCARS

Additional cannulas are needed through which various instruments are inserted into the abdomen for manipulation and operative procedures. Placement sites depend on the patient's anatomy, the contemplated procedure, and the surgeon's preference. For diagnostic purposes, an incision generally is made 4 cm to 5 cm above the symphysis pubis in the midline. This area, delineated by the 2 umbilical ligaments and the bladder dome, is safe and usually avascular.

For operative laparoscopy, 2 accessory trocars (5 mm) are placed 4 cm to 5 cm above the symphysis pubis at the outer border of the rectus muscle, 3 cm to 4 cm below the iliac crest, 2 cm to 3 cm lateral to the deep inferior epigastric vessels. These trocars are inserted under direct vision to lessen the risk of intraabdominal visceral, uterine, and vascular injury and to provide free access to the posterior cul-de-sac. Vascularization of the lower abdomen is provided by 2 vessels: the deep inferior epigastric originating from the external iliac artery and the superficial epigastric, a branch of the femoral artery. Transillumination helps identify the superficial vessels, but they are difficult to see in obese patients. The deep inferior epigastric vessels run lateral to the umbilical ligaments and are seen intraperitoneally and identified easily. These vessels pass the round ligament, proceed to the anterior abdominal wall, and are seen above the peritoneum. To avoid injuring these vessels, the trocar is inserted medial or lateral to the umbilical ligaments by viewing the underside of the abdomen wall laparoscopically (Figure 11). Despite these precautions, aberrant vascular branches occasionally are traumatized, and the operator must be able to manage this type of injury.

To reduce the chance of trauma to the abdominal structures, the proposed site for the secondary puncture is indented by applying abdominal pressure with the index finger and observing the peritoneal surface with the laparoscope. Next, mapping of the potential sites for accessory trocar placement is done by advancing the tip of an 18-gauge needle attached to a syringe transabdominally through the peritoneum, revealing the exact course and placement of the accessory trocar. This allows optimal placement. These maneuvers are important, particularly in a patient with evidence of abdominal wall adhesions, and help ensure safe access.

After the skin incision has been made, the trocar, held with the index finger extended on the sheath to control the depth of penetration, is inserted through the fat and fascia. Further advancement is controlled under laparoscopic view. The trocar is aimed toward the center of the abdomen and hollow of the sacrum. If it is aimed laterally, it can slide down the pelvic side wall without being seen through the laparoscope, resulting in injury to the iliac vessels. The accessory trocars are never inserted without laparoscopic observation of their indentation on the abdominal wall or before mapping the abdomen. When insertion of the trocars is viewed directly from the monitor, the surgeon should be sure the camera has not been rotated so that it shows the wrong view of the pelvis. Other sites of entry include the midpoint between the symphysis pubis and the umbilicus and McBurney's point.

Some accessory trocar sleeves are too long or too short to allow free access to the pelvic structures and tend to slip out of the peritoneal cavity. The presence of trap valves can interfere with efficient instrument exchange, prevent the introduction and removal of suture material, and prevent the removal of tissue. Several accessory trocar sleeves either screw in or have an umbrella to secure them to the abdominal wall. Radially expanding trocars may reduce laparoscopic complications, lessen a surgeon's exposure to liability, and improve patient outcomes [26]. Two hundred twelve women underwent various laparoscopic procedures involving the placement of 541 radially expanding access cannulas and no major complications occurred. One patient developed a postoperative mesenteric hematoma that was assumed to be secondary to a venous injury from the Veress needle. Despite the absence of fascial anchoring devices, only six (1%) cannulas slipped.

Figure 1. This patient is in a dorsolithotomy position, but the thighs are not flexed so that the suprapubic trocars may be maneuvered.

Figure 3. Angle of trocar insertion with operating table in flat (A) and Trendelenburg (B) positions.

Figure 4. Note the anatomic location of the umbilicus and abdominal aorta in nonobese (A), overweight (B), and obese (C) patients.

Figure 8. Countertraction is applied by grasping the lower abdomen; the surgeon inserts the trocar into the abdomen by palming it and using the index finger as a guard against sudden entry into the abdomen. Inset shows the position of the trocar and intestines.

Figure 11. Accessory trocars are placed under direct vision to avoid injury to the inferior epigastric vessels and any organs that may be adherent to the pelvic sidewall or the anterior abdominal wall. The trocar is inserted lateral to the left umbilical ligament. To avoid inferior epigastric vessels that are invariably lateral to umbilical ligaments.

Camran Nezhat, MD, is Clinical Professor of Gynecology and Obstetrics and Clinical Professor of  Surgery at Stanford University Medical School, Stanford  University; Director of the Center for Special Minimally Invasive Surgery; and Past President of the Society of Laparoendoscopic Surgeons. Dr Nezhat pioneered the technique of operating endoscopically directly off the video monitor (videolaparoscopy) which revolutionized  modern day endoscopic surgery and has performed  many procedures laparoscopically for the first time.

Nanette LaShay, MD, is a part of The Permanente Medical Group in the Department of Obstetrics and Gynecology of Redwood City Medical Center and is an Adjunct Clinical Faculty member at Stanford University Medical Center. Dr LaShay received specialty training in advance laparoendoscopic surgery for extensive endometriosis, infertility, and fibroids at Stanford University School of Medicine as a Fellow in the Center for Special Minimally Invasive Pelvic Surgery.

John Morton, MD, is the Assistant Professor of Surgery and the Director of Bariatric Surgery at Stanford University Medical Center in Stanford, California. In 2005, Dr Morton received the Stanford School Medicine Excellence in Teaching award. He is an Associate Editor of Surgery for Obesity and Related Diseases, the official journal of the American Society for Bariatric Surgery. Dr Morton's research interests include bariatric surgery, evidence-based surgery, and surgical education.

Massimiliano Marziali, MD, is with the Hospital University Tor Vergata of Rome School of Medicine in the Section of Gynecology and Obstetrics, Department of Surgery. Dr Marziali has contributed to articles recently published in JSLS, Journal of the Society of Laparoendoscopic Surgeons, the Journal of Minimally Invasive Gynecology, and the Journal of Reproductive Medicine.

References

1. Nezhat C, Nezhat F, Pennington E. Laparoscopic treatment of infiltrative rec- tosigmoid colon and rectovaginal septum endometriosis by the technique of video- laseroscopy and the CO2 laser. Br J Obstet Gynaecol. 1992;99:664-667.

2. East MC, Steele PRM. Laparoscopic incisions at the lower umbilical verge. Br Med J. 1988;296:753-754.

3. Loffer FD. Endoscopy in high risk patients. In: Martin DC, ed. Manual of Endoscopy. Santa Fe Springs, CA: American Association of Gynecologic Laparoscopists; 1990.

4.    Nezhat F, Brill AI, Nezhat CH, et al. Laparoscopic appraisal of the anatomic relationship of the umbilicus to the aortic bifurcation. J Am Assoc Gynecol Laparosc. 1998;5:135-140.

11.    Corson SL, Batzer FR, Gocial B, Maislin C. Measurement of the force necessary for laparoscopic entry. J Reprod Med. 1989;34:282-284.

12.    Phillips JM. Laparoscopy. Baltimore, MD: Williams & Wilkins; 1977.

13.    Soderstrom RM, Butler JC. A critical evaluation of complications in laparoscopy. J Reprod Med. 1973; 10:245-248.

14.    Nezhat FR, Silfen SL, Evans D, Nezhat C. Comparison of direct insertion of dispos- able and standard reusable laparoscopic trocars and previous pneumoperitoneum with veress needle. Obstet Gynecol. 1991;78:148-150.

15.    Borgatta L, Gruss L, Barad D, Kaali SG. Direct trocar insertion versus Veress needle use for laparoscopic sterilization. J Reprod Med. 1990;35:891-894.

16.    Jarrett JC. Laparoscopy: direct trocar insertion without pneumoperitoneum. Obstet Gynecol. 1990;75:725-727.

17.    Kaali SG, Bartfai G. Direct insertion of the laparoscopic trocar after an earlier laparotomy. J Reprod Med. 1988;33:739-340.

18.    Saidi MH. Direct laparoscopy without prior pneumoperitoneum. J Reprod Med. 1986;31:684-686.

19.    Copeland C, Wing R, Hulka JF Direct trocar insertion at laparoscopy: an evaluation. Obstet Gynecol. 1983;62:655-659.

20.    Dingfelder JR. Direct laparoscopic trocar insertion without prior pneumoperitoneum. J Reprod Med. 1978;21:45-47.

21.    Byron JW Markenson GA. A randomized comparison of Veress needle and direct trocar insertion for laparoscopy. Surg Gynecol Obstet. 1993;177:259-262.

22.     Jacobson MT, Osias J, Bizhang R, et al. The direct trocar technique: an alternative approach to abdominal entry for laparoscopy [erratum in: JSLS. 2002; 6(3):224]. JSLS.2002; 6(2):169-174.

23.    Hasson HM. Open laparoscopy versus closed laparoscopy: a comparison of complication rates. Adv Plan Parent. 1978;13:41-50.

24.    Gomel V, Taylor PJ, Yuzpe AA, Rioux JE, eds. The technique of endoscopy. In: Laparoscopy and Hysteroscopy in Gynecologic Practice. Chicago, IL: Year Book; 1986.

25.    Penfield AJ. How to prevent complications of open laparoscopy. J Reprod Med. 1985;30:660-663.

26.    Galen DI, Jacobson A, Weckstein LN, Kaplan RA, DeNevi KL. Reduction of cannula-related laparoscopic complications using a radially expanding access device. J Am Assoc Gynecol Laparosc. 1999;6:79-84.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Chronic Pelvic Pain: Endometriosis and Interstitial Cystitis

LAPAROSCOPIC UPDATE

MAURICE K. CHUNG, MD, RPH

INTRODUCTION

The more common gynecologic diagnoses of chronic pelvic pain (CPP) are pelvic adhesions, adnexal cysts, endometriosis, endosalpingiosis, ovarian remnant syndrome, pelvic congestion syndrome, residual ovarian syndrome, pelvic inflammatory disease, adenomyosis, and uterine leiomyomatas [1,2]. Often, management of women with CPP involves invasive procedures or surgical interventions. In fact, more than 40% of laparoscopies and 10% to 12% of all hysterectomies are performed as a result of CPP, which contributes to its significant economic burden [3,4]. Endometriosis is one of the more prevalent gynecologic diagnoses among women with recurrent and progressive CPP [1]. Among 58 patients who presented to a pelvic pain center for treatment, 48 (83%) had biopsy confirmed active endometriosis [5]. This finding is consistent with findings in the current literature [3,6-10]. Endometriosis is the presence of ectopic endometrial glandular tissue outside of the endometrial cavity. Symptoms include dyspareunia; cyclic premenstrual, menstrual, or both, low abdominal pelvic pain; irritative voiding; and flares after sexual intimacy [11]. Ideally, the diagnosis of endometriosis involves visual confirmation of the lesion during laparoscopy and histologic confirmation of the presence of both ectopic endometrial glands and stroma [11].

INTERSTITIAL CYSTITIS
Painful Bladder Syndrome

Interstitial cystitis (IC), or pelvic pain of bladder origin, occurs predominantly in women 30 to 59 years of age,12 with up to 85% of reported cases in those 40 to 45 years of age [13,14]. Along with endometriosis, IC is considered one of the more common disorders associated with CPP [15]. Yet, only 500,000 patients with debilitating bladder problems have been diagnosed with IC, while the number of those with undiagnosed IC has been estimated to be more than 8 million [16]. Still, some estimates range up to 28 million, with the overwhelming majority of these individuals incorrectly diagnosed or undiagnosed [17].

Symptoms include urinary urgency, frequency and/or pelvic pain in the absence of urinary tract infection. Although these symptoms represent the classic triad of IC, some patients have no pain and present with symptoms of overactive bladder. In addition, 15% of patients present with chronic pain and no urologic symptoms [16]. Furthermore, many patients have dyspareunia and cyclic premenstrual, menstrual, or both, low abdominal pain exacerbated by sexual intimacy [16,18].

In the mid-1980s, the National Institutes of Health-National Institute of Diabetes and Digestive and Kidney Diseases (NIH-NIDDK) established clinical and cystoscopic diagnostic criteria for research studies of IC (Table 1) [19,20]. The consensus criteria for diagnosis of IC, including exclusions and cystoscopic evidence of ulcers and glomerulations, were widely accepted for both clinical and research purposes and thereafter became the de facto criteria for establishing a clinical diagnosis [20,21]. Glomerulations, however, are not pathognomonic of IC (Figure 1) [19,21]. A recent study reported glomerulations in about 45% of “normal” women undergoing tubal ligation [22]. Unfortunately, the women were not specifically questioned about urinary or gynecologic symptoms, such as CPP, and were not asked to complete voiding logs or pain questionnaires. Some of these women may have had occult IC characterized by pelvic pain, irritative voiding symptoms, or both of these [21].

Figure 1. Left lower corner shows mucosal cracks, which are frequently found in patients with IC. All the others show glomerulations.

The NIH-NIDDK criteria were found to be too restrictive for clinical use based on results of the Interstitial Cystitis Database Study because more than 60% of patients evaluated by experienced clinicians and thought to have or to definitely have IC did not meet the NIH-NIDDK criteria [19].

Similar to the diagnostic criteria for IC, the pathogenesis and cause of IC remain incompletely defined. A consensus is emerging, however, regarding the central role of bladder epithelial dysfunction, bladder sensory nerve upregulation, and mast-cell activation in the genesis of IC [16,23]. The urothelial surface is lined by impermeable bladder surface mucin composed of sulfonated glycosaminoglycans and glycoproteins. Injury to this surface can cause changes in permeability that allow potassium ions to traverse the urothelium, depolarize sensory and motor nerves, and activate mast cells [18,23,24].

On the basis of this hypothesis, Parsons et al [25] developed the Potassium Sensitivity Test (PST) to indicate abnormal permeability of the epithelium, which may be used to support a diagnosis of IC. The use of PST has been validated in several studies. Over 80% of CPP patients demonstrated positive potassium sensitivity, suggesting a bladder component to their pain (IC) [18,26].

Parsons et al [25] also designed a Pelvic Pain and Urgency/Frequency (PUF) symptom scale that provides balanced attention to bladder-origin pelvic pain (IC) and to pelvic pain or dyspareunia. The severity of IC symptoms and the extent to which the patient is bothered by each symptom are measured on a scale of 0 (no symptoms) to 35 (most severe). PST was used to validate PUF as a diagnostic tool. In patients suspected of having IC with a PUF score of 10 to 14 (moderate symptoms), 74% showed positive potassium sensitivity [17]. Furthermore, it was shown that a PUF score of 15 or higher is associated with an 84% chance of a positive PST, which provides strong evidence for the presence of IC [17].

ENDOMETRIOSIS

Endometriosis is considered one of the 4 most common diagnoses in women with CPP [15]. Based on findings from many studies, at least 80% of patients with CPP have endometriosis [5-8,10,26,27].

To establish a definitive diagnosis of endometriosis, many opinion leaders still believe that laparoscopy is necessary [11]. However, diagnosing endometriosis during laparoscopy can be difficult and is dependent on the surgeon’s level of experience. An inexperienced surgeon may miss the diagnosis of endometriosis because its appearance can vary widely [11,28]. Diagnosis also presents other challenges. Although surgeons are urged to obtain histologic confirmation of endometriosis, it is often uncertain whether endometriotic implants or adhesions found during surgery are the source of the patient’s pain. Although pelvic adhesions are diagnosed in approximately 25% of women with CPP or without endometriosis, their relationship to CPP is still controversial [15]. It is prudent, therefore, to consider other possible causes of CPP even in the presence of endometriosis, especially in patients whose symptoms persist despite therapy.

Although endometriosis has been recognized as a major cause of CPP, the treatment of endometriosis is often not successful. Due to a lack of adequate randomized controlled trials, evidence is insufficient to support the efficacy of medical therapy, surgical therapy, or both, for CPP and endometriosis. As a result, management of women with CPP considered secondary to endometriosis includes a vast range of therapeutic approaches that are often suboptimal and costly [29]. To complicate management even further, endometriosis has been found in more than 60% of asymptomatic patients and progressive disease exists in close to 60% of patients overall [5,30,31].

When endometriosis is found at the time of surgery, destruction of the lesions by fulguration, excision, or both, is recommended. Although excisional surgery offers a better success rate in treating endometriosis in patients with CPP, it also requires a higher level of surgical skill [29]. Many patients, therefore, may receive inadequate treatment for their endometriosis by less experienced surgeons, which, in turn, can lead to persistent and recurrent disease. Furthermore patients have undergone numerous laparoscopies and have had a hysterectomy and still suffer from CPP.

Interestingly, endometriosis has been found to involve the urinary tract and has been reported in at least 16% of women undergoing a laparotomy for the condition [32]. Recently, there was a report on a small series of patients with bladder endometriosis [33]. In addition, it has been demonstrated that 79% of patients with persistent chronic pelvic pain after a hysterectomy have IC [34]. It is advisable, therefore, to evaluate urinary symptoms in patients with CPP and endometriosis. Strict adherence to this principle has led to the discovery that IC and endometriosis, the evil twins, can coexist in women with CPP.

ENDOMETRIOSIS AND INTERSTITIAL CYSTITIS
The Evil Twins Study

Results of recently published papers [5,26,27,35] demonstrate the presence of endometriosis and IC, the “Evil Twins,” in 38% to 80% of patients with chronic pelvic pain based on the potassium sensitivity test and laparoscopic and cystoscopic evaluation.

In our recent “The Evil Twins” study [26] of 178 patients, 159 (89%) were diagnosed with interstitial cystitis by cystoscopic evidence. A positive potassium sensitivity test was achieved in 146 patients (82%). Both IC and PST were found in 140 (78.6%) patients. Biopsy confirmed endo-metriosis was found in 134 patients (75.2%). Both IC and endometriosis were found in 115 patients (65%). In the positive PST group of 146 patients, 140 (96%) were diagnosed with IC by cystoscopy. Irritable urinary symptoms occurred in 145 of 178 patients (81.5%) with chronic pelvic pain. Urinary incontinence was present in 77 (43.3%) patients. The average pelvic pain (PUF) score was 14 of 35. An average of 20% of the study patients had no urinary symptoms. Painful overactive bladder symptoms were complaints among not only patients with endometriosis but also those with negative findings following laparoscopic evaluation. In fact, the 44 patients with no endometriosis showed significant improvement in their symptoms of CPP, including their painful overactive bladder symptoms after cystoscopic hydrodistention, indicating that IC could be the cause of their CPP. It was concluded, therefore, that patients with CPP (80%) with or without urologic symptoms of urgency/frequency (20%) may in fact have IC as a component of their pelvic pain [26].

If cystoscopy had been performed only in patients with irritative voiding symptoms/overactive bladder, a diagnosis of IC would have been missed in approximately 20% of patients. Furthermore, cystoscopy/hydrodistention is often performed only in patients with a negative laparoscopic evaluation. Consequently, patients are required to undergo 2 separate procedures while under general anesthesia, and the diagnosis of IC is delayed in approximately 80% of patients. Cystoscopy/
hydrodistention should be considered as an integral part of the surgical evaluation of patients with CPP.

Several modalities are used to diagnose IC. Cystoscopic hydrodistention and clinical presentation remain the “gold standard.” However, this gold standard is not ideal and is considered controversial by many [21,22]. In addition, the stringent diagnostic criteria for IC developed by the NIH-NIDDK and the controversy concerning the accuracy of less stringent criteria have interfered with recognition of IC as a major cause of CPP. To make the problem worse, gynecologists in general are not accustomed to addressing irritable urinary symptoms in patients with CPP, thus making the diagnosis of IC less common.

The PUF questionnaire and the PST as advocated by Parsons and colleagues have emerged as a simple office screening tool and diagnostic procedure, respectively, for patients with symptoms of CPP and IC. These tests have been recently validated as diagnostic approaches for IC [17,36]. In this study, the diagnostic accuracy of PST increased when performed in conjunction with cystoscopic hydrodistention. Notably, it has been shown that a PUF score of 15 or higher is associated with an 84% chance of a positive PST, which provides strong evidence for the presence of IC.

It is very important to use all existing screening and diagnostic modalities to establish an early diagnosis of IC. When surgery is indicated, cystoscopic hydrodistention in conjunction with laparoscopy is recommended to establish an earlier diagnosis of endometriosis and IC/CPP of bladder origin [5,26,27,35,37], the evil twins of CPP.

Simple conservative methods exist for treating IC, including diet, pelvic floor physical therapy, and medications, such as hydroxyzine and pentosan polysulfate sodium (Elmiron, Ortho-McNeil Pharmaceutical, Inc, Raritan, NJ). Recent published articles have indicated the efficacy of oral contraceptives in treating CPP and IC [33,38]. We have presented a clinical study of using intravesical instillation of anesthetic in patients with chronic pelvic pain resulting in close to a 40% reduction in pain symptoms in 8 to 10 weeks [39].

Many thought leaders believe that the treatment of women with CPP has been ineffective because the underlying cause is actually urologic rather than gynecologic [40]. Therefore, it is reasonable to conclude that ineffective management of CPP and treatment failures may be in part the result of missed diagnoses of IC.

In summary, it is desirable to have a urologist perform cystoscopy and hydrodistention, especially when these procedures are new to the gynecologist. If, however, a urologist is not available to assist in the procedure, or alternatively, if the gynecologist does not wish to perform a cystoscopy and hydrodistention, he or she should consider using the PST test. This test has validated the PUF questionnaire, and together the PUF and PST are more than adequate to confirm a diagnosis of IC.

OVERLAP OF INTERSTITIAL CYSTITIS AND ENDOMETRIOSIS: THE UNDERLYING NEUROPATHOLOGY

Both endometriosis and IC are CPP syndromes that can be frustrating for patients and physicians alike. These CPP syndromes are associated with other pain syndromes, including irritable bowel syndrome (IBS), fibromyalgia, dyspareunia, and vulvodynia [41,42]. The association may be as a result of neuro-upregulation, and pain centralization; other neuropathic states are reviewed elsewhere [43,44] and include visceral hyperalgesia (eg, irritable bowel syndrome), viscerosomatic hyperalgesia (eg, essential vulvodynia associated with IC), viscerovisceral hyperalgesia (eg, IBS associated with IC), and abnormal visceromuscular reflexes (eg, pelvic floor tension myalgia) [45-50].

A review of the neuropathology of CPP and multisystem interactions involved in all the above-mentioned clinical pain syndromes demonstrates that the significant overlap of IC and endometriosis observed in our studies is to be expected [51]. A multidisciplinary approach to chronic pain has been repeatedly shown to be highly efficacious [52-55]. The substantial efficacy of this approach can potentially be attributed to down-regulation of the upregulated dorsal horn with resultant relief of chronic pain. This concept of the visceral pain syndrome should encourage clinicians to abandon an organ-specific approach to the evaluation and treatment of their patients with CPP. Instead, they should pursue a more holistic and mechanistic management strategy in this patient population. Our study strongly supports the rationale for this approach.

Reprinted with permission: Maurice K. Chung, MD, RPh.
Address reprint requests to: Maurice K. Chung, MD, RPh, Midwest Regional Center for Chronic Pelvic Pain and Bladder Control, 310 S Cable Rd, Lima, OH 45805, USA. Telephone: 419 227 3085, Fax: 419 228 1000.

Maurice K. Chung, MD, RPh, is a Clinical Associate Professor at the University of Toledo School of Medicine and an Adjunct Professor of Pharmacy at Ohio Northern University. He is the Director of the Midwest Regional Center for Chronic Pelvic Pain and Bladder Control. Dr Chung is also in private practice in Lima, Ohio. He has published in JSLS, Journal of the Society of Laparoendoscopic Surgeons and other journals as well as presented his clinical studies in national and international conferences. Dr Chung sits on the boards of the International Pelvic Pain Society and the International Society of Gynecologic Endoscopy.

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