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Objective: To describe clinical and epidemiological aspects of patients with pelvic endometriosis who underwent laparoscopy at our service., Methods: Retrospective study of 892 post-laparoscopy patients with histologically confirmed diagnosis of endometriosis., Results: Mean age was 33.2 ± 6.3 years, and 78.7% of patients were Caucasian. We found that 76.9% of women in the sample had a higher education. Most (56.5%) patients were nulliparous, and 62.2% reported dysmenorrhea as the chief complaint. Chronic pelvic pain was the most prevalent symptom, followed by deep dyspareunia, reported by 56.8% and 54.7% of patients respectively. Infertility was reported by 39.8% of the 892 patients in the sample., Conclusion: Endometriosis is most often diagnosed in the fourth decade of life. Patients with this condition present with multiple complaints, and must always undergo thorough questioning to properly guide diagnosis and monitor treatment results.

To study whether treatment with 5'-adenosine triphosphate (ATP), an agonist of P2 purine receptors, attenuated intestinal dysfunction caused by ischemia (I) and/or reperfusion (R), rabbits were treated with ATP (15 mgxkg(-1), intravenously) or saline solution (SS) 60 minutes before I by occlusion of the superior mesenteric artery and/or R (120 minutes). After I or I/R isolated 2-cm jejunal segments were mounted in an organ bath to study nerve-mediated contractions stimulated by electrical pulses or KCl using a digital recording system. Thin jejunal slices were stained (hematoxylin and eosin) for optical microscopy. Compared to a sham group, the jejunal contractions were similar to sham hosts among I + ATP, but reduced in I + SS, I/R + SS, and I/R + ATP groups. The jejunal-enteric nerves were damaged in I + SS, I/R + SS, and I/R + ATP, but not the I + ATP group. These results suggested that ATP attenuated intestinal dysfunction produced by I, but not that caused by R., (Copyright (c) 2010. Published by Elsevier Inc.)

To study if the treatment with adenosine (ADO), an agonist of adenosine receptors, attenuates intestinal dysfunction caused by ischemia (I) and reperfusion (R), we treated rabbits with ADO (15 mg x kg(-1), intravenously) or saline solution (SS) to I (60 minutes) before occlusion of superior mesenteric artery and/or R (120 min). After I or I/R, isolated jejunal segments (2 cm) were mounted in an organ bath to study nerve-mediated contractions stimulated by electrical pulses or KCl using a digital recording system. Thin jejunal slices were stained (hematoxylin and eosin) for analysis by optical microscopy. Compared to the sham group, the jejunal contractions were similar in I + ADO, but reduced in I + SS, I/R + SS, and I/R + ADO groups. We concluded that the jejunal enteric nerves were damaged in I + SS, I/R + SS, and I/R + ADO, but not in I + ADO group. These results suggested that ADO attenuated intestinal dysfunction due to I, but not to R., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Objective: To describe a new FOXL2 gene mutation in a woman with sporadic blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) and hypergonadotropic hypogonadism., Design: Case report., Setting: University medical center., Patient(s): A 28-year-old woman., Intervention(s): Clinical evaluation, hormone assays, gene mutation research., Main Outcome Measure(s): FOXL2 gene mutation., Result(s): The patient with hypergonadotropic hypogonadism was diagnosed with BPES due to a new FOXL2 gene mutation., Conclusion(s): Blepharophimosis-ptosis-epicanthus inversus syndrome is a rare disorder associated with premature ovarian failure (POF). The syndrome is an autosomal dominant trait that causes eyelid malformations and POF in affected women. Mutations in FOXL2 gene, located in chromosome 3, are related to the development of BPES with POF (BPES type I) or without POF (BPES type II). This report demonstrates a previously undescribed de novo mutation in the FOXL2 gene-a thymidine deletion, c.627delT (g.864delT)-in a woman with a sporadic case of BPES and POF. This mutation leads to truncated protein production that is related to a BPES type I phenotype. This report shows the importance of family history and genetic analysis in the evaluation of patients with POF and corroborates the relationship between mutations on the FOXL2 gene and ovarian insufficiency., (Copyright 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: This study analyzed the relationship between clinical characteristics of endometriosis and Th1/Th2 immune response patterns., Methods: A prospective study was performed with 65 patients with endometriosis (Group A) and 33 without the disease (Group B). Measurement of IL 2, 4 and 10, TNF-alpha and IFN-gamma was carried out in peripheral blood and peritoneal fluid., Results: Serum TNF-alpha was higher in patients with endometriosis who had deep dyspareunia compared to controls (mean 4.5 pg/ml and 2.3 pg/ml, p<0.05). Among these patients (n=32), 65.5% had deep endometriosis. Patients with endometriosis and infertility had higher IL-2 concentrations in peritoneal fluid than controls (mean 5.9 pg/ml and 0.2 pg/ml, p<0.05). Among these patients (n=22), 63.5% (n=14) had deep endometriosis. A higher concentration of IL-10 was also observed in patients with ovarian endometriosis when compared to those without this type of disease, as well as when compared to control group patients (mean 50 pg/ml, 18.7 pg/ml and 25.7 pg/ml, p<0.05)., Conclusions: These results suggest that when specific clinical data are associated with a higher production of certain cytokines, there is a Th1 response pattern that may be related to deep infiltrating endometriosis.

Laparoscopic colorectal surgery is believed to be technically and oncologically feasible. Robotic surgery is an attractive mode in performing minimally-invasive surgery once it has several advantages if compared to standard laparoscopic surgery. The aim of this paper is to report the first known case of colorectal resection surgery using the robotic assisted surgical device in Brazil. A 35-year-old woman with deep infiltrating endometriosis with rectal involvement was referred for colorectal resection using da Vinci surgical system. The authors also reviewed the most current series and discussed not only the safety and feasibility but also the real benefits of robotic colorectal surgery.

In this retrospective observational study involving 176 patients and 271 biopsies, the histologic differentiation in superficial endometriosis, deeply infiltrating endometriosis, and ovarian endometriomas was evaluated according to a previously proposed classification system. Results showed a predominance of the undifferentiated glandular pattern (33.5%) and mixed glandular pattern (46.9%) in deeply infiltrating endometriosis lesions, whereas the well-differentiated glandular pattern (41.8%) was most frequently seen in superficial endometriosis lesions, and in ovarian endometriomas a predominance of both the undifferentiated (40.5%) and mixed patterns (37.8%) was observed.

Objective: To evaluate the accuracy of preoperative magnetic resonance imaging (MRI) findings relative to surgical presence of deeply infiltrating endometriosis (DIE)., Methods: This prospective study included 92 women with clinical suspicion of DIE. The MR images were compared with laparoscopy and pathology findings. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI for diagnosis of DIE were assessed., Results: DIE was confirmed at histopathology in 77 of the 92 patients (83.7%). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI to diagnose DIE at each of the specific sites evaluated were as follows: retrocervical space (89.4%, 92.3%, 96.7%, 77.4%, 90.2%); rectosigmoid (86.0%, 92.9%, 93.5%, 84.8%, 89.1%); bladder (23.1%, 100%, 100%, 88.8%, 89.1%); ureters (50.0%, 100%, 95.5%, 95.7%); and vagina (72.7%, 100%, 100%, 96.4%, 96.7%)., Conclusion: MRI demonstrates high accuracy in diagnosing DIE in the retrocervical region, rectosigmoid, bladder, ureters, and vagina.

Deeply infiltrating endometriosis is the clinical form of the disease that is generally associated with conditions of more intense pain and may require more complex surgical management, consequently resulting in greater risks to the patient. In recent years, various investigators have confirmed the usefulness of methods such as magnetic resonance imaging (MRI), transrectal ultrasound and transvaginal ultrasound (TVUS) for the diagnosis of deep endometriotic lesions. The objectives of the present study are to describe the method used to perform TVUS for the detection of deeply infiltrating endometriosis, and to discuss the clinical benefits that the data obtained may offer clinicians providing care for patients suspected of having this type of endometriosis.

Objective: To evaluate interleukin (IL)-12 and IL-18 levels in the serum and peritoneal fluid of women with and without endometriosis., Design: Cross-sectional survey., Setting: University hospital., Patients: Interleukin-12 and IL-18 levels were compared in 105 patients submitted to laparoscopy because of symptoms suggestive of endometriosis (pain and/or infertility). The disease was confirmed in 72 patients (study group), while in 33 patients findings were not compatible with endometriosis (control group). INTEVENTION(S): Blood sample and peritoneal fluid were obtained from patients during videolaparoscopy., Main Outcome Measure(s): The levels of IL-12 and IL-18 in peripheral blood and peritoneal fluid were determined and compared with the stage and site of the disease and histologic classification., Result(s): IL-12 levels measured in peritoneal fluid were higher in patients with endometriosis compared with the control group. A significant increase in IL-12 levels was found when the more advanced stages of the disease were compared with the initial stages. No statistically significant differences were found in IL-18 levels, either in serum or in peritoneal fluid samples., Conclusion(s): Patients with severe endometriosis have higher IL-12 levels irrespective of IL-18 levels, suggesting that in this disease an alternative pathway is involved in induction of the Th1 immune response.

Context and Objective: Endometriosis is a common affliction that may affect the intestinal tract. The objective of this case report was to describe an unusual clinical presentation of this form of the disease., Case Report: The patient was a 35-year-old woman with epigastric pain that only occurred during menstruation, who had a history of bladder endometriosis. Endoscopy of the upper digestive tract showed normal results. Transvaginal ultrasound and nuclear magnetic resonance of the pelvis showed a lesion involving the ileocecal junction and appendix, measuring 30 x 22/x/13/mm, that was suggestive of endometriosis. The patient underwent laparoscopic resection of the bowel segment affected by the disease, followed by anastomosis of the ileum and ascending colon for immediate restoration of intestinal transit. Histological analysis confirmed the diagnosis of endometriosis., Conclusions: In young women, recurrent epigastric pain should be evaluated with regard to its relationship to menstruation, particularly if there is a history of endometriosis, since this may be a clinical sign that the disease is affecting the intestinal transit.

Study Objective: To estimate the relationship between the depth of lesions of rectal endometriosis and the percentage of the circumference of the bowel segment affected by the disease., Design: A prospective pathologic analysis of 45 surgical specimens of bowel endometriosis obtained by laparoscopic segmental resection of the rectosigmoid (Canadian Task Force classification II-1)., Setting: Tertiary referral hospital., Patients: forty-five patients were submitted to a segmental resection of the rectum due to endometriosis between July 2004 and September 2006., Interventions: Morphometric aspects of endometriotic lesions were analyzed, such as size and thickness of the lesion, deepest layer of bowel affected by lesion, and percentage of circumference of bowel affected by endometriosis., Measurements and Main Results: Results showed that in lesions that reached the submucous layer of the bowel, the circumference affected was 31.6% greater than in lesions that reached only the outer muscular layer, whereas in lesions that reached the mucous layer, the circumference affected was 52.5% greater than in those that reached the outer muscular layer of the bowel. In addition, 89.3% of lesions with an affected circumference greater than 40% were those affecting the submucous or mucous layers of the bowel. These results suggest that when a lesion reaches these 2 deepest layers of the rectosigmoid, risk increases that the circumference affected will be greater than 40% (relative risk = 1.5; 95% CI: 1.0-2.3; p = .03)., Conclusion: In endometriotic lesions affecting the rectosigmoid beyond the inner muscular layer of the bowel wall, more than 40% of the circumference of the rectosigmoid is affected by the disease, confirming the recommendation of segmental resection of the bowel for this form of the disease.

This study compared the long-term effects of the levonorgestrel-releasing intrauterine device with those of GnRH agonist administration on serum levels of CA-125 in patients with endometriosis. The levonorgestrel-releasing intrauterine device was found to be as efficient as GnRH agonist in reducing CA-125 serum levels.

Sulfated glycosaminoglycan (GAG) composition was characterized in the human endometrium during proliferative and secretory phases of the menstrual cycle. Sulfated GAGs were analyzed in endometrium tissue using metachromatic staining, biochemical analysis including electrophoresis before and after specific enzymatic or chemical degradations, and immunostaining with an antibody against chondroitin sulfate (CS). Our results showed that CS was the main sulfated GAG species detected, accompanied by small amounts of heparan sulfate and dermatan sulfate. CS was distributed overall the connective stroma, around arteriole vessels and glands, and there was no important difference in the immunostaining between the proliferative and secretory endometrium phases. Our findings extend previous observations on the GAG composition in the human endometrium providing new information regarding the tissue distribution and location of endometrial CS.

Objective: To evaluate the advantages and disadvantages of microlaparoscopy vs. conventional laparoscopy in the management of patients with early-stage pelvic endometriosis., Study Design: In this prospective, randomized study we evaluated 54 patients with a clinical diagnosis of stage I and II pelvic endometriosis according to the classification of the American Society for Reproductive Medicine, revised in 1996. The patients were divided into 3 groups and underwent, respectively, microlaparoscopy under sedation, microlaparoscopy under general anesthesia and conventional laparoscopy for definitive diagnosis and treatment of the disease., Results: Microlaparoscopy caused less pain, required lower consumption of analgesics and permitted a faster return to daily activities. Sedation decreased the incidence of nausea, vomiting and oropharyngeal pain. Microlaparoscopy under sedation led to a shorter hospital stay and reduced cost., Conclusion: Microlaparoscopy under sedation is a viable alternative for the management of patients with suspected early-stage pelvic endometriosis.

Study Objective: To evaluate the accuracy of rectal endoscopic ultrasound and to evaluate endometriosis in the rectovaginal septum, rectum, and sigmoid walls., Design: Validation of diagnostic test (Canadian Task Force classification II-1)., Setting: Tertiary care hospital., Patients: Thirty-two consecutive women clinically suspected of having rectovaginal septum endometriosis without previous surgical treatment., Intervention: Colonoscopy, transrectal ultrasound, and rectal endoscopic ultrasound, followed by laparoscopy or laparotomy., Measurements and Main Results: The disease was classified according to 1996 standards of the American Society of Reproductive Medicine. Images obtained by colonoscopy, endoscopic ultrasound, and surgery and histologic findings were compared. In 6 patients endometriosis infiltrated bowel muscularis wall, in 20 it infiltrated rectovaginal septum, and in the remaining 6 there was no evidence of lesions. In all women in whom infiltration of the intestinal wall was suspected, rectal endoscopic ultrasound and colonoscopy confirmed the lesions (sensitivity 100%, specificity 67%)., Conclusion: Endoscopic ultrasound was useful in preoperative assessment of women with endometriosis.

Background: The involvement of the rectovaginal septum, of rectum and sigmoid by endometriosis leads to intense symptoms as dysmenorrhea, pelvic pain, deep dyspareunia, tenesmus and hematochezia in young and middle aged women during periods. The diagnosis can be made by tipycal history and vaginal examination, rectal examination, barium enema, proctoscopy and so on. The indications of operation include severe clinic symptoms and failed conservative therapy. The treatment of choice for this type of endometriosis is the surgical resection of affected tissue, in order to relieve patient symptoms, and avoid disease progression. The correct assessment as to the presence and extension of the endometriosis-affected sites such as the rectum, uterosacral ligaments and rectovaginal septum is extremely important to provide better results with the surgical treatment of endometriosis., Aim: To describe the main aspects related to rectovaginal septum endometriosis and offer the general surgeon some information about this enigmatic disease., Conclusion: Rectovaginal septum endometriosis is a frequent disease, with specific diagnosis and treatment.

Background: The study aim was to assess the time elapsed between onset of symptoms and diagnosis of endometriosis, and to identify the factors associated with diagnostic delay in a group of Brazilian women., Methods: In this retrospective cohort study, 200 women with surgically confirmed endometriosis were interviewed at an endometriosis outpatient clinic., Results: The median (interquartile range) time elapsed from onset of symptoms until diagnosis of endometriosis was 7.0 (range 3.5-12.1) years. The younger the women at onset of symptoms, the longer the period for diagnosis to be made: the median delay was 12.1 (range 8.0-17.2) years in women aged < or =19 years, and 3.3 (range 2.0-5.5) years in women aged > or =30 years. The median time period between onset of symptoms and diagnosis was 4.0 (2.0-6.0) years for women whose main complaint was infertility, but 7.4 (3.6-13.0) years for those with pelvic pain., Conclusions: The delay in diagnosis of endometriosis was considered to be long, and especially so for young women with pelvic pain. More information relating to endometriosis should be offered to general physicians and gynaecologists in order to reduce the time taken to diagnose this condition.

Microlaparoscopy represents the development of endoscopic surgery towards a minimally invasive surgical procedure. The advantages include fewer surgical complications, faster return to daily activities, more comfortable postoperative recovery, and satisfactory aesthetic results. The possibility of performing surgery under sedation may result in shorter hospitalization, lower hospital costs, and easier anesthetic procedures. The authors report their preliminary experience with the use of microlaparoscopy, using optics and 2mm instruments, as well as a review of the literature since the introduction of this new technique. The report of these 16 cases demonstrates that microlaparoscopy is a feasible technique with satisfactory results. On the other hand, this new technique requires precise indications and a training period for the development of the skills necessary for performing these surgeries.

Objectives: The objective of the present study was to determine the concentrations of CA 125, CA 15-3, CA 19-9, carcioembryogenic antigen (CEA), alpha-fetoprotein (AFP) and beta-2 microglobulin (B2MG) in patients with pelvic endometriosis., Method: Fifty women were divided into two groups: group A (control) had no endometriosis or other diseases, and group B consisted of 35 women with pelvic endometriosis. All women were submitted to serum determination of CA 125, CA 15-3, CA 19-9, CEA, AFP and B2MG. Samples were collected during the menstrual cycle and 1 week later., Results: Mean CA 125 concentrations were altered in patients with endometriosis, but all 50 patients studied presented normal CEA, AFP and B2MG concentrations. Small variations detected in CA 19-9 and CA 15-3 had no statistical significance., Conclusion: CA 125 is the only important marker in the diagnosis of stages III/IV of endometriosis, especially when blood samples for its determination are obtained during the first 3 days of the menstrual cycle.

Objective: The authors report a case of extremely aggressive endometriosis involving a 32-year-old woman., Methods: Different types of medication were used and various surgical procedures applied in order to reduce the clinical signs and symptoms. Among the surgical procedures employed was presacral neurectomy when endometriosis was identified in the presacral nerve., Results: Receptor determination in the surgical piece was negative., Conclusions: The etiopathogenic and therapeutic aspects of this process are discussed.

The authors present the result of an educational investigation of knowledge retention concerning a Gynecology program. The research was developed by comparing the marks obtained in the fourth, fifth and sixth years. The examinations had the same content but were not identical. Between the fourth and fifth year, the loss of knowledge observed was -45.0% +/- 1.4% (average +/- standard error) and was not influenced by the time between the two examinations. The examinations between the fifth and sixth years indicated a gain of knowledge of +72.8% +/- 11.1% (average +/- standard error) and was influenced by the time between the two examinations.

The aim of this study was to evaluate CA 125 II, C-reactive protein (CRP) and serum amyloid A (SAA) and anticardiolipin antibody (aCL) concentrations for the diagnosis of pelvic endometriosis. The study population consisted of 15 women without endometriosis, as confirmed by laparoscopy (group A), and 35 patients with pelvic endometriosis diagnosed by laparoscopy or laparotomy (group B). Group B patients were divided into those at stages I and II of the disease (BI/II) and those at stages III and IV (BIII/IV). Blood samples were obtained twice during the menstrual cycle: on day 1, 2 or 3 of the cycle and on day 8, 9 or 10 of the cycle. CA 125 II and CRP concentrations were higher in group III/IV patients compared with healthy controls, mainly during the first 3 days of the menstrual cycle; SAA concentrations were also higher in this group of patients compared with healthy controls, but only during the first 3 days of the menstrual cycle. Immunoglobulin (Ig) M aCL concentrations were higher in all patients with endometriosis compared with healthy controls, mainly during the first 3 days of the menstrual cycle. It is concluded that these determinations may contribute to the diagnosis and the indication of treatment for pelvic endometriosis. Determination of CA 125 II concentrations at the beginning of the menstrual cycle may aid the diagnosis of stage III and IV endometriosis. IgM aCL appears to be associated with the presence of all stages of the disease, while SAA values are elevated in severe situations. Measurement of these molecules may therefore provide a valuable tool in the diagnosis and management of endometriosis.

Colorectal endometriosis is a relatively rare entity that may have a wide array of clinical symptoms and radiographic findings. A 42-year-old female patient with rectal endometriosis treated with danazol under CA 125, CA 19-9 and estrogen monitoring is described. The treatment was successful and the patient underwent excision of reproductive organs without colorectal excision.

MCH (melanin concentrating hormone) is a heptadecapeptide, Asp-Thr-Met-Arg-Cys-Met-Val-Gly-Arg-Val-Tyr-Arg-Pro-Cys-Trp-Glu-Val, which stimulates melanosome (melanin granule) aggregation to a perinuclear position within teleost fish integumental melanocytes, resulting in lightening of the skin. The mechanisms of action of MCH are unknown. Drugs that affect the diacylglycerol/inositol triphosphate pathway were used to investigate the possible roles of this pathway in the mechanisms of action of MCH on Synbranchus marmoratus (teleost) melanocytes. The shift of the dose-response curve to MCH in the presence of various concentrations of 4-bromophenacyl bromide and neomycin sulphate, phospholipase C inhibitors, suggests that phospholipase C is stimulated after MCH receptor activation. Low concentrations (10(-9) to 10(-8) M) of the phorbol ester TPA exhibited MCH-like activity, eliciting a dose-dependent melanosome aggregation. Higher doses, however, displaced to the right the dose-response curve to MCH, as did the protein kinase C inhibitors, dibucaine and 1-(5-isoquinolinylsulfonyl)-2-methylpiperazine (H-7). These results support the assumption that protein kinase C mediates the pigment aggregating activity of MCH. Both MCH and norepinephrine lightening actions were abolished by beta-glycerophosphate, a phosphatase inhibitor, suggesting that a protein dephosphorylation occurs during melanosome aggregation, and is, therefore, a common event triggered by MCH and norepinephrine, although both agonists act through separate receptors and exhibit different transduction mechanisms.

Eighty-five women with vulvar squamous cell carcinoma were subjected to radical vulvectomy with bilateral inguinal and femoral node dissection or to radical vulvectomy with bilateral inguinofemoral and deep pelvic node dissection. The association between lymph node status (metastatic or not) and several parameters was analyzed: tumor location, size and clinical stage; tumor thickness, histologic grade and mitotic index; blood vessel, lymphatic and perineural infiltration; and lymphocytic and plasma cell infiltrates. There were no metastases to the pelvic lymph nodes without previous inguinal lymph node involvement. Unilateral vulvar carcinomas did not have contralateral metastatic nodes when there was no ipsilateral nodal involvement. Lymphatic vessel infiltration showed a statistically significant correlation with inguinal node metastases (P less than .05). No correlation was found between lymph node metastasis and tumor size, clitoral invasion, tumor thickness, histologic grade, blood vessel and perineural infiltration, lymphocytic and plasma cell infiltrates, and mitotic index.