The objective of this study was to examine the ability of preoperative transvaginal ultrasound (TVS) scanning to assess the severity of pelvic endometriosis.Consecutive women with clinically suspected or proven pelvic endometriosis, who were booked for laparoscopy, were invited to join the study. The severity of endometriosis was assessed preoperatively using TVS and the findings were compared with the results obtained by laparoscopy using the American Society for Reproductive Medicine (ASRM) classification.In total, 201 women had preoperative TVS and laparoscopies. Of these, no endometriosis was found at laparoscopy for 62/201 (30.8%; 95% CI, 24.8-37.5), whereas 33/201 (16.4%; 95% CI, 11.9-22.2) had minimal endometriosis, 31/201 (15.4%; 95% CI, 11.1-21.1) had mild endometriosis, 27/201 (13.4%; 95% CI, 9.4-18.8) had moderate endometriosis and 48/201 (23.9%; 95% CI, 18.5-30.2) had severe endometriosis. The sensitivity and specificity of the TVS diagnosis of severe pelvic endometriosis were 0.85 (95% CI, 0.716-0.934) and 0.98 (95% CI, 0.939-0.994), respectively, and the positive and negative likelihood ratios were 43.5 (95% CI, 14.1-134) and 0.15 (95% CI, 0.075-0.295), respectively. Overall, there was a good level of agreement between ultrasound and laparoscopy in identifying absent, minimal, mild, moderate and severe disease (quadratic weighted kappa = 0.786). The mean ASRM score difference between TVS and laparoscopy in assessing severity of endometriosis was -2.398 (95% CI, -4.685 to -0.1112) and the limits of agreement were -34.62 (95% CI, -38.54 to -30.709) to 29.83 (95% CI, 25.91-33.74).TVS is a good test for assessing the severity of pelvic endometriosis. TVS is particularly accurate in detecting severe disease, which could facilitate more effective triaging of women for appropriate surgical care.
Laparoscopic surgery is progressing rapidly is becoming the normal route for many abdominal operations, even for major complex surgery. The integrated laparoscopic theatre is a state-of-the-art system in which the laparoscopic equipment and multiple flat-screen monitors are permanently installed to be operational on demand inside the theatre. These expensive systems are being widely adopted, however very little research has been published regarding which features of these systems are desired by the surgeons who use them. The study objective was to assess the strength of preference for key attributes of integrated laparoscopic theatres and to compare these preferences between Gynaecologists and General surgeons.This was an electronically distributed discrete choice experiment survey of British practicing Laparoscopic Gynaecologists and General Surgeons (Through The British Society of Gynaecology Endoscopy and The Association of Laparoscopic Surgeons of Great Britain and Ireland). An electronic survey was designed and pre-tested. This was then sent to practicing British Laparoscopic Gynaecologists and General-Surgeons. There were structured questions regarding the seven key attributes of integrated laparoscopic theatres in the standard form for a discrete choice experiment.Questionnaires from 167 respondents were analysed. One hundred three were gynaecologists and 64 were general-surgeons. Adjustable screens for height and position was the most favoured attribute and it is 4.7 times more desirable than the next most desirable attribute, which was a wire free floor. The least desirable features were piped CO2, ceiling-mounted-screens and external-transmission-of-images.Both groups favour adjustable screens for position and height above all the other features. These findings are in contrast with previous research, which showed that when asked to rank the attributes in order, gynaecologists chose ceiling mounted screens first and adjustable screens fourth. When asked to "trade off" attributes in the discrete choice experiment the adjustability of the screens became much more important than how the screens were mounted. With new wireless technology the benefits of a fully integrated theatre could be delivered with floor mounted systems at a considerably reduced cost. This information is important to manufacturers and purchasers of these systems in order to design cost effective ergonomic theatres that are fit for purpose.
Intra-articular injection of drugs is increasingly used in human medicines. We report a method for the direct administration of a test substance to the synovial fluid of the canine stifle joint. This method caused little distress or pathology, making it suitable for pre-clinical assessment of new drugs in dogs and other species.
To examine the impact of adenomyosis on outcome of in vitro fertilisation cycle and whether specific features of adenomyosis are associated with poor outcome. This is a prospective observational study in a population of women undergoing their first IVF cycle in two London teaching hospitals between April 2013 and October 2015. Women underwent a detailed transvaginal ultrasound scan prior to starting fertility treatment. The diagnosis of adenomyosis was made by visualisation of established ultrasonic criteria: an asymmetric myometrium, a globular shaped uterus, myometrial cysts and endometrial striae. We followed up all women and recorded the outcome of their IVF cycle. Women with other uterine pathology were not recruited. During the study period 425 women were recruited. 66 women were excluded from further analysis for a variety of reasons. 72/359 (20.1%, 95% CI 16.0 – 24.3) women had evidence of adenomyosis on scan. Clinical pregnancy rate was 143/359 (39.8%, 95% CI 34.7 – 44.9), miscarriage rate was 28/143 (19.6%, 95% CI 13.1 – 26.1) and 115/359 (32.0%, 95% CI 27.2 – 36.8) women had livebirth. Clinical pregnancy rate in women with adenomyosis was 20/72 (27.8% 95% CI 17.5 – 38.2) vs. 123/287 (42.9%, 95% CI 37.2 – 48.6) in those without (RR 0.65 95% CI 0.44 – 0.96, p = 0.0317). Logistic regression selected myometrial cysts as significant poor outcome predictor (OR 0.391, 95% CI 0.202 – 0.756). Globular uterus (OR 0.499, 95% CI 0.164 – 1.520), endometrial striae (OR 1. 441, 95% CI 0.484 – 4.289) and asymmetrical thickening of the myometrium (OR 0.770, 95% CI 0.250 – 2.335) were not included in the model. Clinical pregnancy was significantly lower in women with multiple morphological features of adenomyosis (OR 0.745, 95% CI 0.592 – 0.932) with only 1/11 (9.1% 95% CI 0.0 – 26.1) women with all 4 features achieving clinical pregnancy (p = 0.001). Adenomyosis has a significant negative impact on IVF outcome. Probably successful treatment was lower in women with evidence of myometrial cysts and those with multiple features of adenomyosis.
Key content Laparoscopic myomectomy (LM) is considered to be particularly technically difficult because it requires advanced intracorporeal suturing. LM involves a wide continuum of surgical difficulty; surgeons must be self‐aware of both their skill‐set and their limitations when selecting appropriate patients for this surgery. The greater a woman's age, the less there is to be gained by preserving her future fertility and the greater the risk of leiomyosarcoma. Hysterectomy should be considered when fertility is no longer desired or feasible. When asking a patient to give consent for LM, the following risks must be mentioned: parasitic myomata and disseminated peritoneal leiomyomatosis, and potentially upstaging an occult malignancy (such as leiomyosarcoma). There is currently no preoperative test to definitively exclude leiomyosarcoma. Learning objectives To understand the importance of thorough preoperative counselling before LM, including the potential risks of intracorporeal morcellation. To understand the key steps involved in performing an LM. Ethical issues The potential benefits of a laparoscopic versus open myomectomy must be considered; for example, does the worsened prognosis in women with unsuspected leiomyosarcoma, inadvertently morcellated, outweigh adverse outcomes in patients who undergo open myomectomy? Since in‐bag morcellation remains an experimental technique, its possible benefits and long‐term outcomes are yet to be established.
To examine the impact of adenomyosis on obstetric outcome after in vitro fertilisation. This is a prospective observational study in a population of women undergoing their first IVF cycle in two London teaching hospitals between April 2013 and October 2015. All women underwent a detailed transvaginal ultrasound scan prior to starting fertility treatment. The diagnosis of adenomyosis was made by visualisation of established ultrasonic criteria: an asymmetric myometrium, a globular shaped uterus, myometrial cysts and endometrial striae. We followed up all women and recorded the outcome of their IVF cycle. Women with other uterine pathology were not recruited in the study. During the study period 425 women were recruited. 66 women were excluded from further analysis for a variety of reasons. The prevalence of adenomyosis was 72/359 (20.1%, 95% CI 16.0 – 24.3). Clinical pregnancy rate was 143/359 (39.8%, 95% CI 34.7 – 44.9), miscarriage rate was 28/143 (19.6%, 95% CI 13.1 – 26.1) and 115/359 (32.0%, 95% CI 27.2 – 36.8) women had a livebirth. The median gestational age at delivery was 40.0 weeks (IQR 38.0 – 41.0), median birthweight was 3189 g (IQR 2807–3671) and median estimated blood loss 500 ml (IQR 300 – 812). There was no significant difference in median gestational age at delivery, median birthweight and median estimated blood loss between women with and without adenomyosis (40.0 weeks vs. 39.0 weeks, 3714 g vs. 3175 g and 600 ml vs. 500 ml) (p = 0.66, p = 0.97, p = 1.0). Our results suggest that adenomyosis diagnosed before assisted conception does not exert a large negative effect on obstetric outcome after IVF. However the power of our study is limited by a small sample size.
It is highly desirable to use experimental methodologies in toxicological pathology that combine statistical power, practicality, and objective reviewability to detect small differences. The different ways of gathering data at the microscope can result in clear differences in power to discriminate small, but real, differences between treated and control rodent groups with nonneoplastic lesions. Six alternative methods of gathering and analysing results are compared. They are referred to as the Measuring, Ordering, Scoring (or Grading), Pair-contrast, Outside-control, and Affected methods. Measuring and Ordering methods are uniformly more powerful than other more common and highly esteemed methods, such as Scoring/Grading. From the practical perspective, Measuring and Ordering can be applied objectively, reviewed objectively, and interpreted to standards that are widely accepted as valid throughout experimental science e.g., using confidence limits and intervals. They also are intuitively natural extensions of routine toxicological histopathological examinations. Establishing a small difference between control and treated groups is commonly a problem when reporting no-observed-effect levels. Ordering is the recommended method for assessing if a small difference between treated and control groups is within chance variation or is the result of a true treatment effect, when measurement is impractical.
Is there any benefit to including the routine examination by ultrasound of the bladder, ureters and kidneys of women with endometriosis? The benefit of examination of the complete urinary tract of women with suspected endometriosis is that ureteric endometriosis, with or without hydronephrosis, can be detected which facilitates early intervention to prevent nephropathy. Women with endometriosis can get ureteric obstruction but there is no clear consensus on the correct diagnostic technique. Ultrasound is accurate at detecting women with bladder endometriosis but ureteric involvement has not been assessed previously. This was a prospective observational study, conducted at a teaching hospital over a period of 14 months. A total of 848 women presenting with chronic pelvic pain were included into the study. All women with chronic pelvic pain underwent a detailed transvaginal and transabdominal pelvic ultrasound examination to investigate possible causes of their symptoms. This included a systematic assessment of the urinary bladder, pelvic sections of the ureters and kidneys. The ultrasound findings were compared with findings at surgery and the results of targeted urological imaging and interventions. A total of 848 women presenting with chronic pelvic pain were included into the study. 28/848 women (3.3% 95% CI 2.1–4.5) had evidence of urinary tract abnormalities on initial ultrasound scan. Among these 17/848 (2.0% 95% CI 1.06–2.94) had evidence of urinary tract endometriosis, whilst 11/848 (1.3% 95% CI 0.54–2.06) women had other urinary tract abnormalities. Among women with urinary tract endometriosis 11/17 (65%) had evidence of ureteric involvement, 3/17 (18%) had both ureteric and bladder disease and 3/17 (18%) had bladder disease only. 12/17 (59%) women with urinary tract endometriosis also had evidence of hydronephrosis. The diagnosis of ureteral endometriosis had a sensitivity of 12/13 (92%) (95% CI 63.9–99.8), specificity 151/151 100% (95% CI 97.6–100), PPV 100% (95% CI 73.5–100), NPV 99.3% (95% CI 96.3–99.9%) LR− 0.08 (95% CI 0.01–0.39). The routine examination of the complete urinary tract including the distal ureters is a novel technique that should be evaluated in different populations. Ultrasound is an accurate test to diagnose urinary tract involvement in women with suspected pelvic endometriosis and examination of the complete urinary tract should become an integral part of ultrasound assessment of women with suspected endometriosis. The authors have no competing interests. The study was not supported by an external grant.
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