INFORMATION SITE GYNECOLOGIC SURGERY
ADVANCED LAPAROSCOPIC SURGERY
ENDOMETRIOSIS IS A SURGICAL DISEASE
SURGERY WITHOUT ADHESIONS
The Gruppo Italo Belga
The Gruppo Italo Belga was founded after pioneering and teaching endoscopic surgery in Leuven Belgium, Oxford UK and in Rome, Italy. Besides correct patient information, The MKW club provides training and offer a platform for difficult surgery in the Rome Woman Hospital.
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- outpatient visits
- Video SKYPE consultations
- Medico-legal advice
We are an experienced group with over 3000 deep endometriosis surgeries and over 1000 hysterectomies.
News and updates
HRT and wrinkles
Premenstrual syndrome and endometriosis
What is endometriosis : what is the therapy
Endometrium is the tissue lining the inside of the uterus, causing menstruation.
Endometriosis is defined as endometrial stroma and glands outside the uterus.Adenomyose is endometrial stroma and glands in the muscle of the uterus
The definition should be changed since not all glands and stroma outside the uterus is pathologysee our recent editorial in Fertil steril .
Endometriosis is not 1 diseaseSubtle endometriosis is not pathology, typical-cystic-deep endometriosis are 3 diseases causing pain and infertility
from minor to severe disease
from small and superficial implants to cystic ovarian endometriosis and deep endometriosis .
Endometriosis is a surgical disease
Women with severe pain and or infertility deserve a laparoscopy,which will
- diagnose the disease without delay
- treat the disease and avoid medical treatment without a diagnosis
- prevent progression
- permit treatment during diagnostic laparoscopy if the surgeon has the expertise
But no surgery is better than bad surgery :the first surgery should be the last
What is quality Surgery ?
- A correct indication and no unnecessary interventions
- A skilled surgeon : if the surgery exceeds the skill of the surgeon no surgery should be performed. For severe endometriosis this means a low number of bowel resections.
- Laparoscopic surgery is better than open surgery since less pain, shorter hospitalization and smaller incisions.
- Control of quality needs Video-registration . Videoregistation with a copy to the patient, is a strong indication that the surgeon feels confident.
- No complications. The surgeon should know HIS complications as evidenced from publications and presentations.
- Little pain and few adhesions : this requires a skilled surgeon, a short intervention with little bleeding and conditioning see : EndoSAT NV.
Quality surgery in gynecology
- Hysterectomy : can always be done by laparoscopy unless the uterus is bigger than 1500 grams.
- Urinary incontinence : the surgeon should master vaginal (eg TOT) and laparoscopic techniques as promontofixation (level II)
- Adhesiolysis can be very difficult (level III)
- Endometriosis varies from superficial lesions (level I) to very difficult deep endometriosis (level III). Ovarian endometriosis is level III since the risk of ovarian damage is high if unskilled
- Oncologic surgery : will not be discussed
PainFor more images and causes of pelvic pain
- Chronic pelvic pain has many causes and needs a correct diagnosis.
- It is important to understand the pathophysiology of pelvic pain : visceral pain is more sensitive to distension (like a full bladder) than to lesion .
- Endometriosis is an important cause of pain.
- Deep endometriosis causes a lot of pain but 5-7% of women are pain-free,
- cystic endometriosis also causes severe pain but not in 25 %,
- typical endometriosis is a cause of pain but 50% is pain-free. Important is to realize that pain is not always cycle dependent.
- Subtle endometriosis and stromatosis or endosalpingiosis are not a cause of pain.
- Pain in adenomyosis is variable
Fundamental to understand fertility and infertility are MFR (monthly fecundity rate ) and CPR (cumulative pregnancy rate).
MFR (monthly fecundity rate ): is the probability of conception in one month. CPR (cumulative pregnancy rate : is the cumulative probability of conception over the next 6 or 12 months.
A normal couple in Europe will have a nearly 50% of conception the first month (MFR). Since the most fertile will be pregnant the remaining population will be less fertile, and after 1 year of infertility the MFR has dropped to 10%. Yet after 1 year of infertility still 80% of couples will get pregnant spontaneously over the following years after 2 years of infertility the cumulative pregnancy rate drops to 50%.
after 5 years : less than 20% will get pregnant spontaneously.
A major cause of infertility is inadequate surgery with ovarian damage and adhesion formation.
During surgery adhesion formation should be prevented.
Unless severe male infertility, IVF should not be started without a diagnostic laparoscopy. Non invasive techniques as ultrasound and MRI are unable to diagnose adhesions, mild endometriosis etc.
What is menopause
Menopause is when the ovaries stop to produce female hormones (estrogens and progestagens). Generally around 50 years but as late as 65 and as early as 35 During the transition from a regular cycle to the menopause, ovarian function and menstrual cycles become irregular. After menopause the women has very low levels of estrogens with all consequences. After menopause the ovaries continue to produce androgens as before.
Why women should take hormone replacement therapy
The advantages are
- on the brain : less flushes, sweats, insomnia and better memory
- on the support tissue : less wrinkles, less osteoporosis, less pelvic floor descent
- on the heart and vessels : 50% fewer accidents if taken from the beginning
- on bowel cancer : 50% less bowel cancers
- on cancer of the uterus : less cancers
- on cancer of the breast : no induction of cancers but an acceleration of growth. Thus a better cancer but 7 years earlier
What is hormone replacement therapy (HRT)
The intake of hormones as produced before - comparable to reading glasses. The dose varies and they can be given as pills, as a cream or vaginally, with and without menstruation
Why many doctors oppose HRT?
It requires a profound knowledge of endocrinology and pharmacology Afraid to change nature The fear of breast cancer : because of the accelerated growth (of existing cancers), the diagnosis of breast cancer is slightly higher (OR=1.25) which by non-experts is considered more cancers
Informed consent requires
- correct information of
- the indication of surgery
- the planned surgery
- the alternatives
- the personal experience, the complications and results of the surgeon for this intervention.
Video registration is an indication that the surgeon feels confident.
Rules of thumb to judge information
- The literature is difficult to interpret by non specialists. Endometriosis is a typical example : more than 20.000 articles have been published but most are clinically irrelevant. What is worse is that hypotheses and speculation often create false expectations. In addition the information is difficult to interpret by zooming in on details without the larger picture (something that is normal in the peer-reviewed literature since the reader is supposed to be able to interpret the data ).
- Websites and the lay press have not been peer-reviewed.
- Important is the credibility of who is giving information : this can best be judged by his background and his publications on the topic.
- Those who do not do surgery could give a biased information on surgery.
- Controversies should be explained Even well performed Randomized Controlled Trials can be interpreted differently. HRT is a typical example. It is useful to understand the background of the controversy and to know what the position is of a doctor.