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OBJECTIVE: To describe a 5-year experience of fluoroscopically guided hysteroscopic synechiolysis for Asherman's syndrome. DESIGN: Retrospective, uncontrolled cohort study. SETTING: Department of Endo-Gynaecology, University of New South Wales, Royal Hospital for Women, Randwick, Sydney, New South Wales, Australia. PATIENT(S): Thirty consecutive patients with confirmed Asherman's syndrome (March 1999-March 2004). INTERVENTION(S): Women had hysteroscopy performed under general anesthetic, with the use of a spinal needle in parallel to the hysteroscope to perform synechiolysis. The progress of the procedure was determined by injecting radiographic contrast medium, and visualized with the use of an image intensifier. Individual procedures were terminated when the endometrial cavity was reconstructed, or at 60 minutes. Cyclic high-dose estrogen therapy was used to stimulate endometrial proliferation. Repeat procedures were performed monthly until the endometrial cavity was reestablished. MAIN OUTCOME MEASURE(S): Menstrual and fertility outcomes were obtained from patient records and by postal questionnaire. RESULT(S): Thirty patients were treated for Asherman's syndrome (13% AFS Grade I, 43% AFS Grade II, and 43% AFS Grade III). Prior to treatment, 60% of patients were amenorrheic. The median number of procedures per patient was 1.5 (range, 1-6), and the mean length of the procedure was 42 minutes (range, 10-70 minutes). After treatment, 96% had regular menses. Seventeen patients attempted to conceive after surgery, and 9 (53%) were successful. CONCLUSION(S): Hysteroscopic synechiolysis under image-intensifier control appears to be an effective treatment for Asherman's syndrome.

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STUDY OBJECTIVE: To describe the effect of fertility-sparing laparoscopic excision of endometriosis and bowel resection on clinical and quality-of-life outcomes. DESIGN: Prospective observational cohort study (Canadian Task Force classification II-2). SETTING: Australian tertiary referral center for the surgical treatment of endometriosis. PATIENTS: Seven consecutive patients with known endometriosis involving the bowel. INTERVENTION: Laparoscopic resection of all endometriosis, including laparoscopic bowel resection with end-to-end anastomosis with or without temporary ileostomy. MEASUREMENTS AND MAIN RESULTS: Preoperative and 12-month postoperative data were collected by use of visual analogue scores for dysmenorrhea, nonmenstrual pelvic pain, dyspareunia, and dyschezia. Validated research tools (SF12, EuroQOL, and Sexual Activity Questionnaire) also assessed quality of life. Reduction in median pain scores at baseline was demonstrated and at 12 months after operation for dysmenorrhea 71 (interquartile range 43-85) versus 5 (0-10); p=.028, nonmenstrual pelvic pain 74 (48-85) versus 11 (0-18); p=.046, dyspareunia 66 (0-98) versus 5 (0-8); p=.080, and dyschezia 48 (20-64) versus 20 (0-40); p=.173. All measures of quality of life were improved at 12 months after surgery, although not reaching statistical significance because of the small sample size. All three women wishing to conceive after operation have been successful, resulting in three live births at term. There were few complications associated with this surgery. CONCLUSION: Fertility-sparing laparoscopic excision of endometriosis with bowel resection results in improvements in all aspects of pain and quality of life. Results appear to parallel published data for conservative resection of endometriosis not involving bowel. For women with severe endometriosis involving bowel, this surgical treatment provides a viable alternative to pelvic clearance and successfully maintains fertility.

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STUDY OBJECTIVE: To assess a method using instillation of saline to expel all residual intraperitoneal CO2 after laparoscopy. If successful, this would enable clinicians to use radiography as a simple diagnostic test to detect bowel perforation following laparoscopic surgery. DESIGN: Cohort study (Canadian Task Force classification II-2). SETTING: Department of Endo-Gynecology, Royal Hospital for Women, Sydney, Australia. PATIENTS: Thirty women undergoing elective gynecologic laparoscopic surgery. INTERVENTIONS: At completion of surgery, the patient remained in maximum head- down position as the abdomen was filled with up to 1 L of normal saline. The suprapubic port remained open to allow the CO2 to escape as it was displaced by the saline. Closure of abdominal ports was completed in routine manner. Erect upper abdominal radiographs were taken 24 hours after surgery, and measurements of any subdiaphragmatic gas were recorded. If gas was evident at 24 hours, a repeat radiograph was performed at 48 hours. MEASUREMENTS AND MAIN RESULTS: Of the 30 patients recruited, four did not complete the study protocol. There was evidence of subdiaphragmatic gas in 25 (96%) of 26 patients on the radiograph taken 24 hours postsurgery. The median volume of gas was 12.9 mL (range 0-2003 mL; IQ range 2.0-144 mL). Of the patients that had a second radiograph, 76% still had subdiaphragmatic gas present. CONCLUSION: This method for displacement of residual intraperitoneal gas at the end of laparoscopy does not appear to be effective.

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OBJECTIVE: To investigate whether botulinum toxin type A (BOTOX) injected into the levator ani muscles of women with objective pelvic floor muscle spasm decreases pain symptoms and improves quality of life. DESIGN: A prospective cohort study. SETTING: Outpatient clinic in a tertiary referral centre, Sydney, Australia. SAMPLE: Twelve women, aged 18-55 years, with objective pelvic floor muscle hypertonicity and a minimum 2-year history of chronic pelvic pain were recruited. METHODS: All women completed visual analog scale pain assessments; questionnaires relating to bladder and bowel symptoms and quality of life; and specific examinations. Forty units of BOTOX at three different dilutions were given bilaterally into the puborectalis and pubococcygeus muscles under conscious sedation. RESULTS: Median visual analog scale scores were significantly improved for dyspareunia (80 vs 28; P=0.01) and dysmenorrhea (67 vs 28; P=0.03), with non-significant reductions in non-menstrual pelvic pain (64 vs 37) and dyschesia (47 vs 29). Pelvic floor muscles manometry showed a 37% reduction in resting pressure at week 4 and a 25% reduction was maintained at week 12 (P <0.0001). Quality of life scores (EQ-5D and SF-12) were improved from baseline at week 12, but did not reach statistical significance. Sexual activity scores were markedly improved, with a significant reduction in discomfort (4.8 vs 2.2; P=0.02) and improvement in habit (0.2 vs 1.9; P=0.03). These results were not influenced by dilution. CONCLUSION: There is evidence from the present pilot study suggesting that women with pelvic floor muscles hypertonicity and pelvic pain may respond to BOTOX injections into the pelvic floor muscles. Further research into this novel treatment of chronic pelvic pain is strongly recommended.

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