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Notes: Summary. Twenty-four women with symptomatic multiple uterine myomas were allocated randomly to treatment with buserelin, 1200μg/day intranasally, for 3 months followed by myomectomy (n = 8) or to immediate myomectomy (n = 16). Pre-operative treatment with buserelin reduced the mean uterine volume from 432 (SD 165) to 242 (SD 82) ml (P 〈 0.01) but intra-operative blood loss and postoperative morbidity were not significantly less in this group. Six months after operation, pelvic examination was normal in all the patients. However, ultrasonography with transvaginal probe demonstrated the presence of myomas of 〈 1.5 cm in five women (63%) treated pre-operatively with the analogue and in two women (13%) who underwent immediate surgery (P 〈 0.05). Induction of a period of hypo-oestrogenism before myomectomy seems to favour short-term recurrence of uterine myomas, limiting the efficacy of surgery.

Notes: To investigate the left- and right-sided distribution of ovarian malignant surface epithelial tumours, data were collected on 209 women undergoing first-line surgery for Stage I and II disease. Considering the unilateral cancers, the observed proportion of left-sided lesions was 35/54 (65%) in the endometrioid, 20/45 (44%) in the serous, 19/35 (54%) in the clear cell, 13/29 (45%) in the mucinous, 2/8 (25%) in the mixed, and 2/5 (40%) in the undifferentiated histological type group. The proportion of left-sided unilateral endometrioid cancers was significantly different from the expected 50% (χ21, 4.74, P= 0.03) and very similar to that previously observed for benign endometriotic cysts, constituting further evidence in favour of a possible development of endometrioid cancers from the latter lesions.

Notes: Objective To ascertain whether treatment with a gonadotrophin releasing hormone agonist before endometrial resection reduces absorption of distension fluid and operating time and facilitates the procedure.Design A multicentre, prospective, randomised controlled study.Participants Seventy-one premenopausal women with established menorrhagia.Interventions Eight weeks of goserelin depot treatment before endometrial resection of immediate surgery in the early proliferative phase of the cycle.Main outcome measures Irrigation fluid deficit, operating time and degree or difficulty of the procedure.Results After randomisation eight women withdrew from the study, leaving 33 women in the goserelin arm and 30 in the immediate surgery arm. Mean (SD) operating time was 15.1 (9.0) min in the goserelin group versus 16.9 (9.5) min in the controls; mean difference † 1.8 min, 95% CI, −2.9 to + 64. Mean (SD) distension medium deficit was, respectively, 422 (287) ml versus 564 (291 ml); mean difference + 142 ml, 95 % CI-4 to + 288. The goserelin effect was restricted to the 29 women with adenomyosis as the mean (SD) fluid deficit was considerably less in the 19 treated women than in the 10 controls (299 (206) ml versus 597 (135) ml; mean difference + 298 ml, 95YO CI +149 to + 447). The surgeons classified the intraoperative difficulties as none in 6, minimal in 20, moderate in 7, and severe in no cases in the goserelin group; corresponding figures in the group without pretreatment were 2, 14, 13, and 1.Conclusions Goserelin administration before endometrial resection may reduce absorption of fluid at surgery in women with adenomyosis and may facilitate intrauterine operating conditions.

Notes: Six cases of endometriosis obstructing the left ureter were observed among 1054 consecutive patients undergoing surgery in an eight-year period. In addition, 125 women with ureteral endometriosis (left-sided, n= 66; right-sided, n= 40; bilateral, n= 19) were described in 62 articles identified in a systematic review of the English language literature between 1980 and 1998. Considering only the patients with unilateral ureteral endometriosis and combining the published figures with those of our surgical series, the observed proportion of left lesions (72/112, 64%; 95% CI 55% to 73%) was significantly different from the expected proportion of 50% (χ2i, 9.14, P= 0.002). The lateral asymmetry found in the location of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomical differences of the left and right hemipelvis

Notes: Objectives To ascertain whether uterine shrinkage induced by a gonadotrophin releasing hormone agonist before hysterectomy for fibroids increases the possibility of a vaginal procedure.Design A multicentre, prospective, randomised, controlled study.Participants One hundred and twenty-seven premenopausal women with a uterine volume of 12 to 16 gestational weeks.Interventions Twelve weeks of triptorelin depot treatment before hysterectomy or immediate surgery.Main outcome measures Number of vaginal and abdominal hysterectomies, operating time, blood loss, degree of difficulty of the procedure, perioperative serum haemoglobin and haematocrit levels, hospital stay, and patients' overall satisfaction with treatment.Results After randomisation, four women withdrew from the study, leaving 60 women in the triptorelin arm and 63 in the immediate surgery arm. At baseline evaluation a vaginal hysterectomy was indicated in seven women allocated to pre-operative medical therapy (12%), and in 10 of those allocated to immediate surgery (16%). Clinical assessment after the 12–week GnRH agonist course showed that abdominal hysterectomy was no longer indicated in 25/53 women (47%) as a vaginal procedure appeared appropriate. Thus the overall rate of indication for a vaginal procedure in the pre-operative medical treatment arm was 32/60 cases (53%), with a between-group difference of 37% (95% CI, 26% to 51%; χ21= 19.18, P 〈 0.0001; OR 6.06; 95% CI, 2.60 to 14.10). Pre- and post-operative serum haemoglobin and haematocrit levels were significantly higher in the GnRH agonist than in the immediate surgery arm. No appreciable difference was observed between the groups in the other intra- and post-operative variables, including patients' satisfaction.Conclusions Pre-operative GnRH agonist therapy increased the rate of vaginal hysterectomy in selected women with fibroids and uterine volume of 12 to 16 gestational weeks.

Notes: To investigate the left- and right-sided distribution of nonendometriotic benign ovarian cysts, data were collected on 406 women undergoing first-line surgery for tumours with various histotypes. Considering the unilateral cysts, the observed proportion of left lesions was 65/129 (50.4%) in the serous, 38/79 (48.1%) in the mucinous, 59/134 (44.0%) in the dermoid, 11/21 (52.4%) in the parovarian, and 3/7 (42.9%) in the miscellaneous cysts group, without significant differences from the expected 50%. This contrasts with the finding of a significantly more frequent development of endometriomas on the left ovary, and suggests that the pathogenesis of endometriotic and nonendometriotic cysts is different.

Notes: Objective To ascertain whether the frequency of pelvic pain recurrence is reduced and time to symptoms recurrence is prolonged in women with symptomatic endometriosis undergoing conservative surgery and post-operative hormonal therapy compared with women treated with surgery only. Pregnancy rates and time to conception in women wanting children were also evaluated.Design A multicentre, prospective, randomised controlled study.Setting Nineteen Italian academic departments and teaching hospitals specialising in reparative and reconstructive surgery.Population A total of 269 women undergoing conservative surgery for mild to severe symptomatic endometriosis.Methods After surgery the women were assigned to treatment with subcutaneous goserelin depot injections for six months or to expectant management. Dysmenorrhoea, deep dyspareunia, nonmenstrual pain and general discomfort were graded according to a verbal rating scale from 0 (absent) to 3 (severe) and the scores summed to give a total symptoms score. Only patients with at least one preoperative moderate or severe symptom were enrolled. The women were evaluated regularly for two years.Main outcome measures Post-operative pain recurrences (total symptoms scores ≥ 5), time to recurrence, pregnancy rates and time to conception in the two study groups.Results At oneand two-year follow up visits, 14/107 (13.1%) and 19/81 (23.5%) patients had moderate or severe symptoms recurrence in the goserelin group compared with, respectively, 22/103 (21.4%) and 27/74 (36.5%) in the expectant management group (P= 0.143 at 1 year and 0.082 at 2 years). Time to symptoms recurrence was significantly longer in the goserelin group according to survival analysis (Wilcoxon test, P= 0.041). Among women wanting children, few conceptions occurred in both the goserelin (8/69, 11.6%) and the expectant management group (14/76, 18.4%). There was no significant difference at survival analysis (Wilcoxon test, P= 0.427).Conclusion Post-operative treatment with goserelin significantly prolonged the pain-free interval after conservative surgery for symptomatic endometriosis and did not influence reproductive prognosis.

Notes: Objective To investigate whether asymmetry exists in the left- and right-handed distribution of ovarian cystic lesions in a large series of women with endometriosis.Design Retrospective evaluation of a case series.Setting Tertiary care and referral academic centre for the study and treatment of endometriosis.Population A total of 1054 consecutive women undergoing first-line surgical treatment for endometriosis in an eight-year period.Methods Data were collected on indication for the intervention, age at surgery, parity and disease stage as well as side and size of ovarian endometriomas.Main outcome measure Frequency of left- and right-sided ovarian endometriomas.Results Histologically confirmed endometriotic ovarian cysts were present in 561 women, which were on the left side in 255 instances, on the right in 148, and bilateral in 158. In the patients with unilateral endometriomas, the observed proportion of left cysts (255/403, 63%; 95% confidence interval, 58% to 68%) was significantly different from the expected proportion of 50% (χ21, 28.41, P 〈 0.001). Including also the bilateral endometriotic cysts gave a total of 413/719 (57%) left-sided and 306/719 right-sided endometriomas. The magnitude of these proportions did not vary appreciably during the eight years considered. The difference in proportion of left- and right-sided endometriotic cysts was virtually similar in subgroups of women with different indications for surgery. Cyst side was not related to age, parity or cyst diameter.Conclusions The finding of a lateral asymmetry in the occurrence of ovarian endometriotic cysts is compatible with the anatomical differences of the left and right hemipelvis and supports the menstrual reflux theory.