Imaging and molecular features of adenomyosis after menopause.

OBJECTIVES: To explore the imaging features and the molecular characterization of adenomyosis after menopause. STUDY DESIGN: An observational cross-sectional study was performed in a group of postmenopausal patients undergoing a transvaginal ultrasound (TVUS) (n = 468). Among those presenting the US criteria for adenomyosis, also confirmed by magnetic resonance imaging (MRI), previous menstrual symptoms, gynecological and obstetric history were reviewed. In a subgroup undergoing hysterectomy, uterine specimens were analyzed by histology and expression of genes implicated in the epithelial-mesenchymal transition, inflammation and fibrosis, including the sphingosine-1-phosphate (S1P) pathway, was evaluated and compared to matched non-menopausal adenomyosis specimens. MAIN OUTCOME MEASURES: Direct and indirect US features of adenomyosis according to Morphological Uterus Sonographic Assessment at TVUS. Molecular characterization of postmenopausal versus pre-menopausal adenomyosis samples. RESULTS: According to TVUS and MRI, adenomyosis was identified in 49 patients (10.4 %). On US, diffuse adenomyosis was the most common phenotype, whereas internal adenomyosis with diffuse pattern and asymmetric type was the most prevalent on MRI. Molecular analysis showed that adenomyosis lesions express markers of epithelial-mesenchymal transition, inflammation and fibrosis also in postmenopausal women. By comparing the results with those from pre-menopausal samples, the expression of α smooth muscle actin (αSMA), a marker of fibrosis, was significantly greater after menopause, and altered S1P catabolism and signaling were observed. CONCLUSIONS: Adenomyosis may be identified in postmenopausal women by imaging, either TVUS or MRI, and fibrosis is one of the key features on molecular analysis.

Laparotomy vs. minimally invasive surgery for ovarian cancer recurrence: a systematic review.

The objective of the present review is to thoroughly investigate the role of minimally invasive surgery (MIS) in the setting of secondary cytoreduction for ovarian cancer recurrence, comparing this approach to traditional open surgery. PubMed, ClinicalTrials.gov, Scopus and Web of Science databases (between 1st January 1989 and 1st January 2020), have been systematically queried to identify all articles reporting either laparoscopic or robotic-assisted secondary surgical cytoreduction for recurrent ovarian cancer. We also manually searched the reference lists of the identified studies. Only English language papers were considered. Two independent reviewers screened and identified the reports. A sub-analysis was performed including studies comparing MIS vs. open abdominal secondary cytoreduction. A total of 617 articles were considered. Among them, we included 12 retrospective studies on minimally invasive secondary cytoreduction, enrolling 372 patients (260 of whom were submitted to whether robotics or laparosopy). Three studies compared 69 patients who underwent MIS vs. 112 cases of open abdominal secondary cytoreduction. Other 9 articles described a total of 191 patients who had minimally invasive secondary cytoreduction for recurrent ovarian cancer without a comparative arm. The quality of the evidence was low. The decision regarding the use of MIS was left to surgeon's discretion; in general, the candidates to MIS were selected patients with single-site disease or few localizations of relapse. Compared to open surgery, MIS was associated with significantly lower blood loss, shorter hospital stay and less postoperative complications; the rate of complete cytoreduction to residual tumor =0 was 95.5% in MIS cases vs. 87.5% in laparotomy cases. The risk of complications was generally low. Disease-free and overall survival were comparable between groups. There is no consensus on the criteria to select patients for laparoscopic or robotic secondary cytoreduction. Intra-operative ultrasound has been proposed as a possible tool to better identify the site of recurrence and for confirmation of complete resection of disease. In conclusion, MIS is an option in selected patients with recurrent ovarian cancer, provided there is no widespread disease. Selection of patients appears of utmost importance to obtain satisfactory survival outcomes.

Impact of Sport Activity and Physical Exercise on Obstetrical and Perineal Outcomes at Delivery: A Prospective Study.

OBJECTIVE: This study was aimed to investigate the effects of physical activity on perineal outcomes at delivery according to the different levels and types of maternal physical activity before and during pregnancy. STUDY DESIGN: We prospectively evaluated the obstetrical and perineal outcomes of all consecutive women who delivered at the Del Ponte Hospital, in the period between July 2014 and September 2014. Women were divided into three groups according to the features of physical activity performed before pregnancy: group 1: "very sporty women," group 2: "moderately sporty women," and group 3: "inactive women." A subanalysis of our data was performed based on the specific type of sport activity, on the degree of involvement of perineal muscles during physical activity, and on the continuation/discontinuation of this activity during pregnancy. RESULTS: A total of 135, 84, and 85 women were included in group 1, group 2, and group 3, respectively. The demographic characteristics were comparable among all the groups. Sport activity during pregnancy was more frequent in groups 1 and 2 (59.3 and 53.6%, respectively, vs. 29.4% in group 3; p = 0.003). No differences among groups were detected in terms of perineal outcomes. A lower rate of episiotomy/lacerations ≥ 2nd degree was found among women who practiced sports that specifically involved the perineal muscles and who continued this practice during pregnancy. CONCLUSION: Perineal outcomes are not influenced by the intensity of sport activity performed before/during pregnancy. Continuous sports during pregnancy that specifically train the perineal muscles are associated with a lower rate of episiotomy and perineal lacerations ≥ 2nd degree.

Pregnancy after Endometriosis: Maternal and Neonatal Outcomes according to the Location of the Disease.

OBJECTIVE: To systematically evaluate pregnancy and labor course, obstetrical complications, and maternal and neonatal outcomes in women with endometriosis, stratifying according to the specific location of the disease. STUDY DESIGN: We retrospectively analyzed our prospectively maintained obstetrical database from January 2011 to August 2014 to identify all women with a previous histological diagnosis of endometriosis who delivered at our institution (cases). We divided the cases according to the specific location of the disease (deep infiltrating endometriosis, ovarian endometriosis, and peritoneal endometriosis). As controls, we identified all unaffected women who delivered in the year 2013. To avoid the confounding effect of parity, we limited our analysis to nulliparous women. RESULTS: A total of 118 nulliparous women with endometriosis and 1,690 nulliparous controls were identified. Women with endometriosis were significantly older, had a lower body mass index, and had a higher incidence of assisted reproductive technology. The duration of pregnancy was significantly shorter among women with endometriosis. A higher incidence of placenta previa (3.4 vs. 0.5%; p = 0.006), hypertension (11 vs. 5.9%; p = 0.04), cesarean section (41.5 vs. 24.2%; p < 0.0001), and vacuum delivery (10.1 vs. 2.9%; p = 0.006) was found in women with endometriosis. Neonatal outcomes were similar between groups. The incidence of placenta previa in patients with deep endometriosis was 11.7 versus 0.5% among controls (p < 0.0001), whereas in women with ovarian and peritoneal endometriosis, it was similar to the controls. CONCLUSION: Women with endometriosis have a higher incidence of vacuum delivery, cesarean section, and placenta previa compared with unaffected women. The higher risk of placenta previa is attributable exclusively to women with deep endometriosis. Neonatal outcomes are unaffected by the presence of the disease.

Fertility rates, course of pregnancy and perinatal outcomes after laparoscopic ureterolysis for deep endometriosis: A long-term follow-up study.

We evaluated fertility rates, pregnancy course and maternal/neonatal outcomes following laparoscopic ureterolysis for deep endometriosis. Data about women who underwent laparoscopic excision of ureteral endometriosis were analysed. After exclusion of women who underwent hysterectomy/bilateral adnexectomy at initial surgery, and those lost-to-follow-up or with follow-up <1 year, a total of 61 patients were included. Of them, 36 (59%) wished to conceive after surgery. Twenty women became pregnant: nine (45%) of them after assisted reproductive technologies. Twenty-six pregnancies were observed with four (15.6%) miscarriages. Median gestational week at delivery was 38 weeks + 2 days (range, 33 + 1-41 + 6), with three (13.6%) and two (9%) deliveries before 37 and 34 weeks, respectively. Nine caesarean sections were performed (40.9%). Fertility rates after laparoscopic ureterolysis are comparable to those of other women operated for other forms of deep endometriosis. Apart from a higher risk of caesarean and preterm birth, the course of pregnancy and peripartum outcomes appear encouraging.