A Systematic Review and Meta-analysis of Surgical Treatment of Ectopic Pregnancy with Salpingectomy versus Salpingostomy.

OBJECTIVE: To evaluate the fertility outcomes of salpingectomy compared with those of salpingostomy among patients treated for tubal ectopic pregnancies, including a separate analysis of women with risk factors along with a review of the surgical technique. DATA SOURCES: Systematic review and meta-analysis from 1990 to the present through PubMed, Embase, CINAHL, and Ovid MEDLINE. The search string included "tubal pregnancy" or "ectopic" as well as "salpingectomy" and various terms describing salpingotomy. METHODS OF STUDY SELECTION: Articles studying women who underwent surgical management of an ectopic pregnancy and the contrasted outcomes of salpingectomy vs salpingostomy were reviewed. The primary outcomes included subsequent intrauterine pregnancy (IUP) and repeat ectopic pregnancy (REP). TABULATION, INTEGRATION, AND RESULTS: Two randomized controlled trials (RCTs), which consisted mostly of patients classified as low risk, and patients from 16 cohort studies were included. In the RCTs, there was no significant difference in the odds of subsequent IUP in patients who underwent a salpingectomy compared with those who were treated with salpingotomy (odds ratio [OR] 0.97; 95% confidence interval [CI], 0.71-1.33). However, a significant and clinically meaningful difference was noted in the cohort studies, with the patients having a lower chance of IUP after salpingectomy (OR 0.45; 95% CI, 0.39-0.52). No significant difference was noted in the OR for a REP in the randomized trials (OR 0.77; 95% CI, 0.41-1.47), but the patients followed in the cohort studies had a cumulatively higher risk of REP after a salpingostomy (OR 0.73; 95% CI, 0.60-0.90). The subgroup analysis examining women within the studies with risk factors for tubal pathology found an even more impressive lowering in the odds of a subsequent IUP in patients classified as at-risk who were treated with salpingectomy (OR 0.30; 95% CI, 0.17-0.54), with a change in the direction of the odds for an REP rate favoring those who were treated with salpingostomy (OR 1.96; 95% CI, 0.88-4.35). CONCLUSION: Salpingectomy has clear advantages over salpingostomy, and RCTs consisting mainly of patients classified as low risk show no difference in outcomes between salpingectomy and salpingostomy. However, in cohort studies inclusive of all patients, the likelihood of a subsequent spontaneous IUP is decreased in patients treated with salpingectomy, and salpingostomies may be especially underused in women with risk factors for tubal disease.

Management of Hydrosalpinx in the Era of Assisted Reproductive Technology: A Systematic Review and Meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis evaluating the effect of hydrosalpinx on pregnancy outcomes, to compare different types of management of hydrosalpinx and their impact on pregnancy rates as well as on the ovarian reserve. DATA SOURCES: Electronic search using Pubmed, EMBASE, Ovid MEDLINE, Google Scholar, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials and including all published studies that examined tubal infertility and its management (assisted reproductive technology or surgery) as well as the effects on ovarian reserve. The following medical subject headings (Mesh) terms combinations were used: "fallopian tube disease," hydrosalpinx," "tubal or salpinx occlusion or obstruction," "in vitro fertilization," "fallopian tube surgery," "salpingectomy," "salpingostomy," "infertility," "subfertility," "sterility" and "ovarian reserve." METHODS OF STUDY SELECTION: All randomized trials, cohort, and case controls studies were included. We excluded review articles, meeting abstracts, case series and case reports, and abstracts without access to full texts. The search was limited to trials in humans and published in English. TABULATION, INTEGRATION, AND RESULTS: Our electronic search initially retrieved 6354 articles. Finally, 19 studies were included in the quantitative evaluation of the effects of hydrosalpinx: 23 in the qualitative evaluation and 5 in the quantitative evaluation of different types of hydrosalpinx treatments; and 17 in the quantitative evaluation of ovarian reserve. The presence of a hydrosalpinx was associated with decreased rates of implantation and clinical pregnancy, and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx with salpingectomy, tubal occlusion, or hydrosalpinx aspiration led to better in vitro fertilization pregnancy rates. We found no difference in ovarian response to stimulation after salpingectomy except a decrease in antimüllerian hormone compared to no surgery. CONCLUSIONS: The presence of hydrosalpinx is associated with decreased pregnancy rate and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx, regardless of the type of treatment, leads to an increased chance of pregnancy.

Interstitial Pregnancy after Ipsilateral Salpingectomy: Analysis of 46 Cases and a Literature Review.

STUDY OBJECTIVE: To investigate the relationship between previous ipsilateral salpingectomy and interstitial pregnancy and report on our experience of laparoscopic cornuostomy for interstitial pregnancy. DESIGN: Single-center, retrospective review. SETTING: University-based hospital. PATIENTS: All patients who had undergone ipsilateral salpingectomy previously, diagnosed with interstitial pregnancy and treated between July 2010 and September 2018. INTERVENTIONS: Laparoscopy or laparotomy as a treatment for interstitial pregnancy after ipsilateral salpingectomy. MEASUREMENTS AND MAIN RESULTS: A total of 414 cases of interstitial pregnancy were identified, of which 46 (11.1%) were after ipsilateral salpingectomy. Of the 46 patients, 20 (43.5%) became pregnant by in vitro fertilization and embryo transfer. Ipsilateral salpingectomy was the result of an ectopic pregnancy in 40 patients, hydrosalpinx in 5 patients, and torsion of an ovarian tumor in 1 patient. The laparoscopic approach was used to treat 78.3% of patients with history of previous salpingectomy. Patients who underwent ipsilateral salpingectomy by laparoscopy previously had a shorter interval from salpingectomy to interstitial pregnancy (24 months vs 60 months; p = .038) compared with patients who underwent ipsilateral salpingectomy by laparotomy. Laparoscopic cornuostomy was performed in 38 patients (82.6%); 12 had fetal cardiac activity, 15 had ruptured masses, and 16 used prophylactic methotrexate (MTX) intraoperatively. The median size of the ectopic mass was 2.5 cm (1.0-5.0 cm). At the time of laparoscopic cornuostomy, more patients with interstitial pregnancies with intact ectopic masses were administered prophylactic MTX (81.3% vs 45.5%; p = .043). Only 1 patient with a ruptured ectopic mass, high preoperative human chorionic gonadotropin levels, and without prophylactic MTX administration experienced a persistent ectopic pregnancy. CONCLUSION: Patients with a history of ipsilateral salpingectomy should be cautioned regarding the possibility of interstitial pregnancy. Laparoscopic cornuostomy appears to be an appropriate treatment for interstitial pregnancy in patients wishing to preserve fertility, and the use of concomitant prophylactic MTX may reduce the risk of persistent ectopic pregnancy, especially in patients with ruptured masses and high human chorionic gonadotropin levels.

Analysis of pregnancy outcome after anastomosis of oviduct and its influencing factors.

BACKGROUND: This study aims to investigate the influencing factors of pregnancy after laparoscopic oviduct anastomosis. METHODS: The data of 156 cases of laparoscopic oviduct anastomosis in our hospital were analyzed. RESULTS: The pregnancy rate decreased with age (P < 0.005). The pregnancy rate after six years of anastomosis was higher in those with ligation (P < 0.005). The postoperative pregnancy rate significantly increased in subjects with oviduct lengths of > 7 cm (P < 0.01). The pregnancy rate of isthmus end-to-end anastomosis was higher (P < 0.005). The pregnancy rate after bilateral tubal recanalization was higher than that after unilateral tubal recanalization (P < 0.005). The pregnancy rate after laparoscopic tubal ligation and laparoscopic anastomosis was higher than that of open tubal ligation and laparoscopic anastomosis (P < 0.005). CONCLUSION: The pregnancy rate after laparoscopic oviduct anastomosis is higher in subjects below 35 years old, with a ligation duration of < 6 years, and a length of oviduct of > 7 cm, and those who underwent isthmus anastomosis and laparoscopic oviduct ligation and recanalization.

Factors Predicting Persistent Ectopic Pregnancy After Laparoscopic Salpingostomy or Salpingotomy for Tubal Pregnancy: A Retrospective Cohort Study.

STUDY OBJECTIVE: To identify factors predictive of persistent ectopic pregnancy (PEP) in women who have undergone laparoscopic salpingostomy or salpingotomy for tubal pregnancy. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Tertiary referral center. PATIENTS: Ninety-nine women who underwent laparoscopic tubal preservation surgery for ectopic pregnancy. INTERVENTIONS: Seventy women underwent laparoscopic salpingostomy, and the remaining 29 women underwent laparoscopic salpingotomy. MEASUREMENTS AND MAIN RESULTS: Factors predicting PEP were evaluated. The change in serum beta human chorionic gonadotropin (ß-hCG) levels from baseline observed between postoperative days 5 and 10 (ChCGD5-10) was a predictor of PEP (odds ratio [OR], 0.80; p = .01). Based on receiver operating characteristic (ROC) curve analysis, a cutoff value of 93.1% was determined, with an area under the ROC curve of 0.95 (sensitivity, 85.7%; specificity, 100%). Nonetheless, when considering perioperative variables only, body mass index (BMI) was identified as a predictor of PEP (OR, 0.71; p = .03). Based on the ROC analysis, a BMI cutoff value of ≤22 kg/m2 was determined, with an ROC area of 0.73 (sensitivity, 43.2%; specificity, 100%). In addition, a higher baseline ß-hCG level (hazard ratio [HR], 1.0002; p = .009) and left tubal pregnancy (HR, 6.46; p = .03) were predictive of recurrent ectopic pregnancy. There were no differences in the perioperative outcomes, PEP rates, or subsequent intrauterine pregnancy rates between the salpingostomy and salpingotomy groups. In addition, surgical method was not a predictor of recurrent ectopic pregnancy. CONCLUSIONS: ChCGD5-10 was identified as a predictor for PEP, suggesting that it might be more clinically useful for the follow-up of PEP. When considering perioperative variables only, BMI was a predictor for PEP. In addition, there was no significant difference in clinical outcomes between the salpingostomy and salpingotomy groups.

Partial tubal devascularisation: a novel procedure for tubal conservation in ectopic pregnancy.

Ectopic pregnancy is a serious condition that complicates 1-2% of pregnancies. Using surgical management is efficient, but may have an impact on future fertility. Although conservative tubal surgery has not been shown to have a significant advantage over a salpingectomy in terms of the future fertility potential, the conservative surgical techniques remain widely-utilised, particularly in the context of a contralateral diseased or absent tube. We hereby report a case series of a novel procedure to conserve the fallopian tube with the minimal risk of an incisional site bleeding through a partial segmental devascularisation. This technique seems to be an efficient method to minimise the intraoperative bleeding, limit the need for a blood transfusion, and yields a higher success rate of the procedure without jeopardising the blood supply and vitality of the tubes. Impact Statement What is already known on this subject? Conservative surgery has a significant value in women with a contralateral absent or diseased tube. However, a conservative management could be challenging due to the significant bleeding which can be encountered during the surgery. What the results of this study add? The partial devascularisation technique could achieve an adequate haemostasis by blocking the ascending blood supply only to the affected segment of the fallopian tube. What the implications are of these findings for clinical practice and/or further research? A partial devascularisation is a successful conservative surgical treatment option in most patients when the procedure is indicated.

Technical Video: Bilateral Tubal Adhesiolysis With Cuff Salpingostomy.

STUDY OBJECTIVE: To show the steps involved in a bilateral tubal adhesiolysis and cuff salpingostomy. DESIGN: Technical video showing tubal adhesiolysis and cuff salpingostomy in a step-by-step approach. SETTING: Minimal Access Therapy Training Unit, Royal Surrey County Hospital, Guildford, UK, a tertiary referral unit for complex gynecologic endoscopic surgery. INTERVENTIONS: A 38-year-old woman presented with left-sided pelvic pain and primary infertility for 13 years. An ultrasound scan showed bilateral hydrosalpinges with suspected adnexal adhesions. Hysterosalpingography did not show spill of dye. After counseling, she opted to have tubal adhesiolysis and bilateral cuff salpingostomy. CONCLUSION: Tubal surgery for occlusion has become less popular because of the superior success rates of assisted reproductive techniques. As a result, tubal surgery may eventually become a historic operation. However, in cases of distal tubal blockage after adhesionlysis and cuff salpingostomy or neosalpingostomy, pregnancy rates up to 35% have been reported in the literature. Furthermore, performing a bilateral salpingectomy instead in these cases renders a patient entirely dependent on assisted reproductive techniques for tubal factor infertility. Therefore, a bilateral cuff salpingostomy should be considered in a select group of patients.

Effect of second-look laparoscopy on subsequent fertility outcome after laparoscopic salpingostomy for tubal pregnancy: a randomized controlled study.

OBJECTIVE: To clarify the potential value of second-look laparoscopy (SLL) in improving fertility outcomes after laparoscopic salpingostomy for tubal pregnancy. DESIGN: Randomized controlled trial. SETTING: West China Second University Hospital, Sichuan University. PATIENTS: 216 women with future birth demand who underwent laparoscopic salpingostomy for tubal pregnancy. INTERVENTIONS: SLL was performed in the SLL group at 3 months after the primary surgery. MEASUREMENT AND MAIN RESULTS: In both the SLL and control groups, the subjects were assigned to a slight adhesion (SLA) or severe adhesion (SEA) subgroup. At 3-year follow-up, the fertility outcomes were compared between the SLL and control groups and also between the SLA and SEA subgroups. The intrauterine pregnancy rate was higher in the SLL group compared with the control group (63.1% vs 48.6%; p = .032), and the incidence of recurrent ectopic pregnancy was lower in the SLL group than in the control group (6.3% vs 16.2%; p = .021). In the control group, the cumulative pregnancy rate was higher in the SLA subgroup compared with the SEA subgroup (p = .017), but in the SLL group, the cumulative pregnancy rate did not differ between the 2 subgroups (p = .502). The cumulative pregnancy rate was higher in the SEA subgroup of the SLL group compared with the SEA subgroup of the control group (p = .014), but did not differ between the SLA subgroup of the SLL group and the SLA subgroup of the control group (p = .456). CONCLUSION: SLL may improve subsequent fertility outcome after laparoscopic salpingostomy for tubal pregnancy, and may be especially recommended for women with severe and extensive pelvic adhesions.

Laparoscopic surgery for ectopic pregnancy: A comparative study on the clinical benefits and impact on tubal patency and reproductive outcomes.

BACKGROUND: Ectopic pregnancy is a major contributor to maternal morbidity and mortality across the globe. OBJECTIVE: This study aims to investigate the clinical benefits of laparoscopic surgery in treating ectopic pregnancy, and its impact on tubal patency and reproductive outcomes. METHODS: A clinical study was conducted to compare laparoscopic and medical conservative treatment for ectopic pregnancy. A total of 206 patients were treated for ectopic pregnancy at our hospital from January 2018 to June 2020. Among them, 46 underwent laparoscopic ipsilateral salpingectomy, 54 underwent laparoscopic ipsilateral salpingostomy with lesion removal, and 106 were treated conservatively with medication. RESULTS: The age range and average age of each group are provided, with no significant differences in these general demographic characteristics (p> 0.05). Both the salpingostomy and medication groups had higher rates of ectopic pregnancy compared to the salpingectomy group, with statistically significant differences (p< 0.05). The comparison of ectopic pregnancy rates between the salpingostomy and medication groups showed no significant difference. Within three years, the salpingostomy group had 10 cases of recurrent ectopic pregnancy, with 2 cases on the same side, while the medication group had 18 cases, with 8 cases on the same side. At 3 months after the normalization of blood ß-HCG, the salpingostomy group showed 43 cases of tubal patency (patency rate: 79.63%), while the medication group showed 57 cases (patency rate: 53.77%), with a statistically significant difference between the two groups (p= 0.01). CONCLUSION: Laparoscopic surgery for ectopic pregnancy offers significant clinical benefits over conservative medical treatment, including higher rates of tubal patency and improved reproductive outcomes. These findings support laparoscopic surgery as an effective approach for the management of ectopic pregnancy.

Safety and feasibility of a single-port laparoscopic adnexal surgery during pregnancy.

STUDY OBJECTIVE: To evaluate the safety and feasibility of single-port laparoscopic adnexal surgery during pregnancy. DESIGN: A retrospective study (Canadian Task Force Classification III). SETTING: A university hospital. PATIENTS: A total of 14 women with intrauterine pregnancy who underwent single-port laparoscopic surgery (SPLS). INTERVENTION: We retrospectively reviewed the medical records of 14 women with intrauterine pregnancy who underwent SPLS between November 2009 and September 2012 for the treatment of an adnexal mass. MEASUREMENTS AND MAIN RESULTS: Factors investigated included the duration of surgery, differences between preoperative and postoperative hemoglobin, the size of the mass as measured by ultrasonography, major intraoperative or postoperative complications, conversion to multiport laparoscopy, and pregnancy outcomes. Single-port laparoscopic adnexal surgery was successfully performed in all 14 pregnant patients with an adnexal mass. The median gestational age at operation was 9 weeks (range, 4 weeks-17 weeks 4 days). Procedures included ovarian cystectomy with or without detorsion (n = 9), cyst aspiration with detorsion (n = 2), salpingectomy (n = 2), and salpingostomy (n = 1). The median duration of surgery was 59 minutes (range, 36-84 minutes). No major intraoperative or postoperative complications were encountered, and there was no need for conversion to multiport laparoscopic surgery. Five women had spontaneous vaginal delivery, and 5 women underwent cesarean delivery at term. One woman had preterm delivery at a gestational age of 24 weeks 5 days. In 1 case, abortion occurred 2 weeks after the operation. CONCLUSION: Based on these initial findings, SPLS appears to be a safe and technically feasible treatment for an adnexal mass during pregnancy.

Intra-operative hydrotubation improves fertility of women with distal tubal occlusion after reproductive surgery.

PURPOSE: Hydrotubation has been considered to be a complimentary procedure to reproductive surgery, usually being conducted after surgery. The objective of this work was to assess the potential value of intra-operative hydrotubation in improving fertility of tubal infertile women. METHODS: 180 tubal infertile women were randomly assigned to one of the three groups: intra-operative hydrotubation (IH), post-operative hydrotubation (PH) or control group. In IH group, the hydrotubation was performed immediately after adhesiolysis during the surgery process, while in PH group it was performed within 3-7 days after the first post-operative menstruation. The incidence of post-operative pelvic infection and average hospitalization length were recorded. The post-operative pregnancy outcomes, including intrauterine pregnancy (IUP) rate and incidence of ectopic pregnancy, were recorded at 2 years follow-up. RESULTS: No significant difference was found among the three groups, either in the incidence of pelvic infection (P = 0.877) or in the average hospitalization length (P = 0.596). At 2 years of follow-up, the rate of IUP in IH group was significantly higher than that in either PH or control group (P = 0.017 and 0.039, respectively), but no difference was observed between PH and control group (P = 0.752). No significant difference in the incidence of ectopic pregnancy was showed among three groups (P = 0.947). CONCLUSIONS: The appropriate use of intra-operative hydrotubation can improve the post-operative IUP rate, serving as a complementary procedure for the surgical treatment of fertility reversal.

Surgical treatment of ectopic pregnancy associated with predisposing factors of tuboperitoneal infertility.

OBJECTIVE: We sought to study the advantages of laparoscopic conservative treatment and pelvic reproductive surgery in patients with ectopic pregnancy and predisposing factors of tuboperitoneal infertility. MATERIAL AND METHODS: Patients who had undergone laparoscopic treatment for ectopic pregnancy were considered, with factors for tuboperitoneal infertility, while patients who underwent previous salpingectomy or assisted reproductive technology were excluded. The groups treated by salpingotomy (conservative) or salpingectomy (radical) were compared in terms of spontaneous intrauterine pregnancy rate, cumulative one-year pregnancy rate and recurrence of ectopic pregnancy. We considered patients treated with adhesiolysis, fimbrioplasty, and neosalpingostomy for tubal pathology as part of the fertility surgery group. RESULTS: Among 41 considered patients, 21 (51%) underwent conservative laparoscopic management of ectopic pregnancy. Twenty patients (49%) had salpingectomy. Despite the treatment of tuboperitoneal infertility factors in both groups, the pregnancy rate was significantly higher in the conservative group than in the radical one (76% vs 25%, p < 0.05). The overall cumulative rate of ectopic pregnancy recurrence was 22% and no significant difference was found between conservative and radical treatment (p 0.645). CONCLUSIONS: Salpingotomy should be preferred in all patients with ectopic pregnancy associated with factors of tuboperitoneal infertility. Infertility surgery clearly cannot help patients treated with salpingectomy, who obtain lower spontaneous pregnancy rates than those of the conservative group.

Treatment outcomes of tubal pregnancy with tubal preservation: A meta-analysis.

BACKGROUND: Ectopic pregnancy is a common gynecological emergency that poses a significant risk of maternal mortality during the first trimester. It also increases the incidence of infertility and repeated ectopic pregnancy. The aim of this study was to evaluate whether there is a difference in the degree of tubal patency between salpingostomy and systemic treatment with methotrexate (MTX), as well as the odds of intrauterine pregnancy and repeat ectopic pregnancy, and the degree of tubal patency in salpingectomy with or without tubal suturing. METHODS: We searched PubMed, EMBASE, and the Cochrane Library up to April 2023. Four randomized controlled trials were included in the review. We analyzed the combined data using Review Manager 5.3 software and Stata 12.0 software, utilizing a random effects model. RESULTS: When comparing salpingostomy and systemic treatment with MTX, there was no significant difference in the degree of tubal patency (OR = 1.09, 95% CI (0.54-2.38), P = .83). For salpingostomy with or without tubal suturing, there were no significant differences in the rates of intrauterine pregnancy, repeat ectopic pregnancy, and tubal patency degree [(OR = 1.05, 95% CI (0.41-2.68), P = .92), (OR = 0.68, 95% CI (0.19-2.42), P = .92), (OR = 1.68, 95% CI (0.14-20.33), P = .68)]. CONCLUSION: This meta-analysis demonstrates that systemic treatment with MTX is an effective treatment for patients who wish to preserve their fallopian tubes without undergoing surgery. This form of treatment can help avoid surgical procedures that may damage the fallopian tubes and improve fertility prospects. If choosing surgery, we believe that opting for salpingostomy without tubal suturing could reduce the operation time and minimize damage.

Transvaginal single-port natural orifice transluminal endoscopic surgery for benign uterine adnexal pathologies.

Transvaginal natural orifice transluminal endoscopic surgery (NOTES) with pneumoperitoneum has been used in cholecystectomies, appendectomies, and nephrectomies, but transvaginal NOTES using a single port in gynecologic procedures has not been described despite gynecologist familiarity with the vaginal approach. We performed transvaginal single-port NOTES in 10 women with benign uterine adnexal disease: oophorectomy in 3 patients, salpingostomy and salpingectomy in 2 each, and ovarian cystectomy, paratubal cystectomy, and ovarian wedge resection in 1 each. The patients were discharged at 1 or 2 days postoperatively, and were satisfied, with minimal pain, no abdominal scar, and no complications at 2-month follow-up. We conclude that transvaginal single-port NOTES to treat benign uterine adnexal disease is a feasible and attractive option.

Long-term outcomes of radical and conservative surgery for late diagnosed tubal pregnancies.

OBJECTIVE: To investigate long-term postoperative outcomes of conservative and radical surgery in ectopic tubal pregnancies, and evaluate the results of these techniques. METHODS: A total of 145 patients that operated for tubal pregnancy between January 2006 and January 2009 were reviewed. Data on patient age, reproductive and surgical history history of ectopic pregnancies, serum hCG levels at the time of diagnosis and intraoperative observation were retrospectively obtained from hospital records. Telephone interviews were used to obtain information about exact postoperative time interval in which the patients were trying to get pregnant, and the time when they spontaneously became pregnant. RESULTS: There was no significant difference in cumulative spontaneous intrauterine pregnancy rate for a 2-year of conception period subsequent to conservative (64.3%) and radical (58.3%) surgery (p = 0.636). During the same time interval, the rates of development of ectopic pregnancy for the conservative and radical surgery groups were 17.9% and 4.2%, respectively (p = 0.093). The patients who developed ectopic pregnancy after conservative surgery had significantly higher levels of serum hCG levels (7413 +/- 3155 IU/L) compared with those of patients who not-developed ectopic pregnancy (3436 +/- 2668 IU/L) (p = 0.007). CONCLUSION: In late-diagnosed cases with higher serum hCG levels, conservative treatment should not be the first choice. Indeed, our results suggested that the cumulative pregnancy rates are not significantly higher and the risk of ectopic pregnancy recurrence may be increased with conservative surgery in late tubal pregnancies.

Radical fimbriectomy: a reasonable temporary risk-reducing surgery for selected women with a germ line mutation of BRCA 1 or 2 genes? Rationale and preliminary development.

OBJECTIVE: Bilateral salpingo-oophorectomy (BSO) is the gold standard prophylactic surgery for BRCA1 or 2 mutation carriers. However, due to the resulting early menopause and fertility desires, young women are reluctant to undergo this procedure. In view of the recent literature on ovarian carcinogenesis, we wish to report a novel conceptual surgical procedure we called "radical fimbriectomy." This procedure is aimed to protect this subset of high-risk women from high-grade serous pelvic carcinoma, while preserving their ovarian function. METHODS: Women with BRCA mutation, who were scheduled for BSO, were informed of the procedure approved by our local review board. Radical fimbriectomy consists of removing all the tube and the fimbrio-ovarian junction, step immediately followed in this developmental phase by completion oophorectomy. Four methods of partial ovarian transsection were prospectively compared: sharp division, stapler, bipolar division and harmonic scalpel. Surgical safety and pathological alterations were assessed. All specimens underwent extensive pathological evaluation using both SEE-FIM protocol and serial sections. RESULTS: Fourteen women were enrolled in the study. Sharp and EndoGIA® appeared to be the safest methods of ovarian resection providing the best specimen quality for pathological examination. CONCLUSION: We believe this technique could be suggested to young mutation carriers reluctant to undergo BSO. This approach is preferable to no prophylactic surgery at all. However, until the safety and validity of this procedure is confirmed by a multi-institutional study, women who undergo radical fimbriectomy should continue to receive regular multimodal evaluation and be advised of the risks involved until they finally accept secondary castration.

Linear salpingotomy with suturing by single incision laparoscopic surgery for tubal ectopic pregnancy.

We investigated the feasibility of linear salpingotomy with suturing for ampullary tubal pregnancy via single incision laparoscopic surgery (SILS). Three patients underwent SILS between April and May 2010 at our hospital due to ampullary tubal pregnancy. A multichannel port was inserted into the umbilicus via a 2.5-cm incision to accommodate a 5-mm flexible laparoscope and a disposable articulating forceps. The linearly incised Fallopian tube was intracorporeally sutured using an articulating suturing device dedicated to SILS. The mean surgical duration was 54 minutes. Tubal preservation by linear salpingotomy was accomplished for all patients without up-conversion to conventional laparoscopy. Serum ß-hCG values of all patients immediately decreased and further medical treatment was unnecessary.

Vaginal hysterectomy aided with surgery by the abdominal approach as a method of hysterectomy with salpingo-oophorectomy due to endometrial carcinoma in a woman with morbid obesity. Case report.

The most important risk factors of endometrial carcinoma are fat consumption, obesity (BMI > or = 25 kg/m2) and use of unbalanced estrogen therapy. Other factors include lack of physical activity, a high-calorie diet, arterial blood pressure above 140/90 mmHg and high concentrations of glucose in the blood. The basic treatment in cases of endometrial carcinoma is surgery including hysterectomy with salpingo-oophorectomy and complete interoperational assessment of the development degree of the disease. Basic operational treatment is difficult as far as obese women are concerned (BMI > or = 50 kg/m2). This is linked with poor access to operated tissues and limited visibility, mainly in the area of the bottom of the pelvis minor. Our 69-year-old patient was admitted to and operated on at the Gynecological Department due to endometrial carcinoma. Because of her giant obesity, BMI - 51.30 kg/m2, surgery by the abdominal approach was very difficult to perform, so vaginal hysterectomy with salpingo-oophorectomy was carried out.

Organ-preserving and reconstructive microsurgery of the fallopian tubes in tubal infertility: still an alternative to in vitro fertilization (IVF).

Tubal infertility mostly results from infections. Conception only is possible through complex treatments (in vitro fertilization or surgery). Success cannot be guaranteed, even after repeated treatments. Unfortunately, many couples are not informed about the prospect for success of tubal reconstruction. Problems of in vitro fertilization are low pregnancy and birth rates of 28.4% and <20% respectively (Germany) and the high number of multiple pregnancies (21%). In this retrospective study 462 women with acquired tubal infertility and further 127 women after previous sterilization underwent microsurgical treatment (microsurgical adhesiolysis, anastomosis, fimbrioplasty, salpingostomy, and refertilization due to former sterilization). The main outcome measures are the pregnancy and birth rates following the microsurgical procedure. Pregnancy and birth rates of 43.4% and 29.2%, respectively, were higher than the outcomes post-single in vitro fertilization (abortion: 6.4%, extrauterine pregnancy: 7.9%). When reversal of sterilization was performed, pregnancy and birth rates were higher at 73% and 50.6%, respectively (abortion: 15.7%, extrauterine pregnancy: 6.7%). The advantages of reconstructive microsurgery over in vitro fertilization include the ideally permanent restoration of woman's ability to conceive naturally (repeated pregnancies are possible without further therapy), a high postoperative birth rate overall, and avoidance of multiple births. It is advisable to inform the patient about the objective possibility of reconstructive tubal surgery.

Platinum, anthracycline, and alkylating agent-based chemotherapy for ovarian carcinosarcoma.

BACKGROUND: Ovarian carcinosarcoma (OCS) is a rare malignancy associated with a poor prognosis. Platinum, anthracyclines, and alkylating agents are the most effective antiblastic drugs for treatment of gynecologic epithelial and stromal tumors. The aim of this study was to determine response rate and overall survival (OS) of patients with OCS who were treated with a combination of these 3 drugs. METHODS: Forty-one women with OCS who were referred to the Department of Gynecologic Oncology of San Gerardo Hospital in Monza and European Institute of Oncology in Milan, between January 1995, and December 2006, and treated with a combination regimen of cisplatin, adriamycin, and cyclophosphamide or a combination regimen containing of cisplatin, epirubicin, and ifosfamide plus granulocyte colony-stimulating factor were considered for this study. RESULTS: Four women had OCS stage I; 7, stage II; 23, stage III; and 7, stage IV. Heterologous, homologous, and mixed stromal components were described in 17, 14, and 10 patients, respectively. Thirteen women were treated with a combination of cisplatin, adriamycin, and cyclophosphamide and 28 with a combination of cisplatin, epirubicin, and ifosfamide plus granulocyte colony-stimulating factor. Two women did not complete their treatment because of the rapid progression of their disease and severe toxicity. Among 22 women considered evaluable for response, 10 (46%) achieved a complete response and 3 (13%) achieved a partial response (global response rate, 59%). Overall progression-free survival was 11.8 months (range, 0.9-96 months) and 13.8 and 10.1 months in stage I-II and III-IV, respectively (P = 0.13). Median OS was 20 months (range, 1-123 months), not reached in stage I-II, and 19.7 months in stage III-IV (P = 0.07). No significant difference between homologous and heterologous sarcomatous components was observed (P = 0.95), whereas no significant trend of improved OS was noticed for stage IIIC-IV with optimal debulking surgery (n = 9), compared with suboptimal cytoreduction (n = 19; 32.6 vs 14.5 months, P = 0.14). CONCLUSION: The combination of anthracycline, alkylating agent, and cisplatin showed a good response rate but also a high toxicity. The prognosis of OCS remains poor. Optimal cytoreduction may improve survival, but new anticancer drugs or more effective regimens are awaited.