Utero-cutaneous fistula after caesarean section delivery: diagnosis and management of a rare complication.

Utero-cutaneous fistula is an extremely rare condition characterized by an abnormal communication between the anterior wall of the uterus and the abdominal wall. The causes include multiple caesarean sections, incomplete hysterorrhaphy, miscarriages, uterine cavity revision, retention of placental material after delivery, use of drains, post-operative infections, or injuries. Herein, we report a case of a 38-year-old female, who underwent caesarean section 42 days earlier and presented to the emergency room complaining of fever, abdominal pain, and purulent discharge from the abdominal wall from 6 days. Her medical history included 2 previous term caesarean section deliveries and an hysteroscopic polypectomy 2 years earlier. A pelvic computed tomography scan with contrast medium showed fluid/super-fluid phlogistic collection reported at the anterior wall of the uterus with a continuous solution of the uterine wall itself. Magnetic resonance imaging demonstrated the presence of a probable hyperintense fistula, extended for 30 mm and 16 mm of thickness, which ended in the subcutaneous area with an abscess joint without continuous solution with the skin. A laparotomic surgical procedure was successfully performed. Histopathology confirmed the surgical suspect of utero-cutaneous fistula. Although utero-cutaneous fistula is an extremely rare complication, it should be considered if after caesarean section delivery signs and symptoms of skin inflammation and/or infection persist.

Characterization of metabolic changes in the phenotypes of women with polycystic ovary syndrome in a large Mediterranean population from Sicily.

OBJECTIVE: To better characterize the metabolic alterations in various phenotypes of polycystic ovary syndrome (PCOS) in a large homogeneous (Sicilian) Mediterranean population with a low prevalence of obesity. DESIGN: Retrospective study. PATIENTS: A total of 1215 consecutively evaluated women with PCOS divided into four Rotterdam phenotypes (A, B, C and D) and in 108 matched ovulatory, nonhyperandrogenic women. MEASUREMENTS: BMI, fasting glucose, total cholesterol, HDL cholesterol, triglycerides, LDL cholesterol and an oral glucose tolerance test. RESULTS: The overall prevalence of obesity was 31%, metabolic syndrome 6.6%, diabetes 2.1%, altered glucose metabolism 13.1%, and abnormal lipid profile 60%. Phenotype B had the highest prevalence of obesity, metabolic syndrome, altered glucose metabolism and lipid abnormalities compared to other PCOS phenotypes and controls. Phenotype A was more obese and more women had metabolic syndrome compared to phenotypes C and D but phenotype C had a similar prevalence of altered glucose metabolism and lipid abnormalities compared to phenotype A which had a higher BMI. These metabolic abnormalities in A and C were higher compared to phenotype D and controls. Multivariate analysis showed that BMI predicts only abnormalities in fasting glucose and triglycerides, while there was no association with androgens. CONCLUSIONS: In Mediterranean women with PCOS from Sicily with a lower prevalence of obesity, the prevalence of diabetes, altered glucose metabolism and metabolic syndrome were much lower than reported in US studies. Phenotype B was the most metabolically affected phenotype, followed by phenotype A. Phenotype C had an intermediate disorder but with a high prevalence of altered glucose metabolism and lipid alterations. Only the normoandrogenic phenotype D had no metabolic abnormalities.

Uterine preservation in pelvic organ prolapse and urinary stress incontinence using robot-assisted laparoscopic surgery. Case report.

INTRODUCTION: To report a case of uterine preservation in pelvic organ prolapse robot-assisted laparoscopic surgery. PRESENTATION OF CASE: The patient is a 42-year old Caucasian woman with pelvic organ prolapse. She previously had undergone a pelvic floor reconstruction with vaginal surgical approach, she had suffered from anorexia nervosa and she had two childbirths with vaginal deliveries. The woman was treated with robotic-assisted laparoscopic sacrohysteropexy and retropubic colposuspension. DISCUSSION: Data suggest that abdominal surgery, typically with an abdominal sacralcolpopexy, provides better objective anatomic outcomes, than vaginal procedures, despite the longer operating times and grater delay in the resumption of activities which can be mitigated by the use of laparoscopic or robotic surgery. Several studies about vaginal approaches suggest that uterus-preserving surgery with vaginal procedures have similar success rates, less blood loss and shorter surgical time compared with hysterectomy. A multicenter study compared laparoscopic sacrohysteropexy with vaginal mesh hysteropexy reported similar one-year cure rates, improvement in pelvic floor symptoms, improvement in sexual function, and satisfaction rates. CONCLUSION: We found robotic-assisted laparoscopic sacrohysteropexy to be a feasible and successful procedure. Combining robotic retropubic colposuspension to sacrohysteropexy is a safe and efficient approach for the treatment of stress urinary incontinence. Further studies are needed to define the standard surgical steps and confirm the efficacy and the advantages of this procedure.

Advances in the Diagnosis and Treatment of PCOS.

While the Rotterdam criteria look simple and easy to follow, in clinical practice diagnosis of PCOS may be problematic because of the use of inaccurate commercial androgen assays. Progresses in ovarian ultrasound and in AMH measurement have modified the way to make the diagnosis of PCOS and an update of Rotterdam criteria may be necessary. In classic severe form of PCOS, ovarian follicle count is a very reliable diagnostic criterion but AMH measurement may also present high diagnostic specificity and sensitivity. This finding is particularly important when no clinical signs of androgen excess are present and only commercial assays for androgen measurement are available. At the contrary, in mild PCOS phenotypes, sensitivity of AMH measurement is too low whileFNPO count maintains a high diagnostic sensitivity. However, at least in ovulatory hyperandrogenic PCOS phenotype, increased AMH values in association with enlarged ovarian size permit the diagnosis of ovulatory PCOS in 85% of these patients. Treatment of PCOS women has to be directed to get fertility or in patients not seeking fertility to solve or attenuate the psychological implications of androgen excess and of irregular menses and the risk of endometrial hyperplasia. The therapeutic protocols that are used in our department are presented.

Clinical and endocrine characteristics of the main polycystic ovary syndrome phenotypes.

OBJECTIVE: To evaluate the clinical and endocrine differences between main polycystic ovary syndrome (PCOS) phenotypes. DESIGN: To evaluate clinical and hormone parameters in a large group of consecutive women with PCOS diagnosed according Rotterdam criteria and divided according their phenotype. SETTING: University department of medicine. PATIENT(S): Three hundred eighty-two consecutive women with PCOS and 85 ovulatory controls. INTERVENTION(S): Evaluation of clinical and hormone parameters. MAIN OUTCOME MEASURE(S): Blood levels of gonadotropins, testosterone, sex-hormone-binding globulin, dehydroepiandrosterone sulfate, 17α-hydroxyprogesterone, progesterone, glucose, and insulin, and calculation of the free androgen index and insulin sensitivity. RESULT(S): The severe PCOS phenotype (hyperandrogenism, chronic anovulation, and polycystic ovaries: type I classic PCOS) was the most common phenotype in 53.9% of the patients. The phenotype of 8.9% of patients was characterized by hyperandrogenism and chronic anovulation but normal ovaries (type II classic PCOS). The two phenotypes of classic PCOS had similar clinical and endocrine characteristics, but the patients with polycystic ovaries had a higher luteinizing hormone/follicle-stimulating hormone (LH/FSH) ratio. Ovulatory PCOS was relatively common (28.8% of PCOS patients) and presented milder clinical and endocrine alterations than the classic PCOS phenotypes. The normoandrogenic phenotype was relatively uncommon. These patients had a normal body mass index, insulin sensitivity, and free androgen index but showed increased levels of LH and LH/FSH ratio. CONCLUSION(S): Ovulatory PCOS represents the mild form of classic PCOS, but the normoandrogenic phenotype, although part of the spectrum, may represent a different disorder or have a different pathogenetic pathway.