The anatomy of the pelvic plexus in female cadavers: implications for retroperitoneal nerve-sparing surgery.

Background: The inferior hypogastric plexus (IHP) is a crucial structure for female continence and sexual function. A nerve-sparing approach should be pursued to reduce the risk of pelvic plexus damage during retroperitoneal pelvic surgery. Objectives: To analyse the relationship between the female IHP and several pelvic anatomical landmarks. Materials and Methods: Standardised cadaveric dissection was performed on 5 nulliparous female cadavers. The relationships of the IHP and the mid-cervical plane (MCP), the mid-sagittal plane (MSP), and the uterosacral ligament (USL) were investigated. Main outcome measures: Distance between IHP and MCP, MSP, and USL. Results: Distances between the right IHP and the right MSP (mean distance: 16.3 mm; range: 10.0-22.5 mm) and the right USL (mean distance: 4.8 mm; range: 0-15.0 mm) were shorter than those between the left IHP and ipsilateral landmarks (left MSP distance: 23.5 mm; range 18.0-30.0 mm; left USL distance: 5.0 mm; range: 0-20.0 mm). Although the MCP was 3.3 mm (range: 2.5-4.0 mm) left and lateral to the midsagittal line, the right IHP was closer to the MCP (mean distance: 19.6 mm; range: 13.0-25.0 mm) than the left one (mean distance: 20.2 mm; range: 15.0-26.0 mm). Conclusions: Distances between the right IHP and the MSP, MCP, and ipsilateral USL, are shorter compared to these associated to the left IHP. What is new?: Right autonomic pelvic plexus is closer to the midline planes and the ipsilateral USL. These anatomical relationships may be greatly helpful for pelvic surgeon while facing retroperitoneal pelvic surgery and looking for a nerve-sparing approach.

Pudendal Neuralgia: Two case reports with laparoscopic nerve decompression.

Pudendal neuralgia (PN) is a rare and underestimated condition. The reported incidence by the International Pudendal Neuropathy Association is 1/100000. However, the actual rate may be significantly higher, with a propensity for women. It is most frequently caused by an entrapment of the nerve at the level of the sacrospinous and sacrotuberous ligament, also known as pudendal nerve entrapment syndrome. Due to the late diagnosis and inadequate management, pudendal nerve entrapment syndrome often leads to considerable reduction in the quality of life and high health care costs. The diagnosis is made using Nantes Criteria, in conjunction with the patient's clinical history and physical findings. Clinical examination with an accurate assessment of the territory of the neuropathic pain is mandatory to set the therapeutic strategy. The aim of the treatment is to control the symptoms and it usually starts with conservative approaches which include analgesics, anticonvulsants, and muscle relaxants. Surgical nerve decompression can be proposed after failure of conservative management. The laparoscopic approach is a feasible and appropriate technique to explore and decompress the pudendal nerve, and to rule out other pelvic conditions that can cause similar symptomatology. In this paper, the clinical history of two patients affected by compressive PN is reported. Both patients underwent laparoscopic pudendal neurolysis suggesting that the treatment for PN should be individualised and carried out by a multidisciplinary team. When conservative treatment fails, laparoscopic nerve exploration and decompression is an adequate option to propose and should be performed by a trained surgeon.

Impact of endometriosis on obstetric outcome after natural conception: a multicenter Italian study.

PURPOSE: To evaluate obstetric outcome in women with endometriosis who conceive naturally and receive standard obstetric care in Italy. METHODS: Cases were consecutive women with endometriosis managed in eleven Italian referral centers. Controls were women in whom endometriosis was excluded. All women filled in a questionnaire addressing previous natural pregnancies. Marginal logistic regression models were fitted to evaluate the impact of endometriosis on obstetric outcome. A post hoc analysis was performed within the endometriosis group comparing women with severe adenomyosis versus women with absent or mild adenomyosis. RESULTS: Three hundred and fifty-five pregnancies in endometriosis group and 741 pregnancies in control group were included. Women with endometriosis had a higher risk of preterm delivery < 34 weeks (6.4% vs 2.8%, OR 2.42, 95% CI 1.22-4.82), preterm delivery < 37 weeks (17.8% vs 9.7%, OR 1.98, 95% CI 1.23-3.19), and neonatal admission to Intensive Care Unit (14.1% vs 7.0%, OR 2.04, 95% CI 1.23-3.36). At post hoc analysis, women with endometriosis and severe adenomyosis had an increased risk of placenta previa (23.1% vs 1.8%, OR 16.68, 95% CI 3.49-79.71), cesarean delivery (84.6% vs 38.9%, OR 8.03, 95% CI 1.69-38.25) and preterm delivery < 34 weeks (23.1% vs 5.7%, OR 5.52, 95% CI 1.38-22.09). CONCLUSION: Women with endometriosis who conceive naturally have increased risk of preterm delivery and neonatal admission to intensive care unit. When severe adenomyosis is coexistent with endometriosis, women may be at increased risk of placenta previa and cesarean delivery. TRIAL REGISTRATION: Clinical trial registration number: NCT03354793.

1 vs 3 days laparoscopic suturing courses: is it feasible to design a valid training curriculum?

BACKGROUND: Laparoscopic skills are unlikely to be achieved exclusively in the operating theatre, so simulation training has become mandatory to acquire specific psychomotor skills to be merged in a more complex procedure. OBJECTIVE: To compare 3-day vs. 1-day laparoscopic suturing courses and to better address participants' needs according to their level of experience. METHODS: Observational cohort study conducted between January 2017 and December 2018 including 107 participants amongst which 61 attended a 3-day and 46 the 1-day suturing course. RESULTS: Data analysis showed no significant difference in the pre-test suturing scores between the two groups. On each course, when comparing the pre- and post-tests results, the participants reached a statistically significant improvement in both precision and knotting score (p< 0.01). However, when comparing the two types of courses, the data showed a better performance in the post-session test for those attending the 3-day course (p<0.05), as well as a higher mean score improvement (4.7 vs. 2.8; p<0.05) and time needed to complete exercises (-270s vs. -150s; p<0.05). Furthermore, grouping the participants according to their experience, the experts achieved a significantly better improvement attending the 3-day course, when compared to the beginners. CONCLUSIONS: Both 3 and 1-day course are successful in improving laparoscopic suturing skills regardless of the participant's experience. However experienced participants benefit more from a longer course while the 1-day one should be dedicated to pre-surgical competences acquisition.

Endometriosis: seeking optimal management in women approaching menopause.

The incidence of endometriosis in middle-aged women is not minimal compared to that in the reproductive age group. The treatment of affected women after childbearing age to the natural transition toward menopause has received considerably poor attention. Disease management is problematic for these women due to increased contraindications regarding hormonal treatment and the possibility for malignant transformation, considering the increased cancer risk in patients with a long-standing history of the disease. This state-of-the-art review aims for the first time to assess the benefits of the available therapies to help guide treatment decisions for the care of endometriosis in women approaching menopause. Progestins are proven effective in reducing pain and should be preferred in these women. According to the international guidelines that lack precise recommendations, hysterectomy with bilateral salpingo-oophorectomy should be the definitive therapy in women who have completed their reproductive arc, if medical therapy has failed. Strict surveillance or surgery with removal of affected gonads should be considered in cases of long-standing or recurrent endometriomas, especially in the presence of modifications of ultrasonographic cyst patterns. Although rare, malignant transformation of various tissues in endometriosis patients has been described, and management is herein discussed.

Transvaginal sonographic features of diffuse adenomyosis in 18-30-year-old nulligravid women without endometriosis: association with symptoms.

OBJECTIVES: To investigate whether there are sonographic features of diffuse adenomyosis in 18-30-year-old nulligravid women without endometriosis and to examine their association with symptoms of dysmenorrhea and abnormal uterine bleeding. METHODS: This was a prospective observational study including women referred from a gynecology outpatient center to our university hospital for ultrasound examination. Inclusion criteria were age between 18 and 30 years, regular menstrual cycle and nulligravid status. Exclusion criteria were a past or current history of endometriosis, fibroids, ovarian cysts or lesions, endometrial pathology, current use of hormonal treatments or medications that would affect the menstrual cycle, previous uterine surgery and history of infertility. Women underwent a detailed clinical assessment and a two- (2D) and three-dimensional (3D) transvaginal ultrasound (TVS) examination. 2D-TVS features associated with diffuse adenomyosis were predefined as: (1) heterogeneous myometrium; (2) hypoechoic striation in the myometrium; (3) myometrial anechoic lacunae or cysts; (4) asymmetrical myometrial thickening of the uterine walls with the presence of straight vessels, extending into the hypertrophic myometrium, on power Doppler examination. On 3D-TVS, endomyometrial junctional zone (JZ) was measured as the distance from the basal endometrium to the internal layer of the outer myometrium on coronal section at any level of the uterus, and the smallest (JZmin) and largest (JZmax) JZ thicknesses and their difference (JZdiff) were recorded. 3D-TVS evaluation was considered suggestive for adenomyosis when JZmax ≥ 8 mm and/or JZdiff ≥ 4 mm. The presence of associated symptomatology represented our main outcome: the amount of menstrual loss was assessed by a pictorial blood loss analysis chart (PBAC) and painful symptoms were evaluated using a visual analog scale (VAS). RESULTS: During the observation period, 205 women (median age, 24 (interquartile range, 23-27) years) were enrolled into the study and 156 met the inclusion criteria. According to the 2D-TVS criteria, diffuse adenomyosis was found in 53 (34.0%) women and asymmetrical myometrial thickening of the uterine walls was the most common sonographic feature observed. ANOVA showed a significant relationship between the number of 2D-TVS features of diffuse adenomyosis and VAS score for dysmenorrhea (P = 0.005) as well as PBAC score for menstrual loss (P = 0.03). 3D-TVS showed that women with 2D-TVS features of diffuse adenomyosis had a significantly higher value of JZmax (6.38 ± 2.30 mm, P < 0.001), JZmin (2.07 ± 0.43 mm, P = 0.002) and JZdiff (4.33 ± 1.99 mm, P < 0.001) than did women without these features. Women with sonographic features of diffuse adenomyosis were symptomatic in 83% of cases, reported dysmenorrhea in 79.2% and showed a higher incidence of heavy bleeding than did those without these features (18.9% vs 2.9%; P = 0.001). CONCLUSIONS: Sonographic features suggestive of diffuse adenomyosis may develop earlier in reproductive life than previously thought, and may occur in association with dysmenorrhea and abnormal uterine bleeding in nulligravid women. Their observation in these women should therefore warrant further gynecological investigation.

Obesity in laparoscopic surgery.

Since the 1980s, minimally invasive techniques have been applied to an increasing number and variety of surgical procedures with a gradual increase in the complexity of procedures being successfully performed laparoscopically. In the past, obesity was considered a contraindication to laparoscopy due to the higher risk of co-morbid conditions such as diabetes, hypertension, coronary artery disease and venous thromboembolism. Performing laparoscopic gynaecological procedures in morbidly obese patients is no longer a rare phenomenon; however, it does necessitate changes in clinical practice patterns. Understanding of the physiological changes induced by laparoscopy, particularly in obese patients, is important so that these may be counteracted and adverse outcomes avoided. Laparoscopy in obese patients confers certain advantages such as shorter hospital stay, less post-operative pain and fewer wound infections. In addition to these benefits, minimal-access surgery has been demonstrated as safe and effective in obese patients; however, specific surgical strategies and operative techniques may need to be adopted.

Cervical and oral teratoma in the fetus: a systematic review of etiology, pathology, diagnosis, treatment and prognosis.

INTRODUCTION: The aim of the study was to produce a systematic review about etiology, pathology, diagnosis, prognosis and clinical management regarding oral and cervical teratomas. MATERIALS AND METHODS: A systematic review of Pubmed/Medline using the following keywords was made: epignathus, cervical teratoma, fetus, oral teratoma, prenatal diagnosis, prognosis, treatment, ultrasound. CONCLUSION: The following clinical conclusions can be reached: (1) teratomas are rare, usually benign congenital tumors which recognized multifactorial etiology; (2) prenatal ultrasound diagnosis can be made early in pregnancy (15-16 weeks); (3) 3D ultrasound and MRI may enhance the accuracy of the antenatal diagnosis (location, extension and intracranial spread) and may aid in the selection of patients requiring treatment; (4) prenatal karyotype and search for associated abnormalities is mandatory in all teratomas; (5) delivery should involve elective Cesarean section with ex utero intrapartum treatment procedure or resection of the tumor mass, which may be performed on placental support operation on placental support procedure to increase the chances of postnatal survival.

Can 3D ultrasound and doppler angiography of great arteries be included in second trimester ecocardiographic examination? A prospective study on low-risk pregnancy population.

The introduction of new applications such as the spatiotemporal image correlation (STIC) and the tomographic ultrasound imaging (TUI) has greatly enhanced the study of cardiac and vessels anatomy. The aim of our study was to assess the feasibility of including real-time volumetric 3D reconstruction of heart anatomy and Doppler angiography of great vessels during routine second trimester pregnancy scan, in a low-risk population. Visualization of the pulmonary veins, ductus venosus and inferior vena cava was significantly superior with 3D ultrasound. Therefore, STIC makes it possible to store heart beats for a mean time of 10 s, to replay acquired volumes in slow motion, to study the heart atrium along three axes and retrace volumetric image storage inversely from the apex to the base of the heart, making reconstruction of the four-chamber view and great artery outflow tract much easier and faster. Furthermore, the use of digital communication allow operators to store and send volume of images that can be postprocessed by external consultant specialists worldwide. Although 3D echocardiography is less time-consuming and independent of fetal positioning in utero when compared with 2D it may be premature to include 3D and 3D Doppler angiography among routine examination. However, the study of the outflow tracts by 2D echocardiography should be implemented in order to improve the diagnostic accuracy of CHDs. At present, only "targeted" cases in which a routine 2D scan has raised diagnostic doubts should undergo a second level sonography for a thorough 2D-3D examination of cardiac and vessels anatomy.

Early oxidative stress in amniotic fluid of pregnancies with Down syndrome.

OBJECTIVE: Some evidence suggests that oxidative stress, due to an imbalance between oxidants and antioxidants, occurs in babies with Down syndrome (DS). This study tests the hypothesis that oxidative stress occurs early in DS pregnancies. DESIGN AND METHODS: Isoprostanes (IPs), a new marker of free radical-catalyzed lipid peroxidation, were measured in amniotic fluid from pregnancies with normal, growth restricted and DS fetuses, diagnosed by karyotype analysis of amniotic cells cultured. RESULTS: A nine-fold increase in IP concentrations was found in amniotic fluid of pregnancies with DS fetuses. This increase (595.15; 542.96-631.64 pg/ml, median; 95% CI), was greater than in pregnancies with fetal growth-restricted fetuses (155; 130.57-172.23 pg/ml, median; 95% CI) and normal fetuses (67; 49.82-98.38 pg/ml, median; 95% CI; p<0.0001). CONCLUSIONS: The study reveals that oxidative stress occurs early in pregnancy and supports the idea of testing whether prenatal antioxidant therapy may prevent or delay the onset of oxidative stress diseases in the DS population.

[The significance of screening tests for aneuploidies in populations at low and high maternal-age-related risk]. / Il significato dei test di screening per le aneuploidie in popolazione a basso e alto rischio per età.

AIM: The aim of this study was to evaluate the validity of the triple test and the screen test in maternal populations at low and high maternal-age-related risk for fetal aneuploidy. METHODS: As a whole, 9,680 pregnant women at low risk and 627 at high risk underwent the triple test; 2,780 pregnant women at low risk and 408 at high risk underwent the screen or combined test; sensitivity, specificity, false positives and detection rate were compared between populations using Student's t-test. RESULTS: The triple test showed a detection rate of 75% in the low and 83.3% in the high risk population with a difference (P<0.003) for detection of trisomies 21 and 18 between the 2 populations; the screen test had a detection rates of 100% and 90% in the 2 populations, respectively, with a difference (P<0.005) between the 2 tests. CONCLUSIONS: Both tests are reliable for screening aneuploidies in the low risk population, the screen test having better performance; in the high risk population, the number of invasive procedures can be reduced by 78% with the triple test and by 84% with the screen test.

Neonatal porencephaly in very low birth weight infants: ultrasound timing of asphyxial injury and neurodevelopmental outcome at two years of age.

OBJECTIVE: To investigate and diagnose the timing of asphyxial injury leading to cerebral cavitation with subsequent developing of neonatal porencephaly in the preterm VLBW infant. All newborns underwent careful neurodevelopmental outcome at 2 years of corrected age. METHODS: 250 consecutive VLBW infants (mean gestational age of 28 weeks and mean birthweight of 1150 g) have been study by means of weekly neonatal transfontanellae ultrasonography. Periventricular white matter necrosis was diagnosed when echolucencies were visible after day 3 from birth. RESULTS: Twelve cases of neonatal porencephaly were diagnosed by ultrasound. The timing of asphyxial insult leading to cerebral cavitation seems to have occurred in 33% of neonates during the antepartum period, in 42% during the peripartum period (antepartum + neonatal period) and 25% in the remaining neonatal period. Periventricular-intraventricular hemorrhage (PVH-IVH) was found in all cases and in 50% a severe IVH (grade III-IV) was diagnosed within 7 days neonatal period. Nine infants had evidence of cerebral palsy at 2 years neurological outcome. CONCLUSIONS: The ultrasound criteria of cerebral cavitation have been priorly selected in order to assure that the damage may have occurred before delivery. A comprehensive prenatal study of fetal brain, integrating ultrasound with high-velocity MRI, is also advocate. This will lead to a more detailed understanding of the underlying cerebral condition that is of critical importance for the clinician in planning the time and mode of delivery and have great deal with further medico-legal consideration.

Cervical ripening and induction of labor by prostaglandin E2: a comparison between intracervical gel and vaginal pessary.

OBJECTIVE: To compare the effectiveness and safety of two formulations of prostaglandin (PG) E2 (gel and pessary) for induction of labor. Primary outcomes were cervical ripening, initiation/duration of labor, and type of delivery. STUDY DESIGN: A total of 115 women with singleton gestations were consecutively enrolled and assigned to receive intracervical PGE2 (dinoprostone 0.5 mg) by gel (n = 66) or PGE2 (dinoprostone 10 mg) by intravaginal pessary (n = 49). RESULTS: Independently from parity, the vaginal pessary induced successful cervical ripening with a slightly higher but not statistically significant occurrence of vaginal delivery with respect to gel induction. The mean time interval from induction to vaginal delivery did not differ between groups, despite being shorter for the pessary group in inducation-delivery intervals > 12 h. No significant differences were found between the groups with respect to patients who required a second course of PGE2 (9% vs. 2%), as well as oxytocin (11% vs. 13%) induction. No significant difference was found in the incidence of uterine hyperstimulation and other adverse reactions in nulliparas, or in fetal and neonatal outcome. CONCLUSION: Independently from parity, both PGE2 administration routes appeared to be effective in achieving cervical ripening, initiation of labor and optimal type of delivery, and showed the same incidence of side-effects.

A report of early (13 + 0 to 14 + 6 weeks) and mid-trimester amniocenteses: 10 years' experience.

OBJECTIVE: To report in singleton pregnancies the post-procedure safety and maternal complications of early amniocenteses performed between 13 + 0 and 14 + 6 weeks of gestation and mid-trimester amniocenteses performed between 15 + 0 and 18 + 6 weeks of gestation. METHODS: The study was carried out at the Prenatal Diagnosis Center, Siena University, Italy, during a 10-year period, following the Regional Protocol for Prenatal Diagnosis. Our study population included 3769 amniocenteses, 475 early and 3294 mid-trimester. Complications considered included miscarriage (immediately after the procedure and until 24 weeks of gestation), blood-stained amniotic fluid, failed cell culture, amniotic fluid leakage, preterm premature rupture of the membranes (PROM), preterm delivery and presence of neonatal talipes equinovarous. RESULTS: Cytogenetic anomalies were found in 111 cases (2.9%), 18 occurring early and the other 93 in mid-trimester. Miscarriage occurred in two cases in the early amniocentesis group (0.4%) and in ten cases among the mid-trimester group (0.3%). The overall loss of pregnancies due to amniocentesis in this study was 0.3%. Amniotic fluid was stained in 1.2% in the early group and 0.9% in the mid-trimester group. Amniotic fluid leakage was noted in 1.4% and 1.2%, preterm PROM was noted in 3.3%) and 3%, and preterm delivery occurred in 8% and 7.6%, respectively. There were no cases of failed amniotic culture and no cases of talipes equinovarous documented. CONCLUSIONS: The risks of early amniocentesis performed between 13 + 0 and 14 + 6 weeks appear to be comparable to those of mid-trimester amniocentesis and thus early amniocentesis could be offered to the parents, as an alternative to chorionic villus sampling, in order to obtain cytogenetic results earlier in pregnancy without a significantly increased risk for both mother and fetus. Further operators' experience with the method, based on long and accurate follow-up, and further studies are necessary to assess the safety of the method.

Prenatal diagnosis of esophageal atresia with the pouch sign.

A 19-year-old primipara was referred to our center for a routine scan at 33 + 4 weeks' gestation. A visible but small stomach bubble (18 mm) was detected in the fetal abdomen, associated with a dilation of the esophagus with a tapering distal part. Direct visualization of filling and emptying of the proximal esophagus suggested the presence of obstruction. A cystic pouch in the region of the esophagus was observed to be full and empty in accordance with fetal swallowing. No other fetal anomalies were detected. Fetal biometric measurements were on the 10th percentile and polyhydramnios was detected. Esophageal atresia type I was suspected. Fetal karyotyping was declined by the parents, no therapy was given and the pregnancy continued until week 37 when a female baby was delivered following spontaneous labor. Esophageal atresia type I was radiographically confirmed. Bougienage was used for 8 weeks and esophageal anastomosis was successfully performed when the infant was 11 months old. No other anomalies were found and the child is currently in excellent health. The present case shows that the upper neck pouch sign may be a delayed manifestation present only in certain types of esophageal atresia. However, when it occurs it should prompt careful fetal examination as it is an important step in the diagnosis of esophageal atresia.

Human placenta as a source of neuroendocrine factors.

Progress in the understanding of the physiological and pathological functions of the placenta introduced the concept that the placenta is a neuroendocrine organ, since it shows local production and release of substances analog to neurohormones. These products act as endocrine, paracrine and autocrine factors to control the secretion of other regulatory molecules, including the pituitary hormones of both mother and fetus and their placental counterparts. Furthermore, they may play a role in the regulation of maternal and fetal physiology during pregnancy, ranging from the control of placental anchoring to fetal growth and maturation, fine regulation of uterine blood flow and/or initiation of labor. All this evidence underlines the decisive contribution of the placenta to all phases of gestation, through a range of substances largely exceeding the classically known sex steroids and chorionic gonadotropin, throughout normal pregnancy as well as in the presence of gestational diseases.

[Iatrogenic lesions of the bile ducts in laparoscopic cholecystectomy. Therapeutic potential of interventional radiology]. / Lesioni iatrogene della via biliare nella colecistectomia laparoscopica. Possibilità terapeutiche della radiologia interventistica.

PURPOSE: We investigated the efficacy of interventional radiology procedures in some patients with iatrogenic injuries of the biliary tree from laparoscopic cholecystectomy. MATERIAL AND METHODS: In the last two years, 8 patients with complications of laparoscopic cholecystectomy were treated in the Department of Radiology of Umberto I Hospital, Ancona, Italy. Five of them had a subhepatic biliary collection due to a cystic duct stump leak, 2 has a leak of the Roux-en-Y hepaticojejunostomy (from a iatrogenic injury of the common biliary duct) and 1 had a right hepatic biliary duct stricture from a clip. In the patients with a cystic duct stump leak, we treated the biloma with percutaneous catheter drainage and the endoscopist positioned a nasobiliary tube, while a percutaneous abdominal catheter was positioned to drain the biloma and a percutaneous transhepatic catheter was positioned through the biliary duct tract or through the hepaticojejunostomy. RESULTS: All injuries were completely repaired within 5-8 weeks of the procedure. There were no maneuver-related complications. All patients had normal serum levels of bilirubin, alkaline phosphatase and transaminase at the monthly follow-up tests performed for 3 months. US and MR cholangiopancreatography at 3 months excluded strictures, fistulas or bilomas of the biliary tree. DISCUSSION: The prompt detection of the injuries is essential to the success of interventional radiology procedures: the patients are less debilitated, small caliber catheters can be used and recovery is quicker. The combined effort of surgeons, endoscopists and radiologists is necessary to optimize the management of patients with laparoscopic cholecystectomy-related biliary complications. CONCLUSIONS: We obtained positive results with minimally invasive procedures costing less than another operation. Thus, we suggest that interventional radiology procedures become the method of choice in patients with iatrogenic injuries of the biliary tree after laparoscopic cholecystectomy.