Can the microcystic, elongated and fragmented pattern of invasion influence the evaluation of the depth of myometrial invasion in low-grade endometrioid endometrial cancer using imaging techniques?

Objectives: The microcystic, elongated and fragmented pattern of invasion can be associated with an underestimation of the depth of myometrial invasion by imaging techniques. We aimed to evaluate the influence of microcystic, elongated and fragmented pattern of invasion in the diagnostic performance of transvaginal ultrasound scan and magnetic resonance imaging for the prediction of the depth of myometrial invasion in low-grade endometrioid endometrial carcinomas. Methods: Prospective and consecutive study including all low-grade (G1-G2) endometrioid endometrial carcinomas diagnosed between October 2013 and July 2018 in a tertiary hospital. Preoperative staging was performed with transvaginal ultrasound scan and/or magnetic resonance imaging followed by surgical staging. Final histology was considered as the reference standard. Sensitivity, specificity and diagnostic accuracy for the prediction of depth of myometrial invasion was calculated for both imaging techniques. The STARD 2015 guidelines were used. Results: A total of 136 patients were consecutively included. Transvaginal ultrasound scan was performed in 132 patients and magnetic resonance imaging in 119 patients. The diagnostic accuracy of transvaginal ultrasound scan for the prediction of depth of myometrial invasion in the microcystic, elongated and fragmented negative group (82% (95% confidence interval = 73-88)) was higher compared to the microcystic, elongated and fragmented positive group (61% (95% confidence interval = 36-83)). The diagnostic accuracy of magnetic resonance imaging was also higher in the microcystic, elongated and fragmented negative group (80% (95% confidence interval = 71-87)) compared to the microcystic, elongated and fragmented positive (47% (95% confidence interval = 21-73)). Conclusions: In low-grade endometrioid endometrial carcinomas with a positive microcystic, elongated and fragmented pattern of invasion, the evaluation of the depth of myometrial invasion using transvaginal ultrasound scan and magnetic resonance imaging may be underestimated.

Hysteroscopic myomectomy without anesthesia.

OBJECTIVE: Scarce literature about myoma removal without anesthesia has been published. The aim of this paper is to evaluate the feasibility of a new alternative for a hysteroscopic myomectomy in a conventional office setting, without need for anesthesia. METHODS: Step-by-step description of the surgical technique has been provided, based on video images. An office hysteroscopy was performed in a Gynecological Endoscopy Department of a tertiary European hospital. RESULTS: A 49-year-old woman was referred for management of severe hypermenorrhea. Consent and approval were received from the patient and the institutional review board, respectively. The introduction of a Truclear® hysteroscopic polyp morcellator of 5.5 mm with optic of 0 degrees into the uterine cavity did not require any kind of anesthesia or cervical dilatation. The use of saline flow helped distend the cavity and identify a submucosal myoma. Under direct vision, a full myomectomy was performed via mechanical energy with continuous cutting movements, without any complication. After the procedure was completed, the excised material was aspirated through the device into a collecting pouch. A successful complete morcellation of a Type-0 submucosal leiomyoma with a polyp morcellator device was performed in an outpatient setting. Good medical results, good tolerance by the patient besides lower surgical risks due to mechanical instead of electrical energy are shown. CONCLUSION: In conclusion, this video demonstrates that a hysteroscopic myomectomy can be performed successfully in office with lower risk of complications from the procedure and without use of general anesthesia besides good tolerance by the patient.

Prolapse assessment supine and standing: do we need different cutoffs for "significant prolapse"?

INTRODUCTION AND HYPOTHESIS: Translabial ultrasound (TLUS) has shown good correlations between clinical examination and imaging findings in the supine position, and limits of normality have been described. This is not the case for imaging in the standing position. This study was designed to test the hypothesis that different cutoff values are required for imaging in the standing position. METHODS: This was a retrospective study carried out in a tertiary urogynecological unit in women presenting with symptoms of lower urinary tract and pelvic floor dysfunction between August 2013 and December 2015. All women underwent a standardized interview, 4D TLUS and a POP-Q assessment. Organ descent on ultrasound was measured relative to the postero-inferior margin of the symphysis pubis (SP) on maximal Valsalva in the supine and standing positions. Receiver operator characteristic (ROC) statistics were used to determine optimal cutoffs for "normal" pelvic organ support. RESULTS: We assessed 243 data sets. Mean patient age was 57 years. Prolapse symptoms were reported by 59.2%, and POP of stage ≥ 2 was found in 82.3%. On analysing imaging data sets obtained in the standing position, we obtained similar cutoff values to those established previously for supine imaging, using ROC statistics. The levator hiatus distended significantly more on Valsalva in the standing position compared with supine, and on ROC analysis we identified a new optimal cutoff of 29 cm2. CONCLUSIONS: Established cutoffs for supine imaging of organ descent are suitable for imaging in the standing position. Hiatal distensibility may require a higher cutoff of 29 cm2.

Current situation: lower genital tract pathology and colposcopy training in spanish gynecology and obstetrics residents.

OBJECTIVE: This study aimed to evaluate the impact of an educational intervention in lower genital tract pathology (LGTP) on the knowledge and skills acquired by the Spanish specialist residents. This didactic change was carried out under the auspices of the Asociación Española de Patología Cervical y Colposcopia and the Sociedad Española Ginecología y Obstetricia and its Resident Section. STUDY DESIGN: This is an observational, descriptive, and cross-sectional study. The survey was composed of 15 questions voluntarily answered by Spanish gynecology and obstetrics trainees. RESULTS: Compared with a previous survey, a substantial increase in the proportion of Spanish teaching hospitals with an LGTP unit (9/42 vs 47/59) has been detected while doubling the percentage of residents who acknowledge medium to high knowledge on this pathology. The same cannot be said about the handling capacity of vulvodynia registering a great improvement. CONCLUSIONS: Spanish scientific societies, concerned in the quality of LGTP training gained by their residents, have focused on the necessity of LGTP units. Our study confirms the usefulness of this performance in the new continued LGTP education.