Safety and patients' satisfaction after hysteroscopic sterilisation.

The aim of this study was to understand the potential complications of the Essure® device as well as the factors influencing its onset and patient satisfaction. We present a 9-year descriptive prospective study that included 1068 patients. The device was placed in 1056 of them (98.8%); 894 had no pain or mild pain during the insertion and only 12 patients experienced pain greater than menstrual pain. The proportion of patients without pain was greater in the group that took NSAIDs or NSAIDs and BZD and the unmedicated group had the highest rate of severe pain (p = .00). In all, 161 of the 1064 patients who had the Essure® inserted reported having an adverse effect during the 3-months post-insertion (pelvic pain or discomfort). The mean score out of 10 attributed to this method was 9.06 (S = 1.11). We concluded that the Essure® shows a low rate of complications and users showed a high degree of satisfaction. Impact statement What is already known on this subject: There are few international publications on Essure®. When we conducted a search in PubMed for the term 'Essure', we obtained 221 publications. When we added the terms 'Essure and complications', we obtained 20 publications, and when we increased the restriction including 'satisfaction', we obtained seven; thus, the uniqueness of our study. What the results of this study add: We present a 9-year descriptive prospective study that included 1068 patients. The aim of this study was to understand the potential complications of the Essure® device (Bayer, Whippany, NJ), as well as factors that can influence its onset and the patient satisfaction. The device was placed in 1056 of the patients (98.8%); 894 had no pain or mild pain during the insertion and only 12 patients experienced pain greater than menstrual pain. The proportion of patients without pain was greater in the group that took NSAIDs or NSAIDs and BZD and the unmedicated group had the highest rate of severe pain (p=.00). What the implications are of these findings for clinical practice and/or further research: Our study shows a low rate of complications with Essure®, mild and transient in most cases, as well as a high degree satisfaction. Nevertheless, given the few published studies on this device, we believe that long-term follow-up is needed.

Human papillomavirus detection by PCR assay in a large series of high-grade squamous intraepithelial lesions with cytohistological correlation and follow-up.

OBJECTIVE: High-grade squamous intraepithelial lesions (HSIL) are the precursors of invasive cervical carcinomas and are generally associated with the integration of mucosotropic human papillomavirus (HPV) DNA into the host cell genome. Detection of HPV is easy to perform nowadays, even in laboratories with limited technological capacity, and follow-up procedures for patients with HSIL are well established. STUDY DESIGN: HPV detection was performed in a large group of patients with HSIL, and results were correlated with cytological, histological, and colposcopic findings. Discrepancies were examined and discussed. RESULTS: Conventional Papanicolaou (Pap) screening detected 446 HSIL (0.20%) in 218,906 cervical smears. HPV detection by PCR was positive in 339/358 (94.7%) patients. The strains involved were: HPV 16 in 180 patients (53.1%), HPV 18 in 35 (10.3%), HPV 31/33 in 27 (8%), HPV 6/11 in 10 (2.96%), and an unidentified type in 73 (30%). For the last 97 patients (2006-2007), HPV typing was expanded with the following results: HPV 52 was detected in 9 patients (9.2%), HPV 58 in 6 (6.1%), HPV 51 in 4 (4.1%), HPV 68 in 2 (2.0%), and HPV 39 in 1 (1.0%). The number of nonidentified patients dropped to 9 (9.4%); in addition, 14/97 (14.4%) patients were infected with 2 or more viral types. Finally, 19 (5.3%) patients were HPV negative. Colposcopy revealed minor changes in 59 patients (17.3%), major changes in 264 (77.6%), and normal findings in 17 (5.1%). A biopsy was taken in 331/446 patients, and the diagnosis of HSIL or overt malignancy was histologically confirmed in 281 (84.9%) patients: CIN II in 46, CIN III in 224, and histologically upgraded in 11 (6 microinvasive squamous carcinomas, 1 squamous carcinoma, 2 in situ endocervical adenocarcinomas, and 2 microinvasive endocervical adenocarcinomas). Thirty-five patients (10.6%) were downgraded to CIN I and 15 (4.5%) patients had a negative biopsy. Follow-up in the negative-biopsy patients confirmed the existence of SIL in 11 patients [1 HSIL and 10 low-grade squamous intraepithelial lesions (LSIL)] while 4 were considered false positives (atrophic changes, 2; reactive changes, 2). After treatment, 31/331 (9.36%) patients displayed recurrence (HSIL in 29 and LSIL in 2). The viral strains involved in patients with recurrence were HPV 16 in 16 patients (51.6%); HPV 18 in 4 (12.9%); HPV 16 and 18 in 1 (3.2%); HPV 31 in 1 (3.2%); HPV 52 in 1 (3.2%); HPV 18, 31, and 58 in 1 (3.2%); HPV 68 in 1 (3.2%); HPV 51 and 73 in 1 (3.2%), and an unidentified type in 5 (16.1%). Follow-up in 14/19 HSIL and HPV-negative patients confirmed the existence of cervical pathology. CONCLUSIONS: HPV detection improves diagnostic sensitivity and provides an ideal tool for monitoring the response to treatment in HSIL patients. The pathogenic relevance of HPV strain 18 may be greater than previously assumed.

Retrospective Cohort Study on the Symptomatic Recurrence Pattern after Hysteroscopic Polypectomy.

OBJECTIVES: The recurrence rate of benign endometrial polyps after a hysteroscopic polypectomy is low, between 0% and 15%. There are limited follow-up duration data on recurrence factors for benign polyps after hysteroscopic polypectomy, including recurrences with Versapoint® versus resectoscope. This study aims to estimate the rate of symptomatic recurrence following hysteroscopic polypectomy and to analyze the possible risk factors involved with Versapoint® versus resectoscope. MATERIALS AND METHODS: We designed a retrospective cohort study in a tertiary university hospital in Seville (Spain) which looked at the results of polypectomy with a 9-mm resectoscope on 42 women between 2008 and 2015 compared to 151 women using Versapoint® during 2014. RESULTS: The rate of first recurrence was 24.35%. There was a strong positive correlation between the recurrence and the follow-up duration (odds ratio [OR] = 2.58; 95% confidence interval [CI] = 1.68-5.04; P = 0.000), the polyps causing abnormal uterine bleeding (OR = 2.5; 95% CI: 1.1-3; P = 0.04), and a polyp size >15 mm (OR = 1.63; 95% CI = 1.3-3.1; P = 0.02). There were no statistical differences in polyps' recurrence among the types of hysteroscopic polypectomy (P > 0.05). CONCLUSION: The main risk factors for recurrence were polyps causing abnormal uterine bleeding, size, and follow-up duration.

Carcinoma basocelular umbilical en paciente con sospecha de endometriosis en la pared abdominal. Reporte de un caso y revisión bibliográfica / Umbilical basal cell carcinoma in a patient with suspected abdominal wall endometriosis. Case report and review of the literature

Resumen ANTECEDENTE: La endometriosis es una enfermedad inflamatoria que llega a afectar incluso a 15 a 44% de las mujeres fértiles; sin embargo, su localización en la pared abdominal es excepcional. Las diferentes lesiones que pueden encontrarse ahí dificultan el diagnóstico preoperatorio. OBJETIVOS: Reportar el caso de una paciente con carcinoma basocelular umbilical en quien se sospechó endometriosis en la pared abdominal y revisar la bibliografía al respecto, en particular la importancia del diagnóstico diferencial. CASO CLÍNICO: Paciente de 45 años con un carcinoma basocelular en torno de la zona umbilical. La situación anatómica y la induración dolorosa y sangrante en el área umbilical favorecieron un diagnóstico erróneo inicial de endometriosis umbilical. Esta tumoración, de un subtipo histológico de alto riesgo, requiere una técnica quirúrgica agresiva, con control de los márgenes afectados. En las revisiones posoperatorias la paciente permaneció asintomática, sin lesiones aparentes de recidiva. De la búsqueda bibliográfica se incluyeron 14 artículos de reportes de casos y revisiones de endometriosis en la pared abdominal y carcinoma basocelular. El acceso quirúrgico mediante la cirugía micrográfica de Mohs se estableció como el método más recomendado en la actualidad. CONCLUSIONES: La sospecha de endometriosis en la pared abdominal suele estar fundamentada en la aparición de una lesión con variaciones cíclicas sobre el lecho de una incisión quirúrgica. Las diferentes lesiones que pueden encontrarse en la pared abdominal dificultan el diagnóstico preoperatorio y solo el estudio histológico es el que finalmente lo establece.

Abstract BACKGROUND: Endometriosis is an inflammatory disease that affects up to 15-44% of fertile women, however its location at the level of the abdominal wall is a rare entity. The different lesions that can settle at this level make preoperative diagnosis difficult OBJECTIVES: To report the case of an umbilical basal cell carcinoma in a patient with suspected endometriosis of the abdominal wall and to review the literature, especially on the importance of differential diagnosis. CLINICAL CASE: A 45-year-old woman who presented a basal cell carcinoma at the umbilical level. The anatomical situation and the painful and bleeding induration at the umbilical level, led to an initial misdiagnosis of umbilical endometriosis. This tumor of a high-risk histological subtype requires optimal management, based on an aggressive surgical technique with control of the affected margins. In postoperative check-ups, the patient remains asymptomatic, with no apparent lesions of recurrence. A bibliographic search was carried out and 14 articles were included on case reports and literature reviews of abdominal wall endometriosis and basal cell carcinoma. The surgical approach using Mohs micrographic surgery has been established as the most recommended method at present. CONCLUSIONS: The suspicion of abdominal wall is usually based on the appearance of a lesion with cyclical variations on the bed of a surgical incision. The different lesions that can settle at the level of the abdominal wall make preoperative diagnosis difficult, with the histological study finally being the one that yields the definitive result.

Carcinoma intraepitelial tubárico seroso como hallazgo posquirúrgico de endometriosis y útero miomatoso. Reporte de un caso / Seuous tubal intraepithelial carcinoma as a post-surgical finding of endometriosis and myomatous uterus. A case report

Resumen: ANTECEDENTES: El carcinoma intraepitelial tubárico seroso es una lesión precursora del carcinoma invasivo de las trompas de Falopio que con frecuencia se diagnostica en el contexto de una salpingooforectomía bilateral profiláctica por patología ginecológica benigna. CASO CLÍNICO: Paciente nulípara, de 51 años, con cuadro clínico de dolor abdominal y elevación de marcadores tumorales CA-125 y CA-19.9, diagnosticada con útero polimiomatoso y sospecha de endometrioma en el ovario derecho. Después de la histerectomía subtotal con anexectomía bilateral, el estudio histológico de la pieza tubárica extirpada reportó focos microscópicos de carcinoma intraepitelial tubárico seroso, sin signos de invasión estromal. Por los hallazgos se solicitaron pruebas de imagen mamarias y el estudio genético de mutación BRCA 1 y 2. CONCLUSIÓN: La salpingooforectomía bilateral profiláctica es un procedimiento que reduce el riesgo de carcinomas peritoneales, tubáricos y serosos de ovario. Las pacientes con carcinoma intraepitelial tubárico seroso deben tener seguimiento basado en controles ecográficos, pruebas de imagen mamarias, determinación de marcadores tumorales y estudios genéticos, debido a su asociación con mutaciones en los genes BRCA 1 y 2.

Abstract: BACKGROUND: Serous tubal intraepithelial carcinoma (STIC) is a precursor lesion of invasive high-grade tubal and serous carcinoma of the ovary, frequently diagnosed in the context of prophylactic bilateral salpingoophorectomy for benign gynecological pathology. The objective of this work is to carry out a literature review on the most relevant aspects of the follow-up of this injury, after its incidental diagnosis in gynecological surgery. CLINICAL CASE: A 51-year-old nulliparous patient who, in the context of a clinical situation of abdominal pain with elevation of tumor markers CA125 and CA19.9, was diagnosed with polymomatous uterus and suspected endometrioma in the right ovary. After a subtotal hysterectomy with bilateral adnexectomy, the histological study of the excised tubal specimen found microscopic foci of STIC without signs of stromal invasion. Given this finding, breast imaging tests and a genetic study of the BRCA 1/2 mutation was requested. CONCLUSION: Prophylactic bilateral salpingoophorectomy in gynecological surgery is a procedure that can reduce the risk of developing peritoneal, tubal, and serous ovarian carcinomas. Patients diagnosed with STIC should be subsidiaries of follow-up based on ultrasound controls, mammary imaging tests, tumor markers, and genetic studies, due to their association in many cases with mutations in the BRCA 1/2 genes. It is necessary to establish a series of standardized clinical protocols for the management of patients with STIC and to continue advancing our understanding of this pathology and its subsequent evolution to high-grade serous carcinoma.

Mioma en remanente cervical tras histerectomía supracervical laparoscópica, presentación de un caso y revisión de la literatura / Myoma in cervical remnant after laparoscopic supracervical hysterectomy, case report and literature review

INTRODUCCIÓN: Los leiomiomas uterinos son el tumor pélvico más frecuente en la mujer, derivan de las células musculares lisas del miometrio y pueden localizarse en cualquiera de las porciones uterinas. Se clasifican según su relación con las diferentes capas del útero mediante la clasificación de la FIGO. Pueden ser asintomáticos o producir síntomas como sangrado, problemas reproductivos o dolor por compresión de estructuras vecinas. El tratamiento puede ser médico o quirúrgico, teniendo dentro de este último grupo, la posibilidad de realizar una miomectomía o una histerectomía total o subtotal. La histerectomía subtotal permite mantener el cérvix uterino, de tal forma que la técnica quirúrgica es más sencilla, sin embargo, requiere de la morcelación de la pieza para su extracción; mientras que la histerectomía total elimina el riesgo de recidiva de la patología uterocervical, aunque precisa de una mayor curva de aprendizaje. CASO CLÍNICO: Presentamos el caso de una paciente de 52 años a la que se le realizó una histerectomía supracervical laparoscópica por miomas. Posteriormente, se objetivó la aparición de un nuevo mioma en el remanente cervical, que requirió de una traquelectomía vía vaginal. CONCLUSIÓN: La histerectomía subtotal laparoscópica en úteros con múltiples miomas puede tener como efecto adverso la recidiva miomatosa en el cérvix o la aparición de miomas parasitarios secundarios a la morcelación uterina no estanca. Además, implica continuar con el cribado para la prevención del cáncer de cérvix uterino.

BACKGROUND: Uterine leiomyomas are the most frequent pelvic tumor in women. They derive from smooth muscle cells of the myometrium and can be in any of the uterine parts. They are classified according to their relationship with the different layers of the uterus by the FIGO classification. Uterine leiomyomas can be asymptomatic or produce symptoms such as compression pain, reproductive problems and metrorrhagia. The treatment can be medical or surgical. Within this last group there is the possibility of performing a myomectomy or a total or subtotal hysterectomy. The subtotal hysterectomy allows the uterine cervix to be maintained and therefore the surgical technique is simpler. However, it requires the morcellation of the piece for its removal. Alternatively, total hysterectomy eliminates the risk of recurrence of uterocervical pathology, but this procedure presents a steeper learning curve. CLINICAL CASE: We present the case of a patient of 52 years who underwent a laparoscopic supracervical hysterectomy for myomas. Subsequently, the appearance of a new myoma in the cervical remnant was observed, which required a vaginal trachelectomy. CONCLUSION: Laparoscopic subtotal hysterectomy in myomatous uterus can have as an adverse effect myomatous recurrence in the cervix or the appearance of parasitic myomas secondary to non-contained uterine morcellation. In addition, it involves continuing screening for the prevention of cervical cancer.

Resección histeroscópica de septo uterino conformado por mioma submucoso / Hysteroscopy Resection of the Uterine Septum Due To Submucosal Myoma

Las malformaciones uterinas congénitas presentan una baja prevalencia en la población general (0,5-6,7 por ciento), el útero septo es la más frecuente. Estas enfermedades pueden afectar a los resultados reproductivos de las pacientes, así como aumentar la incidencia de abortos de repetición, presentaciones fetales anómalas o partos pretérminos. De la misma forma, los miomas uterinos submucosos también pueden producir alteraciones de la fertilidad, aunque la sintomatología más relacionada con los mismos es el sangrado. Constituyen el tumor benigno más frecuente del aparato genital femenino. El diagnóstico de estas patologías puede realizarse mediante pruebas de imagen como la ecografía transvaginal y la resonancia magnética, aunque la visualización directa vía histeroscópica sigue siendo de elección. Esta técnica constituye, además, la primera opción terapéutica, ya que se puede realizar tanto la resección del septo uterino como la miomectomía, sin apenas complicaciones y mediante una técnica quirúrgica segura y poco invasiva. El tratamiento histeroscópico está especialmente indicado en pacientes sintomáticas, con esterilidad o abortos de repetición, incluso antes de iniciar terapias de reproducción asistida. En el siguiente trabajo exponemos el caso de una paciente que presentaba un septo uterino constituido en su mayor parte por un leiomioma submucoso tratado vía histeroscópica; siendo un caso muy raro, dada la infrecuente asociación entre ambas patologías(AU)

Congenital uterine malformations present low prevalence in the general population (0.5-6.7 percent), and uterus septum is the most frequent. These pathologies can affect the reproductive outcomes of patients, as well as increase the incidence of repeating abortions, abnormal fetal presentations or preterm deliveries. In the same way, submucosal uterine fibroids can also produce alterations in fertility, although the most related symptomatology is bleeding. They are the most frequent benign tumor of the female genital tract. Diagnosis can be carried out through imaging tests such as transvaginal ultrasound and magnetic resonance imaging, although direct visualization, via hysteroscopy, is still the preferred option. This technique is also the first therapeutic option, since both, resection of the uterine septum and myomectomy can be performed with few complications and a safe and minimally invasive surgical technique. Hysteroscopy is especially indicated in symptomatic patients, with sterility or repeated abortions, even before initiating assisted reproduction therapies. In the following paper, we present the case of a patient who presented a uterine septum formed mostly by a submucosal leiomyoma. She was treated by hysteroscopy. This case is very rare given the infrequent association between both pathologies(AU)