[Klippel-Trenaunay-Weber syndrome with vesical and uterine involvement treated by endoscopic and endovascular routes]. / Síndrome de Klippel-Trenaunay-Weber con compromiso vesical y uterino tratado por vía endoscópica y endovascular.

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare venous malformation that generally affects the lower limbs and, more infrequently, the upper limbs. It is characterized by cutaneous angiomatous formations, varicose veins and hypertrophy of the affected limb. The involvement of the genitourinary tract is extremely infrequent. We expose the case of a 14 years old female patient who was admitted for macroscopic hematuria of 48 hours of evolution and metrorrhagia with severe hemodynamic decompensation. The patient was under study for presenting a hemangioma in the lower left limb that extended to the pelvic region. Urethrocystofibroscopy showed the presence of multiple wide-spread angiomatous lesions in the bladder, some of them with active bleeding. The angio-resonance showed a voluminous hypervascular formation in contact with the bladder wall showing several arteriovenous fistulas at the pelvic level and in the left lower limb confirming the etiological diagnosis. A selective arterial embolization of the internal and external iliac territories was performed and then, a laser endocoagulation of the bleeding angiomatous foci was carried out. The hematuria completely stopped within 24 hours later of the procedure. The metrorrhagia associated with KTWS was controlled by the use of LHRH analogs and progestogens.

El síndrome de Klippel-Trenaunay-Weber (SKTW) es una rara malformación venosa que, en general afecta a los miembros inferiores y, más raramente, a los superiores. Se caracteriza por formaciones angiomatosas cutáneas, várices e hipertrofia del miembro afectado. El compromiso genitourinario es sumamente infrecuente. Se presenta el caso de una paciente de 14 años. Ingresó por hematuria macroscópica de 48 h de evolución y metrorragia con grave compromiso hemodinámico. Se encontraba en estudio por presentar un hemangioma en el miembro inferior izquierdo que se extendía hasta la región pelviana. La uretrocistofibroscopía demostró la presencia de múltiples lesiones angiomatosas diseminadas en forma amplia en la vejiga, algunas de ellas con sangrado activo. La angioresonancia mostró una voluminosa formación hipervascularizada en contacto con la pared vesical a la cual desplazaba y fístulas arteriovenosas a nivel pelviano y en el miembro inferior izquierdo confirmando el diagnóstico etiológico. Se realizó una embolización arterial selectiva de los territorios ilíacos interno y externo e inmediatamente después una endocoagulación láser de los focos angiomatosos sangrantes. La hematuria remitió completamente en las 24 h posteriores al procedimiento. La metrorragia asociada al SKTW fue controlada mediante la utilización de análogos LHRH y progestágenos.

Síndrome de Klipper-Trenaunay-Weber con compromiso vesical y uterino tratado por vía endoscópica y endovascular / Klippel-Trenaunay-Weber syndrome with vesical and uterine involvement treated by endoscopic and endovascular routes

El síndrome de Klippel-Trenaunay-Weber (SKTW) es una rara malformación venosa que, en general afecta a los miembros inferiores y, más raramente, a los superiores. Se caracteriza por formaciones angiomatosas cutáneas, várices e hipertrofia del miembro afectado. El compromiso genitourinario es sumamente infrecuente. Se presenta el caso de una paciente de 14 años. Ingresó por hematuria macroscópica de 48 h de evolución y metrorragia con grave compromiso hemodinámico. Se encontraba en estudio por presentar un hemangioma en el miembro inferior izquierdo que se extendía hasta la región pelviana. La uretrocistofibroscopía demostró la presencia de múltiples lesiones angiomatosas diseminadas en forma amplia en la vejiga, algunas de ellas con sangrado activo. La angioresonancia mostró una voluminosa formación hipervascularizada en contacto con la pared vesical a la cual desplazaba y fístulas arteriovenosas a nivel pelviano y en el miembro inferior izquierdo confirmando el diagnóstico etiológico. Se realizó una embolización arterial selectiva de los territorios ilíacos interno y externo e inmediatamente después una endocoagulación láser de los focos angiomatosos sangrantes. La hematuria remitió completamente en las 24 h posteriores al procedimiento. La metrorragia asociada al SKTW fue controlada mediante la utilización de análogos LHRH y progestágenos.

Klippel-Trenaunay-Weber syndrome (KTWS) is a rare venous malformation that generally affects the lower limbs and, more infrequently, the upper limbs. It is characterized by cutaneous angiomatous formations, varicose veins and hypertrophy of the affected limb. The involvement of the genitourinary tract is extremely infrequent. We expose the case of a 14 years old female patient who was admitted for macroscopic hematuria of 48 hours of evolution and metrorrhagia with severe hemodynamic decompensation. The patient was under study for presenting a hemangioma in the lower left limb that extended to the pelvic region. Urethrocystofibroscopy showed the presence of multiple wide-spread angiomatous lesions in the bladder, some of them with active bleeding. The angio-resonance showed a voluminous hypervascular formation in contact with the bladder wall showing several arteriovenous fistulas at the pelvic level and in the left lower limb confirming the etiological diagnosis. A selective arterial embolization of the internal and external iliac territories was performed and then, a laser endocoagulation of the bleeding angiomatous foci was carried out. The hematuria completely stopped within 24 hours later of the procedure. The metrorrhagia associated with KTWS was controlled by the use of LHRH analogs and progestogens.

Step by Step Total Laparoscopic Hysterectomy with Uterine Arteries Ligation at the Origin.

STUDY OBJECTIVE: To reveal principles and the feasibility of a total laparoscopic hysterectomy (TLH) with uterine artery ligation at the origin. DESIGN: Step-by-step demonstration and explanation of technique using videos from patients. SETTING: Gynecologic oncology unit at a university hospital. PATIENT: A 54-year-old woman with uterine fibromatosis and metrorrhagia. INTERVENTION: TLH has 7 common components. First, round ligaments are coagulated and cut to enter the retroperitoneum. The ureter is identified. Second, pararectal spaces are entered between the ureter and the internal iliac artery. This maneuver allows the identification of the uterine artery as it leaves its origin from the internal iliac artery. The uterine vessels are stapled with a vascular endoscopic stapler at their origin from the hypogastric vessels or sealed with a bipolar device. Third, adnexal structures are separated from the uterine corpus for subsequent preservation or removal. Fourth, the blood supply is dissected, occluded, and divided before extirpation of the uterine corpus. Fifth, the cardinal ligament complex is transected with colpotomy, and the cervix is amputated from the vaginal apex. Sixth, the specimen is removed. Finally, the vaginal cuff is closed [1]. MEASUREMENTS AND MAIN RESULTS: Laparoscopic hysterectomy was first described by Reich et al. [2] in 1989 and has slowly gained popularity. Today, hysterectomy is the most common gynecologic procedure performed. TLH is where the entire operation (including suturing of the vaginal vault) is performed laparoscopically and there is no vaginal component except for the removal of the uterus. Currently, hysterectomies are performed by different approaches, and individual surgeons have different indications for the approach to hysterectomy based largely on their own array and patient characteristics. TLH requires the highest degree of laparoscopic surgical skills [3], and knowledge of pelvic anatomy defines a safe space for sharp entry into the retroperitoneum and safe identification of pelvic vasculature. CONCLUSION: We present an educational video with step-by-step explanation of the technique to highlight the anatomic landmarks that guides the procedure.

The accuracy of endometrial sampling for the diagnosis of patterns of endometrial pathology in women presenting with abnormal uterine bleeding. More conservative therapeutic approaches.

OBJECTIVES: Abnormal uterine bleeding (AUB) is a leading cause of hysterectomies, the cause of which is usually diagnosed with preoperative endometrial sampling. We planned this study to assess the accuracy of diagnosing the histologic patterns of endometrium in the preoperative sample in reference to the final histologic diagnosis in hysterectomy. METHODS: We retrospectively reviewed medical charts between January 2011 and December 2015 at a tertiary hospital in Saudi Arabia and identified 43 cases of AUB with complete documentation. The histologic diagnoses were classified into normal and benign pathology group (N/B), or carcinoma and hyperplasia category (Ca/H). Measures of validity were used to compare endometrial sampling histological diagnoses to diagnoses following hysterectomy and Cohen's kappa to assess for agreement between the 2 modalities. Results: The median age of all patients was 49 years. Preoperative histologic examination showed 53.8% sensitivity, 90% specificity, 70% positive predictive values and 81.8% negative predictive values, 30.1%  false positive rates and 18.2% false negative rates. The agreement between preoperative and postoperative histologic diagnoses was moderate (79.1%, k=0.469). Conclusion: The accuracy of preoperative histologic examination was moderate. Our findings recommend cautious clinical decision making and limiting hysterectomy to women who do not respond to other therapeutic measures.

Endometrial sampling in low-risk patients with abnormal uterine bleeding: a systematic review and meta-synthesis.

BACKGROUND: One million women per year seek medical advice for abnormal uterine bleeding (AUB) in the United Kingdom. Many low-risk patients who could be managed exclusively in primary care are referred to hospital based gynaecology services. Performing endometrial sampling (ES) in the community may improve care, reduce the rate of referrals and minimise costs. We aimed to search and synthesise the literature on the effectiveness of ES (Pipelle versus other devices) in managing AUB in low-risk patients. METHODS: We undertook an electronic literature search in MEDLINE via OvidSP, Scopus, and Web of Science for relevant English-language articles from 1984 to 2016 using a combination of MeSH and keywords. Two reviewers independently pre-selected 317 articles and agreed on 60 articles reporting data from over 7300 patients. Five themes were identified: sample adequacy, test performance, pain and discomfort, cost-effectiveness, and barriers and complications of office ES. RESULTS: Pipelle seems to perform as well as dilation and curettage and, as well or better than other ES devices in terms of sampling adequacy and sensitivity. It also seems to be better regarding pain/discomfort and costs. However, Pipelle can disrupt the sonographic appearance of the endometrium and may be limited by cervical stenosis, pelvic organ prolapse and endometrial atrophy. CONCLUSIONS: The current evidence supports the use of Pipelle in the management of low-risk women presenting in the outpatient setting with symptomatic AUB when combined with clinical assessment and ultrasound scanning. However, the implications of its widespread use in primary care are uncertain and more research is required.

Abnormal Uterine Bleeding Is Associated With Increased BMP7 Expression in Human Endometrium.

Abnormal uterine bleeding (AUB), a common health concern of women, is a heterogeneous clinical entity that is traditionally categorized into organic and nonorganic causes. Despite varied pharmacologic treatments, few offer sustained efficacy, as most are empiric, unfocused, and do not directly address underlying dysregulated molecular mechanisms. Characterization of such molecular derangements affords the opportunity to develop and use novel, more successful treatments for AUB. Given its implication in other organ systems, we hypothesized that bone morphogenetic protein (BMP) expression is altered in patients with AUB and hence comprehensively investigated dysregulation of BMP signaling pathways by systematically screening 489 samples from 365 patients for differences in the expression of BMP2, 4, 6, and 7 ligands, BMPR1A and B receptors, and downstream SMAD4, 6, and 7 proteins. Expression analysis was correlated clinically with data abstracted from medical records, including bleeding history, age at procedure, ethnicity, body mass index, hormone treatment, and histological diagnosis of fibroids, polyps, adenomyosis, hyperplasia, and cancer. Expression of BMP7 ligand was significantly increased in patients with AUB (H-score: 18.0 vs 26.7; P < .0001). Patients reporting heavy menstrual bleeding (menorrhagia) as their specific AUB pattern demonstrated significantly higher BMP7 expression. Significantly, no differences in the expression of any other BMP ligands, receptors, or SMAD proteins were observed in this large patient cohort. However, expression of BMPR1A, BMPR1B, and SMAD4 was significantly decreased in cancer compared to benign samples. Our study demonstrates that BMP7 is a promising target for future investigation and pharmacologic treatment of AUB.

Características clínico-epidemiológicas y manejo del cáncer endometrial (2010-2013) / Clinical-epidemiological characteristics and management of endometrial cancer (2010-2013)

Introducción: el cáncer de endometrio ha incrementado su incidencia y se asocia a factores de riesgo presentes en muchas mujeres en la perimenopausia. El síntoma más común es el sangramiento y la modalidad de tratamiento más empleada es la cirugía. Objetivo: caracterizar el cáncer endometrial en el Hospital América Arias desde enero de 2010 hasta junio de 2013. Métodos: se realizó un estudio descriptivo en el Hospital América Arias, desde 1ro de enero de 2010 hasta el 30 de junio de 2013. Se incluyó el total las pacientes con sangramiento uterino anormal en la etapa peri y posmenopáusico a partir de 40 años de edad. Las pacientes con diagnóstico histopatológico de cáncer endometrial constituyeron la muestra (n= 49). Resultados: la edad promedio de las pacientes fue de 60,8 ± 9,9 años. Presentaban sobrepeso 30,6 por ciento, y 44,9 por ciento eran obesas. El examen histopatológico posquirúrgico muestra que la lesión estuvo limitada al endometrio en 14,3 por ciento de las pacientes; pero hubo invasión de los dos tercios externos del miometrio en 61,2 por ciento de ellas. La extensión al cuello y a los anejos uterinos fue de 38,8 por ciento y 22,4 por ciento respectivamente. Conclusiones: existe una tendencia a la aparición del adenocarcinoma endometrial en edades cada vez más avanzadas. Se asocia a factores de riesgo como obesidad, infertilidad y el uso de terapia hormonal de remplazo. Además de la cirugía, algunas pacientes requirieron tratamiento oncológico específico(AU)

Introduction: The incidence of endometrial cancer has increased and it is associated with risk factors present in many perimenopausewomen. The most common symptom is bleeding and the most widely used treatment modality is surgery. Objective: Characterize endometrial cancer at America Arias Hospital from January 2010 to June 2013. Methods: A descriptive study was conductedat America Arias Hospital, from 1 January 2010 to 30 June 2013. The total included over 40 year patients with abnormal uterine bleeding in perimenopausal and postmenopausal. Patients with histopathologic diagnosis of endometrial cancer constituted the sample (n= 49). Results: The mean age of patients was 60.8 ± 9.9 years. 30.6 percent were overweight and 44.9 percent were obese. Postoperative histopathologic examination shows that the lesion was limited to the endometrium in 14.3 percent of patients, but there was invasion of the two outer thirds of the myometrium in 61.2 percent. The extension cervix and adnexa was 38.8 percent and 22.4 percent, respectively. Conclusions: There is a tendency to the appearance of endometrial adenocarcinoma at increasingly advanced ages. It is associated with risk factors such as obesity, infertility, and the use of hormone replacement therapy. In addition to surgery, some patients required specific cancer treatment(AU)

Correlation between transvaginal ultrasound measured endometrial thickness and histopathological findings in Turkish women with abnormal uterine bleeding.

AIM: The present study aims to determine how transvaginal ultrasonography and histopathological examination findings are correlated in a cohort of premenopausal and postmenopausal Turkish women with abnormal uterine bleeding. METHODS: This is a retrospective review of 350 Turkish women who underwent transvaginal ultrasonography and suction curettage as a result of abnormal uterine bleeding. RESULTS: Sonographic appearance of the endometrium was normal in 244 patients (69.7%), while homogeneous thickening was detected in 47 patients (13.4%) and cystic thickening in 21 patients (6.0%). A sonographic diagnosis of endometrial polyp was made in 38 patients (10.9%). Histopathological analysis of endometrial samplings revealed proliferative endometrium (36%), secretory endometrium (24.6%), decidualization (10.9%), endometrial polyp (8.3%), endometritis (6.8%), endometrial hyperplasia (4.6%), irregular shedding (3.7%), atrophic endometrium (3.1%), endometrial cancer (1.1%) and placental retention (0.9%). The sonographic and histopathological findings correlated significantly (χ(2) = 122 768, P = 0.001; r = 0.215, P = 0.001). Approximately 51% of the women with homogeneous endometrial thickening had proliferative endometrium. Only 44.7% of the women with ultrasonographically visualized endometrial polyps had histopathologically diagnosed endometrial polyps. Nearly 57% of the women with cystic endometrial thickening had proliferative endometrium. CONCLUSION: If there is no facility for hysteroscopy or hysteroscopy-guided endometrial biopsy for women with abnormal uterine bleeding, transvaginal ultrasonography findings can be efficiently used to make a preliminary diagnosis and, thus, notify the pathologists.

Morphological study of Pipelle biopsy specimens in cases of abnormal uterine bleeding.

OBJECTIVE: To determine the frequencies of common morphological patterns of abnormal uterine bleeding on Pipelle biopsy specimen. METHODS: The cross-sectional study was conducted at PNS Shifa Hospital, Karachi, and comprised endometrial Pipelle biopsies of patients with abnormal uterine bleeding received between January 2013 and January 2014. Patient's age, marital status, parity and histopatholgical spectrum were recorded. SPSS 17 was used for data analysis. RESULTS: Of the 101 patients, 53(52.50%) presented with proliferative endometrium, 22(21.80%) had secretory endometrium, 13(12.9%) presented with chronic non-specific endometritis, 8(7.9%) had endometrial hyperplasia without atypia, and 5(5%) had endometrial hyperplasia with atypia. Besides, 86(85.1 %) were nulliparous; 15(14.9%) were parous; 92(91.1%) were married and 9(8.9%) were unmarried. CONCLUSIONS: The most common morphological pattern was proliferative endometrium. Though Pipelle has its own limitations, it performed better when endometrial pathology was global rather than focal.

Impact of Surgery on the Evolution of Uterine Sarcomas.

STUDY OBJECTIVE: To identify the characteristics of uterine sarcomas and assess the impact of morcellation on prognosis. DESIGN: Case-control study. (Canadian Task Force classification II-2). SETTING: Hospital Quiron-Dexeus, an academic hospital. PATIENTS: Patients with uterine sarcoma histologically diagnosed and treated in our center between 1987 and 2013. INTERVENTION: All descriptive data, including type of surgery and clinical and pathological data, were reviewed. Survival analysis was performed comparing patients with hysterectomy/myomectomy without any type of morcellation and patients with morcellation during surgery. MEASUREMENTS AND MAIN RESULTS: A total of 37 sarcomas were diagnosed during the study period. The most common symptom was metrorrhagia (50%). The indication for surgery was related to myoma growth in 40% of cases and to metrorrhagia in 37.1% of cases. Open surgery was performed in 23 patients (62.2%), and laparoscopy was performed in 9 (24.3%). Myomectomy was performed in 14 patients (37.8%), and 23 patients (62.1%) underwent hysterectomy as initial surgery. Morcellation for tumor extraction was done in 8 cases (21.6%). Survival analysis by surgical approach showed increased disease-free survival (DFS) in the laparotomy group compared with the laparoscopy group (median, 70.3 months vs 10.4 months; p = .018). Median DFS according to type of surgery was 6.3 months in morcellation cases, 11.9 months in vaginal fragmentation cases, and 149.9 months in nonmorcellated cases (p < .002). The median time to progression was shorter in morcellated cases (laparocopic and vaginal) compared with nonmorcellated cases (11.9 vs 14.9 months; p < .001). No statistically significant differences in prognosis were related to myomectomy versus hysterectomy; however, there were significants difference between morcellation and nonmorcellation cases. CONCLUSION: Taking into account the negative impact of morcellation in sarcomas, the use of this technique should be reconsidered in cases of myoma with atypical clinical presentation or symptomatology. Patients must be informed about the possibility of a nonidentified sarcoma and the possible impact on prognosis resulting from its morcellation.

Transvaginal ultrasonography and hysteroscopy as predictors of endometrial polyps in postmenopause.

The study compared ultrasound and ambulatorial hysteroscopy as diagnostic methods detecting endometrial polyps in postmenopause women. 281 women aged 41-82 years who underwent ambulatorial hysteroscopy were analyzed for presence of uterine bleeding and/or altered transvaginal ultrasound (endometrial thickness ≥5 mm). Ultrasonography detected endometrial polyps in 22.8% of patients and endometrial thickening in the other 59.8%. Hysteroscopy diagnosed endometrial polyps in 80.8%. Ultrasonography showed sensitivity of 88.7%, specificity of 25.4%, positive predictive value of 81.7%, negative predictive value of 37.5% and accuracy of 75.4% in diagnosing endometrial polyps. Hysteroscopy showed 96.4% sensitivity, 74.6% specificity, 93.4% positive predictive value, 84.6% negative predictive value and 91.8% accuracy. Hysteroscopy demonstrated more accuracy than ultrasonography, which is not sufficient for accurate diagnosis.

Clinical pattern and spectrum of endometrial pathologies in patients with abnormal uterine bleeding in Pakistan: need to adopt a more conservative approach to treatment.

BACKGROUND: Abnormal uterine bleeding (AUB) is one of the most common debilitating menstrual problems and has remained one of the most frequent indications for hysterectomy in developing countries. Approximately in 40% of hysterectomy specimens, no definite organic pathology could be established. The problem is common worldwide but causes may vary from one region to another. This study may help gynecologists in our population to improve their therapeutic strategies by promoting minimally invasive uterus sparing modalities such as endometrial ablation and hysteroscopic resection of early proliferative lesions. METHODS: It was a prospective, cross-sectional study conducted at Liaquat National Hospital from 15(th) January 2010 till 14(th) July 2011 over a period of 18 months. Women who underwent dilatation and curettage for endometrial sampling with complaints of AUB were included in the study and histopathologic spectrum was determined. RESULTS: Polymenorrhea was the most common presenting pattern (30%, 72/241) with reproductive age women being the most susceptible (49.3%,119/241). The commonest histopathological spectrum was normal menstrual pattern (34%, 82/241) and the commonest pathology was hormonal imbalance (27%, 65/241), followed by endometrial polyp (14%, 34/241), chronic endometritis (12%, 28/241), atrophic endometrium (6%, 15/241), endometrial hyperplasia (5%, 12/241), and endometrial carcinoma (2%, 5/241). Chronic endometritis was commonly seen in reproductive age (18%, 21/119); hormonal imbalance (45%, 35/77) and endometrial hyperplasia (6.5%, 5/77) in perimenopausal age; endometrial polyp (35.5%, 16/45) and endometrial carcinoma (9%, 4/45) in postmenopausal age. CONCLUSION: Frequency of benign endometrial pathology is quite high in AUB, 236 participants (98%, 236/241). Histopathological spectrum in patients with AUB is quite variable with respect to age. The most common pattern of AUB was polymenorrhea. The most common pathology was hormonal imbalance. It is suggested that age was associated with more progressive lesions found in peri and postmenopausal age group such as endometrial hyperplasia and endometrial carcinoma. Yet endometrial polyp was the most common pathology found in postmenopausal women. Therefore, the management strategy should be individualized, as in most cases a restrictive approach is appropriate in order to avoid unnecessary hysterectomies.

Endometrial biopsy in women with abnormal uterine bleeding: inadequate and unassessable categorisation is not clinically relevant.

AIMS: Inadequate endometrial biopsy comprises a dilemma for gynaecologists and histopathologists alike. This study was conducted to assess the clinical merit of classifying scant endometrial biopsy into inadequate and unassessable using McCluggage criteria. METHODS: We retrospectively classified 268 endometrial biopsies, initially reported as inadequate, into inadequate (n=74) and unassessable (n=174) using McCluggage criteria after excluding 20 cases; all taken from patients aged ≥50 years with abnormal uterine bleeding attending Sandwell and West Birmingham Hospitals, UK from 1 January 2007 until 30 September 2012. The electronic clinical records were reviewed to find out the consequent clinical decisions and final outcomes. The follow-up period was 15 months after including the last patient. RESULTS: The median age was 57 years (range: 50-97), and the median number of visits to hospital till the diagnosis was achieved was 2 (range: 1-4). The final diagnosis of endometrial hyperplasia or cancer was reported in 9 cases; 5 (7.1%) with an initial finding of inadequate and 4 with unassessable (2.4%); the difference was statistically insignificant (p=0.13). More patients in the inadequate category (82.4%) underwent further investigations when compared with the unassessable category (68.4%); the difference was statistically significant (p=0.029). There was no statistically significant difference in the inadequate to unassessable ratio when the endometrial thickness was ≥5 mm or <5 mm within the Pipelle group (p=0.46) or the curettage group (p=0.34). CONCLUSIONS: Our findings suggest that categorising scant endometrial specimens into inadequate or unassessable has no clinical implications. The gynaecologist should interpret the histopathology report in the light of clinical scenario.

Levonorgestrel-releasing intrauterine device in the treatment of abnormal uterine bleeding: a 6- and 12-month morphological and clinical follow-up.

BACKGROUND: Abnormal uterine bleeding is defined as any alteration in the pattern or volume of menstrual blood flow, and it is preferably treated using hysterectomy, endometrial destruction or the levonorgestrel-releasing intrauterine system (Mirena(®) ). Recently, it has been demonstrated that studies of Mirena(®) were generally small and consequently imprecise. AIMS: Our study was aimed at assessing the effects of a slow-release levonorgestrel (20 µg/day) intrauterine device in fertile and postmenopausal women experiencing abnormal uterine bleeding that did not respond to traditional medical management. MATERIALS AND METHODS: A total of 40 women, of whom 24 were of reproductive capacity and 16 were postmenopausal, were enrolled in the trial. Removal of the intrauterine device was required for only 2 of the 24 fertile women and for only 3 of the 16 postmenopausal women. After 6 and 12 months of treatment, the remaining women were clinically evaluated and underwent ultrasound and hysteroscopy using biopsy specimens as a control. The EuroQol Group EQ-5D questionnaire was used for evaluation of quality of life. RESULTS: The device showed good tolerability and efficacy. It resulted in a reduction in the endometrial mucosal thickness with a regression of bleeding and collateral effects, which were more evident after 12 months of treatment. A positive effect of the device on the woman's quality of life was demonstrated. CONCLUSIONS: The slow-release levonorgestrel intrauterine device may be a valid therapeutic tool for treating basic symptomatology and increasing quality of life in women with abnormal uterine bleeding.

Carcinoma de endometrio: revisión clínico-patológica de 6 años en relación con los factores pronósticos / Endometrial carcinoma: Clinico-pathological revision after 6 years, related to prognostic factors

Los carcinomas de endometrio se dividen en dos categorías mayores (I y II), según los datos clínico-patológicos y las alteraciones genéticas. Los de tipo I se asocian con hiperestimulación estrogénica, obesidad, tratamiento hormonal exógeno y reconocen como lesión precursora a la hiperplasia endometrial con desarrollo de carcinomas endometrioides (CE). Los de tipo II predominan en mujeres postmenopáusicas, de subtipos histológicos más frecuentes serosos y de células claras. El objetivo es realizar una revisión anátomo-clínica de los carcinomas de endometrio, estudiados en nuestra institución entre el periodo comprendido entre 1/01/2005 y 31/12/2010. Se realizó estudio retrospectivo y descriptivo de 234 casos de pacientes con diagnóstico de carcinoma endometrial. La edad promedio de las pacientes fue de 68,6 años. El motivo de la consulta en la mayoría de los casos fue metrorragia de la postmenopausia (91,2 por ciento). El factor de riesgo más frecuente fue hipertensión arterial (22 pacientes). El 67,5 por ciento de las pacientes tenían antecedentes de biopsia previa por videohisteroscopía realizada en nuestra institución, observándose concordancia diagnóstica en un 91 por ciento. Se clasificaron según la OMS en CE (79 por ciento), adenocarcinoma seroso (9 por ciento) y mixtos (12 por ciento). El grado histológico (GH) FIGO fue en el 86 por ciento tipo I (exclusión de carcinomas serosos) y el estadío más frecuente fue el I ( 65 por ciento). La metaplasia (Me) más frecuente observada en estas neoplasias fue la mucinosa (35 por ciento). Las mórulas se presentaron en 2 casos comprobados por IHQ con positividad para CD 10 y CDX-2 y negatividad para p63. Se evidenciaron cambios reactivos en el 26 por ciento. El patrón MELF (glándulas microquísticas, elongadas y fragmentadas), de infiltración en la pared miometrial, se identificó en 3 casos. El CE fue el tipo histológico más frecuente y su presentación (mayoritariamente en estadios tempranos de enfermedad), se asoció en un alto porcentaje con las metaplasias mucinosa y tubaria...

Endometrial carcinomas are divided into two major categories (I and II), according to clinicopathologic and genetic alterations. The type I is associated with estrogen hyperstimulation, obesity, exogenous hormonal treatment, and endometrial hyperplasia is recognized as a precursor lesion, with the consecuent endometroid carcinoma. The type II predominate in post-menopausal women, most common histologic subtypes are serous and clear cell. The aim is to review the anatomical and clinical characteristic of endometrial carcinomas, studied at our institution between 01/01/2005 and 31/12/2010. We performed a retrospective and descriptive study of 34 cases of patients with endometrial carcinoma. The average age was 68.6 years. The reason for consultation in most cases was post-menopausal's metrorrhagia (91.2 percent) Hypertension (22 patients) was the more prevalent risk fctor. 67.5 percent of the patients had a history of prior biopsy (histeroscopy) performed at our institution; diagnostic concordance was observed in 91 percent. Were classified according to the WHO in endometrioid carcinomas (79 percent), serous adenocarcinoma (9 percent) and mixed (12 percent). FIGO histologic grade was 86 percent in type I (excluding serous carcinomas) and stage I was the most frequent (65 percent). Mucinous metaplasia was the most frequently observed (35 percent). The morulae were presented in 2 cases (IHC positive for CDX-2 and CD10, and negative for p63). Reactive changes were in 26 percent. The MELF pattern of myometrial infiltration was identified in 3 cases. Endometrioid carcinoma was the most common histological type and presentation (mostly in early stages of disease). Was associated with a high percentaje of tubal and mucinous metaplasia (this would indicate malignancy attenuated). Not yet known meaning of morulae in carcinomas. While it must be record horns infiltration, the presence or not of the same does not change the treatment.

Leiomiomatosis intravenosa de localización cervicovaginal / Intravenous cervicovaginal Leiomyomatosis

La leiomiomatosis intravenosa (LIV) es una patología poco frecuente caracterizada por la presencia de músculo liso en las venas miometriales del cuerpo uterino. Se presenta un caso de LIV limitado a cuello uterino y manguito vaginal. Se realizó histerectomía total con diagnóstico prequirúrgico de miomatosis uterina y menometrorragia. El diagnóstico de LIV fue anatomopatológico mediante técnicas de inmunohistoquímica. Si bien el 70 por ciento de las pacientes con LIV pueden ser curadas con cirugía, en un 30 por ciento de los casos existe persistencia o recurrencia a distancia de la enfermedad. En nuestro caso los controles a treinta meses de la cirugía fueron negativos e incluyeron estudios cardiovasculares, pulmonares, hepáticos y cerebrales.

Intravenous leiomyomatosis (IVL) cervicovaginal is an uncommon pathology, characterized by the presence of sooth muscle in the myometrial veins of the uterine body. A case of IVL is reported, limited to the cervix uteri and the vaginal muff. A total hysterctomy was performed, with presurgical diagnosis of uterine myomatosis and menometrorrhagia. The diagnosis of IVL was performed by clinicopathological analysis and by immunohistochemistry techniques. Although the 70 percent of the patients with IVL can be cured by surgery, in a 30 percentof the cases, there exists persistence and recurrency at distancy from the disease. In our case, the controls after 30 months since surgery were negatives, and included cardiovascular, pulmonary, hepatic and cerebral studies.

Hysteroscopic treatment of postcesarean scar defect.

STUDY OBJECTIVE: To estimate the usefulness of hysteroscopy in the diagnosis and treatment of postcesarean scar defect. DESIGN: Retrospective study (Canadian Task Force classification III). SETTING: Two university-affiliated hospitals. PATIENTS: Sixty-two patients with postcesarean scar defects were retrospectively analyzed. INTERVENTIONS: All patients with postcesarean scar defects diagnosed using ultrasonography and hysteroscopy underwent hysteroscopic surgery, and were followed up for longer than 1 year. MEASUREMENTS AND MAIN RESULTS: Hysteroscopy revealed that 38 patients had valve-like motions at the incision sites, 22 had dome-like defects, and 2 with a history of 2 previous deliveries via cesarean section had umbilications of 2 different shades. Fifty-seven of 62 patients underwent corrective surgery via hysteroscopy. In another 3 patients, because the left wall of the fundus of the uterus was too thin (<2 mm at ultrasonography) to undergo corrective surgery, only clearance of residual blood and/or suture materials was performed. Of these 57 patients, 5 underwent removal of residual suture materials and endometrial fulguration. No complications were observed in these patients. Furthermore, after surgery, abnormal vaginal bleeding stopped in 38 patients, and its duration was shortened in 20 patients. In addition, dysmenorrhea was alleviated in 15 patients, and resolved in 7 patients. CONCLUSION: Hysteroscopy is an accurate means of diagnosis apart from surgical correction.

Comparison of sagittal T2-weighted BLADE and fast spin-echo MRI of the female pelvis for motion artifact and lesion detection.

OBJECTIVE: The objective of this study was to evaluate the effectiveness of BLADE (proprietary name for periodically rotated overlapping parallel lines with enhanced reconstruction [PROPELLER] in MR systems from Siemens Healthcare) MRI compared with conventional T2-weighted fast spin-echo (FSE) MRI for reducing artifacts and improving image quality when imaging the female pelvis. MATERIALS AND METHODS: Sagittal T2-weighted BLADE and FSE examinations of the pelvis of 26 women were performed on a 1.5-T scanner. Three radiologists assessed the images for the presence of artifacts, level of anatomic detail, and overall image quality using a modified Likert scale. Scores for each radiologist and each imaging sequence were analyzed with a linear mixed model, adjusting for correlation within radiologist and within patient. A quantitative comparison was conducted to investigate signal uniformity. RESULTS: The BLADE sequence was superior for evaluation of the junctional zone (p = 0.0019), delineation of ovarian borders and depiction of follicles (p < 0.0001), and detection of fibroids (p = 0.022). Overall image quality was improved with BLADE, with fewer respiratory motion artifacts. The BLADE sequence introduced "radial" artifact that was absent from the FSE images, but this artifact did not affect image quality. Quantitative analysis revealed mean coefficients of variation for BLADE and FSE in the uterus of 21.6% and 22.5%, respectively (p = 0.36). The mean coefficients of variation were 4.6% and 6.1% in fat (p = 0.0007), indicating less variation with BLADE. The mean acquisition times for the BLADE and FSE sequences were 4 minutes 31 seconds and 3 minutes 46 seconds, respectively. CONCLUSION: Imaging of uterine junctional zone anatomy, ovaries, and fibroids was improved and artifacts were reduced with BLADE compared with FSE. Radial artifact introduced by the BLADE sequence and slightly longer imaging times needed for the BLADE sequence were offset by improved image quality.