Reproductive and Oncologic Outcomes in Young Women with Stage IA and Grade 2 Endometrial Carcinoma Undergoing Fertility-Sparing Treatment: A Systematic Review.

BACKGROUND: Endometrial cancer (EC) is the most common gynecological malignancy in both Europe and the USA. Approximately 3-5% of cases occur in women of reproductive age. Fertility-sparing treatment (FST) options are available, but very limited evidence regarding grade 2 (G2) ECs exists in the current literature. This systematic review aimed to comprehensively evaluate reproductive and oncologic outcomes among young women diagnosed with stage IA or G2EC disease who underwent FST. METHODS: A comprehensive search of the literature was carried out on the following databases: MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), the Health Technology Assessment Database, and Web of Science. Only original studies that reported the oncologic and reproductive outcomes of patients with stage IA and G2EC tumors who underwent FST were considered eligible for inclusion in this systematic review (CRD42023484892). Studies describing only the FST for endometrial hyperplasia or G1 EC were excluded. RESULTS: Twenty-two papers that met the abovementioned inclusion criteria were included in the present systematic review. Preliminary analysis suggested encouraging oncologic and reproductive outcomes after FST. CONCLUSIONS: The FST approach may represent a feasible and safe option for women of childbearing age diagnosed with G2EC. Despite these promising findings, cautious interpretation is warranted due to inherent limitations, including heterogeneity in study designs and potential biases. Further research with standardized methodologies and larger sample sizes is imperative for obtaining more robust conclusions.

Transvaginal Sonography for the Preoperative Assessment of Parametrial Deep Infiltrating Endometriosis: A Diagnostic Accuracy Study.

OBJECTIVE: The aim of the study was to evaluate the diagnostic accuracy for parametria endometriosis (PE) of transvaginal sonography (TVS) performed following a systematic approach for the assessment of the lateral parametria. DESIGN: A diagnostic accuracy study was employed based on a prospective observational design. PARTICIPANTS: All consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020 were considered. SETTING: The study was conducted at endometriosis referral hospitals. METHODS: We prospectively collected clinical, imaging, and surgical data of all consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020. A standardized technique with a systematic approach for the assessment of the lateral parametria following specific anatomic landmarks was used for the TVS. The diagnostic accuracy for PE in TVS was assessed using the intraoperative and pathologic diagnosis of PE as the gold standard. RESULTS: In 476 patients who underwent surgery, PE was identified in 114 out of 476 patients (23.95%): 91 left and 54 right PE out of 476 surgical procedures were identified (19.12% vs. 11.34%; p = 0.001); bilateral involvement in 27.19% (31/114 patients) cases. The sensitivity of TVS for PE was 90.74% (79.70-96.92%, 95% CI) for the right side and 87.91% (79.40-93.81%, 95% CI) for the left side. The specificity was almost identical for both sides (98.58% vs. 98.18%). For the right parametrium, the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 63.82 (28.70-141.90, 95% CI) and 0.09 (0.04-0.22, 95% CI), respectively. On the left parametrium, the PLR and NLR were 48.35 (23.12-101.4, 95% CI) and 0.12 (0.07-0.21, 95% CI), respectively. The diagnostic accuracy for right and left PE was 97.69% (95.90-98.84%, 95% CI) and 96.22% (94.04-97.74%, 95% CI), respectively. LIMITATIONS: The principal limit is the high dependence of TVS on the operator experience. Therefore, although a standardized approach following precise definitions of anatomical landmarks was used, we cannot conclude that the observed accuracy of TVS for PE is the same for all sonographers. In this regard, the learning curve was not assessed. In the case of negative TVS for parametrial involvement with an absent intraoperative suspect, a complete dissection of the parametrium was not performed to avoid surgical complications; therefore, cases of minor PE may be missed, underestimating false negatives. CONCLUSIONS: TVS performed following a systematic approach for assessing the lateral parametria seems to have good diagnostic accuracy for PE with large changes in the posttest probability of parametrial involvement based on the TVS evaluation. Considering the clinical and surgical implications of PE, further studies implementing a standardized approach for assessing the parametrium by TVS are recommended to confirm our observations and implement a standardized protocol in clinical practice.

Cornual Pregnancy: Results of a Single-Center Retrospective Experience and Systematic Review on Reproductive Outcomes.

Background and Objectives: Cornual pregnancies (CPs) are rare forms of ectopic pregnancy. When abortion does not occur, it can be a life-threatening condition for the mother and can also impair future fertility. We present our experience in the diagnosis and management of CPs. A systematic review was also conducted to investigate the reproductive outcomes after treatment. Materials and Methods: Between January 2010 and December 2022, we performed a retrospective, cross-sectional, single-center, and descriptive data collection and analysis (ClinicalTrial ID: NCT06165770). The search for suitable articles published in English was carried out using the following databases (PROSPERO ID: CRD42023484909): MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cochrane Methodology Register), Health Technology Assessment Database, Web of Science, and search register such as ClinicalTrial. Only studies describing the impact of CP treatment on fertility were selected. Results: Two studies were included in the systematic review. Seventeen patients suffering from CPs were selected. In our series, a pelvic ultrasound allowed for the diagnosis of a cornual localization in 35.30% of cases. Thirteen women (76.47%) underwent immediate surgical management. The laparoscopic approach was the most used (76.92%), with a laparotomic conversion rate of 30%. Four patients (23.52%) received medical treatment with methotrexate. After treatment, two patients managed to achieve pregnancy. Conclusions: CP is a rare form of ectopic pregnancy that can quickly become life-threatening for the mother. Ultrasound does not lead to a precise diagnosis in all cases. In the absence of complications and emergencies, laparoscopy is an approach that could be considered valid. For selected asymptomatic patients, medical treatment may be a valid alternative. The data from the studies included in the systematic review, although demonstrating a superiority of medical treatment in terms of future pregnancies, are heterogeneous and do not allow us to reach a definitive conclusion.

A Markov-model simulation of IVF programs for PCOS patients indicates that coupling myo-Inositol with rFSH is cost-effective for the Italian Health System.

Accumulating evidence suggests that oral supplementation with myo-Inositol (myo-Ins) is able to reduce the amount of gonadotropins and days of controlled ovarian hyperstimulation (COS) necessary to achieve adequate oocyte maturation in assisted reproduction technology (ART) protocols, particularly in women affected by polycystic ovary syndrome (PCOS). We used computational calculations based on simulation modellings. We simulated in vitro fertilization (IVF) procedures-with or without intracytoplasmic sperm injection (ICSI)-with 100,000 virtual patients, accounting for all the stages of the entire IVF procedure. A Monte Carlo technique was used to account for data uncertainty and to generate the outcome distribution at each stage. We considered virtual patients with PCOS undergoing IVF cycles to achieve pregnancy. Computational data were retrieved from clinical experience and published data. We investigated three parameters related to ART protocols: cost of single procedure; efficacy to achieve ongoing pregnancy at 12 gestational weeks; overall cost per single pregnancy. The administration of oral myo-Ins during COH protocols, compared to the standard COH with recombinant Follicle Stimulating Hormone (rFSH) only, may be considered a potential strategy to reduce costs of ART for the Italian Health System.

Clinical Outcomes after the Use of Antiadhesive Agents in Laparoscopic Reproductive Surgery.

INTRODUCTION: Intra-abdominal adhesions are abnormal fibrous attachments between tissues and organs that can be congenital or acquired. Adhesion formation is a critical postoperative complication that may lead to bowel obstruction, chronic abdominal pain, and infertility. Physical barrier agents separate opposing peritoneal surfaces in the critical 5-day period of remesotheliazation. These agents are subdivided into solid or liquid/gel. Liquid agents seem easier to use in laparoscopic procedures than solid agents. METHODS: The search for suitable articles published in English was carried out using the following databases: MEDLINE, Embase, Global Health, the Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Health Technology Assessment Database, Web of Science, and search register (ClinicalTrial.gov). Only studies reporting data about the impact of the use of an antiadhesive agent on adhesion formation after a primary gynecologic laparoscopic surgery were considered eligible. RESULTS: Twenty-two papers that met the inclusion criteria were included in this systematic review. CONCLUSIONS: Surgeons should consider applying antiadhesive agents after gynecologic surgery to help reduce adhesion formation and its adverse effects. However, further studies are still needed to confirm their impact on reproductive outcome and to implement clear guidelines on their per-operative application.

Feasibility and Surgical Outcomes of Hysteroscopic Myomectomy of FIGO Type 3 Myoma: A Systematic Review.

The latest classification from the Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) has reclassified type 3 myomas, changing their classification from intramural to submucosal. While hysteroscopic myomectomy is considered the gold standard treatment for patients experiencing symptoms from submucosal myomas, there are currently no specific guidelines available for managing type 3 myomas, and the optimal surgical approach remains uncertain. Methods: The search for suitable articles published in English was carried out using the following databases (PROSPERO ID CRD42023418602): MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Health Technology Assessment Database, Web of Science and search register. Only original studies reporting data on hysteroscopic myomectomy of type 3 myoma were considered eligible. The main outcomes investigated were the effectiveness and feasibility of hysteroscopic myomectomy and reproductive outcomes after surgical treatment. Results: Two hundred and sixty-one studies were screened and nineteen of these were read for eligibility. Three studies encompassing 56 patients in total were included. Among the overall population studied, three patients needed an additional procedure to completely remove the myoma and five cases of post-surgical synechiae were recorded. No complications were reported. Of 42 patients wishing for pregnancy, the cumulative live birth rates before and after the hysteroscopic myomectomy were 14.3% and 42.9%, respectively. Conclusions: Hysteroscopic myomectomy appears to be a safe and feasible approach. Nevertheless, data reported in the literature are extremely scarce and based on studies with few patients enrolled. New evidence is needed to assess the safety and effectiveness of hysteroscopic treatment for FIGO type 3 myomas.

Concurrent Diagnosis of Adenomyosis and Congenital Uterine Anomalies: A Review.

Background: Adenomyosis and congenital uterine anomalies (CUAs) can compromise reproductive potential and may coexist in the same patient, especially in cases of infertility. This review (CRD42022382850) aims to evaluate the published cases of concurrent adenomyosis and syndromic and nonsyndromic CUAs. Methods: A literature search for suitable articles published in the English language was performed using the following databases from inception to 30 November 2022: MEDLINE, EMBASE, Global Health, the Cochrane Library, Health Technology Assessment Database, and Web of Science. Articles including both CUAs and adenomyosis, with data about their potential relationship, were included. Results: The literature search retrieved 14 articles that met the purpose of this review and summarized the most recent findings regarding the concurrent diagnosis of adenomyosis and CUAs. Conclusions: Adenomyosis can be found in both syndromic and nonsyndromic CUAs, and may arise from several etiologies. The hypothesis that obstructions in CUAs increase uterine pressure and promote the development of adenomyosis remains to be further elucidated, and additional findings may also play a role. The patient's genetic, epigenetic, and hormonal patterns, as well as normal physiological processes, such as pregnancy, may influence the growth of adenomyosis.

The short form endometriosis health profile questionnaire (EHP-5): psychometric validity assessment of a Croatian version.

PURPOSE: To translate, adapt and validate the Endometriosis Health Profile-5 (EHP-5) in Croatian population. METHODS: This validation study is a part of a prospective, observational study (EHP-5 CRO) with aim of implementation of EHP-5 and to provide better insight in quality of life consideration of women with endometriosis in Croatian clinical practice. A 150 consecutive patients with surgically proven endometriosis were enrolled. The translation to Croatian followed standardized procedure. Cronbach's Alpha was calculated to calculate internal consistency reliability of EHP-5. The test-retest reliability was calculated using intraclass correlation coefficient (ICC). The t test for independent samples was used to assess known-groups validity. RESULTS: Both EHP-5 core and EHP-5 modular parts of the questionnaire had good internal consistency, assessed by the Cronbach's Alpha coefficient (α = 0.793 and α = 0.842, respectively). Obtained results indicate very good reliability for core as well as for modular part of EHP-5 questionnaire (ICC = 0.896 and 0.936, respectively). The independent t test showed that women who reported their pain with VAS scale 7 or more had significantly higher results (p < 0.001) on EHP-5 (M = 50.63) compared with women who reported their pain 6 or less (M = 26.91). Furthermore, we found statistically significant difference between women who are infertile with women who are fertile (p < 0.001), whereby infertile women had higher average result on EHP-5 (M = 49.55) compared with fertile women (M = 34.36). CONCLUSIONS: The Croatian version of the EHP-5 have very good psychometric characteristics and can be used as a reliable tool for assessing patients with endometriosis in everyday clinical practice.

CTLA4-Linked Autoimmunity in the Pathogenesis of Endometriosis and Related Infertility: A Systematic Review.

Several studies, although with conflicting results, have sought to determine the concentration of soluble CTLA4 antigens in peripheral blood plasma and peritoneal fluid in patients with endometriosis-related infertility. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) through a search of the following databases: MEDLINE, EMBASE, Global Health, The Cochrane Library, Health Technology Assessment Database and Web of Science, and Clinical Trials research register. We included observational or prospective human and animal studies with any features related to endometriosis and/or infertility studies involving CTLA4-related pathogenesis published in English. The results of studies in which the size and characteristics of the observed groups were not stated were excluded. From the initial pool of 73 publications identified and screened, we finally included 5 articles to summarize the most recent knowledge about CTLA4-linked autoimmunity in the pathogenesis of endometriosis and related infertility. Evidence from clinical studies shows that CTLA4-based autoimmunity is involved in the maintenance of chronic inflammation in the peritoneal environment, with pre-clinical evidence of anti-CTLA antibodies as a potential novel target therapy for endometriosis. However, CTLA4 gene analyses do not support findings of CTLA4-linked autoimmunity as a primary determinant of the pathogenesis of endometriosis. These findings underlie the role of complex interactions within the family of immune checkpoint molecules involved. Further studies are needed to investigate the clinical relevance of anti-CTLA target therapy, taking into account the potential adverse events and repercussions of novel immunologic therapy modalities. However, with the general scarcity of studies investigating this topic, the clinical importance of CTLA4 autoimmunity still remains unclear.

Pain Management during Office Hysteroscopy: An Evidence-Based Approach.

Background and Objectives: Hysteroscopy is a reliable technique which is highly useful for the evaluation and management of intrauterine pathology. Recently, the widespread nature of in-office procedures without the need for anesthesia has been requesting validation of practical approach in order to reduce procedure-related pain. In this regard, we performed a comprehensive review of literature regarding pain management in office hysteroscopic procedures. Materials and Methods: MEDLINE, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Global Health, Health Technology Assessment Database and Web of Science, other research registers (for example Clinical Trials database) were searched. We searched for all original articles regarding pain relief strategy during office hysteroscopy, without date restriction. Results have been collected and recommendations have been summarized according to the Appraisal of Guidelines for Research and Evaluation (AGREE) tool. Moreover, the strength of each recommendation was scored following the Grading of Recommendations Assessment (GRADE) system, in order to present the best available evidence. Results: Both pharmacological and non-pharmacological strategies for pain management are feasible and can be applied in office setting for hysteroscopic procedures. The selection of strategy should be modulated according to the characteristics of the patient and difficulty of the procedure. Conclusions: Accumulating evidence support the use of pharmacological and other pharmacological-free strategies for reducing pain during office hysteroscopy. Nevertheless, future research priorities should aim to identify the recommended approach (or combined approaches) according to the characteristics of the patient and difficulty of the procedure.

Endometrium as Control of Endometriosis in Experimental Research: Assessment of Sample Suitability.

Endometriosis is a chronic gynecological disease that causes numerous severe symptoms in affected women. Revealing alterations of the molecular processes in ectopic endometrial tissue is the current policy for understanding the pathomechanisms and discovering potential novel therapeutic targets. Examining molecular processes of eutopic endometrium is likely to be a convenient method to compare it with the molecular alterations observed in ectopic tissues. The aim of the present study was to determine what proportion of the surgically resected eutopic endometrial samples is suitable for further experiments so that these can be comparable with endometriosis. Final hospital reports and histopathology reports of a 3-year-long period (1162 cases) were analysed. The application of a retrospective screening method promoted the categorization of these cases, and quantification of the categorized cases was accomplished. In addition, results obtained from cultured endometrium samples were also detailed. Only a small number of the harvested endometrial samples was suitable for further molecular analysis, while preoperative screening protocol could enlarge this fraction. Applying clinical and histopathological selection and exclusion criteria for tissue screening and histopathological examination of samples could ensure the comparability of healthy endometrium with endometriosis. The present study could be useful for researchers who intend to perform molecular experiments to compare endometriosis with the physiological processes of the endometrium.

Virtual sonographic hysteroscopy in assisted reproduction: A retrospective cost-effectiveness analysis.

OBJECTIVE: To analyze the cost-effectiveness of virtual sonographic hysteroscopy (VSH) performed before in vitro fertilization (IVF) (Scenario 1), frozen embryo transfer (Scenario 2), and oocyte donation (Scenario 3) attempts. METHODS: A retrospective analysis of data extracted from patients' files was conducted. Before undergoing the assigned treatment, VSH was offered to all patients. Cost-effectiveness was calculated on the basis of cost per live birth. The total cost was compared with a control group of patients who declined to have hysteroscopy before their treatment. RESULTS: A total of 292 women were involved. Virtual sonographic hysteroscopy was performed in 192 women. Conventional operative hysteroscopy was subsequently required in 34 of them (17.7%). Subsequent assisted reproduction attempts resulted in live birth in 111 women-34/69 (49.3%), 35/69 (50.7%), and 42/54 (77.8%) in Scenarios 1, 2, and 3, respectively. This compared favorably with 100 women who declined VSH, with live birth achieved in 15/39 (38.5%), 14/37 (37.8%), and 15/24 (62.5%) in Scenarios 1, 2, and 3, respectively. The overall cost-effectiveness of VSH compared favorably with straightforward treatment performed without this test. CONCLUSION: The overall cost-effectiveness of treatment attempts carried out after previous VSH compared favorably with straightforward treatment performed without this test.

Structured report for dynamic ultrasonography in patients with suspected or known endometriosis: Recommendations of the International Society for Gynecologic Endoscopy (ISGE).

OBJECTIVE: The International Society for Gynecologic Endoscopy (ISGE) developed this project to establish the recommendations for structured reporting of dynamic ultrasound findings, promoting on this manner the practice of standardized, comprehensive and systematic evaluation and reporting of endometriosis in pelvic structures, in correlation with the #Enzian classification. STUDY DESIGN: A non-systematic review was done through a search on the following databases: MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Health Technology Assessment Database and Web of Science, using the medical subject heading (MeSH) term "endometriosis" (MeSH Unique ID: D004715) in combination with "diagnostic imaging" (MeSH Unique ID Q000000981) and "consensus" (MeSH Unique ID D032921). The information extracted from the articles of interest, written in English and published from inception of the above-mentioned databases until May 2021, was graded by the level of evidence using the American College of Chest Physicians (ACCP) classification system. The recommendations for a structured reporting of ultrasound findings were developed through multiple cycles of literature analysis and expert discussion following the Delphi method. RESULTS: The ISGE recommends the adoption of the terms, definitions and methods proposed by the International Deep Endometriosis Analysis (IDEA) Group for ultrasound assessment of patients with suspected or known endometriosis (grade 1C), since this is the most comprehensive and systematic concept currently available. This paper provides the ISGE structured reporting template for presenting quantitative and qualitative information upon the IDEA consensus-based sonographic assessment of the uterus, adnexa, anterior and posterior compartment. The #Enzian classification is recommended to summarize the findings in a standard fashion (grade 1B). CONCLUSION: Mapping of pelvic endometriosis by ultrasound is accurate when trained sonographers perform the technique. Structured reporting of the lesions may improve patient counseling and treatment planning, including the organization of multidisciplinary teams and the selection of the most appropriate medical or surgical therapeutic strategy.

The pharmacoeconomic impact of follitropin alpha biosimilars in IVF therapy in Europe: a report of the literature.

Introduction: To study the impact of biosimilars in assisted reproductive treatments, we performed a review of the literature. Biosimilars are a bioequivalent chemical drug referred to the original. Their production is strongly requested in order to reduce drug cost and reduce health economic impact on national health system. In assisted reproductive treatments different gonadotropin biosimilars are being produced.Areas covered: For this reason, we performed a review of the literature on follitropin alfa Gonal-F biosimilar, Ovaleap and Bemfola, to assess their cost efficacy in national health system. Cost effective (CE) analysis and incremental cost-effectiveness ratio (ICER) were used as parameters for biosimilar impact evaluation in the national health system economy. In particular, they had only slight impact on cost reduction of recombinant follitropin alfa products in Europe.Expert opinion: considering cost-effective analysis, Gonal-F remains the first choice for national health systems. However, well-designed powered methods are strongly needed to assess biosimilars cost-effectiveness.

Impaired inflammatory state of the endometrium: a multifaceted approach to endometrial inflammation. Current insights and future directions.

New insights into the complex and fine-regulated inflammatory mechanisms involved in the endometrium reveal multiple facets to the problem of endometrial inflammation. However, the entity termed chronic endometritis is to date restricted to infectious etiology and managed with antibiotics. Conversely, the concept of impaired inflammatory state of the endometrium (IISE) provides a more global approach to defective endometrial inflammation, considering both infectious and non-infectious etiology. A non-systematic review was done through a search on MEDLINE, EMBASE, Global Health, The Cochrane Library, Health Technology Assessment Database and Web of Science, research registers. Pertinent original and review articles, published in English or French until December 31, 2019, were selected. A compelling body of evidence demonstrates transient, repeated and persistent IISE to be a major factor of most problematic disorders in obstetrics/gynecology, such as endometrial polyps, unexplained infertility, miscarriage, placenta-related pathology and endometrial cancer. When scheduled accordingly, hysteroscopy can play a key role in the IISE assessment. Robust data suggests the pertinence of minimal-effective anti-inflammatory regimens for therapeutic IISE targeting. This review provides a comprehensive update on the multiple facets of inflammation in the endometrial physiology and pathology. Further research is needed to improve classification, diagnosis and treatment of IISE.

The role of Kisspeptin levels in polycystic ovary syndrome: a systematic review and meta-analysis.

PURPOSE: Polycystic ovarian syndrome (PCOS) is a complex and not fully elucidated pathology. This prevalent endocrinopathy affects patients in reproductive age, impacts on estrogen-dependent diseases, as well as in infertility. In this context, Kisspeptin (KP) may be considered a potential biomarker for PCOS diagnosis and follow-up. Here, we aimed to verify the levels of KP in obese and non-obese patients with PCOS, their relationship with other hormones, in comparison to healthy controls. METHODS: A systematic review and meta-analysis were performed according to the PRISMA guidelines. We searched MEDLINE, EMBASE, PsycINFO, Global Health, The Cochrane Library, Health Technology Assessment Database, and Web of Science for eligible studies. A random effects model meta-analysis of standardized mean difference (SMD) was conducted and the I2 was used to assess heterogeneity. Meta-regression was conducted through mixed-effects model. RESULTS: A total of 12 studies were included, comprising 660 PCOS patients and 600 controls. The KP levels were lower in the control group (0.76: 0.17-1.35; 95% CI). In the subgroup analyses, patients were divided in non-overweight/obese (BMI < 25) and overweight/obese (BMI ≥ 25) groups. The meta-regression revealed a difference between the obese and non-obese groups (z = 2.81; p = 0.0050). CONCLUSIONS: PCOS patients showed higher KP levels than control, and obese non-PCOS patients also showed altered KP levels. All studies had poor descriptions of sample collection, pre-analytical and analytical procedures, which is critical considering structural characteristics of the KP molecule.

Unintentional transvesical caesarean section: incidence, risk factors, surgical technique and post-operative management.

OBJECTIVE(S): To assess incidence, risk factors, management, and short and long-term outcomes of unintentional transvesical caesarean section (UTV-CS) defined as any extraction of the fetus through a double full thickness bladder wall cystotomy. STUDY DESIGN: Data about all UTV-CS between January 2013 and December 2017 were retrieved searching the diagnosis of bladder injury and bladder repair during caesarean section (CS) in our comprehensive computerized labor and delivery database and register. CS with bladder wall injury not classified as UTV-CS were excluded. Data analysis included maternal history, demographics and obstetric parameters, details regarding CSs, bladder injury location and extension, and short- and long-term maternal outcomes. RESULTS: Among 28,822 deliveries, 7,616 (26.42%) were CSs. Three cases of UTV-CS were identified with comprehensive incidence of 0.039%. We provided details of the reported cases and described bladder repair procedure. CONCLUSION(S): This is the first study that assessed the incidence of UTV-CS. UTV-CS risk factors are consistent with factors related to milder bladder injuries. The risk of bladder injury during CS should be always considered, despite the low incidence of this complication. Prompt diagnosis and surgical repair seem to allow avoiding severe complications and recovery of a normal urological function even in UTV-CS.

Vitamin B12 among Vegetarians: Status, Assessment and Supplementation.

Cobalamin is an essential molecule for humans. It acts as a cofactor in one-carbon transfers through methylation and molecular rearrangement. These functions take place in fatty acid, amino acid and nucleic acid metabolic pathways. The deficiency of vitamin B12 is clinically manifested in the blood and nervous system where the cobalamin plays a key role in cell replication and in fatty acid metabolism. Hypovitaminosis arises from inadequate absorption, from genetic defects that alter transport through the body, or from inadequate intake as a result of diet. With the growing adoption of vegetarian eating styles in Western countries, there is growing focus on whether diets that exclude animal foods are adequate. Since food availability in these countries is not a problem, and therefore plant foods are sufficiently adequate, the most delicate issue remains the contribution of cobalamin, which is poorly represented in plants. In this review, we will discuss the status of vitamin B12 among vegetarians, the diagnostic markers for the detection of cobalamin deficiency and appropriate sources for sufficient intake, through the description of the features and functions of vitamin B12 and its absorption mechanism.