LYMPHA Technique to Prevent Secondary Lower Limb Lymphedema.

BACKGROUND: Inguinofemoral lymphadenectomy carries a high risk of lower limb lymphedema. This report describes the feasibility of performing multiple lymphatic-venous anastomoses (MLVA) after inguinofemoral lymph node completion (LYMPHA technique) and the possible benefit of LYMPHA for preventing lymphedema. METHODS: Between February, 2011 and October, 2014, 11 patients with vulvar cancer and 16 patients with melanoma of the trunk requiring inguinofemoral lymphadenectomy underwent lymph node dissection and the LYMPHA technique. Blue dye was injected into the thigh 10 min before surgery. Lymphatics afferent to the blue nodes were used to perform MLVA using a collateral branch of the great saphenous vein. RESULTS: The mean age of patients in the vulvar cancer group was 52 years (range, 48-75 years). The melanoma group comprised seven men and nine women with a mean age of 41 years (range, 37-56 years). Of the 16 patients, 5 with vulvar cancer underwent bilateral inguinofemoral lymphadenectomy, whereas the remaining 6 patients with vulvar cancer and all 16 patients with melanoma of the trunk had unilateral node dissection. All the patients were treated by the LYMPHA technique. No lymphocele or infectious complications occurred. Transient lower-extremity edema occurred for one melanoma patient (6.25 %), which resolved after 2 months, and permanent lower-extremity edema occurred for one patient (9 %) with vulvar cancer. CONCLUSIONS: The LYMPHA technique appears to be feasible, safe, and effective for the prevention of lower limb lymphedema, thereby improving the patient's quality of life and decreasing health care costs.

Transobturator adjustable tape (TOA) in female stress urinary incontinence associated with low maximal urethral closure pressure.

PURPOSE: To determine the success rate of transobturator adjustable tape (TOA, Agency for Medical Innovations, A.M.I., Austria) in stress urinary incontinent patients with maximal urethral closure pressure (MUCP) < or =20 cm H(2)O compared to those with MUCP >20 cm H(2)O. MATERIALS AND METHODS: In this retrospective study, all female patients with a diagnosis of stress urinary incontinence underwent TOA, from September 2005 to August 2007. All patients had preoperative multichannel urodynamic tests (cystometry, urethral profile and uroflowmetry). During September 2008, patients were contacted by telephone and the validated short forms of the Urogenital Distress Inventory (UDI-6) questionnaire and the Incontinence Impact Questionnaire (IIQ-7) were administered. RESULTS: The chart review identified 146 patients (125 with MUCP >20 cm H(2)O and 21 with MUCP < or =20 cm H(2)O) who had undergone TOA and who met the inclusion criteria. Of these, 121 patients (82.9%) were contacted by telephone. Results showed a very good quality of life (score 0-7 in the IIQ-7) in 95.9% of patients. Only two (1.6%) patients had persistent significant urine leakage related to physical activity. In the MUCP < or =20 cm H(2)O group, 90% of patients could be considered as being very satisfied, with a very good quality of life. CONCLUSION: With the TOA procedure, the obturator route could be used to treat patients with urinary incontinence and also with low MUCP.

Nuchal translucency and lymphatic system maldevelopment.

We describe the histological examination of 18 aborted fetuses that had increased nuchal translucency (NT) between 11(+0) and 13(+6) weeks' gestation. The aim of this study was to assess the corresponding NT anatomic features by immunohistochemical (IHC) investigation. A morphological study was performed using lymphatic and blood endothelial specific markers, as well as smooth muscle actin (SMA). We found that all 18 cases were D2-40 positive, CD31 positive, and CD34 negative, suggesting the presence of nuchal lymph vessel ectasia. We found that 12/18 cases were SMA staining positive and 6/18 cases were SMA negative, suggesting that 6/18 cases had nuchal cystic lymphangiectasia, whereas 12/18 had cystic hygromas. The present data seem to confirm the reasonable hypothesis that lymphangiogenesis plays a relevant role in nuchal edema, increased NT, and that increased NT is the result of a lymphatic malformation or a delayed development of the lymphatic system.

Transvaginal sonohysterographic evaluation of uterine malformations.

OBJECTIVE: The aim of this study was to assess the diagnostic value and the usefulness of sonohysterography (SHG) in the detection of uterine anomalies, compared with other diagnostic methods. STUDY DESIGN: From January 2002 to December 2003, we collected 54 patients with a history of primary or secondary infertility or repeated spontaneous abortion and with a clinically or sonographically suspected abnormal uterus. All patients had previously undergone hysterosalpingography (ISG). All patients were examined by standard transvaginal ultrasound. Sonohysterography was then carried out by the intrauterine injection of an isotonic saline solution. Suspected uterine anomalies were also confirmed by hysteroscopy (HS) and/or laparoscopy. RESULTS: Sonohysterography was able to detect all the anomalies. The sensitivity and specificity of sonohysterography were the same as for hysteroscopy. However, there was no significant difference between the diagnostic capabilities of the methods analyzed. CONCLUSIONS: Transvaginal sonohysterography with saline solution is a low-cost, easy, and helpful examination method for uterine malformations. We propose that sonohysterography should be performed for the primary investigation of infertility and repeated miscarriages.

Vaginal ultrasonographic and hysterosonographic evaluation of the low transverse incision after caesarean section: correlation with gynaecological symptoms.

AIM: We investigated whether there is a correlation between morphological changes of the lower uterine segment after caesarean section (CS), visualized by means of either a transvaginal sonography (TVS) or a sonohysterography (SHG), and the frequency of abnormal uterine bleedings reported by the women. METHODS: By means of a random selection of our population, anamnesis, medical records, and TVS and SHG images of the lower uterine segment were collected in 217 women (116 with previous CS and 101 with previous vaginal birth), and an observational case-control study was performed. RESULTS: The uterine incision was identified in almost all women after CS (102/116) using TVS. It was observed that abnormal uterine bleeding was significantly more frequent in the CS group in comparison with the group of women who delivered vaginally. A correlation between the presence of abnormal uterine bleeding and the presence of significant sonographic findings in the lower uterine transverse incision in the women after CS was found. In the CS group, TVS findings were confirmed by those obtained by SHG, and, with this technique, a triangular anechoic area at the presumed site of incision (the niche) was identified in 69 of the 116 women (59.5%). CONCLUSIONS: In this study, we found a correlation between abnormal uterine bleeding and sonographic findings in women after CS. This correlation appears to be more significant in women who had CS 5-10 years ago. A significant difference exists between the CS group and the group of women who delivered vaginally for both frequency of abnormal uterine bleeding and sonographic findings.

Perineal ultrasound evaluation of the urethrovesical junction angle and urethral mobility in nulliparous women and women following vaginal delivery.

The objective of this study was to demonstrate the differences in the urethrovesical junction angle and urethral mobility by means of perineal ultrasounds in women following vaginal delivery with respect to nulliparous women. We have enrolled 34 women, 12 nulliparous (Group A) and 22 women in the post-partum period (Group B). The ultrasounds were employed to measure the urethrovesical junction angle ("urethro-pelvic" angle) and the urethral mobility. Data obtained show that the urethro-pelvic angle is narrower in Group A (97.3 degrees) with respect to Group B (112.5 degrees). Urethral mobility while coughing was significantly higher in Group B (30.4 degrees) with respect to Group A (-2 degrees). This study demonstrates the difference in the urethral support at rest and during cough in nulliparous versus recently delivered parous women.

The value of sonohysterography in detecting intracavitary benign abnormalities.

The aim of this retrospective study was to assess the diagnostic value and the usefulness of sonohysterography in the detection of uterine intracavitary benign abnormalities, compared with other diagnostic methods (transvaginal ultrasonography and diagnostic hysteroscopy). From January 2003 to December 2003, a total of 73 patients (47 premenopausal (middle age 38.9) and 26 postmenopausal women (middle age 60.5)) underwent transvaginal ultrasonography (TVS) and sonohysterography (SHG), consisting of an intrauterine infusion of saline solution during transvaginal ultrasound. The women referred to our Ultrasonography Center because of intermenstrual (38) or postmenopausal bleeding (19), or an abnormal or a poorly defined endometrial interface (16) as seen as baseline ultrasonography. The findings at TVS and SHG were compared with hysteroscopy (HS). In one case, the SHG was technically impossible to perform. In premenopausal group the sensitivity of SHG had been 100% in detecting submucosal fibroids, endometrial polyps and hyperplasia and 75% in detecting normal uterus. The specificity had been always 100%. In postmenopausal group the sensitivity of SHG had been 75% in detecting submucosal fibroids, 93.8% in endometrial polyps and 100% in hyperplasia and normal uterus. The specificity had been 100% in submucosal fibroids and hyperplasia and had been 90.0 and 95.5% in endometrial polyps and normal uterus, respectively. SHG allows to obtain a precise diagnosis of benign uterine pathology and it is more accurate in the diagnosis of intracavitary abnormalities than that obtained by TVS. Preoperative use of SHG may assist in choosing the best surgical treatment for the patient.

Five-year follow-up of placental involution after abdominal pregnancy.

A 29-year-old woman with an abdominal pregnancy was admitted to the hospital at 29 weeks' menstrual age. At 30 weeks, laparotomy was performed, and a live fetus, wrapped in membrane remnants, was taken from the abdominal cavity. The placenta, inserted in the right hemipelvis, was left in situ. The patient's postoperative recovery was uneventful, and she was monitored periodically as follow-up. At her 5-year follow-up visit, we assessed placental involution by measuring serum beta human chorionic gonadotropin and by using color and pulsed Doppler sonography. The dynamics of the regression of placental volume yielded a bimodal curve: a phase of decrease over the first 2 months, coincident with a reduction in vascularization, followed by stability that lasted 6-8 months, and a second phase of gradual volume reduction. At 5 years, the placenta appeared as a small residual echogenic mass with no vascularity. The use of MRI in this case provided no additional information to what we found using sonography.