Impact of endometriosis on obstetric outcome after natural conception: a multicenter Italian study.

PURPOSE: To evaluate obstetric outcome in women with endometriosis who conceive naturally and receive standard obstetric care in Italy. METHODS: Cases were consecutive women with endometriosis managed in eleven Italian referral centers. Controls were women in whom endometriosis was excluded. All women filled in a questionnaire addressing previous natural pregnancies. Marginal logistic regression models were fitted to evaluate the impact of endometriosis on obstetric outcome. A post hoc analysis was performed within the endometriosis group comparing women with severe adenomyosis versus women with absent or mild adenomyosis. RESULTS: Three hundred and fifty-five pregnancies in endometriosis group and 741 pregnancies in control group were included. Women with endometriosis had a higher risk of preterm delivery < 34 weeks (6.4% vs 2.8%, OR 2.42, 95% CI 1.22-4.82), preterm delivery < 37 weeks (17.8% vs 9.7%, OR 1.98, 95% CI 1.23-3.19), and neonatal admission to Intensive Care Unit (14.1% vs 7.0%, OR 2.04, 95% CI 1.23-3.36). At post hoc analysis, women with endometriosis and severe adenomyosis had an increased risk of placenta previa (23.1% vs 1.8%, OR 16.68, 95% CI 3.49-79.71), cesarean delivery (84.6% vs 38.9%, OR 8.03, 95% CI 1.69-38.25) and preterm delivery < 34 weeks (23.1% vs 5.7%, OR 5.52, 95% CI 1.38-22.09). CONCLUSION: Women with endometriosis who conceive naturally have increased risk of preterm delivery and neonatal admission to intensive care unit. When severe adenomyosis is coexistent with endometriosis, women may be at increased risk of placenta previa and cesarean delivery. TRIAL REGISTRATION: Clinical trial registration number: NCT03354793.

Endometriosis: seeking optimal management in women approaching menopause.

The incidence of endometriosis in middle-aged women is not minimal compared to that in the reproductive age group. The treatment of affected women after childbearing age to the natural transition toward menopause has received considerably poor attention. Disease management is problematic for these women due to increased contraindications regarding hormonal treatment and the possibility for malignant transformation, considering the increased cancer risk in patients with a long-standing history of the disease. This state-of-the-art review aims for the first time to assess the benefits of the available therapies to help guide treatment decisions for the care of endometriosis in women approaching menopause. Progestins are proven effective in reducing pain and should be preferred in these women. According to the international guidelines that lack precise recommendations, hysterectomy with bilateral salpingo-oophorectomy should be the definitive therapy in women who have completed their reproductive arc, if medical therapy has failed. Strict surveillance or surgery with removal of affected gonads should be considered in cases of long-standing or recurrent endometriomas, especially in the presence of modifications of ultrasonographic cyst patterns. Although rare, malignant transformation of various tissues in endometriosis patients has been described, and management is herein discussed.

'Guess who'? An Italian multicentric study on pigmentation traits prevalence in endometriosis localizations.

OBJECTIVES: Previous evidence seems to support the more common presence of certain pigmentation types in women with endometriosis. The aim of this study was to assess the association of certain somatic phenotypes with specific localizations of the disease. The genetic makeup of those somatic traits may will help in better define the disease pathogenesis. STUDY DESIGN: Multicentric, retrospective study of women aged 18 to 45 with histologically confirmed endometriosis. 575 patients were recruited at eleven different Italian endometriosis clinics from March 2015 to January 2021. Data regarding clinical and surgical features were recorded following the self-administered endometriosis patient questionnaire and the surgical standard of reports approved by the World Endometriosis Research Foundation (WERF). Pigmentation types/somatic phenotypes frequencies among endometriosis localizations were reported. A logistic regression analysis was performed to determine somatic types independently associated with disease' localizations. RESULTS: Having green eyes increased by ∼4 folds (OR 3.7; 95% CI: 1.42-9.61; p = 0.007) the risk of having a ureteral nodule, whereas brown/black eyes decreased this risk (OR 0.34; 95% CI: 0.13-0.87; p = 0.025). Consistently, the combination of green eyes and blonde/light brown hairs increased the odds of ureteral endometriosis by more than 5 folds (OR 5.40; 95%CI: 2.02-14.49; p = 0.001), even after correction for anthropometric confounders (aOR 5.85; 95% CI: 2.13-16.09; p < 0.001). CONCLUSIONS: The association between endometriosis and pigmentary traits has been herein confirmed, with the novel finding of the possible predisposition of ureteral endometriosis in patients with green eyes and blonde/light brown hairs. Further investigation on the genetic makeup of somatic traits may provide new inroads also into the molecular aspects of endometriosis leading to a better understanding of this complex disease.

Laparoscopic management of ovarian dermoid cysts: ten years' experience.

OBJECTIVE: To determine the safety and efficacy of laparoscopic management of ovarian dermoid cysts based upon our ten years' experience. METHODS: Charts of 81 patients who underwent laparoscopic removal of dermoid cysts since March 1988 at Stanford University Medical Center or the Center for Special Pelvic Surgery in Atlanta were reviewed retrospectively. RESULTS: Ninety-three dermoid cysts with a mean diameter of 4.5 cm were removed in 81 patients. Operative techniques used were cystectomy for 70 cysts, salpingooophorectomy for 14, and 9 salpingo-oophorectomy with hysterectomy. Fifty-three cysts were treated via enucleation followed by cystectomy or salpingo-oophorectomy and removal through a trocar sleeve. Twenty-two were treated via enucleation and removal within an impermeable sack. Nine were treated via enucleation and removal by posterior colpotomy. Nine were removed via colpotomy following hysterectomy. We had a total of 39 spillages. Spillage rates varied with removal method: 32 (62%) for trocar removal without an endobag, 3 (13.6%) for removal within an endobag, and 4 (40%) with colpotomy removal. No spillage occurred for the nine patients who had a colpotomy done for hysterectomy. Mean hospital stay after surgery was 0.98 days, and there were no intraoperative complications. In one case, there was a postoperative complication of an incisional infection in the umbilicus. CONCLUSION: Including this and 13 other studies, review of the literature reveals a 0.2% incidence of chemical peritonitis following laparoscopic removal of dermoid cysts. Thus, we conclude that laparoscopic management of dermoid cysts is a safe and beneficial method in selected patients when performed by an experienced laparoscopic surgeon.

Laparoscopic creation of a neovagina and recovery of menstrual function in a patient with Rokitansky syndrome: a case report.

A 16-year-old woman experiencing primary amenorrhoea and cyclic pelvic pain was diagnosed with Rokitansky syndrome, which was characterized by the absence of the uterus and the upper two-thirds of the vagina, normal salpinges and ovaries and a 4 x 3 cm Müllerian remnant containing functioning endometrium located near the left adnexa. With a combined laparoscopic-vaginal operation, the remnant was anastomized with the apex of the retrohymenal fovea. The operation allowed not only the creation of a neovagina but also the recovery of a regular menstrual activity and the theoretical restoration of the reproductive capacity of this patient. An accurate pre- and intra-operative evaluation of patients with Rokitansky syndrome is necessary to identify those who might benefit from this procedure.

Identifying the indications for laparoscopically assisted vaginal hysterectomy: a prospective, randomised comparison with abdominal hysterectomy in patients with symptomatic uterine fibroids.

OBJECTIVE: To compare laparoscopically assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH) in patients with uterine fibroids. DESIGN: A prospective randomised study. SETTING: The San Paolo Hospital, Milan. POPULATION: Sixty-two patients, who were not suitable for a vaginal hysterectomy, requiring treatment for uterine fibroids. METHODS: Randomisation between LAVH and TAH. Comparison of outcomes on the whole series, patients with uteri < or = 500 g (Group 1) and patients with uteri > 500 g (Group 2). MAIN OUTCOME MEASURES: To establish operating time, blood loss, complications, febrile morbidity, analgesics administration and hospital stay for both treatment approaches. RESULTS: Median uterine weight was 400 g in both LAVH and TAH group. Median operating time was longer for LAVH (135 min compared with 120 min for TAH; P = 0.001), but patients undergoing LAVH had less analgesics administration (23% compared with 77%, P < 0.001) and a shorter median hospital stay (3.8 compared with 5.8 days; P < 0.001). LAVH, when compared with TAH in the two weight subgroups, required a significantly longer operating time only in Group 2, significantly reduced analgesics administration only in Group 1, and significantly reduced hospital stay in both groups. Conversions of LAVH to laparotomy were significantly more frequent in Group 2 (3/11) than in Group 1 (0/20) (P = 0.04). CONCLUSIONS: Compared with TAH, LAVH has advantages in removing uteri weighing < or = 500 g, with comparable operating time, less post-operative pain and shorter recovery. Among uteri weighing > 500 g LAVH showed a shorter recovery, but longer operating time than TAH and a 27% rate of conversion to laparotomy.

Controlled fetal blood-letting of the recipient twin as a new method for the treatment of severe twin-twin transfusion syndrome: preliminary results.

OBJECTIVE: To investigate the feasibility of withdrawal of blood from the recipient twin as a new method for the treatment of severe twin-twin transfusion syndrome. METHODS: Seven consecutive monozygotic monochorionic twin pregnancies affected by severe twin-twin transfusion syndrome were treated. Fetal blood was withdrawn from the recipient twin using cordocentesis. The volume of blood to be removed was determined using the formula for intrauterine blood transfusion of anemic fetuses. Fetal outcome was evaluated in relation to changes in the amniotic fluid and in growth curves (comparing the differences between the centiles of the estimated fetal weight before the procedure and the centiles of weight at birth), fetal mortality, gestational age at delivery, neonatal weight and neurological damage. RESULTS: Overall, seven of the 14 (50%) fetuses survived; at least one fetus survived in five (71%) pregnancies, both fetuses survived in two (29%) pregnancies, while in two (29%) pregnancies there were no survivors. No maternal complications were observed. At follow-up, one (14%) baby had minor neurological damage. CONCLUSIONS: Withdrawal of blood from the recipient twin in the treatment of severe twin-twin transfusion syndrome was associated with survival similar to that of the alternative techniques of serial amniodrainage and fetoscopic laser surgery, with some possible advantages such as reduced neurological damage compared with serial amniodrainage. It is also less invasive compared with fetoscopic laser surgery.

Impact of a multiparameter, ultrasound-based triage on surgical management of adnexal masses.

OBJECTIVE: To prospectively evaluate the accuracy of a multiparameter, ultrasound-based triage and its impact on surgical management of adnexal masses. METHODS: Masses evaluated as normal according to Ferrazzi's sonographic morphological score were considered as being at low risk of malignancy and eligible for laparoscopic treatment without further evaluation. Masses evaluated as abnormal, but without additional risk factors such as ascites, diameter > or = 10 cm, bilaterality, immobility, resistance index < or = 0.6 and serum CA 125 > 35 IU/mL were considered at moderate risk and eligible for laparoscopic evaluation and treatment. Masses with abnormal morphological score and any of these additional risk factors were considered at high risk and treated by laparotomy. The results of pathological examination were obtained for each mass. RESULTS: Two hundred and four (87%) masses were benign and 30 (13%) were malignant. Among 182 low-risk, 19 moderate-risk and 33 high-risk masses, the odds of malignancy were 1 : 90, 1 : 18 and 4.5 : 1, respectively. To calculate the diagnostic accuracy of this algorithm, low- and moderate-risk groups were considered together: the sensitivity was 90%, specificity 97%, positive predictive value 82% and negative predictive value 99%. The new algorithm was significantly more accurate than was morphological score alone (P = 0.0002). Ninety-six percent of benign masses were treated by laparoscopy. All three patients with malignant masses that were incorrectly assigned to laparoscopy underwent laparoscopic adnexectomy and frozen section. CONCLUSIONS: The accuracy of this new algorithm was higher than that of the sonographic morphological scoring system alone. In the present series, it allowed the treatment by laparoscopy of 96% of benign adnexal masses without mismanagement of any cases of ovarian cancer.

Transvaginal ultrasonographic characterization of ovarian masses: comparison of five scoring systems in a multicenter study.

The aim of this work was to test and compare the accuracy of five different morphological scoring systems to identify malignant ovarian masses in a prospective multicenter study. Four of the systems had previously been reported by Granberg, Sassone, De Priest and Lerner and the fifth is newly developed. A total of 330 ovarian neoplasms were collected in three different centers, which adopted the same diagnostic procedures. Of these, 261 masses were benign (mean diameter 50 +/- 26 mm) and 69 were malignant (mean diameter 69 +/- 33 mm) (prevalence 21%). The area under the receiver operating characteristic (ROC) curve for the multicenter score was 0.84. This was significantly better than the areas of the other four scores which ranged from 0.72 to 0.75. The cut-off levels derived from the five ROC curves achieved a sensitivity that ranged from 74% (Sassone score) to 88% (De Priest score > or = 5), and a specificity from 40% (De Priest) to 67% (multicenter); the highest positive predictive value was 41% (multicenter). With a cut-off level of 9, the accuracy of the multicenter score was significantly better than the scores of Granberg and De Priest (McNemar's test p < 0.0001). Similar results were obtained in 207 ovarian masses of < or = 5 cm in mean diameter, and when 19 borderline and 11 stage 1 cancers only were considered. For the clinical purposes of a screening test we also checked a possible cut-off level of > or = 8, which increased the sensitivity to 93% with a drop of specificity to 56%. With the use of the same criteria for the scores of the different authors, the following values were obtained for sensitivity: 96%, 81%, 93% and 90%; and for specificity: 23%, 56%, 28% and 49%. The multicenter score performed well at distinguishing malignant from benign lesions, and was better than the other four traditional scores, for both large and small masses. This was mainly due to the introduction of two criteria that allowed correction for typical dermoids and endohemorrhagic corpora lutea. A completely reliable differentiation of benign from malignant masses cannot be obtained by sonographic imaging alone.