A review of phase II and III drugs for the treatment and management of endometriosis.

INTRODUCTION: Endometriosis is an estrogen-dependent disease that gives rise to pelvic pain and infertility. Although estroprogestins and progestins currently stand as the first-line treatments for this condition, demonstrating efficacy in two-thirds of patients, a significant portion of individuals experience only partial relief or symptom recurrence following the cessation of these therapies. The coexistence of superficial, deep endometriosis, and ovarian endometriomas, as three distinct phenotypes with unique pathogenetic and molecular characteristics, may elucidate the current heterogeneous biological response to available therapy. AREAS COVERED: The objective of this review is to furnish the reader with a comprehensive summary pertaining to phase II-III hormonal treatments for endometriosis. EXPERT OPINION: Ongoing research endeavors are directed toward the development of novel hormonal options for this benign yet debilitating disease. Among them, oral GnRH antagonists emerge as a noteworthy option, furnishing rapid therapeutic onset without an initial flare-up; these drugs facilitate partial or complete estrogen suppression, and promote prompt ovarian function recovery upon discontinuation, effectively surmounting the limitations associated with previously employed GnRH agonists. Limited evidence supports the use of selective estrogen and progesterone receptor modulators. Consequently, further extensive clinical research is imperative to garner a more profound understanding of innovative targets for novel hormonal options.

Comparison between Robotic Single-Site and Laparoendoscopic Single-Site Hysterectomy: Multicentric Analysis of Surgical Outcomes.

Background and Objectives: Minimally invasive surgery, especially the single-site approach, has demonstrated several advantages in the gynaecological setting. The aim of this study was to compare the surgical outcomes of single-site hysterectomy for benign conditions between the traditional laparoendoscopic approach and robotic surgery. MATERIALS AND METHODS: We consecutively enrolled 278 women between 2012 and 2019 in this multicentre trial. The patients underwent robotic single-site hysterectomy (RSSH) or laparoendoscopic single-site hysterectomy (LESSH) procedures with or without salpingo-oophorectomy for benign indications. Surgical parameters and surgical outcomes were analysed. RESULTS: There was a statistical difference between the two surgical techniques for total operative time (p = 0.001), set-up time (p = 0.013), and anaesthesia time (p = 0.001). Significant differences in intraoperative blood loss were observed (p = 0.001), but no differences were shown for blood transfusion or intraoperative or postoperative complications in the two groups. CONCLUSIONS: LESSH outperformed RSSH in terms of surgical performance and clinical outcomes, with no differences in adverse events.

Laparoscopic Single-Port versus Mini-Laparoscopic Hysterectomy: An International Study.

OBJECTIVES: Laparoendoscopic single-site surgery (LESS) and mini-laparoscopic surgery (Mini-LPS) have been performed with comparable results to conventional laparoscopy. However, there are few data on the comparison between them. Our main objective was to compare LESS and Mini-LPS in terms of surgical time, postoperative pain, and hospital stay in patients who underwent hysterectomy for benign pathology. DESIGN: It is a retrospective international multicentric study carried out in 5 centers including 2 Spanish and 3 Italian. METHODS: Data from patients who underwent hysterectomy for benign pathology between January 1, 2010, and December 31, 2015, were reviewed. We collected the clinical-pathological characteristics of the patients and the perioperative results. The main variables of the study were surgical time, the switch to oral analgesia, and the hospital stay. The two comparison groups in the study included patients undergoing hysterectomy for benign pathology by LESS or by Mini-LPS. The decision to perform the type of procedure was left to the discretion of the surgeon, based primarily on the surgical skills and experience of the center. All data were collected retrospectively by an online encrypted platform. RESULTS: 161 patients were included in the study. 104 (64.6%) patients underwent LESS hysterectomy and 57 (35.4%) Mini-LPS. Median surgical time was significantly longer in the LESS group when compared to the Mini-LPS group (120 vs. 75 min, respectively; p < 0.001). Moreover, longer median hospital stay was observed in the LESS group compared to Mini-LPS (48 vs. 36 h, respectively; p < 0.001). Conversion of the technique to conventional LPS was performed in 4 (2.5%) patients, all of them in the Mini-LPS group (p = 0.015). LIMITATIONS: It is a retrospective study with the biases that this implies. Furthermore, some variables have been incompletely registered in the database, which implies loss of information. This is a nonrandomized study since the decision to intervene with one or another technique was made by the surgeon, which generated 2 nonhomogeneous groups in terms of the number of patients. On the other hand, all the patients who underwent Mini-LPS hysterectomy belonged to the same center, which may have made these results center dependent. CONCLUSIONS: Significant shorter surgical time and shorter hospital stay were observed in patients undergoing Mini-LPS hysterectomy compared to LESS technique; however, intraoperative complications related to instrumentation flaws were higher in the mini-LPS group that required conversion to standard laparoscopy in all cases. Both ultra-minimally invasive techniques seem safe to perform hysterectomies for benign pathology and emphasize the importance in surgical training to adapt them to our current practice.

Analysis of surgical outcomes and learning curve of surgical parameters for robotic hysterectomy: a comparison between multiport versus single-site.

Introduction: The primary goal is to analyze the learning curve of surgical parameters (docking, operation and console time) between multiport and single-site robotic hysterectomy techniques, performed by expert laparoscopic surgeons.Material and methods: The trial is a retrospective analysis of 229 patients enrolled between 2010 and 2018 who underwent robotic hysterectomies with bilateral salpingo-oophorectomies (HBSO) for gynecological diseases.Results: Surgical parameters, learning curve and surgical outcomes were analyzed in order to evaluate the transition from multiport to single-site programs, performed by non-expert surgeons using the multiport technique. All surgical times (total, docking and console time) were shorter in the multiport robotic hysterectomy group, while the intraoperative complication rate was lower in the robotic single-site hysterectomy group (p = 0.007). The learning curve of operative, console and docking time significantly decreased more in the robotic-single site hysterectomy group, than in the multiport robotic hysterectomy group over time (p value < 0.001).Conclusions: The direct transition from the laparoscopy program to the single-site approach is feasible and effective in HBSO performed by expert laparoscopic surgeons. The learning curve of robotic single-site hysterectomy shows that the proficiency in this technique requires more cases than the multiport robotic hysterectomy cases and needs more time to fit the surgical step to the single-site platform.

Oncologic Outcomes of Robotic Radical Hysterectomy (RRH) for Patients with Early-Stage Cervical Cancer: Experience at a Referral Cancer Center.

PURPOSE: To evaluate oncologic outcomes of early stage cervical cancer patients who underwent robotic radical hysterectomy (RRH) in a referral center, a retrospective analysis was performed. METHODS: From January 2010 to December 2018, medical records of stage IA2-IIA1 cervical cancer patients, who underwent radical hysterectomy at our institute, were retrospectively reviewed. We focused our analysis on those who underwent RRH. RESULTS: A total of 198 patients were included in the final analysis. Median follow up was 52 months. At last follow-up, 188 (94.9%) women were disease-free, 9 (4.5%) had died, and 1 (0.5%) was alive with recurrent disease. At 4.5 years, PFS was 93.1% (SE ± 2.1) and OS was 95.1% (SE ± 1.8). Stratified by tumor size, PFS for tumor < 2 cm versus tumor ≥ 2 cm was statistically different (96.8% ± 2.3 and 87.9% ± 4.1 respectively, p = 0.01), as well as OS (100% and 89.8% ± 40 respectively, p = 0.01).Stratified by evidence of tumor at time of robotic surgery, PFS was statistically different in women with no residual tumor after conisation versus those with residual disease (100% ± 2.5 and 90.8% ± 2.8 respectively, p = 0.04). A recurrence occurred in 11 patients (5.6%). CONCLUSIONS: Based on our results, we could speculate that robotic approach, along with some technical precautions to avoid spillage, might be safe as primary treatment of early-stage cervical cancer, especially for tumor < 2 cm and in case of no evidence of disease at time of radical hysterectomy after previous conisation.

Characteristics and outcome of BRCA mutated epithelial ovarian cancer patients in Italy: A retrospective multicenter study (MITO 21).

OBJECTIVE: Around 15% of epithelial ovarian cancer (EOC) patients (pts) harbor a germline BRCA1 or 2 mutation, showing different features than BRCA wild-type pts. The clinical and pathological features of an Italian BRCA mutated EOC cohort were described. METHODS: We retrospectively analyzed clinical, pathological and mutational data from a cohort of Italian BRCA mutated EOC pts. treated in 15 MITO centers between 1995 and 2017. RESULTS: Three-hundred thirty-one pts. were recorded. Two-hundred forty (72%) and 91 (27.5%) pts. harbored a BRCA1 and BRCA2 mutation, respectively. Median age at diagnosis was 52 years. The most frequent diagnosis was a high grade serous FIGO III or IV EOC and platinum doublet in first-line was administered to almost all pts. Fifty-three % of them had no residual disease (R = 0) at surgery. Median progression-free-survival (mPFS) after first-line chemotherapy was 29 months. Expected percentage of pts. alive at 5 years was 72.5% (CI 60.2-80.8%) and R = 0 predicted a significantly longer overall survival (OS). Sixty-six pts. (19,9%) had both an EOC and a breast cancer (BC) diagnosis. The first diagnosis was BC in 81,8% of cases with a mean interval between the two diagnoses (IBTDs) of 132.4 months. Mutational data show that the founder mutation c.5266dupC in BRCA1 was the most frequently recorded. CONCLUSIONS: This is the largest Italian BRCA mutEOC cohort. The only predictor of longer OS was R = 0. EOC pts. that developed subsequently a BC are long-term survivors.

Palliative treatment of endometrial cancer: what is the role of anastrozole in elderly women?

BACKGROUND: Type I endometrial cancer is the most common gynaecological tumour in developed countries and its incidence is increasing also because of population aging. The aim of this work is to test the feasibility and safety of anastrozole as palliative treatment of endometrial cancer in elderly women ineligible for standard surgical treatment. METHODS: Patients with histological diagnosis of type I endometrial cancer not suitable for surgical treatment were enrolled in this pilot study. Anastrozole was administered 1 mg daily orally after performing an accurate clinical and radiological staging. Validated questionnaire and self-reported outcomes were used to evaluate quality of life and compliance during the study period. RESULTS: Eight patients with a mean age of 85 (range 80-88 years) were enrolled. All patients had endometrial cancer confined to the uterus, and none progression of disease was observed during the study period. A partial response to the therapy was reported in seven patients, while one patient had stable disease. Tumour symptoms improvement such as pain, vaginal bleeding and vaginal discomfort was reported. The endometrial thickness after twelve months has showed a reduction of 9.25 ± 4.77 mm. The average follow-up time was 18.25 months. Four women died for non oncological reasons, none death related to endometrial cancer was reported. Evaluation of symptoms showed a significant reduction of appetite loss and insomnia, while a significant increase of global health status and fatigue was reported. CONCLUSIONS: Our preliminary data suggested that the palliative use of anastrozole may be a suitable therapy for the proper management of early stages endometrial cancer in elderly women not suitable for surgical treatment with good compliance and tolerance. TRIAL REGISTRATION: 2013000840. Date of registration: 21/09/2013. URL: trials.sanmatteo.loc .

What Is the Role of Barbed Suture in Laparoscopic Myomectomy? A Meta-Analysis and Pregnancy Outcome Evaluation.

BACKGROUND: This work analyzes the feasibility and effectiveness of barbed suture during laparoscopic myomectomy. METHODS: Eight works have been carefully examined for the meta-analysis from all papers published online until November 2017. RESULTS: Barbed suture proved to be superior to traditional suture technique in blood loss in laparoscopic myomectomy (Standardized Mean Difference [SMD] -0.650, 95% CI -1.420 to -0.119, p = 0.098, test for heterogenity p < 0.0001, I2 = 95.54%), Hb drop (SMD -1.452, 95% CI -3.590 to 0.687, p = 0.183, test for heterogenity p < 0.0001, I2 = 99.08%), suturing difficulty (SMD -0.638, 95% CI -0.935 to -0.342, p ≤ 0.001, test for heterogenity p = 0.25, I2 = 27.84%), suturing time (SMD -1.197, 95% CI -1.848 to -0.549, p ≤0.001, test for heterogenity p = 0.0001, I2 = 83.30%) and total operative time (SMD -0.687, 95% CI -0.804 to -0.569, p ≤ 0.001, test for heterogenity p = 0.292, I2 = 17.44%). Barbed suture demonstrated to be better in comparison with the control group even with regard to the length of hospitalization (SMD -0.278, 95% CI -0.543 to 0.012, p = 0.040, test for heterogenity p = 0.025, I2 = 61.85%), and to perioperative complications (SMD 0.708, 95% CI 0.503-0.996, p = 0.048, test for heterogenity p = 0.79, I2 = 0%). CONCLUSION: Barbed suture significantly facilitates laparoscopic myomectomy by reducing the total operative/suturing time, estimated blood loss/Hb drop, and reduction of perioperative complications.

Morcellation worsens survival outcomes in patients with undiagnosed uterine leiomyosarcomas: A retrospective MITO group study.

OBJECTIVE: To investigate the impact of morcellation on survival outcomes of patients affected by undiagnosed uterine sarcoma. METHODS: This is a retrospective study performed in 8 referral centers of MITO group. Data of women undergoing morcellation for apparent benign uterine myomas who were ultimately diagnosed with stage I uterine sarcoma on final pathology were compared with data of women who did not undergo morcellation. Uterine sarcoma included: leiomyosarcomas (LMS), smooth muscle tumors of uncertain malignant potential (STUMP), low-grade endometrial stromal sarcomas (LG-ESS) and undifferentiated uterine sarcomas (UUS). Two-year survival outcomes were evaluated using Kaplan-Meir and Cox models. RESULTS: Overall 125 patients were identified: 31(24.8%), 21(16.8%) and 73(58.4%) patients had power morcellation during laparoscopy, non power morcellation during open surgery and non morcellation during open procedures, respectively. Considering patients affected by LMS, morcellation did not correlated with disease-free survival. However, patients undergoing either morcellation or power morcellation experienced a 3-fold increase risk of death in comparison to patients who had not morcellation (p=0.02). A trend towards an increase of recurrence was observed for patients undergoing morcellation for STUMP (HR 7.7, p=0.09); while no differences in survival outcomes were observed for patients with LG-ESS and UUS. CONCLUSIONS: Our data suggest that morcellation increase the risk of death in patients affected by undiagnosed LMS. Further prospective studies are warranted in order to assess the risk to benefit ratio of power morcellator utilization in patients with apparent benign uterine myomas.

Brain metastases in patients with EOC: Clinico-pathological and prognostic factors. A multicentric retrospective analysis from the MITO group (MITO 19).

BACKGROUND: Brain metastases (BM) from epithelial ovarian cancer (EOC) are considered a rare and unfavourable event. There is no consensus regarding the best management of these patients. METHODS: A multicenter retrospective analysis of patients with BM from EOC treated between 1997 and 2014 in 18 institutions of the MITO (Multicenter Italian Trials in Ovarian cancer) group was conducted. Univariate and multivariate analysis were performed. RESULTS: A total of 174 women were identified as having BM from EOC. The median time interval between primary diagnosis of EOC and occurrence of BM was 26months (range 2-129months). The median overall survival from primary EOC diagnosis was 48months (95% CI 39.5-56.4months) and from diagnosis of BM was 12months (95% CI 9.6-14.3months). The majority of enrolled women (81.7%) were classified as sensitive to platinum-based chemotherapy. Four variables were significantly associated with poor overall survival in multivariate analysis: multiple BM [HR: 1.86 (95% CI: 1.22-2.84)], presence of extracranial disease [HR: 1.77 (95% CI: 1.11-2.83)] age [HR: 1.74 (95% CI: 1.17-2.59)], and monotherapy [HR: 2.57 (95% CI: 1.64-3.86)]. On the contrary, residual tumor at primary surgery, FIGO stage at primary diagnosis and platinum sensitivity were found to have no significant impact on survival from diagnosis of brain lesions. CONCLUSIONS: Our results suggest that BM is a rare and late manifestation of EOC, with a 12-month life-span expectation. Multiple approach is a positive independent prognostic factor and should be proposed to carefully selected patients.

Single-site Versus Multiport Robotic Hysterectomy in Benign Gynecologic Diseases: A Retrospective Evaluation of Surgical Outcomes and Cost Analysis.

OBJECTIVE: To compare the surgical outcomes and costs of robotic-assisted hysterectomy with the single-site (RSSH) or multiport approach (RH). DESIGN: A retrospective analysis of a prospectively collected database (Canadian Task Force classification II1). SETTING: A university hospital. PATIENTS: Consecutive women who underwent robotic-assisted total laparoscopic hysterectomy and bilateral salpingo-oophorectomy for the treatment of benign gynecologic diseases. INTERVENTIONS: Data on surgical approach, surgical outcomes, and costs were collected in a prospective database and retrospectively analyzed. MEASUREMENTS AND MAIN RESULTS: The total operative time, console time, docking time, estimated blood loss, conversion rate, and surgical complications rate were compared between the 2 study groups. Cost analysis was performed. One hundred four patients underwent total robotic-assisted hysterectomy and bilateral salpingo-oophorectomy (45 RSSH and 59 RH). There was no significant difference in the indications for surgery and in the characteristics of the patients between the 2 study groups. There was no significant difference between the single-site and multiport approach in console time, surgical complication rate, conversion rate, and postoperative pain. The docking time was lower in the RH group (p = .0001). The estimated blood loss and length of hospitalization were lower in the RSSH group (p = .0008 and p = .009, respectively). The cost analysis showed significant differences in favor of RSSH. CONCLUSION: RSSH should be preferred to RH when hysterectomy is performed for benign disease because it could be at least as equally effective and safe with a potential cost reduction. However, because of the high cost and absence of clear advantages, the robotic approach should be considered only for selected patients.

Effectiveness of aromatase inhibitors in the treatment of advanced endometrial adenocarcinoma.

PURPOSE: Type I endometrial cancer is a common tumor of the female genital tract. Since in post-menopausal women aromatase enzyme can stimulate the endometrial tissue neoplastic growth, the use of aromatase inhibitors may have a therapeutic effect, especially in patients not eligible for surgery. METHODS: A systematic review has been performed, with a very specific scope, i.e., the use of aromatase inhibitors in the treatment of advanced or recurrent endometrial cancer, as a single agent or in combination with others drugs. RESULTS: On the basis of the 117 records retrieved from the bibliographic search, the rationale for the use of aromatase inhibitors in endometrial cancer therapy is discussed. Six papers fall within the scope of our systematic review and their results are thoroughly analyzed. Moreover, we report our experience on the clinical effectiveness of anastrozole in the post-chemotherapy treatment of a patient affected by advanced-stage endometrial cancer. CONCLUSION: In general, aromatase inhibitors seem to have limited clinical benefit in the treatment of advanced and recurrent endometrial cancer, although further clinical trials are necessary to investigate more in depth their role. In our case, we experienced a positive feedback in terms of control of an advanced-stage disease.

The Mucosal Innate Immune Response in Primary Human Papillomavirus Infection: A Pilot Study.

OBJECTIVES: The purpose of the study was to evaluate the mucosal immune response in women affected by primary human papillomavirus (HPV) infection, in comparison with HPV-negative women with no previous history of HPV. METHODS: A case-control study comparing the activity of myeloperoxidase (MPO) and lactoferrin (LF) between 19 HPV-positive and 19 HPV-negative women matched for age. Plasmatic and cervicovaginal levels of polymorphonuclear neutrophils (PMN) exhibiting MPO and LF receptors were measured using cytofluorimetric analysis and expressed as mean of percentages. RESULTS: Cervicovaginal levels of MPO-/LF- PMN were lower among HPV-negative women, with a mean rate of 18.81% (SD, 21.38), as opposed to a mean rate of 35.56% (SD, 21.02) (P = 0.020) in HPV-positive women. A similar significant difference was not proven in plasma. The mean rates of plasmatic levels of MPO-/LF- PMN were 36.21% (SD, 16.87) and 36.93% (SD, 10.54) (P = 0.875) in cases and controls, respectively. All patients were evaluated 1 year later, and only 6 cases became negative. CONCLUSIONS: The presence of MPO-/LF- PMN has been considered as a marker of lower rate of apoptosis of HPV-infected cells. This could explain why HPV-positive women are less capable to deal with a primary infection.

Obstetric risk factors and time trends of neurodevelopmental outcome at 2 years in very-low-birthweight infants: a single institution study.

AIM: To assess the time trends of neonatal survival and infant neurodevelopmental outcome in very-low-birthweight children at 24 months corrected age over a 20-year period. METHOD: The study cohort comprised 857 infants (439 males and 418 females) weighing less than 1500g at birth or delivered before 32 weeks gestational age in the period 1989 to 2008. Neurological examination and cognitive assessment of the infants (Bayley Scales of Infant Development and Griffiths Mental Developmental Scale) were performed at 24 months corrected age. RESULTS: The prevalence of neonatal survival with normal neurodevelopmental outcome increased from 55.3% (104/188) in 1989 to 1993, to 61.4% in 1994-1998 (116/189), 68.3% in 1999 to 2003 (138/202), and 84.5% in 2004 to 2008 (235/278) (annual increase=1%, 95% CI 2.1-4.1; p<0.001). In logistic models, the increase in the rate of normal neurodevelopmental outcome during the periods studied was consistent across the categories of birthweight (≤1000g as opposed to >1000g), gestational age (≤28wks as opposed to >28wks), and clinical characteristics (pre-eclampsia/growth restriction as opposed to spontaneous prematurity/rupture of membranes). INTERPRETATION: The increased rate of normal neurodevelopmental outcome at 2 years among very-low-birthweight infants is independent of obstetric risk factors.

Barbed suture in minimally invasive hysterectomy: a systematic review and meta-analysis.

PURPOSE: Total laparoscopic or robotic hysterectomy represents one of the most performed gynecological procedures nowadays. Minimally invasive procedures seem to increase the risk of vaginal cuff dehiscence (VCD). Barbed suture is a new class of suture introduced to aid surgeons during laparoscopic suturing, with the aim to reduce operative time, blood loss, and vaginal dehiscence. METHODS: We identified all articles that report a series of laparoscopic or robotic-assisted hysterectomy using barbed suture compared to conventional suture for vaginal cuff closure. The main outcome measures were vaginal cuff suturing time, vaginal bleeding, and vaginal dehiscence with or without small bowel evisceration. Suturing time was meta-analyzed as the standardized mean difference, which is the difference in means of two arms divided by pooled standard deviation with 95 % confidence intervals. For vaginal bleeding and dehiscence risk difference were calculated for each study and then meta-analyzed. Fixed models were considered if heterogeneity was low (I (2) < 50 %), otherwise random models were preferred. RESULTS: We show that minor bleeding (RD = 0, 95 % CI 0.03-0.03; p value = 0.907) and VCD (RD = -0.01, 95 % CI 0.02-0.00; p value = 0.119) are comparable in minimally invasive hysterectomy with or without the use of barbed suture. The major bleeding (RD = -0.03; 95 % CI 0.05-0.00; p value = 0.047) appears borderline significant, but the difference between the two types of sutures is not high and the upper limit of 95 % IC is equal to 0 so they were considered comparable. Instead, meta-analysis on vaginal cuff suturing time demonstrates that suturing time is reduced with the use of barbed suture (SMD = -0.96, 95 % CI 1.26-0.70; p value <0.001). CONCLUSIONS: Barbed suture is safe and well tolerated as traditional sutures and is associated with reduced operative time of laparoscopic vaginal vault closure.

Robotic single-site surgery for female-to-male transsexuals: preliminary experience.

Hysterectomy with bilateral salpingo-oophorectomy is a part of gender reassignment surgery for the treatment of female-to-male transsexualism. Over the last years many efforts were made in order to reduce invasiveness of laparoscopic and robotic surgery such as the introduction of single-site approach. We report our preliminary experience on single-site robotic hysterectomy for cross-sex reassignment surgery. Our data suggest that single-site robotic hysterectomy is feasible and safe in female-to-male transsexualism with some benefits in terms of postoperative pain and aesthetic results.

"From the tip to the deep of the iceberg": Parametrial involvement in endometriosis.

Deep endometriosis (DE) can be localized in the parametrium, a complex bilateral anatomical structure, sometimes necessitating intricate surgical intervention due to the potential involvement of autonomic nerves, uterine artery, and ureter. If endometriotic ovarian cysts have been considered metaphorically representative of "the tip of the iceberg" concerning concealed DE lesions, it is reasonable to assert that parametrial lesions should be construed as the most profound region of this iceberg. Also, based on a subdual clinical presentation, a comprehensive diagnostic parametrial evaluation becomes imperative to strategize optimal management for patients with suspected DE. Recently, the ULTRAPARAMETRENDO studies aimed to evaluate the role of transvaginal ultrasound for parametrial endometriosis, showing distinctive features, such as a mild hypoechoic appearance, starry morphology, irregular margins, and limited vascularization. The impact of medical therapy on parametrial lesions has not been described in the current literature, primarily due to the lack of adequate detection at imaging. The extension of DE into the parametrium poses significant challenges during the surgical approach, thereby increasing the risk of intra- and postoperative complications, mainly if performed by centers with low expertise and following multiple surgical procedures where parametrial involvement has gone unrecognized. Over time, the principles of nerve-sparing surgery have been incorporated into the surgical DE treatment to minimize iatrogenic damage and potentially reduce the risk of functional complications.

Endometrioma surgery: Hit with your best shot (But know when to stop).

Ovarian endometriomas (OEs) are commonly detected by ultrasound in individuals affected by endometriosis. Although surgery was widely regarded in the past as the gold standard for treating OEs, especially in the case of large cysts, the surgical management of OEs remains debated. Firstly, OEs often represent the "tip of the iceberg" of underlying deep endometriosis, and this should be considered when treating OEs to ameliorate patients' pain for focusing on the surgical objectives and providing better patient counseling. In the context of fertility care, OEs may have a detrimental effect on ovarian reserve through structural alterations, inflammatory responses, and oocyte reserve depletion. Conversely, the surgical approach may exacerbate the decline within the same ovarian reserve. While evidence suggests no improvement in in-vitro fertilization (IVF) outcomes following OE surgery, further studies are needed to understand the impact of OE surgery on spontaneous fertility. Therefore, optimal management of OEs is based on individual patient and fertility characteristics such as the woman's age, length of infertility, results of ovarian reserve tests, and surgical background. Among the available surgical approaches, cystectomy appears advantageous in terms of reduced recurrence rates, and traditionally, bipolar coagulation has been used to achieve hemostasis following this approach. Driven by concerns about the negative impact on ovarian reserve, alternative methods to obtain hemostasis include suturing the cyst bed, and novel methodologies such as CO2 laser and plasma energy have emerged as viable surgical options for OEs. In instances where sonographic OE features are non-reassuring, surgery should be contemplated to obtain tissue for histological diagnosis and rule out eventual ovarian malignancy.