Horizontal versus vertical direction of posterior vaginal wall suture after eradication of rectovaginal endometriosis: A multicenter study.

OBJECTIVE: To compare safety and effectiveness of two-different directions of suturing the posterior vaginal breach (horizontal [Ho] vs vertical [Ve]) in women undergoing recto-vaginal endometriosis (RVE) nodule resection. METHODS: A multicenter, retrospective, observational, cohort study was performed including all women of reproductive age undergoing RVE nodule resection between March 2013 and December 2018 at our tertiary centers. Patients included in the present study were divided into two groups based on the direction in suturing the posterior vaginal fornix defect, for comparisons in terms of rate of postoperative complications, pain relief, pain and anatomical recurrence, and length of hospital stay. Univariate comparisons were performed adopting the t test or the Mann-Whitney test for continuous data and the chi-square test or the Fisher exact test for categorical data, with a significant P value set to <0.05. RESULTS: A total of 101 women were included: 67 in the Ho-group and 34 in the Ve-group. The two groups did not significantly differ in length of hospital stay (6.7 ± 6.9 vs 6.6 ± 3.3 days; P = 0.95), overall postoperative complications (32.8% vs 14.7%; P = 0.05), pain recurrence (35.8% vs 26.5%; P = 0.34) and anatomical recurrence rate (19.4% vs 23.5%; P = 0.62). Conversely, grade III complications were significantly more common in the Ho-group than in the Ve-group (22.7% vs 20%, P = 0.009), while pain relief in terms of deep dyspareunia, dyschezia, dysuria and chronic pelvic pain was more consistent in the Ve-group patients (P = 0.04, 0.04, 0.05, 0.004, respectively). CONCLUSION: In symptomatic women undergoing RVE nodule resection, Ho suturing of the vaginal breach appears more commonly associated with severe postoperative complications and a worse pain control.

Uterine cervical stenosis: from classification to advances in management. Overcoming the obstacles to access the uterine cavity.

BACKGROUND: To date hysteroscopy is the gold standard technique for the evaluation and management of intrauterine pathologies. The cervical canal represents the access route to the uterine cavity. The presence of cervical stenosis often makes entry into the uterine cavity difficult and occasionally impossible. Cervical stenosis has a multifactorial etiology. It is the result of adhesion processes that can lead to the narrowing or total obliteration of the cervical canal. PURPOSE: In this review, we summarize the scientific evidence about cervical stenosis, aiming to identify the best strategy to overcome this challenging condition. METHODS: The literature review followed the scale for the quality assessment of narrative review articles (SANRA). All articles describing the hysteroscopic management of cervical stenosis were considered eligible. Only original papers that reported data on the topic were included. RESULTS: Various strategies have been proposed to address cervical stenosis, including surgical and non-surgical methods. Medical treatments such as the preprocedural use of cervical-ripening agents or osmotic dilators have been explored. Surgical options include the use of cervical dilators and hysteroscopic treatments. CONCLUSIONS: Cervical stenosis can present challenges in achieving successful intrauterine procedures. Operative hysteroscopy has been shown to have the highest success rate, particularly in cases of severe cervical stenosis, and is currently considered the gold standard for managing this condition. Despite the availability of miniaturized instruments that have made the management of cervical stenosis more feasible, it remains a complex task, even for experienced hysteroscopists.

Aggressive Pelvic Angiomyxoma in a Patient with Twin Pregnancy: Diagnosis, Treatment, and Clinical Complications in Light of the Literature.

(1) Background: Aggressive angiomyxoma is a mesenchymal cancer that is rare during pregnancy. It is a neoplasm that relapses and infiltrates the nearest structures. Our aim is to evaluate the management and outcomes of an observed case, in light of the current literature. (2) Methods: We observed this condition at the "Maggiore della Carità" Hospital in Novara (Italy) in a patient with an initial twin pregnancy and a suspected pelvic mass. The words "angiomyxoma" and "pregnancy" were searched on the main online scientific search sources (PubMed, Google Scholar, Scopus, WES, and Embase, etc.). (3) Results: The patient underwent surgery with a complicated follow-up, but recent negative controls. We analyzed the literature about the topic and found only 24 similar clinical cases. (4) Conclusions: Considering the current literature, it is useful to assess an aggressive angiomyxoma in the differential diagnosis of soft masses in pregnant women. The treatment of choice is surgical excision, and vaginal delivery is feasible. The therapeutic decision depends on each case.

Outcomes of High-Grade Cervical Dysplasia with Positive Margins and HPV Persistence after Cervical Conization.

The objective of this work is to assess the 5-year outcomes of patients undergoing conization for high-grade cervical lesions that simultaneously present as risk factors in the persistence of HPV infection and the positivity of surgical resection margins. This is a retrospective study evaluating patients undergoing conization for high-grade cervical lesions. All patients included had both positive surgical margins and experienced HPV persistence at 6 months. Associations were evaluated with Cox proportional hazard regression and summarized using hazard ratio (HR). The charts of 2966 patients undergoing conization were reviewed. Among the whole population, 163 (5.5%) patients met the inclusion criteria, being at high risk due to the presence of positive surgical margins and experiencing HPV persistence. Of 163 patients included, 17 (10.4%) patients developed a CIN2+ recurrence during the 5-year follow-up. Via univariate analyses, diagnosis of CIN3 instead of CIN2 (HR: 4.88 (95%CI: 1.10, 12.41); p = 0.035) and positive endocervical instead of ectocervical margins (HR: 6.44 (95%CI: 2.80, 9.65); p < 0.001) were associated with increased risk of persistence/recurrence. Via multivariate analyses, only positive endocervical instead of ectocervical margins (HR: 4.56 (95%CI: 1.23, 7.95); p = 0.021) were associated with worse outcomes. In this high-risk group, positive endocervical margins is the main risk factor predicting 5-year recurrence.

Lactobacillus crispatus M247 oral administration: Is it really an effective strategy in the management of papillomavirus-infected women?

BACKGROUND: Recent studies have shown the importance of the microbiota in women's health. Indeed, the persistence of Human Papilloma Virus (HPV)-related lesions in patients with dysbiosis can be the antechamber to cervical cancer. The aim of this study was to evaluate whether long term administration of oral Lactobacillus crispatus can restore eubiosis in women with HPV infections and hence achieve viral clearance. METHODS: In total, 160 women affected by HPV infections were enrolled at the Department of Gynecological Obstetrics of "San Paolo" Hospital, Italy between February 2021 and February 2022. The women were randomly assigned to two groups, one in treatment with oral Lactobacillus crispatus M247 (group 1, n = 80) versus the control group, that hence only in follow-up (Group 2, n = 80). RESULTS: After a median follow-up of 12 months (range 10-30 months), the likelihood of resolving HPV-related cytological anomalies was higher in patients in treatment with the long term oral probiotic (group 1) versus the group that perfom only follow-up (group 2) (60.5% vs. 41.3%, p = 0.05). Total HPV clearance was shown in 9.3% of patients undergoing only follow-up compared to 15.3% of patients in the group taking long term oral Lactobacillus crispatus M247 (p = 0.34). However, the percentage of HPV-negative patients, assessed with the HPV-DNA test, documented at the end of the study period was not significantly different from the control group. CONCLUSIONS: Despite the limitations of our analysis, we found a higher percentage of clearance of PAP-smear abnormalities in patients who took long term oral Lactobacillus crispatus M247 than in the control group. Larger studies are warranted, but we believe that future research should be aimed in this direction. Trial registration This study is retrospectively registered.

SARS-CoV-2 Vaccines and Adverse Effects in Gynecology and Obstetrics: The First Italian Retrospective Study.

The most common effects reported by the Italian Medicine Agency following administration of SARS-CoV-2 vaccine are myalgia, soreness to the arm of inoculation, fever, and asthenia. To date, there are no specific and official reports registered by the Italian Medicine Agency on possible alterations of the menstrual cycle, or of the female reproductive system, following the vaccine. Actually, clinical experience showed a spread of transient adverse drug reactions of the menstrual cycle, following the administration of all COVID-19 vaccine types, both mRNA and Adenovirus vectored ones. In this work, we conducted the first retrospective study on Italian patients vaccinated for SARS-CoV-2 in the period between April 2021 and April 2022, to report the onset of menstrual changes after the vaccine in order to understand: etiology, duration of possible adverse effects, and the extent of the phenomenon. We recruited 100 women aged 18-45, vaccinated for SARS-CoV-2, who were asked to complete a questionnaire consisting of 12 multiple choice questions about the effects of the vaccine on the reproductive system. Thirty-seven of them received three doses of the vaccine, while the remaining 63 received two doses. Symptoms such as delayed menstruation and abnormal uterine bleeding (metrorrhagia, menometrorrhagia, and menorrhagia) were generally reported within the first three weeks of vaccination, especially after the second dose, with a percentage of 23% and 77%, respectively. These preliminary data suggest that this problem may be broader and deserving of further investigation in the future.

Effects of Oral Supplementation with Myo-Inositol and D-Chiro-Inositol on Ovarian Functions in Female Long-Term Survivors of Lymphoma: Results from a Prospective Case-Control Analysis.

The progressive improvement of lymphoma treatment has led to an important prolongation of patient survival and life expectancy. The principal international scientific societies of oncology now therefore recommend that long-term survivors of lymphoma join fertility programs. Specifically, fertile-age patients should be assisted by a multidisciplinary team, including specialists dedicated to fertility preservation in oncology, in order to support the completion of their reproductive project. In the general population, the use of Myo-Inositol and D-Chiro-Inositol (MI/DCI) has been demonstrated to be an effective choice to treat ovarian dysfunctions, with a consequent improvement in reproductive outcomes, so it may represent an adjuvant strategy for this purpose. We therefore conducted a pilot prospective case-control study to evaluate the potentialities of this nutritional supplement, with the aim of optimizing reproductive function in female long-term survivors of lymphoma. One group underwent oral supplementation with MI 1200 mg and DCI 135 mg per day for 12 months, compared with controls who underwent no treatment in the same period. After 12 months, FSH, LH, and progesterone levels, as well as oligomenorrhea and antral follicle count (AFC), were significantly improved in the MI/DCI group. In addition, a significantly higher mean value in FSH and LH and a significantly lower mean AFC value in the right ovary were observed in controls compared to the MI/DCI group. Despite the need for further investigation, MI/DCI could be considered a potential adjuvant strategy to restore ovarian function in female long-term survivors of lymphoma.

Isolated tumour cells in a sentinel lymph node of apparent early-stage ovarian cancer: Ultrastaging of all other 27 lymph nodes.

Sentinel lymph node (SLN) biopsy in apparent early-stage ovarian cancer may spare the surgical staging with extensive retroperitoneal dissection and its associated morbidity. However, SLN biopsy in ovarian cancer is still experimental and under investigation. A 46-year-old post-menopausal woman with bilateral apparent stage IC1 endometrioid ovarian cancer underwent surgical staging by SLN biopsy and subsequent comprehensive laparoscopic pelvic and para-aortic lymphadenectomy. Out of 4 SLNs submitted to ultrastaging, one was positive for isolated tumour cells (ITCs). We submitted to ultra-staging all the other 24 pelvic and para-aortic non-SLNs, which were reported negative for disease. This is the first reported case of comprehensive lymphadenectomy after SLN biopsy with universal ultrastaging of all non-SLNs in ovarian cancer. The presence of ITCs in only one SLN, with all other 27 lymph nodes negative at ultrastaging, is consistent with the SLN concept and the assumption of a reliable lymphatic pathway in ovarian cancer.

Ovarian Stem Cells (OSCs) from the Cryopreserved Ovarian Cortex: A Potential for Neo-Oogenesis in Women with Cancer-Treatment Related Infertility: A Case Report and a Review of Literature.

Cancer treatment related infertility (CTRI) affects more than one third of young women undergoing anti-cancer protocols, inducing a premature exhaustion of the ovarian reserve. In addition to ovarian suppression by GnRHa, oocyte and cortex cryopreservation has gained interest in patients with estrogen-sensitive tumors for whom the hormonal burst to prompt the multiple follicular growth could provide a further pro-life tumor pulsing. On the other hand, cortex reimplantation implies a few drawbacks due to the unknown consistency of the follicles to be reimplanted or the risk of reintroducing malignant cells. The capability of ovarian stem cells (OCSs) from fresh ovarian cortex fragments to differentiate in vitro to mature oocytes provides a tool to overcome these drawbacks. In fact, since ovarian cortex sampling and cryopreservation is practicable before gonadotoxic treatments, the recruitment of OSCs from defrosted fragments could provide a novel opportunity to verify their suitability to be expanded in vitro as oocyte like cells (OLCs). Here, we describe in very preliminary experiments the consistency of an OSC population from a single cryopreserved ovarian cortex after thawing as well as both their viability and their suitability to be further explored in their property to differentiate in OLCs, thus reinforcing interest in stemness studies in the treatment of female CTRI.

Fertility preservation techniques in cervical carcinoma.

ASTRACT: The usefulness of this review is to highlight how a fertility preservation (FP) approach is currently feasible for patients diagnosed with uterine cervical cancer. To this regard, a fertility sparing surgery has just overcome its traditional limits, gained acceptance within the major gynecologic oncology societies thanks to the ability to identify the "ideal" candidates to this conservative treatment. On the other hand, the use of other FPs for oocyte and ovarian cortex cryopreservation is still extremely debated. In fact, the existing risk of tumor spreading during oocyte retrieval necessary for oocyte cryostorage for patients' candidates for neo-adjuvant therapy, as well as the potential hazard of cancer cell dissemination after ovarian tissue replacement in cases of non-squamous type cervical carcinomas should not be underestimated. Therefore, in consideration of the encountered limitations and the need to ensure adequate reproductive health for young uterine cervical cancer survivors, translational research regarding the FP has progressively collected innovative insights into the employment of stemness technology. In this context, the property of ovarian stem cells obtained from the ovarian cortex to generate functional oocytes in women could represent a promising therapeutic alternative to the current procedures for a novel and safer FP approach in cancer survivors.

Development of a Nomogram Predicting the Risk of Persistence/Recurrence of Cervical Dysplasia.

Background: Cervical dysplasia persistence/recurrence has a great impact on women's health and quality of life. In this study, we investigated whether a prognostic nomogram may improve risk assessment after primary conization. Methods: This is a retrospective multi-institutional study based on charts of consecutive patients undergoing conization between 1 January 2010 and 31 December 2014. A nomogram assessing the importance of different variables was built. A cohort of patients treated between 1 January 2015 and 30 June 2016 was used to validate the nomogram. Results: A total of 2966 patients undergoing primary conization were analyzed. The median (range) patient age was 40 (18-89) years. At 5-year of follow-up, 6% of patients (175/2966) had developed a persistent/recurrent cervical dysplasia. Median (range) recurrence-free survival was 18 (5-52) months. Diagnosis of CIN3, presence of HR-HPV types, positive endocervical margins, HPV persistence, and the omission of HPV vaccination after conization increased significantly and independently of the risk of developing cervical dysplasia persistence/recurrence. A nomogram weighting the impact of all variables was built with a C-Index of 0.809. A dataset of 549 patients was used to validate the nomogram, with a C-index of 0.809. Conclusions: The present nomogram represents a useful tool for counseling women about their risk of persistence/recurrence after primary conization. HPV vaccination after conization is associated with a reduced risk of CIN2+.

Left External Iliac Vein Injury During Laparoscopic Pelvic Lymphadenectomy for Early-Stage Ovarian Cancer: Our Experience and Review of Literature.

Laparoscopic surgical staging is the standard treatment of early-stage ovarian tumors with similar survival outcomes if compared with laparotomic procedures. In this article, we report a case regarding an incidental external iliac vein injury during a pelvic lymphadenectomy for fertility sparing treatment of early-stage ovarian cancer with a video showing the laparoscopic repair without any consequence or side effect. A 36 year-old obese woman with Body Mass Index 30 kg/m2 referred at our hospital with an histological diagnosis of high grade ovarian serous carcinoma after a left laparoscopic salpingo-oophorectomy performed in another hospital. After an hysteroscopy with endometrial biopsy, a laparoscopic surgical staging with a pelvic and aortic lymphadenectomy with lymph-node dissection until the left renal vein, omentectomy, and appendectomy were performed. A thermal injury to the left external iliac vein occurred using the bipolar forceps during lymphadenectomy and was repaired after an immediate clamping of the site using endoclinch and the suction irrigator probe. The laceration on the iliac vein was successfully repaired using 10 mm laparoscopic titanium clips; after a follow-up of 42 months no recurrence was detected. In conclusion, laparoscopy is a safe and effective therapeutic option for fertility sparing treatment patients with early stage ovarian carcinoma with a significantly low morbidity and postoperative hospitalization, but it should be reserved for oncologic surgeons trained in advanced laparoscopic procedures and repair of vascular injuries potentially associated with high mortality rate.

Eradication of Isolated Para-Aortic Nodal Recurrence in a Patient with an Advanced High Grade Serous Ovarian Carcinoma: Our Experience and Review of Literature.

We report a case report regarding the eradication of isolated lymph-nodal para-aortic recurrence in the aortic region down the left renal vein (LRV) in a patient treated two years earlier in another hospital for a FIGO stage IC2 high-grade serous ovarian carcinoma with a video showing the para-aortic space after eradication of the metastatic tissue. A 66 year-old woman was admitted 24 months after the initial surgical procedure for an increased Ca 125 level and CT scan that revealed a 3 cm para-aortic infrarenal lymph-nodal recurrence that was confirmed by PET/CT scan. A secondary cytoreductive surgery (SCS) with a para-aortic lymph-nodal dissection of the tissue down the LRV and radical omentectomy were performed: during the cytoreduction, the right hemicolon was mobilized. The anterior surface of the inferior vena cava (IVC), aorta and LRV were exposed. The metastatic lymph nodes were detected in the para-ortic space down the proximal part of the LRV and eradicated; an en bloc infrarenal lymph-node dissection from the aortocaval region was performed. The operative time during the surgical procedure was 212 min with a blood loss of 120 mL. No intra- and postoperative complications, including ureteral or vascular injury or renal dysfunction, occurred. At histological examination, three dissected lymph nodes were positive for metastasis, and the patient was discharged five days after laparotomy without side effects and underwent chemotherapy 3 weeks later; after a follow-up of 42 months, no recurrence was detected. In conclusion, secondary debulking surgery can be considered a safe and effective therapeutic option for the management of recurrences, although long-term follow-ups are necessary to evaluate the overall oncologic outcomes of this procedure.

Pregnancy outcomes in women with polycystic ovarian syndrome.

Polycystic ovarian syndrome (PCOS) is the most common endocrinological disease of reproductive-aged women, with an estimated incidence ranging from 5% to 15%. The clinical manifestations of PCOS are heterogeneous and vary according to the age of the patient. Insulin resistance (IR), hyperandrogenism, and obesity are widely assumed to play a pivotal role in the pathophysiological mechanism of PCOS. As previously stated by many conducted meta-analyses, PCOS can cause a rising risk of pregnancy complications, including maternal, fetal, and neonatal complications. Pregnancy-induced hypertension (PIH), preeclampsia (PE), gestational diabetes mellitus (GDM), spontaneous preterm birth (PTB), and an increased necessity for a cesarean section (CS) are the most documented maternal implications. Regarding fetal outcomes, PCOS has also been correlated with elevated neonatal morbidity, prematurity, fetal growth restriction (FGR), birth weight variations (large for gestational age [LGA] and small for gestational age [SGA]), and transfer to the Neonatal Intensive Care Unit (NICU). Owing to the variability of the studies performed, the association of PCOS with an elevated risk of adverse pregnancy outcomes is still controversial. This variability is found in the diagnosis and clinical presentations of PCOS, and can be influenced by prepregnancy circumstances and therapies as well as particular population and environmental features. The Amsterdam Consensus Guidelines confirm that obesity and IR can worsen maternal and fetal complications; thus, a closer follow-up should be offered to PCOS women during pregnancy.

Preventing the human factor: organizational aspects linked to fetal asphyxia.

BACKGROUND: Perinatal asphyxia can cause cerebral palsy and hypoxic-ischemic encephalopathy. They are public health problems because they cause permanent disability. METHODS: This is a retrospective, analytical, observational study. Overall, 162 cases of mothers whose children experienced fetal asphyxia were compared to 361 controls where this condition did not occur. The variables analyzed were classified as: prepartum, intrapartum and organizational. RESULTS: Assisted reproductive technology obtained pregnancies, smoking, maternal body mass index, lack of one-to-one assistance during labor, birth on a day of high-volume activity increased the risk of fetal asphyxia, as well as other traditionally linked factors like shoulder dystocia or age over 35 years. CONCLUSIONS: Cerebral palsy cannot always be prevented because it is a syndrome with a multitude of potential causes. But a small number of cases is likely to be linked to acute intrapartum events that could be limited by changing organizational policies such as staff training and implementing teamwork and discussion. Our paper proposes strategies to try and modify organizational risk factors and therefore limit the incidence of fetal asphyxia.

Prenatal diagnosis of Pfeiffer syndrome and role of three-dimensional ultrasound: case report and review of literature.

Purpose/aim of the study: We report a rare case of autosomal dominant genetic syndrome "Pfeiffer", which is part of the group of acrocephalosyndactyly, with an annual incidence <1/100,000. Three forms are known. Type I is the less common form and it is characterized by moderate-severe mediofacial hypoplasia usually with normal cognitive development. Conversely, types 2 and 3 are more common and they are associated with more severe signs and complications with a more unfavorable prognosis. The type 3 form due to the presence of a cloverleaf skull distinguishes type 2.Materials and methods: Thirty-eight-year-old primigravida was referred to our center, at 28 weeks of gestation due to borderline ventriculomegaly, macrocrania, and a short femur. First trimester screening for chromosomopathies and CF-DNA was low risk; II trimester screening ultrasound showed the presence of "short femur" and macrocrania.Result: Our ultrasound evaluation, assisted by 3D ultrasound, showed cloverleaf skull, turricephaly, moderate ventriculomegaly (13 mm), hypertelorism and exophthalmos, low ear implantation, mild rhizomelia. Ultrasound depicts Pfeiffer syndrome or other acrocephalosyndactyly syndromes (Apert syndromes, Saethre-Chotzen) or other syndromic forms of craniosynostosis like Crouzon syndrome. The NGS panel for molecular analysis of genes involved in skeletal dysplasias showed the mutation of the FGFR2 gene, de novo.Conclusions: Using three-dimensional (3D) ultrasound, it is easier to distinguish rare syndromes characterized by facial dysmorphisms such as exophthalmos, mediofacial hypoplasia, and craniosynostosis.

Laparoscopic treatment of deep endometriosis with a diode laser: our experience.

PURPOSE: To evaluate whether laparoscopic treatment with a diode laser is feasible, safe, and effective in symptomatic patients affected by deep endometriosis (DE). METHODS: This retrospective study was performed using medical record data. The surgical reports, chronic pain scores, and quality of life (QoL) data were evaluated for 50 patients who had undergone laparoscopic surgery between November 2017 and March 2019 at two university hospitals (Monserrato (CA) and Foggia, Italy). Indications for surgery were chronic pelvic pain and/or infertility in patients who wished to conceive spontaneously. Endometriosis lesions/nodules were excised using a diode laser (Leonardo®, Biolitec® DUAL 45) that can combine 980 and 1470 nm wavelengths transmitted through a 1000 µm conical optical fibre. RESULTS: The median patient age was 32 years (range 21-44), with a body mass index (BMI) mean of 21.7  ±  2.9 kg/m2. The mean operation time was 147 min (range 106-190). No intraoperative or early complications (< 30 days) were reported. All patients left the hospital, on average, within 3 days (range 2-9 days) after surgery. A significant improvement in pain was observed at the 3-, 6-, and 12-month follow-up (p < 0.01) in all patients. Moreover, patients reported a significant QoL improvement at the 12-month follow-up. CONCLUSION: The diode laser confirmed its feasibility and safety for treating endometriosis. During the shaving surgical procedure, the diode laser system ensures a safe and effective laparoscopic dissection of deep endometriotic lesions. Further comprehensive randomized trials are necessary to confirm these preliminary data in terms of efficacy, recurrence rates, and pregnancy outcomes.

Cesarean Scar Pregnancy Treated by Artery Embolization Combined with Diode Laser: A Novel Approach for a Rare Disease.

Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy which represents a consequence of a previous cesarean section. It is associated with major maternal morbidity and mortality and has potential implications on future fertility. Because of possible serious complications, CSP should be swiftly diagnosed and treated. There is no management protocol for this rare, life-threatening condition, and each patient should be evaluated individually. Several types of conservative treatment have been used to treat cesarean scar pregnancy: dilation and curettage (D&C), excision of trophoblastic tissues, local or systemic administration of methotrexate, bilateral hypogastric artery ligation, and selective uterine artery embolization with curettage and/or methotrexate administration. In our study we present a cesarean scar pregnancy of a 40-year-old woman who was treated with angiographic uterine artery embolization (UAE) followed by hysteroscopic diode laser resection. Our combined UAE-hysteroscopic laser surgery appears to offer an effective, safe, and minimally invasive surgical treatment.

Management Challenges of Deep Infiltrating Endometriosis.

Deep infiltrating endometriosis (DIE) is the most aggressive of the three phenotypes that constitute endometriosis. It can affect the whole pelvis, subverting the anatomy and functionality of vital organs, with an important negative impact on the patient's quality of life. The diagnosis of DIE is based on clinical and physical examination, instrumental examination, and, if surgery is needed, the identification and biopsy of lesions. The choice of the best therapeutic approach for women with DIE is often challenging. Therapeutic options include medical and surgical treatment, and the decision should be dictated by the patient's medical history, disease stage, symptom severity, and personal choice. Medical therapy can control the symptoms and stop the development of pathology, keeping in mind the side effects derived from a long-term treatment and the risk of recurrence once suspended. Surgical treatment should be proposed only when it is strictly necessary (failed hormone therapy, contraindications to hormone treatment, severity of symptoms, infertility), preferring, whenever possible, a conservative approach performed by a multidisciplinary team. All therapeutic possibilities have to be explained by the physicians in order to help the patients to make the right choice and minimize the impact of the disease on their lives.

High-risk HPV-positive and -negative high-grade cervical dysplasia: Analysis of 5-year outcomes.

OBJECTIVE: To evaluate the outcomes of high-risk (HR) HPV-positive and -negative women affected by high-grade cervical dysplasia. METHODS: This is a retrospective multi-institutional study. Medical records of consecutive patients with high-grade cervical dysplasia undergoing conization between 2010 and 2014 were retrieved. All patients included had at least 5 years of follow-up. A propensity-score matching was adopted in order to reduce the presence of confounding factors between groups. Kaplan-Meir and Cox hazard models were used to estimate 5-year outcomes. RESULTS: Overall, data of 2966 women, affected by high-grade cervical dysplasia were reviewed. The study population included 1478 (85%) and 260 (15%) women affected by HR-HPV-positive and HR-HPV-negative high-grade cervical dysplasia. The prevalence of CIN2 and CIN3 among the HR-HPV-positive and -negative cohort was similar (p = 0.315). Patients with HR-HPV-positive high-grade cervical dysplasia were at higher risk of 5-year recurrence (after primary conization) that HR-HPV-negative patients (p < 0.001, log-rank test). Via multivariate analysis, HR-HPV-negative women were at low risk of recurrence (HR: 1.69 (95%CI: 1.05, 4.80); p = 0.018, Cox Hazard model). A propensity-score matched comparison was carried out in order to reduce biases that are related to the retrospective study design. In comparison to HR-HPV-negative patients, thosewith HR-HPV-positive CIN3 was associate with a 8-fold increase in the risk of recurrence (p < 0.001, log-rank test). CONCLUSIONS: HR-HPV-negative high-grade cervical dysplasia is not uncommon, accounting for 15% of our study population. Those patients experience more favorable outcomes than patients with documented HR-HPV infection(s). Further prospective studies are needed to corroborate our data.