Vaginal Leiomyomas - Safe Steps for Laparoscopic removal: feasibility from 3 case reports.

Background: Leiomyomas are a common pathology in reproductive-aged women. However, they rarely originate from extrauterine sites. Vaginal leiomyomas constitute a challenging diagnosis, regarding their surgical treatment. Despite the well- established advantages of laparoscopic myomectomy, the efficacy and feasibility of a total laparoscopic approach for such cases has not been yet investigated. Objectives: To describe step-by-step the laparoscopic technique for vaginal leiomyoma removal (narrated video presentation) and demonstrate the outcomes of a small series managed at our institution. Patients: Three patients diagnosed with symptomatic vaginal leiomyomas that presented to our laparoscopic department. Patients aged 29, 35 and 47 years with BMI 20.6 kg/m2, 19.5kg/m2 and 30.1 kg/m2, respectively. Results: Total laparoscopic excision of the vaginal leiomyomas was successful in all three cases without conversion to laparotomy. The technique is demonstrated in a step-by-step video narration. There were no major complications. Average operative time was 146.25 min (range 90- 190 min) and intraoperative blood loss was 120 ml (range 20-300ml). Fertility was preserved in all patients. Conclusion: Laparoscopy is a feasible technique to approach vaginal masses. Further studies are needed to assess safety and efficacy of the laparoscopic technique in such cases.

Distinct types of uterine adenomyosis based on laparoscopic and histopathologic criteria.

PURPOSE: To analyze laparoscopically treated cases of adenomyosis based on intraoperative and histopathology findings and to correlate different types with patients' presenting symptoms and characteristics, as well as with the surgical approach. MATERIALS AND METHODS: Sixty-eight women who underwent laparoscopic treatment of adenomyosis at a referral center for gynecological laparoscopy. RESULTS: Four distinct types of adenomyosis could be identified: diffuse, sclerotic, nodular, and cystic (54.5%, 13%, 28%, and 4.5% of cases, respectively). Menorrhagia as the main presenting symptom was significantly more frequent in patients with the diffuse type (84%) compared to those with sclerotic (44%) and nodular (37%) types (p = 0.025 andp = 0.001, respectively). All cases of cystic and nodular adenomyosis were treated by laparoscopic excision of the lesion. Eighty-nine percent of patients with sclerotic adenomyosis were treated with wide laparoscopic excision of the abnormal tissue. Eighty-one percent of patients with diffuse adenomyosis were treated with laparoscopic hysterectomy. CONCLUSIONS: Adenomyosis can be classified in four distinct types with differences in the presenting symptoms, as well as in the ideal surgical approach.

Gynaecological endoscopic evaluation of 4% icodextrin solution: a European, multicentre, double-blind, randomized study of the efficacy and safety in the reduction of de novo adhesions after laparoscopic gynaecological surgery.

BACKGROUND: Gynaecological laparoscopic surgery outcomes can be compromised by the formation of de novo adhesions. This randomized, double-blind study was designed to assess the efficacy and safety of 4% icodextrin solution (Adept(®)) in the reduction of de novo adhesion incidence compared to lactated Ringer's solution (LRS). METHODS: Patients undergoing laparoscopic surgery for removal of myomas or endometriotic cysts were treated with randomized solution as an intra-operative irrigant and 1l post-operative instillate. De novo adhesion incidence (number of sites with adhesions), severity and extent were independently scored at a second-look procedure and the efficacy of the two solutions compared. The effect of surgical covariates on adhesion formation was also investigated. Initial exploratory analysis of individual anatomical sites of clinical importance was progressed. RESULTS Of 498 patients randomized, 330 were evaluable (160 LRS--75% myomectomy/25% endometriotic cysts; 170 Adept--79% myomectomy/21% endometriotic cysts). At study completion, 76.2% LRS and 77.6% Adept had ≥ 1 de novo adhesion. The mean (SD) number of de novo adhesions was 2.58 (2.11) for Adept and 2.58 (2.38) for LRS. The treatment effect difference was not significant (P = 0.909). Assessment of surgical covariates identified significant influences on the mean number of de novo adhesions regardless of treatment, including surgery duration (P = 0.048), blood loss in myomectomy patients (P = 0.019), length of uterine incision in myomectomy patients (P < 0.001) and number of suture knots (P < 0.001). There were 15 adverse events considered treatment-related in the LRS patients (7.2%) and 18 in the Adept group (8.3%). Of 17 reported serious adverse events (9 LRS; 8 Adept) none were considered treatment-related. CONCLUSIONS: The study confirmed the safety of Adept in laparoscopic surgery. The proportion of patients with de novo adhesion formation was considerably higher than previous literature suggested. Overall there was no evidence of a clinical effect but various surgical covariates including surgery duration, blood loss, number and size of incisions, suturing and number of knots were found to influence de novo adhesion formation. The study provides direction for future research into adhesion reduction strategies in site specific surgery.

Increased nerve density in deep infiltrating endometriotic nodules.

BACKGROUND/AIMS: Deep infiltrating endometriosis is a very painful condition and the mechanism of pain is still poorly understood. Pain and hyperalgesia can partly be explained by an increased number of nerve structures in the painful lesion. In order to clarify this issue, we assessed the nerve density in deep infiltrating endometriotic nodules of the posterior vagina and in the adjacent healthy vaginal tissue of the same patient. METHODS: A prospective clinical and pathological study of 31 cases of deep infiltrating vaginal endometriotic nodules was conducted. Fifteen patients were in the proliferative phase and 16 in the secretory phase. The nerve density was studied by immunohistochemistry with the monoclonal antibody NF against neurofilaments in deep infiltrating endometriosis and in the adjacent unaffected vaginal tissue in the proliferative and in the secretory phases. Neurofilaments constitute the main structural elements of neuronal axons and dendrites. RESULTS: The nerve density was significantly different in the endometriotic nodule than in the adjacent unaffected vaginal tissue (p = 0.0013). The same significant difference was found between endometriotic nodules and the unaffected vagina in the proliferative phase (p = 0.009) and in the secretory phase (p = 0.04). This difference was not significant between the proliferative and the secretory phases in the endometriotic lesions and in the controls. CONCLUSIONS: We hypothesize that the significantly increased number of nerve structures in the endometriotic nodules may contribute to the occurrence of severe and neuropathic pain that characterizes these lesions.

Heterotopic pregnancy at 16 weeks of gestation after in-vitro fertilization and embryo transfer.

We present an heterotopic pregnancy at 16 weeks of gestation following IVF/ET treatment with the ectopic pregnancy located in the left fallopian tube. Intra-abdominal bleeding secondary to an heterotopic pregnancy, causing acute abdominal pain and hemorrhagic shock, should be included in the differential diagnosis even in the second trimester of pregnancy, especially in patients, achieving conception with the use of assisted reproduction techniques.

Cystic fibrosis mutation screening in CBAVD patients and men with obstructive azoospermia or severe oligozoospermia.

Congenital bilateral absence of the vas deferens (CBAVD) found in otherwise healthy infertile males, is associated with a high incidence of mutated cystic fibrosis transmembrane conductance regulator (CFTR) alleles, and is considered a genital form of cystic fibrosis (CF). The CF gene may also be involved in the aetiology of male infertility in cases other than CBAVD. The present study was undertaken to test the involvement of CFTR gene mutations in 14 CBAVD males and additionally in cases of male infertility caused by obstructive azoospermia (n = 10) and severe oligozoospermia (n = 3). The entire coding region of the CFTR gene was analysed using denaturing gradient gel electrophoresis (DGGE). The three allele (5T, 7T, 9T) polymorphic tract of thymidines in intron 8 (IVS8-polyT) of which the 5T allele acts as a mild mutation, causing reduced levels of normal CFTR mRNA due to deletion of exon 9, was also analysed. Of the 14 CBAVD cases, four (28.6%) were found to have mutations in both copies of the CFTR gene, six (42.8%) had one CFTR mutation, and in the remaining four (28.6%) no CFTR mutations were found. Of the 10 cases with obstructive azoospermia, three (30%) had one CFTR mutation and in the remaining seven (70%) no mutations were found. None of the three severe oligozoospermia cases carried a CFTR mutation. The frequency of the IVS8(5T) allele was 14.3% (4/28) for the CBAVD cases and 5% (1/20) for the obstructive azoospermia cases, none of the severe oligozoospermia males carried the IVS8-5(5T) allele. The data indicate that while there is a strong association between male infertility caused by CBAVD and mutations in the CFTR gene, cases of obstructive azoospermia without CBAVD also seem to be associated with CFTR gene mutations.

Serum concentrations of alkaline phosphatase isoenzymes and osteocalcin in normal pregnancy.

We measured serum alkaline phosphatase isoenzymes and osteocalcin levels in 40 healthy women at 4-week intervals throughout uncomplicated pregnancies and 6 weeks after delivery in 17 women. Serum bone alkaline phosphatase was significantly higher in the third trimester than in early pregnancy (P less than 0.001), and this elevation was still apparent at the end of the puerperium, suggesting increased bone turnover. Serum osteocalcin was not detected (less than 0.2 micrograms/L) after the first trimester in the majority of women, and it reappeared within 48 h after delivery. The disappearance of osteocalcin after the first trimester and its rapid reappearance after delivery suggest placental clearance of this peptide. We conclude that serum osteocalcin measurements cannot be used as a marker of bone metabolism during pregnancy.