Is dienogest the best medical treatment for ovarian endometriomas? Results of a multicentric case control study.

Ovarian endometriomas are common manifestations of endometriosis. Surgical excision has been shown to potentially decrease ovarian reserves. In this prospective study, we included 81 patients with ovarian endometriosis. 40 were treated with 2 mg of dienogest daily (DNG) and 41 were treated with cyclic oral estro-progestins (ethinyl estradiol 30 mcg [EE] plus dienogest 2 mg) (DNG + EE). Aim of the study was the effect of the treatment on the size of the endometriotic cysts. Further, in the symptomatic patients, follow-up included an evaluation of chronic pain before and during treatment. Both treatments were able to significantly decrease the pain in symptomatic patients with no statistical differences. The mean visual analog scale score at enrollment was 65 ± 14 and 70 ± 18, and there was significant improvement (19 ± 15, p < .001, DNG; 18 ± 12, p < .001, DNG + EE). The size of the endometrioma cysts were significantly reduced in the DNG group. The mean cyst diameter was 52 ± 22 mm at baseline and 32 ± 12 mm after six months of treatment (p < .001), yielding a 75% volume reduction in DNG group. The decrease in the size of endometrioma cysts observed in the women treated with only progestin could be noteworthy, as it may reduce the negative impacts on the affected ovary and avoid surgery.

Uterine fibroid size modifications during pregnancy and puerperium: evidence from the first systematic review of literature.

PURPOSE: The influence of pregnancy on uterine fibroid size still remains an unsolved dilemma. Basing on current knowledge, physicians are not able to inform patients about the likelihood of uterine fibroids to modify their size during pregnancy. Study aim was to summarize available evidence concerning the size modifications of uterine fibroids during each trimester of pregnancy and during puerperium. METHODS: The review was reported following the PRISMA guidelines and registered in PROSPERO (registration number: CRD42017071117). A literature search was conducted in electronic database (PubMed, Embase, Sciencedirect, the Cochrane library and Clinicaltrials.gov) until July 2017. All studies evaluating fibroids' changes during pregnancy and puerperium by ultrasound or magnetic-resonance-imaging were included. Descriptive characteristics of studies and patients were collected. The modifications of uterine fibroid diameter and volume were the outcome measures. RESULTS: Concerning the first trimester of pregnancy, all authors reported a significant growth of uterine fibroids. Contradictory evidence was found about uterine fibroid modifications during the second and third trimesters, mainly supporting a slowdown during mid pregnancy and a subsequent size reduction during late pregnancy. Concerning the overall modifications during pregnancy and puerperium, poor evidence quality suggests that uterine fibroids do not modify their volume/slightly enlarge during pregnancy and subsequently reduce in size during puerperium. CONCLUSIONS: Uterine fibroids seem to be subject to a non-linear trend of modifications during pregnancy and puerperium, which may vary from myoma to myoma. Adequate evidence supports uterine fibroid systematic enlargement during the first trimester of pregnancy, while inconsistent evidence is available about the changes of uterine fibroids during second and third trimesters. In addition, the overall modifications of myomas during pregnancy and puerperium remain unclear.

Laparoscopic uterine artery bipolar coagulation plus myomectomy vs traditional laparoscopic myomectomy for "large" uterine fibroids: comparison of clinical efficacy.

PURPOSE: Laparoscopic myomectomy is the uterus-preserving surgical approach of choice in case of symptomatic fibroids. However, it can be a difficult procedure even for an experienced surgeon and can result in excessive blood loss, prolonged operating time and postoperative complications. A combined approach with laparoscopic uterine artery occlusion and simultaneous myomectomy was proposed to reduce these complications. The aim of this study was to evaluate the safety and efficacy of the combined laparoscopic approach in women with symptomatic "large" intramural uterine fibroids, compared to the traditional laparoscopic myomectomy alone. METHODS: Prospective nonrandomized case-controlled study of women who underwent a conservative surgery for symptomatic "large" (≥ 5 cm in the largest diameter) intramural uterine fibroids. The "study group" consisted of women who underwent the combined approach (laparoscopic uterine artery bipolar coagulation and simultaneous myomectomy), while women who underwent the traditional laparoscopic myomectomy constituted the "control group". A comparison between the two groups was performed, and several intraoperative and postoperative outcomes were evaluated. RESULTS: No significant difference in the overall duration of surgery between women of the "study group" and "control group" emerged; however, a significantly shorter surgical time for myomectomy was observed in the "study group". The intraoperative blood loss and the postoperative haemoglobin drop were significantly lower in the "study group". No difference in the postoperative pain between groups emerged, and the postoperative hospital stay was similar in the two groups. CONCLUSIONS: The laparoscopic uterine artery bipolar coagulation and simultaneous myomectomy is a safe and effective procedure, even in women with symptomatic "large" intramural uterine fibroids, with the benefit of a significant reduction in the intraoperative blood loss when compared to the traditional laparoscopic myomectomy.

Feasibility of hysteroscopic endometrial polypectomy using a new dual wavelengths laser system (DWLS): preliminary results of a pilot study.

PURPOSE: Currently, endometrial polyps may be successfully treated in an outpatient setting with 5 Fr mechanical and bipolar instruments. Our aim is to evaluate the benefits of minimally invasive techniques in hysteroscopy, focusing on the use of a new dual wavelengths laser system in the treatment of endometrial polyps in an outpatient setting. METHODS: Between September 2012 and December 2014, all consecutive patients of reproductive and menopausal age with ultrasound diagnosis of endometrial polyp with maximum diameter ≤2.5 cm were eligible to participate in a prospective study. They underwent a hysteroscopic procedure with excision of the polyp using a new dual wavelengths laser system. All procedures were performed on an outpatient basis without anesthesia. RESULTS: Laser polypectomy was successfully performed in 219 out of 225 (97.3%). Success of surgery was not influenced by the initial location of polyp. No main complications were reported during or immediately after the procedure. 6 and 12 months follow-up with ultrasound scan did not show any persistence or recurrence of the pathology. CONCLUSIONS: Our preliminary findings seem to support the safety and the effectiveness of the laser hysteroscopic endometrial polypectomy. However, further studies are mandatory to validate its use in daily hysteroscopic practice.

Peri-incisional and intraperitoneal ropivacaine administration: a new effective tool in pain control after laparoscopic surgery in gynecology: a randomized controlled clinical trial.

BACKGROUND: A proportion of patients undergoing laparoscopic gynecological surgery experiences excessive post-operative pain, which results in high rescue analgesic treatment and prolonged hospitalization. The aim of our study was to evaluate the efficacy of intraoperative topical ropivacaine in the control of post-operative pain in the first 48 h after operative laparoscopy for benign adnexal or uterine pathologies . METHODS: We conducted a prospective, randomized, double-blind, placebo-controlled clinical trial. Patients received a standard dose of topical ropivacaine (injected at the three portal sites and atomized in the abdominal cavity) or placebo. The primary outcome was the evaluation of post-operative pain intensity 6 h after surgery. Secondary outcomes included the intensity of pain during the 48 h after surgery, shoulder tip pain and the request for rescue analgesics during the first 48 h after surgery, time to discharge from recovery room, time to mobilizing on the ward and time to return to daily activities. Patients were divided in two groups (Group_A: benign adnexal pathologies; Group_B: benign uterine diseases) and assigned to Subgroup_1 (receiving ropivacaine) and Subgroup_2 (receiving placebo). RESULTS: A total of 187 women were included: 93 in Group_A and 94 in Group_B. Forty-seven patients entered Subgroup_A1, 46 Subgroup_A2, 48 Subgroup_B1 and 46 Subgroup_B2. Subgroup_A1 experienced lower post-operative pain at 4 (p = 0.008) and 6 h (p = 0.001) as well as a faster return to daily activities (p = 0.01) in comparison with Subgroup_A2. Both Subgroup_A1 and Subgroup_B1 showed lower shoulder tip pain (respectively, p = 0.032 and p = 0.001) as well as shorter time to mobilizing on the ward after surgery (respectively, p = 0.001 and p = 0.01). The remaining variables analysis did not show significant results. CONCLUSIONS: Combined topical analgesia with ropivacaine could represent a new safe and effective tool in the control of post-operative pain in gynecological laparoscopic surgery. Given the greater benefits for adnexal surgery, this strategy may be more suitable for this class of patients.

Menstrual cycle length: a surrogate measure of reproductive health capable of improving the accuracy of biochemical/sonographical ovarian reserve test in estimating the reproductive chances of women referred to ART.

BACKGROUND: Aim of the study was to investigate whether menstrual cycle length may be considered as a surrogate measure of reproductive health, improving the accuracy of biochemical/sonographical ovarian reserve test in estimating the reproductive chances of women referred to ART. METHODS: A retrospective-observational-study in Padua' public tertiary level Centre was conducted. A total of 455 normo-ovulatory infertile women scheduled for their first fresh non-donor IVF/ICSI treatment. The mean menstrual cycle length (MCL) during the preceding 6 months was calculated by physicians on the basis of information contained in our electronic database (first day of menstrual cycle collected every month by telephonic communication by single patients). We evaluated the relations between MCL, ovarian response to stimulation protocol, oocytes fertilization ratio, ovarian sensitivity index (OSI) and pregnancy rate in different cohorts of patients according to the class of age and the estimated ovarian reserve. RESULTS: In women younger than 35 years, MCL over 31 days may be associated with an increased risk of OHSS and with a good OSI. In women older than 35 years, and particularly than 40 years, MCL shortening may be considered as a marker of ovarian aging and may be associated with poor ovarian response, low OSI and reduced fertilization rate. When AMH serum value is lower than 1.1 ng/ml in patients older than 40 years, MCL may help Clinicians discriminate real from expected poor responders. Considering the pool of normoresponders, MCL was not correlated with pregnancy rate while a positive association was found with patients' age. CONCLUSIONS: MCL diary is more predictive than chronological age in estimating ovarian biological age and response to COH and it is more predictive than AMH in discriminating expected from real poor responders. In women older than 35 years MCL shortening may be considered as a marker of ovarian aging while chronological age remains most accurate parameter in predicting pregnancy.

Different stimulation protocols for oocyte cryropreservation in oncological patients: a retrospective analysis of single university centre.

OBJECTIVE: To analyze the results obtain in cancer patients who receive the same controlled ovarian stimulation protocol, started in two different moments of the menstrual cycle, follicular or luteal phase. The stimulation is performed before cancer treatment in order to preserve fertility through oocytes cryopreservation. STUDY DESIGN: The study is a retrospective analysis about 25 cancer patients at our centre, Department of Reproductive Medicine of University of Pisa, in order to preserve their fertility before cancer treatment. Patients are divided into two groups depending on the menstrual cycle phase, follicular or luteal phase, at the moment of first examination. Standard stimulation protocol with gonadotropins is administered in the follicular group, whereas in the second group we use GnRH (gonadotropin-releasing hormone) antagonist before gonadotropins administration in order to have a rapid luteolysis. The outcome measures are the number of days needed before starting procedure, duration of stimulation, cumulative dosage of gonadotropins number of oocyte retrieved and percentage of mature oocytes. RESULTS: Any difference showed between two groups based on days of stimulation, total amount of gonadotropins administered and the number of good mature quality oocytes was retrieved. The real difference is the number of days needed to start the procedure, lesser in the luteal group. CONCLUSIONS: This study suggests that oocytes can be obtained before cancer treatment, irrespective of menstrual cycle phase without compromising the efficacy of procedure. Moreover, starting ovarian stimulation anytime during menstrual cycle allows the patients to not postpone the beginning of cancer treatment. Different stimulation protocols, according to different kinds of disease, are available in order to obtain the maximum results without any complication for patients.

Could surgeon's expertise resolve the debate about surgery effectiveness in treatment of endometriosis-related infertility?

PURPOSE: Restoring the anatomical relationship and preserving the function of pelvic organs represent the ideal outcome of surgical intervention in patients suffering from endometriosis-related infertility. The aim of the study was to compare two large cohorts (Group A and Group B) of infertile patients in terms of postsurgical spontaneous/assisted fertility and perioperative surgical outcomes. The surgical treatment was performed by a skilled surgeon (Group A) and a surgeon dedicated to endometriosis-related infertility (Group B). METHODS: An observational cohort study on women affected by pelvic endometriosis who underwent laparoscopic treatment (to restore/improve their fertility) was conducted. A comparison, between Group A and Group B, in terms of perioperative surgical outcomes, clinical/ongoing pregnancy and live birth rates, spontaneous pregnancy rate and obstetrical outcome was performed. RESULTS: A significantly higher spontaneous fertility rate (particularly in the first year after surgery) and lower ectopic pregnancy rate were found in Group B. ART success rates were not affected by different surgical approaches. Perioperative and obstetrical outcomes were similar in both groups. CONCLUSION: In patients affected by endometriosis, the choice between expectant management versus intervention should be personalized: when the estimated probability of natural conception is low, surgery may be considered as a second-line treatment. Conversely, in all other cases surgery should be offered early (as a first-line approach) as it improves the chance of spontaneous conception. The laparoscopic treatment of infertility due to endometriosis must be performed by a skilled specialized surgeon to ensure a complete "pelvic cleanout" while respecting the anatomical structures and reducing the risk of fertility impairment due to surgical procedures.

Subtotal versus total laparoscopic hysterectomy: could women sexual function recovery overcome the surgical outcomes in pre-operatory decision making?

PURPOSE: Hysterectomy is the most common surgical procedure performed in gynecology and, in over 95% of the cases, does not necessarily require the removal of the uterine cervix to be completed successfully. In clinical practice, however, less than 20% of gynecologists offer patients the possibility to express a personal preference concerning the choice between total laparoscopic hysterectomy (TLH) and laparoscopic subtotal hysterectomy (LSH). The aim of this study is to compare patients who have undergone TLH versus LSH for benign uterine diseases in terms of intra-operative/peri-operative surgical outcomes and short-term recovery of sexual function. METHODS: We performed an observational, retrospective study on 478 women who underwent hysterectomy for benign uterine disease at Gyn/Ob Clinic, Department of Women's and Children's Health of Padua University between January 2003 and December 2012. Surgical data were recorded. We investigated and compared outcomes between the two groups of patients (TLH vs LSH) in terms of the following: surgical complications rate, post-operative therapy, women satisfaction and sexual activity recovery. RESULTS: We found that operating time and length of hospital stay were significantly lower in patients who underwent LSH. A higher rate of post-operative fever was reported in the TLH treatment group although antibiotic prophylaxis was implemented in a similar fashion for both groups. At 60-70 days following surgery, women of LSH group reported a greater ease in recovery of sexual function as opposed to those who underwent TLH. CONCLUSIONS: The advantages and potential drawbacks of both procedures need to be discussed with women presenting with benign disease. LSH is a reasonable option for women, representing both an excellent minimally invasive approach in a proper clinical setting and an appropriate procedure for those women who prefer conservative surgery.

Uncertainties about laparoscopic myomectomy during pregnancy: A lack of evidence or an inherited misconception? A critical literature review starting from a peculiar case.

OBJECTIVE: The aim of this report was to perform a critical review of the literature about feasibility, safety, limitations and contraindications of laparoscopic myomectomy during pregnancy starting from a peculiar case of a 15-weeks pregnant woman affected by a symptomatic large myoma. CASE REPORT: A 35 year-old Caucasian-nulliparous-woman was referred to our unit at nine weeks of gestation for abdominal heaviness and constipation. The ultrasound examination revealed the presence of a 24 cm pedunculated myoma. The initial management was conservative until the achievement of 15 gestational weeks, when the worsening of abdominal pain led to the need of a laparoscopic myomectomy. Intraoperative blood-loss was 600 ml and operating-time was 150 minutes (70 minutes were required for the morcellement); the postoperative course was normal. The pregnancy evolved regularly and, at 41 weeks, the patient delivered by urgent caesarean section (because intrapartum fetal heart rate abnormalities) a healthy male baby weighing 4460 gr. Both post-partum and puerperium period had a regular course. CONCLUSION: Laparoscopic myomectomy is feasible and safe during pregnancy for both mother and fetus and vaginal delivery should not be contraindicated. Evidence from our and other reported cases suggests that, during pregnancy, laparoscopic myomectomy should be considered the best surgical choice when subserous peduncolated myomas are symptomatic.

Could HPV-DNA test solve the dilemma about sentinel node frozen section accuracy in early stage cervical cancer? Hypothesis and rationale.

In order to reduce the surgical invasiveness in early-stage cervical-cancer treatment, the sentinel lymph-node (SLN) technique could be considered as a possible intraoperative-guidance to lymphadenectomy decision making. Unfortunately its accuracy ranges between 33.3% and 100% in different studies. Recent manuscripts suggest that HPV-DNA presence in pelvic-lymph-nodes may represent a molecular marker of micrometastases. According to this hypothesis, the rationale in proposing the HPV-DNA-test when negative frozen-section occurs is due to the expected improvement of its diagnostic-accuracy. HPV-DNA test may represent a marker able to discriminate at frozen section the false-negative from the truth-negative tests filling the gap between optimal and real frozen-section accuracy.

Pregnancy outcome after hysteroscopic myomectomy.

The objective of this longitudinal retrospective study was to evaluate the influence of submucosal myomas on pregnancy outcome in infertile patients after resectoscopic myomectomy. One-hundred and four women with at least a 1-year-long history of infertility and the presence of submucosal myomas as the only cause of infertility were selected after surgical treatment. Pregnancy, delivery and abortion rates were investigated. Patients were divided into three groups according to the myoma classification (G0, G1 and G2). Gestational outcomes were analyzed in the three groups correlated by size, location and number of fibroids. The total pregnancy rate was 85.8% and no difference was shown regarding myoma classification (G0 82.05% versus G1 87.09% versus G2 88.2%; p = ns). Pregnancy and delivery rates were not significantly related to the number, localization or diameter of the fibroids. The abortion rate was not statistically influenced by myoma type, but it was significantly inter-related with myomas situated in the anterior uterine wall (p = 0.03). Pre-term delivery was significantly influenced by myomas localized in the fundic wall (p = 0.02). Caesarean section rates were not affected by the characteristics of the myomas. Our results support the idea that resectoscopic myomectomy should be offered to infertile women who wish to become pregnant independently of their localization and number.

Which luteal phase support is better for each IVF stimulation protocol to achieve the highest pregnancy rate? A superiority randomized clinical trial.

In vitro fertilization (IVF) cycles generate abnormalities in luteal-phase sex steroid concentrations and this represent an important limiting factor to achieve a good pregnancy rate. Although there are evidences about the usefulness of luteal phase support (LPS) after IVF cycles, no consensus exist about the best dose and way of progesterone (PG) administration, the advantages of estradiol (E2) supplementation and which IVF protocol could benefit from one more than other LPS scheme. Aim of the study was to assess the best LPS (low-dose PG, high-dose PG, high-dose PG and E2 supplementation) to achieve the highest clinical/ongoing pregnancy rate according to stimulation protocol, E2 at ovulation induction, endometrial thickness at pick-up and women's age. We conducted a randomized trial on 360 women undergoing IVF (180 treated by long-GnRH agonist, 90 by short-GnRH agonist and 90 by short-GnRH antagonist protocol) and stimulated by recombinant follicle-stimulating hormone alone. Our data demonstrated that high-dose PG is better than low-dose to increase both clinical and ongoing pregnancy rate. E2 supplementation are mandatory in case of short-GnRH antagonist protocol and strongly suggested in all protocols when E2max <5 nmol/l and endometrial thickness <10 mm. In long-GnRH agonist protocols, as well as in patients >35 years, the real advantages of E2 supplementation remain debatable and require further confirmation.

Hysteroscopic enucleation in toto of submucous type 2 myomas: long-term follow-up in women affected by menorrhagia.

STUDY OBJECTIVE: To evaluate long-term efficacy of type 2 myoma enucleation in toto. DESIGN: Longitudinal retrospective study (Canadian Task Force classification II-2). SETTING: University obstetrics and gynecology clinic. PATIENTS: One hundred twelve women with menorrhagia and at least 1 type 2 submucous myoma who underwent hysteroscopic myoma enucleation in toto. INTERVENTION: Clinical long-term follow-up. MEASUREMENTS AND MAIN RESULTS: Success of the procedure and influence of myoma characteristics on recurrence of menorrhagia were evaluated. Mean (SD) follow-up was 58.4 (19.1) months. The success of the procedure was 88.4% (99 patients). Seventeen patients (15.2%) underwent a 2-step procedure. Among patients with relapsed menorrhagia, 10 (8.9%) underwent a repeat operation. Statistical analysis showed that number and diameter of myomas did not influence the outcome. Localization in the posterior wall of the uterus, compared with other sites, was associated with a higher percentage of resolution of menstrual symptoms (p = .03). There was no significant relationship between myomas features and risk of symptom recurrence during follow-up. The 2-step myomectomy was performed in patients with myomas >30 mm in diameter (p < .001). CONCLUSION: Hysteroscopic enucleation in toto of type 2 myomas is a safe and effective technique in long-term management of premenopausal women with menorrhagia.

Limits and complications of laparoscopic myomectomy: which are the best predictors? A large cohort single-center experience.

PURPOSE: To determine whether a correlation exists between size, location, type of myomas and perioperative outcomes. METHODS: This is a observational study in women undergone to laparoscopic myomectomy (LM) because of single symptomatic myoma >4 cm in diameter. We collected data about general features, surgical outcomes, intraoperative/postoperative complications and time to return to normal activity. RESULTS: A total of 444 patients (mean age 36.7 ± 6.4 years) resulted eligible for the study. Myomas sized between 8 and 12 cm were linked to an increased amount of blood loss (significantly higher in intramural than subserosal myoma). The removal of intramural myomas >8 cm and the subserosal ones >12 cm required a significant longer surgical time. Patients returned 17.9 ± 9.5 days after surgery to their personal activities. Six cases (1.35 %) required conversion to laparotomy, and only in two cases blood transfusion was necessary. CONCLUSION: Myomas size and type represent the best predictors of surgical difficulties and possible intrapostoperative complications. Intramural myomas >8 cm and subserosal ones >12 cm should be considered as a challenging procedure. LM remains the gold standard approach because of very low perioperative complication rate and faster return to normal activity.

Female sterilization: update on clinical efficacy, side effects and contraindications.

PURPOSE: The aim of this review is to compare studies concerning female sterilization in order to define the most suitable approach and device for each patient considering timing, safety, cost-effectiveness, failure rate, complication rate and patient satisfaction. METHODS: A systematic literature search was conducted in electronic databases MEDLINE-EMBASE-Sciencedirect and Cochrane Library between 2000 and 2012. All original descriptions, case reports, retrospective and review articles on tubal sterilization methods have been considered. Outcome measures were effectiveness, tolerability, procedure complications and female satisfaction. RESULTS: The ideal female sterilization system should be a simple, safe, highly efficient, easily learned, inexpensive, one-time procedure without negative side-effects. Nowadays, the trans-cervical approach is associated with minimal postoperative pain, allowing short hospitalization and fast resumption of daily activities. Laparoscopic and laparotomic approaches are considered second choices, since, particularly in developing countries, the transcervical hysteroscopic methods will increasingly spread within gynaecological clinical practice. CONCLUSIONS: Safety issues, hospital stay, costs and surgeons' experience are important factors in decision-making of the method for female sterilization. Hysteroscopic devices should be preferred when possible. The counselling time remains a fundamental step in choice. The decision concerning method depends on the setting, the surgeon's experience, the country's economical development and the woman's preference.

Sertoli-Leydig cell tumors: current status of surgical management: literature review and proposal of treatment.

To identify the appropriate management we review the current literature on the diagnostic and different surgical procedures to which the patients affected by Sertoli-Leyding cell tumors (SLCTs) were submitted. Through the description of a case report we also propose an interdisciplinary diagnostic approach and a laparoscopic surgical staging, with a long-term follow-up. The analysis shows that pelvic ultrasound is primary diagnostic procedure, and only 36% of publications clearly describe to have performed more specific investigation. The hormone assessment is performed in the presence of specific endocrine symptoms. Laparoscopic approach is chosen by a few surgeon. Laparotomic surgery is preferred based in not recent recommendations for ovarian cancer treatment, although it is demonstrated the efficacy and safety of laparoscopy in the treatment of ovarian epithelial tumors. Different steps that are usually used for oncological ovarian cancer staging are not always performed. Conservative and fertility sparing surgery is commonly accepted, and even preferred due to the young age of patients. In the surgical treatment of SLCTs is necessary to adopt common guidelines, and evenly define the steps that the patient should be submitted. If are observed epithelial cancer oncological principles, laparoscopic surgery should be the approach of choice for these patients.

Anti-Müllerian hormone trend after laparoscopic surgery in women with ovarian endometrioma.

Operative laparoscopy is the gold standard in the treatment of endometriotic ovarian cysts. Excisional surgery is the best technique to prevent recurrences and improve symptoms but it may result in ovarian reserve damage due to the removal of healthy ovarian cortex. The aim of this study was to investigate the extent of the ovarian reserve damage after stripping technique of unilateral endometriomas, by dosing the Anti-Müllerian Hormone (AMH). This prospective study was conducted at the Center of Minimally Invasive Pelvic Surgery of the Department of Health of Woman and Child, University of Padua, from October 2010 to June 2012. Twenty-five women underwent excision of monolateral endometriosis ovarian cyst by stripping without accessing a bipolar coagulation and performing an intracortical suture. The AMH serum levels were estimated in the early proliferative phase of the cycle, before surgery (time 0), 24 h after surgery (time 1), the first menstrual cycle after surgery (time 2) and the third menstrual cycle after surgery (time 3). We found a nonstatistically significant decreases in serum AMH levels after surgical excision of the cysts. Our results suggest that an appropriate surgical technique, without the use of the bipolar coagulation of ovarian border, does not determine a significant reduction of ovarian reserve.

Reverse hysterectomy: another technique for performing a laparoscopic hysterectomy.

STUDY OBJECTIVE: To show and evaluate outcomes of a modified laparoscopic hysterectomy technique (total reverse laparoscopic hysterectomy). DESIGN: Observational study (Canadian Task Force classification II-2). SETTING: Department of Women's and Children's Health, Obstetrics and Gynecology Clinic, University of Padova, Padova, Italy. PATIENTS: One hundred one women underwent total reverse laparoscopic hysterectomy for benign disease. Indications for surgery, patient characteristics, surgical data, complications, and patient satisfaction were recorded. INTERVENTIONS: Total reverse laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS: The modified procedure was performed starting with the incision of the vesicouterine fold and the pubocervical fascia followed by the dissection of only the anterior layer of the broad ligament, thus preserving the integrity of the posterior leaf (retrograde hysterectomy). This technique permits identification of the ureter until the cross with the uterine artery, creating a "safe triangle" for closure of the uterine vessels. The remaining surgical time did not differ from the standard technique. The average operating time was 112.1 ± 35.6 minutes, and the average intraoperative mean blood loss was 79.5 ± 138.4 mL. Ninety-one (90%) patients were very satisfied after surgery. No injuries to the ureter or bladder occurred in any patients. No other major complications were recorded. CONCLUSION: Reverse hysterectomy is another technique for performing laparoscopic hysterectomy, and it has been proven to be safe and efficient.

Combined transurethral approach with Versapoint(®) and laparoscopic treatment in the management of bladder endometriosis: technique and 12 months follow-up.

BACKGROUND: When endometriosis infiltrates more than 5 mm beneath the peritoneum it is called deeply infiltrating endometriosis and may involve the bladder. Only 1-2% of women with endometriosis have urinary involvement, mainly in the bladder. Resectoscopic transurethral resection alone is no longer recommended because of the surgical risks and recurrence. Usually surgeons prefer a laparotomy or laparoscopic approach depending on nodule localization and personal skill. We describe a new combined transurethral approach with Versapoint(®) and laparoscopic technique in the management of bladder endometriosis and the 12-month follow-up. METHODS: We performed a prospective observational study of 12 women affected by symptomatic bladder endometriosis at the University Hospital of Padova. We utilized a transurethral approach using a 5.2-mm endoscope with a 0.6-mm-diameter bipolar electrode (Gynecare Versapoint(®)). We delimited just the edges of the lesion via cystoscopy, penetrating transmurally at 3 or 9 o'clock without trespassing into the bladder peritoneum. Then, starting from the lateral bladder hole, we excised the lesion by laparoscopy with Harmonic ACE(®). The bladder hole was repaired with a continuous 3-0 monofilament two-layer suture. RESULTS: Operating time ranged from 115 to 167 min and mean blood loss ranged from 10 to 200 ml. No conversion to laparotomy and no intraoperative complications occurred. No dysuria or hematuria were present at follow-up. There was one case of persistent suprapubic pelvic pain at the 12-month follow-up. CONCLUSIONS: A combined transurethral approach with Versapoint(®) and laparoscopic treatment is a safe and easy technique for the management of bladder endometriosis, with low risks and good resolution of symptoms.