Heat can treat: long-term follow-up results after uterine-sparing treatment of adenomyosis with radiofrequency thermal ablation in 60 hysterectomy candidate patients.

BACKGROUND: Adenomyosis may induce pelvic pain, abnormal uterine bleeding or bulk symptoms. If hormonal treatment proves ineffective or contraindicated, hysterectomy may be necessary. For patients who desire to conserve the uterus despite severe symptomatology, uterine-sparing techniques have been introduced. Radiofrequency thermal ablation (RFA) consists of the local application of high temperature to eliminate diseased tissue, applied recently for adenomyosis treatment. The objective of the study was to analyze the efficacy of RFA for avoiding hysterectomy in patients with adenomyosis-related symptoms. METHODS: This is a single-center, retrospective cohort study performed in a referral center for endometriosis. The study population consisted of all consecutive patients who underwent Radiofrequency thermal ablation (RFA) treatment as an alternative to hysterectomy for adenomyosis between March 2011 and June 2019 in our institution. RFA was performed using laparoscopic access. To evaluate the impact of RFA treatment on symptoms, follow-up findings were compared to preoperative symptomatology using the ten-point visual analog scale (VAS) for pain assessment. RESULTS: Sixty patients were included in the study, 39 of them (65%), underwent a concomitant surgery for endometriosis in association to RFA. On a long-term follow-up (mean 56 months (range 10-115, SD 29), hysterectomy was performed in 8 patients (13%). The mean VAS score before vs after surgery was 7.4 vs 3.3 for dysmenorrhea, 3.7 vs 0.3 for dyschezia, 4.7 vs 0.7 for dyspareunia, and 4.0 vs 1.4 for chronic pelvic pain, being significantly reduced after RFA for all these pain components (p < 0.0001 in every case). Thirty-one patients (52%) suffered from AUB before RFA, this symptom persisted in 10 patients (16%) during follow-up (p < 0.001). Bulk symptoms were present in 16 patients (27%) and disappeared after RFA in all cases. CONCLUSIONS: RFA allows for hysterectomy avoidance in most cases. It leads to marked improvements in pain symptomatology, uterine bleeding and bulk symptoms.

Needlestick injuries among obstetrics and gynecology trainees: A survey study.

OBJECTIVE: To assess characteristics, incidence, risk factors, and reporting rate of needlestick injuries (NSIs) among Obstetrics and Gynecology trainees. STUDY DESIGN: We performed a nationwide cross-sectional survey study. The 40-items survey Obstetrics Needlestick Injury Questionnaire (ONSI-Q) was used to investigate the prevalence of NSIs, participant attitudes, associated factors, and the NSI reporting rate among trainees in Obstetrics and Gynecology. The target responders were all trainees of Obstetrics and Gynecology training programs in Italy. The trainees were invited between September 2018 and December 2018 via a web-based platform. RESULTS: Among 1049 trainees, 1041 (99.2%) completed the survey. Out of 1041 trainees, 639 (61.4%) had at least one NSI, and 90.9% (581/639) experienced at least one during obstetric surgery. The number of NSIs increased with the year of training, with 2.48 NSIs per trainee in the fifth year. 90.6% (579/639) reported details about the most recent NSI, which was during obstetric surgery in 95.3% (552/579) of cases. 57.1% (315/552) experienced the most recent NSI during cesarean section, which was mainly inflicted by someone else (72.4%; 228/315). 42.9% (237/552) of NSIs were during perineal suture, and 84% (199/237) of them were self-inflicted. 77.9% (417/535) of trainees did not report the NSI. Associated factors were non-high-risk patients, self-inflicted NSI, and the first NSI. CONCLUSIONS: NSIs are frequent among Obstetrics and Gynecology trainees but not reported, and obstetric surgery is the primary source. These data support the European efforts to improve working practices' safety. The education about protective strategies and reporting should be a priority.

Fertility and reproductive outcome after tubal ectopic pregnancy: comparison among methotrexate, surgery and expectant management.

PURPOSE: To compare fertility and reproductive outcome after surgical, medical, and expectant management for tubal ectopic pregnancy (EP). METHODS: 133 of 228 patients, who were managed between January 2012 and December 2017 for a tubal EP, tried to conceive immediately after treatment: 86 out of 173 (49.7%) underwent surgical treatment; 38 (21.9%) were treated with methotrexate (MTX), and 49 (28.3%) had expectant management. Clinical data were retrieved by medical records, fertility outcomes were obtained by phone follow-up. The cumulative incidence (CI) of intrauterine clinical pregnancy (CP), miscarriage, live birth (LB), and recurrent EP, and the time between treatment and first intrauterine CP were compared between women treated with MTX, surgery and expectant management. RESULTS: The CI of intrauterine CP starting from 12 months after the EP was 65.3% for the expectant management, 55.3% for the MTX group, and 39.5% for surgery (p = 0.012). Post-hoc analysis showed expectant management having higher intrauterine CP and LB, and shorter time between treatment and first intrauterine CP compared to surgery (p < 0.05). The CI of recurrent EP was comparable between the 3 groups. The analysis stratified per ßhCG cut-off of 1745 mUI/mL and EP mass cut-off of 25 mm reported consistent results. CONCLUSIONS: Women successfully managed by expectation appear to have better reproductive outcomes compared to women who underwent surgery, with the shortest time to achieve a subsequent intrauterine CP. Therefore, if safely applicable the expectant management should be considered in the case of tubal EP. The fact that the chosen treatment was primarily guided by the ßhCG value and EP mass diameter based on the protocol, which is intrinsically related to the characteristics of the EP, represents the main limitation of the present study. Indeed, we cannot completely exclude that the observed differences between treatments are related to the EP itself instead of the treatment.

Efficacy of a collagen-fibrin sealant patch (TachoSil®) as adjuvant treatment in the inguinofemoral lymphadenectomy for vulvar cancer: a double-blind randomized-controlled trial.

PURPOSE: To evaluate the effect of a collagen-fibrin sealant patch (TachoSil®) in preventing postoperative complications after inguinofemoral lymphadenectomy for vulvar cancer. METHODS: Double-blind randomized-controlled trial on consecutive patients undergoing bilateral inguinofemoral lymphadenectomy for vulvar cancer. Intraoperatively, inguinofemoral areas were randomized: one was treated with TachoSil®, while the contralateral had standard closure without collagen-fibrin sealant patch. Surgical outcomes, amount of drainage volume, duration of drain placement, and any postoperative complication (vulvar wound dehiscence, inguinal wound dehiscence, cellulitis, lymphangitis, lymphoceles, and hematoma) were recorded. Leg measurements were taken preoperatively and during postoperative follow-up until 6 months to evaluate lymphedema. RESULTS: A total of 19 patients were enrolled and 38 inguinofemoral dissections were performed. There was no significant difference between the investigational and control arm in the amount of drainage volume (p = 0.976), and duration of drain placement (p = 0.793). The postoperative complications, excluding lymphedema, were 10/19 (53%) in investigational arm and 9/19 (47%) in control arm (p = 0.74). At the end of follow-up, the prevalence of grade 1 lymphedema was 44.4% and 50% in investigational and control arm, respectively (p = 0.744); grade 2 and 3 lymphedema had a prevalence of 33.3% in both arms (p = 1). CONCLUSION: Application of TachoSil® does not seem to improve postoperative lymphorrhagia nor to reduce the incidence of postoperative complications in patients undergoing inguinofemoral lymphadenectomy for vulvar cancer. Considering this point, it would be useful to identify additional strategies in inguinofemoral dissection for the prevention of these complications.

Unintentional transvesical caesarean section: incidence, risk factors, surgical technique and post-operative management.

OBJECTIVE(S): To assess incidence, risk factors, management, and short and long-term outcomes of unintentional transvesical caesarean section (UTV-CS) defined as any extraction of the fetus through a double full thickness bladder wall cystotomy. STUDY DESIGN: Data about all UTV-CS between January 2013 and December 2017 were retrieved searching the diagnosis of bladder injury and bladder repair during caesarean section (CS) in our comprehensive computerized labor and delivery database and register. CS with bladder wall injury not classified as UTV-CS were excluded. Data analysis included maternal history, demographics and obstetric parameters, details regarding CSs, bladder injury location and extension, and short- and long-term maternal outcomes. RESULTS: Among 28,822 deliveries, 7,616 (26.42%) were CSs. Three cases of UTV-CS were identified with comprehensive incidence of 0.039%. We provided details of the reported cases and described bladder repair procedure. CONCLUSION(S): This is the first study that assessed the incidence of UTV-CS. UTV-CS risk factors are consistent with factors related to milder bladder injuries. The risk of bladder injury during CS should be always considered, despite the low incidence of this complication. Prompt diagnosis and surgical repair seem to allow avoiding severe complications and recovery of a normal urological function even in UTV-CS.

Functional and endocrine-metabolic oligomenorrhea: proposal of a new diagnostic assessment tool for differential diagnosis in adolescence.

Background To develop a diagnostic assessment tool, using clinical, biochemical and sonographic markers, to help clinicians in the differential diagnosis of functional oligomenorrhea (FO) and endocrine-metabolic oligomenorrhea (EMO). Methods Sixty-two adolescents with oligomenorrhea without evident hormonal imbalances or severe energy deficit were selected. They were divided into two groups (EMO and FO) and they all underwent the following assessment: physical examination (height, weight, presence of hirsutism or acne), blood exams and transabdominal ultrasonography. The biochemical markers included: hemoglobin, thyrotropin stimulating hormone (TSH), prolactin (PRL), follicle stimulating hormone (FSH), luteinizing hormone (LH), free (FT) and total testosterone (TT), androstenedione (A), dehydroepiandrosterone sulfate (DHEAS) and sex hormone binding globulin (SHBG). Uterine and ovarian volume, ovarian morphology, endometrial thickness and pulsatility index (PI) of uterine arteries were evaluated with ultrasound. Results Body mass index (BMI), hemoglobin, LH levels and LH/FSH ratio were significantly higher in women with EMO than in those with FO. Increased androgens values were found in the EMO group, but only A and FT were significantly different (p=0.04). Ovarian volume and uterine artery PI were the only ultrasound features significantly different, with higher values in the EMO population (p<0.05). Considering these variables, with a receiving characteristic operating curve, new cut-offs were calculated, and a diagnostic assessment tool elaborated (area under curve [AUC] 0.88, specificity 99%, sensibility 59%, p<0.001]. Conclusions This diagnostic tool, specific for adolescents, could be useful in the management of oligomenorrhea. Recognizing and distinguishing EMO and FO is very important in order to establish an appropriate treatment and a correct follow-up.

Mesenteric vascular and nerve sparing surgery in laparoscopic segmental intestinal resection for deep infiltrating endometriosis.

OBJECTIVE(S): To investigate Mesenteric vascular and nerve Sparing Surgery (MSS) as surgical laparoscopic technique to perform segmental intestinal resection for deep infiltrating endometriosis (DIE). STUDY DESIGN: Prospective cohort study between January 2013 and December 2016. Consecutive patients with suspected intestinal DIE underwent clinical and imaging evaluation to confirm intestinal involvement. Indications for radical surgery and surgical technique (intestinal resection versus shaving) were consistent with Abrão algorithm. Surgeons aimed to perform MSS in all the consecutive patients that required intestinal resection. MSS consists in mesenteric artery, branching arteries, and surrounding nerve fibers preservation by dissecting mesentery adherent to the intestinal wall. Data about history, preoperative and post-operative evaluation, surgery and complications were recorded. Symptoms were evaluated before and 30-60 days after surgery with numeric rating scale for pain. Constipation was evaluated with the Constipation Assessment Scale (CAS). Patients with diagnosis of irritable bowel syndrome, inflammatory bowel diseases, diverticulitis, and previous segmental intestinal resection were excluded. RESULTS: Sixty-two out of 75 (82.7%) consecutive women with intestinal endometriosis underwent laparoscopic segmental intestinal resection performed with MSS. Major complications that required repeated operation occurred in 4 cases (6.5%). Anastomotic leakage occurred in only 1 case (1.6%). Dysmenorrhea (p < .001; r = -0.86), dyspareunia (p < .001; r = -0.80), dyschezia (p < .001; r = -0.86) and dysuria (p < .001; r = -0.56) were significantly improved after surgery. After an average of 33.1 months from surgery, severe constipation was reported only by two patients (3.6%) (CAS: 13-16). The median time from surgery to intestinal function recovery (flatus or stool passage) was one day. Logistic regression analysis showed constipation related to the distance from anal verge and time since surgery. CONCLUSION(S): MSS in laparoscopic intestinal resection for DIE may be reproducible, safe and effective. MSS could be combined with pelvic nerve-sparing surgery as an effective approach to improve intestinal symptoms after radical surgery for DIE that requires segmental intestinal resection.

Influence of Ulipristal Acetate Therapy on Uterine Fibroid-Related Symptoms and on Uterine and Fibroid Volumes and Vascularity Indices Assessed by Ultrasound.

OBJECTIVES: To investigate the modifications of uterine and fibroid volume, to study Doppler changes in uterine arteries and fibroid-supplying vessels, and to assess possible symptomatic relief after 3 months of treatment with ulipristal acetate. METHODS: Forty-two premenopausal women with symptomatic fibroids were included in the study. They were evaluated clinically for the symptoms reported and underwent ultrasound examinations before starting treatment and after 3 months of therapy with ulipristal acetate. Transvaginal scanning was performed by the same sonographer, who measured the uterine volume and uterine artery pulsatility index and resistive index. Considering that some patients had more than 1 fibroid, the vascularization (supplying vessel pulsatility and resistive indices), locations, and sizes of a total of 73 fibroids were also recorded. RESULTS: After 3 months of ulipristal acetate, patients had a significant improvement of all symptoms (P < .05). The percentage of uterine volume reduction was 14% (P = .03), with fibroid volume reduction of 32.8% (P = .01). Uterine artery vascular indices decreased after treatment, but their reduction did not reach significant results, whereas all fibroid vascular indices decreased significantly after 3 months of ulipristal acetate (P < .05). When the fibroids were divided according to their localization, all had significant volume reduction after therapy, but type 5 had the highest decrease (42%) compared to other fibroid types (P = .03). CONCLUSIONS: Fibroid treatment with ulipristal acetate resulted in a significant improvement of fibroid-related symptoms; moreover, it proved to be effective in decreasing both uterine and fibroid volumes and fibroid vascularization. Type 5 fibroids seem to have the most major response to treatment.

The Role of Computed Tomography Colonography in Detecting Bowel Involvement in Women With Deep Infiltrating Endometriosis: Comparison With Clinical History, Serum Ca125, and Transvaginal Sonography.

OBJECTIVE: We wanted to assess the diagnostic value of computed tomographic colonography (CTC) in recognizing bowel endometriosis in comparison with serum Ca125, transvaginal sonography (TVS), and presence of intestinal symptoms. METHODS: We included in this study 92 women undergoing surgery for symptomatic DIE. Preoperative evaluation included clinical history, Ca125 serum value, and TVS. CTC was performed in 37/92 patients (40.2%), and the results were compared to the other preoperative tools and to surgical exploration, considered the clinical reference standard. RESULTS: Surgery confirmed bowel endometriosis in 49/92 subjects (53.3%). Presence of intestinal symptoms, serum Ca125 values, and TVS were significantly correlated to intestinal involvement, but CTC had the highest accuracy in detecting bowel endometriosis with a sensitivity of 68%, a specificity of 67%, a PPV of 81%, and a NPV of 50% (P = 0.04). CONCLUSIONS: CTC proved to be an accurate and low invasive imaging technique to detect DIE of the bowel and compared favorably with clinical evaluation, serum Ca125 determination, and TVS.

Successful Pregnancy Outcome after Laparoscopic Cerclage in a Patient with Cervicovaginal Fistula.

Obstetric fistula usually originates from obstructed labor or, less often, from invasive maneuvers on the genital tract or the pregnant uterus. Overall, it is a rare finding in the obstetric practice of high income countries. In this report we describe the case of a successful term pregnancy in a patient with a history of recurrent late miscarriage due to a large cervical fistula of traumatic origin, connecting the uterine cavity and the posterior vaginal fornix. A combined approach of laparoscopic cerclage and transvaginal fistula repair effectively restored cervical competence and created the conditions for a viable birth in a subsequent pregnancy. This unusual cause of cervical incompetence may be included in the indications which benefit from an abdominal cerclage carried out as a minimally invasive procedure in the nonpregnant state.

Immunofluorescence vs immunochemiluminescent methods: AIA 2000 vs Immulite 2000.

The aim of this study was to evaluate the measurement of C-peptide, insulin, sex hormone binding globulin (SHBG), and dehydroepiandrosterone sulfate (DHEAS), tests of specific clinical value that are not frequently measured in routine clinical laboratories, carried out using an automated system, AIA 2000 (Tosoh). The obtained data demonstrated that the evaluated system, characterized by fluorescence system detector provides satisfactory analytical performance comparable to those of different instrument that use the well known and widely diffused chemiluminescent principle (Immulite 2000). These characteristics allow an excellent comparability between methods for the measurement of same specific hormones not frequently used in clinical practice.

First evaluation of a multi-capillary electrophoresis CDT assay on Helena Biosciences' V8 analyser.

BACKGROUND: Carbohydrate-deficient transferrin measurement is currently used for the routine monitoring of excessive alcohol intake, thus playing a fundamental role in the management of alcohol consumption disorders as well as for medico-legal purposes. The aim of the present paper is to report the results obtained from the first performance evaluation of a new CDT quantification assay, and to assess its suitability in routine work. METHODS: We assessed the analytical performances of the multi-capillary electrophoresis analyser Helena Biosciences' V8 E-class and compared the results obtained with those from the HPLC BioRad Ready-Prep CDT assay. Furthermore, we evaluated the robustness of the system in a routine work conditions. RESULTS: Within laboratory imprecision CV% (n=40) using four commercially available quality control materials and two serum pool samples with different concentrations of CDT were <11.2%. The comparison made with the established method was CDT [V8capillary electrophoresis]=0.84 × CDT [HPLC]+0.03, with a Pearson coefficient of r=0.970, and with the Bland-Altman plot showing a significant bias -0.3 (-0.4 to -0.22, 95% CI). The obtained accuracy was highly satisfactory. CONCLUSIONS: The findings made in the present study indicated that the proposed analytical system is a valid alternative to other CDT screening assays currently proposed for routine use in clinical laboratories, since it is precise, accurate and robust, with a high throughput. Moreover, investment in the training of staff is of fundamental importance in ensuring correct interpretation of the electrophoretic pattern, thus providing reliable CDT results.

Intracranial subdural hematoma after spinal anesthesia for cesarean section.

Intracranial subdural hematoma following spinal anesthesia is an infrequent occurrence in the obstetric population. Nevertheless, it is a potentially life-threatening complication. In the majority of the cases, the first clinical symptom associated with intracranial subdural bleeding is severe headache, but the clinical course may have different presentations. In this report, we describe the case of a 38-year-old woman with an acute intracranial subdural hematoma shortly after spinal anesthesia for cesarean section. Early recognition of symptoms of neurologic impairment led to an emergency craniotomy for hematoma evacuation with good recovery of neurologic functions. The possibility of subdural hematoma should be considered in any patient complaining of severe persistent headache following regional anesthesia, unrelieved by conservative measures. Only early diagnosis and an appropriate treatment may avoid death or irreversible neurologic damage.