Endometriosis of the appendix: prevalence, associated lesions, and proposal of pathogenetic hypotheses. A retrospective cohort study with prospectively collected data.

OBJECTIVE: To assess the prevalence of endometriosis of the appendix and the association with other pelvic localizations of the disease and to provide pathogenesis hypotheses. METHODS: Monocentric, observational, retrospective, cohort study. Patients undergoing laparoscopic endometriosis surgery in our tertiary referral center were consecutively enrolled. The prevalence of the different localizations of pelvic endometriosis including appendix involvement detected during surgery was collected. Included patients were divided into two groups based on the presence of appendiceal endometriosis. Women with a history of appendectomy were excluded. MEASUREMENTS AND MAIN RESULTS: Four hundred-sixty patients were included for data analysis. The prevalence of appendiceal endometriosis was 2.8%. In patients affected by endometriosis of the appendix, concomitant ovarian and/or bladder endometriosis were more frequently encountered, with prevalence of 53.9% (vs 21.0% in non-appendiceal endometriosis group, p = 0.005) and 38.4% (vs 11.4%, p = 0.003), respectively. Isolated ovarian endometriosis was significantly associated to appendiceal disease compared to isolated uterosacral ligament (USL) endometriosis or USL and ovarian endometriosis combined (46.2% vs 15.4% vs 7.7%, p < 0.001). Poisson regression analysis revealed a 4.1-fold and 4.4-fold higher risk of ovarian and bladder endometriosis, respectively, and a 0.1-fold risk of concomitant USL endometriosis in patients with appendiceal involvement. CONCLUSION: Involvement of the appendix is not uncommon among patients undergoing endometriosis surgery. Significant association was detected between appendiceal, ovarian, and bladder endometriosis that may be explained by disease dissemination coming from endometrioma fluid shedding. Given the prevalence of appendiceal involvement, counseling regarding the potential need for appendectomy during endometriosis surgery should be considered.

Systematic use of intraureteral indocyanine green: a game changer in endometriosis surgery. A proof-of-concept study.

BACKGROUND: Endometriosis of the distal segment of the uterosacral ligament may lead to a displaced ureter in the surgical field and must be identified before safe disease excision can be carried out. The aim of this study is to investigate the benefit of the systematic use of preoperative intraureteral indocyanine green (ICG) fluorescence injection in patients undergoing endometriosis surgery. METHOD: In this proof-of-concept, monocentric, observational, cohort study data were prospectively collected and retrospectively analyzed. Patients underwent laparoscopic surgery for deep infiltrating endometriosis with suspected ureteral involvement between January 2022 and December 2023. Using the propensity score matching (PSM) in a 1:1 matching ratio, patients who underwent preoperative ICG injection were compared with those who did not in terms of ureterolysis length and duration, and operative time. RESULTS: The mean length of ureterolysis was shorter in the ICG group compared to the non-ICG group (p < 0.001). The ICG group also had shorter ureterolysis duration (p < 0.001) and operative time (p = 0.02). No complications were reported at mean 6.8-month follow-up visit. CONCLUSIONS: The systematic use of intraureteral ICG prior to uterosacral ligaments endometriosis surgery may be safe and could assist in reducing the length of ureterolysis and operative time. Larger prospective studies are needed to confirm our findings.

Hydatid of Morgagni in Young Female: A Rare Case of Acute Abdomen-Case Report and Literature Review.

Torsion of the hydatid of Morgagni is a rare condition which can cause acute abdominal pain in young female. We present a case report of a 13-year-old girl with acute abdominal pain and treated for torsion of the hydatid of Morgagni. Less than 20 cases of female younger than 18 years old with this condition are been described in the literature. Through our systematic review performed following the PRISMA statement, we want to emphasize the difficulty in diagnosis and the importance of considering this pathology in the differential diagnosis of acute abdomen in females with the aim of obtaining a timely surgical treatment to preserve fertility in these patients.

Endometriosis-Related Ovarian Cancer: Where Are We Now? A Narrative Review towards a Pragmatic Approach.

BACKGROUND: Endometriosis affects more than 10% of reproductive-aged women, causing pelvic pain and infertility. Despite the benign nature of endometriosis, ovarian endometriomas carry a higher risk of developing endometrioid carcinomas (EnOCs) and clear cell ovarian carcinomas (CCCs). Atypical endometriosis, defined as cytological atypia resembling intraepithelial cancer, is considered the precursor of endometriosis-associated ovarian cancer (EAOC). This narrative review aims to provide an overview of EAOC, proposing a practical approach to clinical and therapeutic decision making. METHODS: An electronic literature search was conducted from inception up to January 2023, using the MEDLINE database via PubMed to evaluate the existing literature on EAOC, including its pathogenesis, the diagnostic process, and the therapeutic possibilities, with articles not relevant to the topic or lacking scientific merit being excluded. RESULTS: Eighty-one articles were included in the review to present the current state of the art regarding EAOC. A pragmatic clinical flowchart is proposed to guide therapeutic decisions and improve patient outcomes. CONCLUSIONS: Endometriosis patients may have an increased risk of developing EAOC (either EnOC or CCC). Despite not being fully accepted, the concept of AE may reshape the endometriosis-ovarian cancer relationship. Further research is needed to understand the unaddressed issues.

In Vitro Effects of Charged and Zwitterionic Liposomes on Human Spermatozoa and Supplementation with Liposomes and Chlorogenic Acid during Sperm Freezing.

Semen handling and cryopreservation induce oxidative stress that should be minimized. In this study, human semen was supplemented during cryopreservation with formulations of handmade liposomes and chlorogenic acid (CGA), an antioxidant compound. Zwitterionic (ZL), anionic (AL), and cationic (CL) liposomes were synthesized and characterized. Three aliquots of swim-up-selected sperm were incubated with ZL, AL, and CL (1:10,000), respectively. The percentages of sperm with progressive motility, high mitochondrial membrane potential (MMP; JC-1), double-stranded DNA (dsDNA acridine orange), and acrosome integrity (Pisum sativum agglutinin) were assessed. Then, human semen was frozen using both 1:10,000 ZL and CGA as follows: freezing medium/empty ZL (EL), freezing medium/empty ZL/CGA in the medium (CGA + EL), freezing medium/CGA loaded ZL (CGA), freezing medium (CTR). The same sperm endpoints were evaluated. ZL were the most tolerated and used for semen cryopreservation protocols. All the supplemented samples showed better endpoints versus CTR (p < 0.001). In particular, spermatozoa from the CGA and CGA + EL A samples showed increased motility, dsDNA, and acrosome integrity versus CTR and EL (p < 0.001; motility EL vs. CGA + EL p < 0.05). ZL and CGA can improve post-thaw sperm quality, acting on both cold shock effect management and oxidative stress. These findings open new perspectives on human and animal reproduction.

The role of hysteroscopy with morcellator without anesthesia in the management of abnormal uterine bleeding.

Objective: To evaluate the feasibility of hysteroscopy with morcellator without anesthesia and the diagnostic accuracy of 2D, 3D and power Doppler transvaginal sonography (TVS) in patients with abnormal uterine bleeding (AUB). Material and Methods: This was a retrospective study including women with AUB. All patients underwent 2D, 3D and power Doppler TVS evaluation of the uterine cavity, and patients with suspicion on ultrasound (US) of endometrial pathology (EP) underwent hysteroscopy with morcellator without anesthesia. The painful symptomatology was assessed during the procedure using a visual analogue scale (VAS). Additionally, histological evaluation was performed. Results: A total of 182 women underwent US imaging, of whom 131 (72%) had hysteroscopy. 130/131 patients completed the hysteroscopic examination with good compliance (VAS <4). One patient (0.8%) was unable to complete the procedure due to nulliparity and cervical stenosis. Of the 130 patients the US diagnosis was confirmed in 120 (92.3%), while in 10 patients (7.7%) the hysteroscopic diagnosis was different from the US diagnosis. Histological examination confirmed benign endometrial polyps in 115/130 patients (88.5%), while premalignant conditions were diagnosed in 3/130 patients (2.3%) and malignant conditions in 2/130 (1.5%). Of the 10 patients with endometrial thickening, two were diagnosed with a malignant condition. Conclusion: This study confirmed the feasibility of managing patients with AUB and suspicion of EP using "see-and-treat" hysteroscopy with morcellator without anesthesia. This procedure has the potential to yield desired outcomes while minimizing pain and discomfort, presenting a feasible outpatient approach for both treating and preventing endometrial carcinoma without requiring anesthesia.

Adenomyosis among patients undergoing postpartum hysterectomy for uncontrollable uterine bleeding: A multicenter, observational, retrospective, cohort study on histologically-based prevalence and clinical characteristics.

OBJECTIVE: To assess the prevalence of adenomyosis at pathologic examination, and its association with obstetric complications, peripartum maternal clinical characteristics and neonatal birth weight in patients undergoing postpartum hysterectomy due to postpartum hemorrhage (PPH). METHODS: A multicenter, observational, retrospective, cohort study was carried out including all women who underwent postpartum hysterectomy due to PPH at gestational week 23+0 or later, between January 2010 and May 2023. Patients were categorized into two groups based on the presence of adenomyosis at pathologic examination, and were compared for obstetric complications, peripartum maternal clinical characteristics, and neonatal birth weight. RESULTS: The histologically-based prevalence of adenomyosis in patients undergoing postpartum hysterectomy due to PPH was 39.4%. Adenomyosis was associated with a longer hospitalization time (regression coefficient: 4.43 days, 95% CI: 0.34-8.52, P = 0.034) and a higher risk of hypertensive disorders (OR: 5.82, 95% CI: 1.38-24.46, P = 0.016), threatened preterm labor (OR: 3.34, 95% CI: 1.08-10.31, P = 0.036), urgent/emergency C-section (OR: 24.15, 95% CI: 2.60-223.96, P = 0.005), postpartum maternal complications (OR: 4.96, 95% CI: 1.48-16.67, P = 0.012), maternal intensive care unit admission (OR: 3.56, 95% CI: 1.05-12.05, P = 0.041), and low birth weight neonates (OR: 3.8, 95% CI: 1.32-11.02, P = 0.013). CONCLUSION: In patients undergoing postpartum hysterectomy due to PPH, adenomyosis is a highly prevalent condition among, and is associated with adverse obstetric, maternal, and neonatal outcomes.

Deep Infiltrating Endometriosis in Adolescence: Early Diagnosis and Possible Prevention of Disease Progression.

Endometriosis has a prevalence of 10% worldwide in premenopausal women. Probably, endometriosis begins early in the life of young girls, and it is commonly diagnosed later in life. The prevalence of deep infiltrating endometriosis (DIE) in adolescence is currently unknown due to diagnostic limits and underestimation of clinical symptoms. Dysmenorrhea is a common symptom in adolescents affected by DIE, often accompanied by dyspareunia and chronic acyclic pelvic pain. Ultrasonography-either performed transabdominal, transvaginal or transrectal-should be considered the first-line imaging technique despite the potential for missed diagnosis due to early-stage disease. Magnetic resonance imaging should be preferred in the case of virgo patients or when ultrasonographic exam is not accepted. Diagnostic laparoscopy is deemed acceptable in the case of suspected DIE not responding to conventional hormonal therapy. An early medical and/or surgical treatment may reduce disease progression with an immediate improvement in quality of life and fertility, but at the same time, painful symptoms may persist or even recur due to the surgery itself. The aim of this narrative review is to report the prevalence of DIE in adolescents, describe the pathogenetic theories and discuss the management in adolescent women, including the challenging road to diagnosis and the treatment alternatives.