Myomectomy in adult women of reproductive age: a propensity score-matched study for pregnancy rates.

PURPOSE: To study whether it is better to perform or not a myomectomy, in terms of surgical and reproductive outcomes in patients of advanced reproductive age, by an observational prospective study in university-affiliated and Community Hospitals. MATERIALS AND METHODS: 40 years and older patients affected by non-submucous symptomatic uterine fibroids and desiring future fertility were enrolled and treated by laparoscopic intracapsular myomectomy by (LIM) or by open laparotomy (OIM), or by a non-surgical management as control group, while attempting to conceive. The primary outcome measures were fibroid characteristics, pre- and post-surgical parameters, pregnancy achievement; the secondary outcome measures were the spontaneous or ART pregnancy outcomes, eventual week of abortion and type of delivery. Propensity scores have been calculated with logistic regression for binary and continuous variables. RESULTS: 202 patients completed the study: 112 operated by LIM, 40 by OIM and 50 patients as control group. Patients undergoing OIM have a worse surgical outcome than LIM. No difference was seen in pregnancy either after myomectomy or control group during follow-up. In the LIM group, there were 44 pregnancies (39.2%), and in the OIM group, there were 9 (22.5%) and 16 in the control group (32%). The weeks of delivery were statistically greater for the control group versus the surgical groups, with no difference in Apgar score between the 3 groups. CONCLUSION: Patients aged over 40 years did not show substantial differences in reproductive outcome, whether operated or not. Myomectomy in over 40-year-old patients has no detrimental effect on future pregnancy rates and over when compared to expectant management.

Comparison of the Effect on the Ovarian Reserve of Modern Methods of Treatment of Endometrioid Cysts.

OBJECTIVE: To compare the efficacy and safety of autologous platelet-rich plasma (PRP) therapy in laparoscopy and transvaginal sclerotherapy for the treatment of endometrioid cysts for maintaining ovarian reserve. METHODS: The study included 71 women under age 35 years with primary and secondary infertility. Twenty women underwent sclerotherapy of endometrioid cysts followed by autologous PRP injection into ovarian tissue, and 21 underwent laparoscopic cyst removal by stripping followed by autologous PRP injection. The control group consisted of 30 women who underwent laparoscopic cystectomy by stripping without autologous PRP injection. We assessed ovarian reserve for all patients before surgery as well 3 and 6 months after surgery by measuring serum anti-Müllerian hormone (AMH) levels and calculating antral follicle count using ultrasound. RESULTS: In the control group, AMH levels had decreased significantly at 3 and 6 months post-surgery, whereas levels in laparoscopy and PRP group remained almost unchanged from initial levels. In the sclerotherapy group, we observed a tendency towards increased AMH levels, but it was not statistically significant when compared with initial results. Follicle count changes were similar to AMH patterns. CONCLUSION: In this study, sclerotherapy in combination with PRP therapy for ovarian endometriomas was associated with improved measures of ovarian reserve, and the combination of laparoscopic excision of the endometrioma with PRP therapy facilitated ovarian reserve preservation.

Prevalence of Intrauterine Adhesions after Myomectomy: A Prospective Multicenter Observational Study.

OBJECTIVES: The aim of this study was to evaluate intrauterine adhesion formation after laparoscopic and laparotomic myomectomy. DESIGN: This is a prospective, multicenter, observational study (ClinicalTrials.gov ID: NCT04030273). METHODS: We included patients after laparotomic and laparoscopic myomectomy. All patients underwent postsurgical diagnostic hysteroscopy, after 3 months. The intrauterine adhesion rate and associated factors were investigated. RESULTS: Between January 2020 and December 2020, 38 and 24 consecutive patients underwent laparoscopic and laparotomic myomectomy, respectively. All diagnostic hysteroscopies were performed in the office setting without complications. Intrauterine adhesions were identified in 19.4% of women (95% CI: of 9-29%). Factors univariately associated (p < 0.2) with the presence of intrauterine adhesions after myomectomy were previous uterine surgery, the surgical approach (laparoscopic or laparotomic), the number of removed fibroids, the type and diameter of the largest myoma, and the opening of the uterine cavity. In the multivariable analysis, only the opening of the uterine cavity (odds ratio [OR] 51.99; 95% confidence interval [CI]: 4.53-596.28) and the laparotomic approach (OR, 16.19; 95% CI: 1.66-158.35) were independently associated with the identification of intrauterine adhesions after myomectomy. LIMITATIONS: One of the main limitations of our study is that we used uterine manipulator only in the laparoscopic group; in addition, we did not perform a preoperative hysteroscopy to evaluate the rate of intrauterine adhesions potentially present even before the myomectomy. CONCLUSIONS: The prevalence of intrauterine adhesions after 3 months from surgery was significantly associated with the opening of the uterine cavity and the laparotomic approach.

Uterine rupture during pregnancy: The URIDA (uterine rupture international data acquisition) study.

OBJECTIVE: To describe the characteristics and peripartum outcomes of patients diagnosed with uterine rupture (UR) by an observational cohort retrospective study on 270 patients. METHODS: Demographic information, surgical history, symptoms, and postoperative outcome of women and neonates after UR were collected in a large database. The statistical analysis searched for correlation between UR, previous uterine interventions, fibroids, and the successive perinatal outcomes in women with previous UR. RESULTS: Uterine rupture was significantly associated with previous uterine surgery, occurring, on average, at 36 weeks of pregnancy in women also without previous uterine surgery. UR did not rise exponentially with an increasing number of uterine operations. Fibroids were related to UR. The earliest UR occurred at 159 days after hysteroscopic myomectomy, followed by laparoscopic myomectomy (251 days) and laparotomic myomectomy (253 days). Fertility preservation was feasible in several women. Gestational age and birth weight seemed not to be affected in the subsequent pregnancy. CONCLUSION: Data analysis showed that previous laparoscopic and abdominal myomectomies were associated with UR in pregnancy, and hysteroscopic myomectomy was associated at earlier gestational ages. UR did not increase exponentially with an increasing number of previous scars. UR should not be considered a contraindication to future pregnancies.

MicroRNA let-7: A promising non-invasive biomarker for diagnosing and treating external genital endometriosis

Objective: To evaluate the possibility of using microrna let-7 and mir-9 as non-invasive biomarkers for the diagnosis and treatment of external genital endometriosis. Materials and Methods: We explored the samples of relatively healthy individuals and patients with endometriosis. All patients had undergone laparoscopic surgical treatment after clinical and laboratory examinations. We used RNA-GO to obtain total RNA from endometriosis samples excised by laparoscopic method. Next step involved reverse transcription for microRNA let-7 and mir-9. Correlation-regression analysis was performed using Mann-Whitney-Wilcoxon method. Subsequently, receiver operating characteristic analysis was conducted to determine the possibility of using let-7 microRNA for noninvasive detection of endometriosis. The results of the analysis in all groups were tested considering the normality of statistical distribution. Results: Mann-Whitney analysis showed that the difference in mir-9 mRNA between the groups with and without endometriosis, as well as between the groups with more clinically and histologically severe and mild endometriosis, was statistically insignificant. In addition, a significant difference was noted regarding let-7 microRNA between the groups with and without endometriosis, as well as between the groups with more clinically and histologically severe and mild endometriosis. Comparison with cancer antigen-125 (CA-125) showed that let-7 microRNA was a more specific test than CA-125. Conclusion: MicroRNA let-7 had the best parameters (sensitivity, specificity, and predictive value of positive and negative results) among the biomarkers studied. These biomarkers may be used for early and sometimes preclinical diagnosis of endometriosis.

A case of neovagina surgical creation using the uterine cervix remnant in a patient with Mayer-Rokitansky-Küster-Hauser syndrome.

OBJECTIVE: To study the efficacy of a novel approach to vaginoplasty in a patient with vaginal aplasia and a preserved cervix. DESIGN: We present the case of a 28-year-old patient who was referred with a history of absent menstruation and vaginal intercourse was absent as well as abnormal development of the internal genitals. The patient underwent a laparoscopic cystectomy in 2012 because of an ovarian cyst and later that year underwent laparotomic supracervical hysterectomy with bilateral salpingectomy because of severe pain caused by a hematometra in their uterine remnant. In the period from 2013 to 2016, multiple pelvic ultrasound examinations revealed a fluid structure in the pelvis. By 2020, the size of the lesion had increased to 10 cm on average. A computed tomography scan and magnetic resonance imaging showed a mucinous lesion in the lower part of the patient's pelvis resembling the cervical origin. No pathology of the urinary tract was found. A laparoscopic approach was chosen to achieve the two main goals of the patient-the possibility of vaginal intercourse and the treatment of the intraabdominal lesion. The procedure started with a vaginal step when the neovagina dissection was performed as in the classical Davydov technique up to the beginning of the dilated cervical remnant. Bilateral ureterolysis was performed laparoscopically to prevent ureteral injury. The peritoneum was widely dissected from both the anterior and posterior surfaces of the uterine cervix, which appeared as a large structure filled with typical cervical mucus. Partial dissection of the sacrouterine and ovarian ligaments on both sides was performed to mobilize the cervix. A transverse incision of the cystically dilated cervix in the cranial part was performed and the edges of the incision were brought down to the introitus of the vagina. The cervicovulvar anastomosis was fixed by separate sutures with Vicryl 2-0. SETTING: The surgery was performed in an inpatient setting equipped with conventional laparoscopic instruments, a 30-degree laparoscope, a high-definition video system, xenon light source, insufflator, irrigator, and bipolar and monopolar energy sources. PATIENT(S): A single patient, mentioned previously. INTERVENTION(S): Surgical vaginoplasty using the preserved cervix. The details are explained in the Design section. MAIN OUTCOME MEASURE(S): Restoration of the normal vaginal anatomy and function. RESULT(S): In the postoperative period, the patient did not have any postoperative complications. The urinary catheter was removed on the first postoperative day. From day 1, the patient was taught to make daily vaginal dilations with a vaginal dilator to maintain normal vaginal depth and width. The patient was discharged on day 3 after surgery. In a 3-month follow-up visit, the patient's vagina appeared normal in size with transverse folds and was very well lubricated because of the natural secretions of the cervical mucosa. The patient had been sexually active by the time of the follow-up visit. CONCLUSION(S): According to a literature search, this was the first published case of a successful neovagina creation through cervicovulvar anastomosis. Although different surgical approaches were widely discussed in previous publications of Fertility and Sterility, such as "Laparoscopic uterovaginal anastomosis in Mayer-Rokitansky-Küster-Hauser syndrome with functioning horn", "Laparoscopy-assisted Ruge procedure for the creation of a neovagina in a patient with Mayer-Rokitansky-Küster-Hauser syndrome", and "Evaluation of amnion in creation of neovagina in women with Mayer-Rokitansky-Küster-Hauser syndrome", which were all variants of vaginoplasty with allograft, vaginal distention (Vecchietti procedure), or the use of native tissues (Davydov technique), our approach could be more feasible in the rare cases of preserved distended cervix because of less induced trauma when compared with that of cervical removal. This is because of the strong and lubricated nature of the cervical epithelium, which is already present and does not require time for epithelization.

Hemorrhagic corpus luteum: Clinical management update.

Hemorrhagic corpus luteum (HCL) is an ovarian cyst formed after ovulation and caused by spontaneous bleeding into a corpus luteum (CL) cyst. When HCL rupture happens, a hemoperitoneum results. Clinical symptoms are mainly due to peritoneal irritation by the blood effusion. The differential diagnosis is extensive and standard management is not defined. The authors elaborated a comparison of the differential diagnosis and therapeutic modalities from the laparoscopic approach to nonsurgical, medical options because hemorrhage from HCL is often self-limiting. The authors reviewed all data implicated with the development of HCL, trying to give homogeneity to literature data. The authors analyzed extensive literature data and subdivided the medical approach into many topics. The wait-and-see attitude avoids unnecessary laparoscopic surgery using supportive therapies (antifibrinolytic, analgesics, liquid infusion, transfusions and antibiotic prophylaxis). Surgical therapy: operative management should be laparoscopic, with surgical options such as luteumectomy, ovarian wedge-shaped excision or oophorectomy. Prevention: the possibility to preserve fertility is essential, mainly in patients with bleeding disorders or undergoing anticoagulant therapy; therefore, they need estro-progestinics or GnRH analogues to prevent ovulation and avoid further episodes of HCL. This review will aid physicians in making an early diagnosis of HCL, to avoid unnecessary surgery, and use the most effective treatment.