Platelet-Rich Plasma for the Treatment of Stress Urinary Incontinence-A Randomized Trial.

IMPORTANCE: Urinary incontinence affects millions of women worldwide. OBJECTIVE: The aim of the current study was to evaluate the efficacy and safety of periurethral platelet-rich plasma (PRP) injections in women with stress urinary incontinence (SUI). STUDY DESIGN: This was a single-center, double-blind, randomized sham-controlled trial. Fifty participants with SUI and urodynamic stress incontinence were randomized in 2 equally sized groups. Women in the PRP group received 2 PRP injections at 3 levels of the urethra at 4- to 6-week intervals. Women in the sham group were injected with sodium chloride 0.9%. At baseline, participants underwent urodynamic studies and a 1-hour pad test and completed the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (ICIQ-FLUTS), the Patient Global Impression Scale of Improvement, and the King's Health Questionnaire. At follow-up visits (1, 3, and 6 months), women underwent the 1-hour pad test and completed the King's Health Questionnaire and the ICIQ-FLUTS. Primary outcome was the subjective evaluation as indicated by the response to question 11a of the ICIQ-FLUTS questionnaire. Secondary outcomes included scores of questionnaires and urine loss assessed on the 1-hour pad test. The level of discomfort during injections and any adverse events were also evaluated. RESULTS: During follow-up, the mean score of the 11a question decreased significantly in the PRP group compared with sham. Subjective cure was significantly higher in the PRP group (32% vs 4%, P < 0.001). A significant reduction of urine loss assessed on the 1-hour pad test was observed in the PRP group compared with the sham group at 6-month follow-up. No adverse events were observed. CONCLUSIONS: Periurethral PRP injections were superior to sham injections in improving SUI symptoms with an excellent safety profile.

A Study Protocol of Micro-Ablative Fractional CO2 Laser in Postmenopausal Women With Overactive Bladder Syndrome.

INTRODUCTION: This is a presentation of a study protocol in order to evaluate whether the application of CO2 laser can additionally benefit the improvement of the symptoms of overactive bladder in postmenopausal women who have just started mirabegron as a treatment. MATERIALS AND METHODS: This is a study protocol of a randomized double-blind placebo-controlled trial. A total of 50 menopausal women will participate in the study. All patients will start treatment with mirabegron 50 mg and will be randomized into two groups. Women in group A (control) will undergo CO2 laser treatments while those in group B (placebo group) will receive placebo CO2 laser treatments. In total, three monthly sessions will be held in both groups. The monitoring and evaluation of the results will be carried out by completing a three-day urination diary, as well as by completing the Female Lower Urinary Tract Symptoms, Overactive Bladder Questionnaire, King's Health Questionnaire, Urinary Distress Inventory, Pelvic Floor Impact Questionnaire, Patient Global Impression of Improvement, before each session and a month after the last one. Differences between groups will be assessed at baseline and every month following the three laser therapies. RESULTS: This is an ongoing study protocol, and we are expecting the analysis of the results in 2024. CONCLUSIONS: The use of laser CO2 in postmenopausal women with overactive bladder syndrome may be a well-tolerated alternative treatment. The goal of our study is to evaluate the efficacy of laser treatment in combination with b3-adrenoreceptor agonist therapy.

CO2 Laser versus Sham Control for the Management of Genitourinary Syndrome of Menopause: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

In the context of the menopausal transition, genitourinary syndrome of menopause (GSM) refers to a range of genitourinary symptoms, from vaginal dryness to dysuria and urinary urgency. While hormonal treatments are standard, their associated side effects have driven the exploration of alternatives like vaginal CO2 laser. We aimed to evaluate the randomized controlled trials (RCTs) comparing vaginal CO2 laser treatment for GSM to sham controls. This systematic review sourced four electronic databases until June 2023. The analysis incorporated seven RCTs with 407 women. The CO2 laser and sham control were comparable for most parameters, including the female sexual function index (FSFI) and visual analogue scale (VAS) for dyspareunia, vaginal health index, pH, and patient satisfaction. However, the CO2 laser group showed significant improvement in the vaginal assessment scale for GSM symptoms. Sensitivity analyses revealed that parameters like FSFI showed significant differences in favor of CO2 laser group upon the exclusion of specific studies. In conclusion, vaginal CO2 laser therapy emerges as a promising alternative for GSM management, especially for most bothersome GSM symptoms; however, the need for further well-designed RCTs remains to validate its broad safety and efficacy.

The Effect of the Allelics of Ser680Asn Polymorphisms of Follicle-Stimulating Hormone Receptor Gene in IVF/ICSI Cycles: a Systematic Review and Meta-analysis.

A significant number of single-nucleotide polymorphisms (SNPs) of the follicle-stimulating hormone receptor (FSHr) can modify the response to exogenous FSH administration. A significant diversity in response to controlled ovarian stimulation (COS) in assisted reproductive technologies (ART) according to the type of allelic has been reported. We aimed to evaluate the relation between the Asn680Ser allelics and COS. A total of 4 electronic databases were searched for articles published up to August 2021. Prospective and retrospective comparative studies which reported outcomes after COS in patients who underwent genotyping for the detection of FSHr polymorphisms were considered eligible. A total of 11 studies including 4343 patients with Asn680Ser polymorphisms of the FSHr were included. Patients carrying the Asn/Asn allelic provide elevated E2 on the day of human chorionic gonadotropin (hCG) administration (1549 patients MD 262.39 pg/ml, p = 0.0007), but less transferrable embryos as compared with Ser/Ser genotype (283 patients MD - 0.11 embryos, p = 0.04). Ans/Ser versus Ser/Ser genotypes showed a higher E2 on the day of hCG administration (1799 patients, MD 207.86 pg/ml, p = 0.02). Pregnancy rates were similar in all combination of genotypes. There is currently no strong evidence suggesting that the examination of one gene in relation to genotypes can be effectively used as single tool to improve COS. However, polygenic analysis of different polymorphisms by analyzing the genetic profile of each individual could be useful. Further research is warranted to develop an algorithm that will enable simultaneous analysis of many genes, which combined with hormonal profile could promote treatment individualization.

Enhanced Recovery Protocols in Urogynecologic and Pelvic Floor Reconstructive Surgery: A Systematic Review and Meta-Analysis.

IMPORTANCE: The implementation of Enhanced Recovery After Surgery (ERAS) protocols may optimize the clinical outcome of surgical patients, by reducing the length of hospital stay (LOS) and improving the quality of recovery. OBJECTIVE: This study aims to evaluate the impact of ERAS protocols in the intraoperative and postoperative course of patients undergoing pelvic floor reconstructive surgery. METHODS: A systematic search of PubMed/MEDLINE, Embase, and the Cochrane Library was conducted up to January 2022, using the Systematic Reviews and Meta-analyses guidelines. Search terms, such as ERAS, urogynecology, sacrocolpopexy were tailored to each database as necessary. Statistical analysis was performed using the RevMan 5.4 software. Confidence intervals (CI) were set at 95%. Mean difference and risk ratio were used in the analysis, and the results were calculated using the random effect model. RESULTS: Six studies that reported outcomes of 1,153 women were included. The ERAS protocols were implemented in 553 women, whereas the remaining 600 received standard perioperative care. A significantly shorter LOS (mean difference, -16.17 hours; 95% CI, -24.07 to -8.26 hours; P < 0.0001) and a higher proportion of patients discharged within 24 hours postoperatively was observed in ERAS patients compared with non-ERAS controls (risk ratio, 3.08; 95% CI, 2.00-4.75; P < 0.00001). Operative time, estimated blood loss, complications, and readmission rates did not differ between the 2 groups. CONCLUSIONS: Our analysis showed that ERAS protocols have a favorable impact on the perioperative course of urogynecologic populations. More research is required to determine those key components of ERAS protocols, specifically applicable and more beneficial to women with pelvic floor disorders.

The Effect of Intravenous Tranexamic Acid on Myomectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Myomectomy is the preferred surgical treatment for symptomatic women with uterine myomas who wish to preserve their fertility. The procedure may be associated with significant intraoperative blood loss, which predisposes to increased transfusion rates and morbidity. The objective of our systematic review and meta-analysis is to investigate whether intravenous (IV) use of tranexamic acid (TXA) may reduce blood loss during myomectomy. Three electronic databases were screened until June 2022. The eligible studies were assessed for risk of bias. Four randomized controlled trials that reported outcomes from a total of 310 women were finally included in the meta-analysis-155 patients received intravenous TXA while the remaining 155 received placebo injection with normal saline or water for injection. Total estimated blood loss was significantly lower in patients who received TXA before myomectomy compared to control (230 patients MD -227.09 mL 95% CI -426.26, -27.91, p = 0.03). This difference in favor of TXA group remained when intraoperative and postoperative blood loss was separately analyzed. Postoperative hematocrit values and hemoglobin levels did not differ among the two groups (180 patients MD 0.67% 95% CI -0.26, 1.59, p = 0.16 and 250 patients MD 0.17 mg/dL 95% CI 0.07, 0.41, p = 0.17, respectively). The number of patients that received blood transfusion was also not different (310 patients OR 0.46 95% CI -0.14, 1.49, p = 0.19). Total operative time was significantly prolonged in control group compared to TXA (310 patients MD -16.39 min 95% CI -31.44, -1.34 p = 0.03). Our data show that the IV use of TXA may significantly reduce intraoperative blood loss in patients undergoing myomectomy and contribute to reduced operative time.

Clinicopathological Characteristics and Outcomes of Patients With Endometriosis-Related Hemorrhagic Ascites: An Updated Systematic Review of the Literature.

The presence of ascites is a common clinical presentation in gynecologic oncology patients. Hemorrhagic ascites (HA) due to endometriosis is a rare presentation that can be easily misdiagnosed as ovarian malignancies. The present study aims to update the currently available knowledge on the characteristics of patients presenting with HA due to endometriosis. A systematic search was conducted for articles published from January 2000 to July 2020 using the Medline, Scopus, and Google Scholar databases along with the references of the full-text articles retrieved. Papers describing cases of women over 18 years with or without previous history of endometriosis were assessed. Only cases with histologically proven hemorrhagic ascites of endometriosis origin were included. Twenty-nine studies (27 case reports and two case series) comprising 32 patients were evaluated. The mean patients' age was 32 years, while six of the patients had a previous history of endometriosis. The mean amount of drained ascitic fluid was 4,200 mL, whereas three patients underwent thoracentesis due to pleural effusions. The treatment options included not only medical but also surgical therapies. Fertility preservation was achieved in 27 patients, while two of them achieved pregnancy with in vitro fertilization (IVF) techniques. Endometriosis-related hemorrhagic ascites is a relatively rare expression of the disease. Endometriosis-related hemorrhagic ascites should be considered in the differential diagnosis (DD) of women with ascites and clinical suspicion of endometriosis. The available literature is limited to case reports and case series and thus indicates further research in the field to decode the pathophysiology of the disease and decide on the optimal treatment.

Platelet rich plasma for the management of urogynecological disorders: the current evidence.

PURPOSE OF REVIEW: Our objective is to review the currently available literature on the use of platelet-rich plasma (PRP) in patients with pelvic floor disorders and to critically appraise the latest evidence on the safety and efficacy of the PRP application. RECENT FINDINGS: The evidence on the use of PRP for the treatment of stress urinary incontinence (SUI) appears promising, although limited to case series, case reports and animal studies. PRP has also been proposed to enhance the surgical outcomes of pelvic organ prolapse (POP) by native tissue repair with promising success rates. The application of PRP in other PFDs including vaginal fistulas, genitourinary syndrome of menopause (GSM), mesh exposure and lichen sclerosus has been also associated with beneficial outcomes and a favorable safety profile. SUMMARY: The currently available literature indicates that PRP could have a beneficial effect as a single or adjuvant treatment in patients with SUI, POP, GSM, vaginal fistula and genital lichen sclerosus with minimal adverse events. However, valid evidence is still lacking and further well-designed studies are warranted in the field to confirm the validity of the so far reported outcomes.

Application of J-Plasma in the excision of diaphragmatic lesions as part of complete cytoreduction in patients with advanced ovarian cancer.

For the resection of diaphragmatic disease in patients with advanced ovarian cancer (OC), a plethora of ablative methods have been utilized. The present study aimed to present preliminary data on the use of J-Plasma in OC with diaphragmatic involvement via a retrospective review of patients who had diaphragmatic stripping with of J-Plasma® from January 2016 to September 2020. A total of 12 patients (median age, 65 years) were analyzed. Median operative time was 240 min while median estimated blood loss was 400 ml. Median operative time for diaphragmatic resection was 25 min. During a median follow-up of 12 months, two recurrences were noted while none of the patients died of the disease. Median disease free survival was 12 months. Overall, the preliminary outcomes of the present study indicated that J-Plasma could be safely used in diaphragmatic resection and it was associated with low rates of short-term morbidity. However, further studies are warranted to reach to safe conclusions.

Preemptive Infiltration of Local Anesthetics During Vaginal Hysterectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

IMPORTANCE: Vaginal hysterectomy (VH) is the preferred route of choice for women desiring hysterectomy to treat uterine pathology, including premalignant conditions and fibroids. OBJECTIVE: The aim of this study was to evaluate the impact of the use of preemptive local analgesia (LA) on postoperative pain and perioperative outcomes for women undergoing VH. STUDY DESIGN: A systematic search of 4 electronic databases (MEDLINE, Scopus, Cochrane CENTRAL Register of Controlled Trials, and Clinicaltrials.gov ) was performed for articles published up to January 2021. All randomized controlled trials that presented outcomes of patients who underwent VH due to pelvic floor disorders or other benign gynecological disorders and received local infiltration analgesia were finally included. RESULTS: A total of 5 studies with 277 women (138 LA group vs 199 no-LA group) who underwent a VH were included in the present meta-analysis. Mean pain scores at both 30 minutes to 2 hours and 3 to 6 hours postoperatively were significantly lower in the LA group compared with the non-LA group (220 patients: mean difference [MD], -1.75; 95% confidence interval [CI], -2.77 to -0.74; P = 0.0007; and 220 patients: MD, -1.68; 95% CI, -2.28 to 1.09; P < 0.00001, respectively). Morphine/narcotic opioid-based consumption up to 24 hours postoperatively was significantly reduced in the LA group compared with the non-LA group (197 patients MD, -9.47 mg; 95% CI, -16.51 to -2.43; P = 0.008). CONCLUSIONS: The use of preemptive LA during VH seems to be beneficial especially with regard to short-term postoperative pain and opioid use. However, further studies are needed to identify the optimal anesthetic regimen, the dosage, and sites of application aiming to achieve the optimal benefit in the postoperative management.

Where Enhanced Recovery after Surgery (ERAS) Protocols Meet the Three Major Current Pandemics: COVID-19, Obesity and Malignancy.

The outbreak of the SARS-CoV-2 (COVID-19) pandemic has transformed the provision of medical services for both patients that receive care for COVID-19 and for those that need care either for benign diseases, including obesity, or for malignancies, such as gynecological cancer. In this perspective article, we focus on the association among three major worldwide health issues and how ERAS protocols can potentially provide optimal management of patients with obesity and malignancy during the COVID-19 pandemic, with special attention to patients who required surgery for gynecologic oncology. A thorough search of the literature on the respective topics was performed. Patients with malignancy and obesity presented with increased vulnerability to COVID-19 infection. However, the management of their disease should not be withheld. Protective measures should be established to reduce exposure of patients with oncological diseases to SARS-CoV-2 while simultaneously enabling their access to vaccination. Since ERAS protocols have proved to be efficient in many surgical fields, including gynecologic oncology, general surgery, and orthopedics, we strongly believe that ERAS protocols may play a significant role in this effort. The end of the COVID-19 pandemic cannot be accurately predicted. Nevertheless, we have to ensure the appropriate and efficient management of certain groups of patients.

Tubal Endometriosis: From Bench to Bedside, A Scoping Review.

Tubal endometriosis (EM) refers to the detection of ectopic endometrial implants on tubes. It may cause a significant defect of the tubes, translating into dysmenorrhea, pelvic pain, and infertility. We aimed to evaluate the disease characteristics, prevalence, histopathological findings and genetic profile of patients with tubal EM. A thorough search of three electronic databases was performed for studies that presented outcomes of patients with tubal EM. Thirteen studies (four observational, seven case reports, two genetic) were considered eligible for inclusion. The prevalence of tubal EM ranged from 6.9% to 69%. The predominant symptoms for referral of patients were infertility and abdominal pain. Women of reproductive age underwent salpingectomy for the management of the disease. Only one case of malignant transformation was recorded in a 60-year-old patient. The prevalence of tubal EM ranges depending on the indication for surgery, the presence of concomitant pelvic EM and the type of diagnosis and treatment. Further, more extensive, larger studies are warranted to evaluate the impact of tubal EM in the progression and prognosis of EM, the effect of salpingectomy in the improvement of disease-related symptoms and to designate the group of patients that could benefit from risk-reducing salpingectomy based on the risk of developing ovarian malignancy.

Clinicopathological characteristics and survival outcomes of patients with large cell neuroendocrine carcinoma of the uterine cervix: A systematic review and meta-analysis.

PURPOSE: Large cell neuroendocrine carcinoma (LCNEC) of the cervix represents a rare tumour entity associated with poor prognosis. Knowledge about carcinogenesis and therapeutic options is scarce, while novel therapeutic targeted approaches are limited. METHODS: We performed a systematic review of four electronic databases from inception to June 2020. Eligible studies included all reports that addressed survival outcomes of women with LCNEC. RESULTS: A total of 31 case studies including 87 LCNEC patients were identified. Median patients' age was 41 years (range: 21-81). Most women (76.3%) had FIGO stage I-II disease. Overall, 72.0% had surgery, 70.1% received chemotherapy and 50.7% received radiotherapy. Of 13 patients with known HPV-status, 15% were HPV negative. Median overall survival (OS) was 24 months (range: 0.5-151), with 3- and 5-year OS of 42% and 29%, respectively. In multivariate analyses, only surgery and lymphadenectomy significantly associated with survival (Surgery OS: HR 0.14; 95% C.I:0.03-0.71, p = 0.018 / Surgery PFS: HR 0.23, 95% C.I. 0.06, 0.92, p = 0.037 / Lymphadenectomy OS: HR 0.26, 95% C.I. 0.07-0.98, p = 0.046 / Lymphadenectomy PFS: HR 0.30, 95% C.I. 0.09-0.98, p = 0.046). Age, chemotherapy or radiotherapy did not significantly impact survival, but lower stage was associated with improved survival. CONCLUSION: Cervical LCNECs overall have a poor prognosis, despite their relatively early-stage initial presentation. Surgery and lymphadenectomy appear to significantly affect survival in contrast to chemotherapy and radiotherapy, which appear to have no significant effect on prognosis. Prospective multicentre cancer registries are warranted to improve treatment options for this rare disease.

The Emerging Role on the Use of Platelet-Rich Plasma Products in the Management of Urogynaecological Disorders.

Background: The regenerative efficacy of platelet-derived products has been recently investigated in the treatment of pelvic floor disorders (PFDs). We aimed to synthesize the current evidence of platelet-rich plasma (PRP) products used in urogynaecological disorders including vaginal atrophy, pelvic organ prolapse (POP), urinary incontinence, vaginal fistulas and vaginal mesh exposure. Methods: A meticulous search of the currently available literature on the use of PRP for the management of PFDs was performed using 3 electronic databases. Results: PRP could be a feasible alternative modality for the management of vaginal atrophy with favourable outcomes in vaginal atrophy parameters and patients' satisfaction, especially when hormone therapy is contraindicated. In patients with POP, an increase in collagen concentration after PRP application was observed while the use of PRP resulted in improvement of stress urinary incontinence symptoms. A considerable proportion of vesicovaginal fistulas were treated after application of PRP-based injections. Conclusions: There is only limited evidence of the use of PRP for PFDs. Platelet-rich plasma appears to be a promising, easy to apply, cost-effective and feasible alternative therapeutic modality for the management of various urogynaecological disorders. Future randomized trials are needed to confirm the efficacy of PRP in the treatment of urogynaecological disorders.

Spiliotis-Farfarelos Maneuver for the Management of Small Bowel Obstruction and Frozen Pelvis in Patients With Peritoneal Metastasis.

The management of the advanced peritoneal disease is demanding especially in cases of extensive bowel infiltration and the obstruction of the gastrointestinal tract in different sites. Patients with bowel obstruction due to peritoneal carcinomatosis have an overall survival that ranges from three to eight months to four to five weeks based on the operability or not of the disease, respectively. The decision to operate should carefully consider the balance between the probability of symptomatic relief and the risk of severe perioperative complications and survival after surgery. The extent of the disease and postoperative malnutrition could further complicate patients' postoperative course. We aim to present an operative maneuver of bowel preparation and fixation in cases of extensive infiltration of the small bowel by peritoneal carcinomatosis (PC) in order to eliminate the risk of postoperative fistula formation or anastomotic leakage.

Mitomycin-C versus oxaliplatin during cytoreductive surgery and HIPEC for peritoneal metastases secondary to colorectal carcinoma: a retrospective analysis.

PURPOSE: Combining cytoreductive surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) can benefit patients with peritoneal metastasis from colorectal cancer, however the optimal choice of the HIPEC chemotherapy is still under debate. The present study compares the clinical outcome in patients with peritoneal metastases treated with CRS and HIPEC using Mitomycin - C versus Oxaliplatin. METHODS: We retrospectively analyzed patients that underwent CRS and HIPEC for recurrent colorectal cancer with peritoneal metastases. Patient characteristics, procedure details, and clinical outcomes were evaluated. RESULTS: 114 consecutive patients were included in the analysis (62 males - 52 females, mean age 58,3 years). The mean intraoperative PCI-score was 15.3 (range: 3 - 36). The mean follow-up period was 28.2 months. Patients receiving MMC - based HIPEC had significantly higher mean overall survival compared to oxaliplatin (54 versus 26 months), translated to a hazard ratio of 0.26 (95% CI 0.128 - 0.529, p<0.01). The HIPEC regimen as well as the completeness of cytoreduction were the only independent prognostic factors of survival in our sample. CONCLUSIONS: Our results imply that the use of MMC offers a survival advantage over oxaliplatin when used for HIPEC in CRC PC. A randomised trial comparing oxaliplatin and MMC would enhance decision-making in such patients.

Cytoreductive surgery and HIPEC for peritoneal metastasis. Justified hope or desperate illusion? Fifteen years of experience from a Greek Peritoneal Surface Malignancy center.

PURPOSE: Peritoneal spread of neoplastic diseases is considered a fatal condition with a dismal prognosis. Few therapeutic options were offered to these patients and surgery had only palliative character. However, advances in surgical techniques and new drugs development, have changed the management of this terminal stage disease. Cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC), has been proposed as a promising alternative to palliative surgery and systemic chemotherapy, since 1980s. Many changes through all these years have refined the technique and standardized indications and limits. METHODS: A retrospective study was performed in our medical records, of all patients treated with CRS and HIPEC since 2006. Survival, complications and prognostic factors were studied in a total of 632 patients. RESULTS: Female patients were 419 and males were 213. Mean age was 52.6 years. Peritoneal metastases secondary to colorectal cancer were the most frequent treated disease (87 patients), whereas hepatobilliary-pancreatic neoplastic diseases and sarcomas were the less frequent causes of peritoneal carcinomatosis. Patients with peritoneal metastases from ovarian cancer, treated with systemic chemotherapy and then received interval cytoreductive surgery with HIPEC, were the largest group that are still alive (43%), while only 35% of patients with hepatobilliary-pancreatic cancer and peritoneal disease are alive at present. Gender, age, peritoneal cancer index (PCI), completeness of cytoreduction score (CCs), and number of complications were important prognostic factors of overall survival. CONCLUSIONS: Peritoneal carcinomatosis is still considered a final stage disease with a poor prognosis. The confinement of the neoplastic disease in the peritoneal cavity has led to the development of local therapies with promising results. CRS and HIPEC have evolved significantly over the past several years and are at the present the most valuable treatment in highly selected patients with peritoneal carcinomatosis.

Past, Present, and Future of Gonadotropin Use in Controlled Ovarian Stimulation During Assisted Reproductive Techniques.

A variety of protocols have evaluated the use of several forms of gonadotropins in controlled ovarian stimulation (COS). We aim to review the evolving trends on the use of gonadotropins human chorionic gonadotropin (hCG), follicle-stimulating hormone (FSH) and luteinizing hormone (LH) over time and their combinations in COS for patients who undergo assisted reproductive techniques (ART) protocols. A meticulous search of three electronic databases was performed for articles published in the field up to September 2020. The administration of hCG seems a promising alternative to conventional modalities for COS related to the enhancement of LH activity. The use of gonadotropins was associated with significantly elevated pregnancy rates that ranged from 20.8% to 46.2%. However, the currently available outcomes with regards to oocytes retrieved, number of embryos are still conflicting. A potential beneficial effect was observed by the majority of the studies in terms of the number of embryos and implantation rates, which is, however, highly affected by the type of protocol used (gonadotropin-releasing hormone [GnRH] agonist or antagonist). Further studies are warranted to elucidate the exact pathways of action of gonadotropins in controlled ovarian stimulation to attain the optimal effect.

Rupture of a mature cystic teratoma in a young girl caused by a car accident: an extremely rare case and review of the literature.

Mature cystic teratomas (MCT) of the ovary or dermoid cysts are commonly encountered benign ovarian lesions accounting for  approximately 70% of benign tumors and originating from germ cells. A rare case of peritonitis in a 17-year-old female patient caused by traumatic rupture of an MCT of the right ovary is herein presented. A meticulous search of the literature has also been performed. Due to deterioration of patient's clinical condition, she was urgently led to surgery and intraoperative investigation of the peritoneal cavity revealed an inflamed ruptured ovarian cyst along with extensive peritoneal adhesions and purulent peritoneal fluid. A cyst resec-tion was performed with preservation of the ovary followed by adhesiolysis and meticulous abdominal washing and the patient had an uneventful recovery. Despite its rarity, traumatic rupture of ovarian cyst should be considered at evaluation of trauma patients with special attention to cases with a discovered or known presence of ovarian cyst.