Prevalence of chronic endometritis in infertile women undergoing hysteroscopy and its association with intrauterine abnormalities: A Cross-Sectional study.

OBJECTIVE: Chronic endometritis (CE) is an inflammatory condition with several different risk factors. We aimed to examine whether intrauterine abnormalities, such as endometrial polyps, submucosal myomas, intrauterine adhesions, or a septate uterus, were associated with an increased likelihood of developing chronic endometritis. METHODS: A cross-sectional study was conducted on 335 infertile women who underwent hysteroscopy surgery at the Ayatollah Taleghani Hospital Infertility Center, affiliated by Shahid Beheshti University of Medical Sciences, in 2022. All participants in the study underwent hysteroscopic surgery, which allowed for direct visualization of the intrauterine cavity, and endometrial biopsies were taken for further analysis. To characterize endometritis, plasma cell infiltration was assessed. Patients with ≥5 plasma cells observed in 10 high-power fields were defined as having chronic endometritis. RESULTS: Endometritis was observed in 51.3% of the patients, totaling 172 individuals. Logistic regression analysis revealed that patients with endometrial polyps had 5.2 times higher odds of developing endometritis compared to patients without polyps (95% CI = 2.9, 9.2) (p-value <0.001). Similarly, patients with intrauterine adhesions had a significant increase in the odds of endometritis (OR = 4.6, 95% CI = 2.1, 10.1) (p-value <0.001). CONCLUSIONS: Treatment or removal of endometrial abnormalities through hysteroscopic procedures may help to reduce the risk of chronic endometritis and improve fertility outcomes. Further research is necessary.

Rol de la laparoscopia en el manejo del síndrome OHVIRA: reporte de un caso y su relación con la endometriosis / Role of laparoscopy in the management of OHVIRA syndrome: a case report and its relation to endometriosis

El síndrome de hemivagina obstruida y anomalía renal ipsilateral (OHVIRA) es producido por una alteración en el desarrollo de los conductos de Müller y Wolff en la vida fetal. El síndrome es poco frecuente, se reporta una prevalencia de 1/2.000 a 1/28.000 casos. La endometriosis se presenta en un 19% de los casos complicando esta patología. El tratamiento del síndrome OHVIRA consiste en resecar el tabique vaginal drenando el hematocolpos. Hasta el momento no existe un consenso en recomendar la realización de una laparoscopia diagnóstica. El objetivo de este estudio es reportar la eventual importancia de la laparoscopia diagnóstica/terapéutica como parte del manejo del síndrome OHVIRA.

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is caused by a defect in the development of Müllerian and Wolffian ducts at fetal life. The syndrome is uncommon, with a reported prevalence of 1/2,000 to 1/28,000 cases. Endometriosis is present in 19% of cases complicating this pathology. Treatment of OHVIRA syndrome consists in resecting the vaginal septum and draining the hematocolpos. Until now there isnt an agreement on recommending diagnostic laparoscopy as part of the treatment. The aim of this study is to report the importance of diagnostic/therapeutic laparoscopy in the management of OHVIRA syndrome.

The effect of platelet-rich plasma on intra-abdominal adhesions in rabbit uterine horn model.

OBJECTIVE: This study was carried out to investigate the effect of autologous platelet-rich plasma (PRP) on intra-abdominal adhesion at the cesarean section incision line in the uterus. MATERIAL AND METHODS: As experimental animals 16 white New Zealand rabbits, 5-months-old, unmated, were used. Animals were divided into two groups the control group and PRP application group. In each group, a transverse incision was made to the uterus to mimic the cesarean section and sutured. Relaparotomy was performed 21 days after the first operation. RESULTS: When the groups were evaluated in terms of inflammation, there was a significant difference between the two groups. When the groups were evaluated in terms of Mason's Trichrome staining and fibrosis, There was a significant difference between groups. When the groups were evaluated in terms of vascular endothelial growth factor-1, there was also a significant difference between the groups. In an experimental rabbit uterine horn adhesion model, PRP is effective in preventing post-operative adhesion formation. CONCLUSIONS: This result may guide clinical studies using autologous PRP to prevent post-operative adhesion formation after gynecological operations.

OBJETIVO: Este estudio se llevó a cabo para investigar el efecto del plasma rico en plaquetas (PRP) autólogo sobre la adhesión intraabdominal en la línea de incisión de la cesárea en el útero. MATERIAL Y MÉTODOS: Como animales de experimentación se utilizaron 16 conejos blancos de Nueva Zelanda, de 5 meses de edad, sin aparear. Los animales se dividieron en dos grupos como grupo de control y grupo de aplicación de PRP. En cada grupo, se hizo una incisión transversal al útero para imitar la cesárea y se suturó. La relaparotomía se realizó 21 días después de la primera operación. RESULTADOS: Cuando los grupos se evaluaron en términos de inflamación, hubo una diferencia significativa entre los dos grupos. Cuando los grupos se evaluaron en términos de tinción MT y fibrosis, hubo una diferencia significativa entre los grupos. Cuando los grupos se evaluaron en términos de VEGF-1, también hubo una diferencia significativa entre los grupos. En un modelo experimental de adherencia al cuerno uterino de conejo, el PRP es eficaz para prevenir la formación de adherencias posoperatorias. CONCLUSIONES: Este resultado puede guiar los estudios clínicos que utilizan PRP autólogo para prevenir la formación de adherencias postoperatorias después de operaciones ginecológicas.

Uterine transposition for fertility and ovarian function preservation after radiotherapy.

OBJECTIVE: To evaluate the feasibility of uterine transposition as a method of preserving fertility and ovarian function after pelvic radiation. METHODS: This prospective multicenter observational study included patients with non-gynecologic pelvic cancers who underwent pelvic radiation as part of their cancer treatment between June 2017 and June 2019. For inclusion in the study, patients were required to have normal menstrual cycles and hormone levels (follicle-stimulating hormone, luteinizing hormone, and estrogen) before treatment. Uterine transposition to the upper abdomen was performed prior to irradiation. Clinical examinations and Doppler ultrasonography were used to evaluate the gonadal vasculature post-surgery. The uterus was repositioned into the pelvis 2-4 weeks after radiation therapy or at the time of rectosigmoid resection in patients with rectal cancer who had undergone neoadjuvant treatment. Cancer treatment and follow-up were performed according to standard guidelines. RESULTS: Eight patients (seven with rectal cancer and one with pelvic liposarcoma) underwent uterine transposition at a median age of 30.5 years (range 19-37). The uterus was successfully preserved in six patients, accompanied by normal menses, hormonal levels, and vaginal intercourse after treatment. One patient with rectal cancer died of carcinomatosis 4 months after uterine transposition. One patient presented with uterine necrosis 4 days after uterine transposition, and the uterus was removed; however, one ovary was preserved. Cervical ischemia was the most common post-surgical complication in three (37.5%) patients. Three patients attempted to conceive, and two (66%) were spontaneously successful and delivered healthy babies at 36 and 38 weeks by cesarean section without complications. CONCLUSIONS: Uterine transposition is a feasible procedure for preserving gonadal and uterine function in patients requiring pelvic radiotherapy for non-gynecological cancer, with the potential for achieving spontaneous pregnancy and successful delivery.

Mucinous Cystadenoma Arising in a Uterine Isthmocele: A Case Report.

Isthmocele is a discontinuation of the myometrium at the uterine scar site in a patient with a previous cesarian section (CS). The cause of isthmocele appears to be multifactorial. Poor surgical technique, low incision location, uterine retroflection, obesity, smoking, inadequate healing of scars, and maternal age are possible related factors. Most patients with this condition are asymptomatic. However, women can present with postmenstrual bleeding, pelvic pain, subfertility, dysmenorrhea, infertility, and scar abscess. Brazil has one of the world's highest cesarean section rates. One of the consequences of the rising rate of CS is the isthmocele, an emerging female health problem. Here we report a case of mucinous cystadenoma arising in a uterine isthmocele, a complication, as far as we could investigate, not yet described in the literature.

Istmocele é a descontinuidade do miométrio no local da cicatriz uterina em paciente com cesariana anterior. A causa da istmocele parece ser multifatorial. Má técnica cirúrgica, baixa localização da incisão, retroflexão uterina, obesidade, tabagismo, cicatrização inadequada de cicatrizes e idade materna são possíveis fatores relacionados. A maioria dos pacientes com esta condição é assintomática. No entanto, as mulheres podem apresentar sangramento pós-menstrual, dor pélvica, subfertilidade, dismenorreia, infertilidade e abscesso cicatricial. O Brasil tem uma das maiores taxas de cesariana do mundo. Uma das consequências da taxa crescente de cesarianas é a istmocele, um problema emergente de saúde feminina. Aqui relatamos um caso de cistoadenoma mucinoso originado em uma istmocele uterina, uma complicação ainda não descrita, até onde pudemos investigar.

Placenta accreta spectrum with severe morbidity: fibrosis associated with cervical-trigonal invasion.

OBJECTIVE: Describe the clinical-surgical results of patients with PAS in the low-posterior cervical-trigonal space associated with fibrosis (PAS type 4) compared with PAS types in other locations (Types 1, upper bladder, 2 in upper parametrium) and in particular with PAS type 3, corresponding to dissectible cervical-trigonal invasion. The clinical-surgical results of using a standard hysterectomy were analyzed with a modified subtotal hysterectomy (MSTH) in patients with PAS type 4. MATERIAL AND METHODS: A descriptive, retrospective, multicenter study included 337 patients of PAS; thirty-two corresponding to PAS type 4, from three PAS reference hospitals, CEMIC, Buenos Aires, Argentina, Fundación Valle de Lili, Cali, Colombia, and Dr. Soetomo General Hospital, Surabaya, Indonesia, between January 2015 and December 2020. PAS was diagnosed by abdominal and transvaginal ultrasound and topographically characterized by ultrafast T2 weighted MRI. In persistent macroscopic hematuria after MSTH, the surgeon performs an intentional cystotomy and uses a square compression suture to achieve the hemostasis inside the bladder wall.According to a PAS topographical classification, the patients with low-vesical cervical involvement compared with PAS located in relation with the upper blader (type1), upper parametrium (type 2 upper), and also with PAS situated in the lower vesical-trigon space (type 3). PAS 3 and 4 are located in identical area, but in type 3, group A, the vesicouterine space was dissectible, and in type 4, group B, significant fibrosis made surgical dissection extremely challenging. Furthermore, group B was divided into patients treated with total hysterectomy (HT) and those treated with a modified subtotal hysterectomy (MSTH). The surgical requirements to perform an MSHT included the availability of proximal vascular control at the aortic level (internal manual aortic compression, aortic endovascular balloon, aortic loop, or aortic cross-clamping). Then surgeon performed an upper segmental hysterotomy, avoiding the abnormal placenta invasion area; after that, the fetus was delivered, and the umbilical cord was ligated.After uterine exteriorization, the surgeon applies a continuous circular suture with number 2 polyglactin 910, taking some portions of the myometrium -to avoid unintentional slipping- around the lower uterine segment and a 3-4 cm proximal to the abnormal adhesion of the placenta. After tightening hard the circular suture, the uterine segment was circumferentially cut, three centimeters proximal to the circular hemostatic sutures. Next, the surgery follows the upper steps of conventional hysterectomy without changes. Additionally, the histological presence of fibrosis was examined in all samples. RESULTS: Modified subtotal hysterectomy in patients with PAS type 4 (cervical-trigonal fibrosis) resulted in a significant clínico-surgical improvement over total hysterectomy. The median operative time and intraoperative bleeding were 140 min (IQR 90--240) and 1895 mL (IQR 1300-2500) in patients undergoing modified subtotal hysterectomy, and 260 min (IQR 210-287) and 2900 mL (IQR 2150-5500) in patients treated with total hysterectomy, respectively. The complication rate was 20% for MSHT and 82.3% for patients with a total hysterectomy. CONCLUSIONS: PAS in the cervical trigonal area associated with fibrosis implies a greater risk of complications due to uncontrollable bleeding and organ damage. MSTH is associated with lower morbidity and difficulties in PAS type 4. Prenatal or intrasurgical diagnosis is essential to plan surgical alternatives to improve the results.

Comparative study of the levonorgestrel intrauterine system and laparoscopic hysterectomy for the treatment of heavy menstrual bleeding in enlarged uteri.

OBJECTIVE: The levonorgestrel intrauterine system treatment prevents 67.7% of surgeries in patients with heavy menstrual bleeding and enlarged uteri. To evaluate the effectiveness of the levonorgestrel intrauterine system in the treatment of patients with heavy menstrual bleeding and an enlarged uterus and to compare satisfaction and its complications with hysterectomy. METHODS: This was a comparative cross-sectional observational study of women with heavy menstrual bleeding and an enlarged uterus. Sixty-two women were treated and followed up for four years. Insertion of the levonorgestrel intrauterine system was performed in Group 1, and laparoscopic hysterectomy was performed in Group 2. RESULTS: In Group 1 (n=31), 21 patients (67.7%) showed improvement in the bleeding pattern, and 11 patients (35.5%) had amenorrhea. Five patients (16.1%) remained with heavy bleeding and were considered to have experienced treatment failure. There were seven expulsions (22.6%); in five patients, bleeding remained heavy, but in two patients the bleeding returned to that of normal menstruation. No relationship was found between treatment failure and greater hysterometries (p=0.40) or greater uterine volumes (p=0.50), whereas expulsion was greater in uteri with smaller hysterometries (p=0.04). There were 13 (21%) complications, seven (53.8%) in the group that underwent insertion of the levonorgestrel intrauterine system (all were device expulsions), and six (46.2%) in the surgical group, which were the most severe ones (p=0.76). Regarding satisfaction, 12 patients (38.7%) were dissatisfied with the levonorgestrel intrauterine system and one (3.23%) was dissatisfied with the surgical treatment (p=0.00). CONCLUSION: Treatment with the levonorgestrel intrauterine system in patients with heavy menstrual bleeding and an enlarged uterus was effective, and when compared with laparoscopic hysterectomy, it had a lower rate of satisfaction and the same rate of complications, although less severe.

Association Between Enlarged Genital Hiatus and Composite Surgical Failure After Vaginal Hysterectomy With Uterosacral Ligament Suspension.

IMPORTANCE: The impact of a persistently enlarged genital hiatus (GH) after vaginal hysterectomy with uterosacral ligament suspension on prolapse outcomes is currently unclear. OBJECTIVES: This secondary analysis of the Study of Uterine Prolapse Procedures Randomized trial was conducted among participants who underwent vaginal hysterectomy with uterosacral ligament suspension. We hypothesized that women with a persistently enlarged GH size would have a higher proportion of prolapse recurrence. STUDY DESIGN: Women who underwent vaginal hysterectomy with uterosacral ligament suspension as part of the Study of Uterine Prolapse Procedures Randomized trial (NCT01802281) were divided into 3 groups based on change in their preoperative to 4- to 6-week postoperative GH measurements: (1) persistently enlarged GH, 2) improved GH, or (3) stably normal GH. Baseline characteristics and 2-year surgical outcomes were compared across groups. A logistic regression model for composite surgical failure controlling for advanced anterior wall prolapse and GH group was fitted. RESULTS: This secondary analysis included 81 women. The proportion with composite surgical failure was significantly higher among those with a persistently enlarged GH (50%) compared with a stably normal GH (12%) with an unadjusted risk difference of 38% (95% confidence interval, 4%-68%). When adjusted for advanced prolapse in the anterior compartment at baseline, the odds of composite surgical failure was 6 times higher in the persistently enlarged GH group compared with the stably normal group (95% confidence interval, 1.0-37.5; P = 0.06). CONCLUSION: A persistently enlarged GH after vaginal hysterectomy with uterosacral ligament suspension for pelvic organ prolapse may be a risk factor for recurrent prolapse.

Microsurgical technique for reconstruction of Hemi-uterus with non-communicating rudimentary uterine horns.

Case description: Three cases of patients diagnosed with Hemi-uterus with non-communicating functional rudimentary cavity are reported. Clinical findings: Adolescent patients with the presence of disabling pelvic pain during menstrual periods, in addition to depressive states and functional disability secondary to pain. Treatment and outcome: Reconstruction of Hemi-uterus with non-communicating functional rudimentary cavity using a microsurgical technique, without the need for non-communicating horn resection. The patients were assessed at the 1st, third, and sixth months, showing a marked improvement in their dysmenorrhea. In addition, there was an improvement in the depressive state; there was no change in the volume of her menstrual bleeding, and one of these patients achieved pregnancy with normal prenatal control and cesarean delivery, obtaining a full-term newborn without complications. Clinical Relevance: Description of a novel microsurgical technique for the management of the hemi-uterus with a non-communicating functional rudimentary cavity, which could benefit not only the reduction of associated symptoms but could also become an alternative to improve fertility in these patients.

Descripción del caso: Se reportan tres casos de pacientes con diagnóstico de Hemiútero con cavidad rudimentaria funcional no comunicante. Hallazgos clínicos: Pacientes adolescentes con presencia de dolor pélvico incapacitante durante los períodos menstruales, además de estados depresivos e incapacidad funcional secundaria al dolor. Tratamiento y resultado: Reconstrucción de Hemiútero con cavidad rudimentaria funcional no comunicante mediante técnica microquirúrgica, sin necesidad de resección de cuerno no comunicante. Las pacientes fueron evaluadas al 1, 3 y 6 mes, mostrando una marcada mejoría en su dismenorrea. Además, hubo mejoría en el estado depresivo; no hubo cambio en el volumen de su sangrado menstrual, y una de estas pacientes logró el embarazo con control prenatal normal y parto por cesárea, obteniendo un recién nacido a término sin complicaciones. Relevancia clínica: Descripción de una novedosa técnica microquirúrgica para el manejo del Hemiútero con cavidad rudimentaria funcional no comunicante, que podría beneficiar no solo la reducción de los síntomas asociados, sino que podría convertirse en una alternativa para mejorar la fertilidad en estas pacientes.

Broad uterine ligament plication by toggle use during laparoscopic surgery / [Plicatura do ligamento largo do útero com utilização de toggle por videocirurgia]

The aim of the present study is to describe the surgical technique and complications of uterine elevation by laparoscopic surgery, using the broad uterine ligament plication with toogles. Five mares of different breeds, weight and age were selected, presenting poor perineal conformation and pendulous uterus. The surgical technique was performed with a toogle applicator, 0.6mm sterile nylon thread and toogles, using three portals on each side of the flank. After one month, a new laparoscopy was performed, with only one portal on each side, to observe uterine positioning and healing. The average surgical time reached in this study was 82 minutes per procedure, and the uterus of all mares was successfully raised, remaining in a more horizontal orientation and presenting satisfactory healing. There are only two articles published with uteropexy in mares, where the proposed techniques take longer, which consequently increases the surgical risk.

O objetivo do presente estudo é descrever a técnica cirúrgica e as complicações da elevação uterina por cirurgia laparoscópica, utilizando-se a plicatura do ligamento uterino com aplicação de toogles. Foram selecionadas cinco éguas de diferentes raças, peso e idade, as quais apresentavam baixa conformação perineal e útero pendular. A técnica cirúrgica foi realizada com aplicador de toogles, fio de nylon estéril de 0,6mm e toogles, sendo utilizados três portais de cada lado do flanco. Após um mês, uma nova laparoscopia foi realizada, com apenas um portal de cada lado, para observar o posicionamento uterino e a cicatrização. O tempo cirúrgico médio alcançado neste estudo foi de 82 minutos por procedimento, e o útero de todas as éguas foi elevado com sucesso, permanecendo em uma orientação mais horizontal e apresentando cicatrização satisfatória. Existem apenas dois artigos publicados com a utilização da uteropexia em éguas, porém nestes as técnicas propostas demoram mais, o que, consequentemente, aumenta o risco cirúrgico.

Uteropexy in sheep as potential method for prevention of uterine torsion

Background: Uterine torsion is one of many causes of dystocia in sheep. Failure in performing of wright-time diagnostic procedures and treatment by certain obstetric procedures, can result with death of both fetus and ewe. There is sufficient knowledge about risk factors which could contribute to the occurrence of uterine torsion in sheep, but there is insufficient knowledge about measures for prevention of uterine torsion. The aim of this study was to evaluate the effects of performing incorporative uteropexy as potential method for prevention of uterine torsion. Cases: This research was part of the experimental research of changes in the anterior presentation in sheep fetuses due to their ventro-sacral position in the 2nd half of gestation. At the same sheep farm where afore mentioned research was conducted, the farmer has reported the death of 3 pregnant ewes. In all of 3 animals, torsion of the uterus was diagnosed by patho-anatomical examination. This study was conducted on 6 ewes. All of the animals were in the period around the 100th day of pregnancy at the time of clinical examination. The exact day of pregnancy was not determinated because of free mating in the herd. Confirmation of pregnancy in all of 6 ewes was performed by ultrasound examination. Uniparous pregnancy was found in all of 6 ewes. The entire surgical procedures were performed in the field conditions. Laparotomy was performed in the animals positioned in the left lateral recumbency. Surgical procedure of incorporative uteropexy was performed during the closure of muscle layers of abdominal wall. In need for experimental research of changes in the anterior presentation in sheep fetuses due to their ventro-sacral position in the 2nd half of gestation, 14 days after surgical procedures were conducted, all of sheep were positioned by assistants into a sitting position so that their trunks were vertical to the ground and kept in that position for 2 min. Ultrasound examination of surgical place of uteropexy confirmed that, in all of animals, uteruses were in place of surgical procedures. All of 6 ewes included in this study lambed naturally. One of 6 sheep was sent for economic exploitation on the 14th day after lambing. At the slaughter line, the abdominal wall was evaluated at the site where the incorporative uteropexy was performed. Patho-anatomical examination revealed tissue adhesions at the junction of the uterine horn with the abdominal wall. Discussion: Postsurgical tissue adhesions develop during normal healing process of tissue. According to our knowledge, previous studies do not mention effective measures that could contribute to the prevention of uterine torsion in sheep, but attention is focused on prompt diagnosis and treatment of the disease. According to the results of this study, postsurgical tissue adhesions were developed and confirmed by patho-anatomical examination in 1 sheep. Other 5 sheep were not economically exploited or sacrificed, and no studies were performed to establish the presence of postsurgical tissue adhesions. In conclusion, it could be said that incorporative uteropexy could be considered as preventive procedure in order to avoid the development of uterine torsion in ewes which have shown a history of this pathology, but also in ewes with identified risk factors for the disease. In future studies, it is necessary to identify more parameters which will contribute to identification of sheep which have high risk factors to obtain the torsion of uterus. Also, it is necessary to use non-invasive methods of clinical diagnostics, primary ultrasound diagnostic, to evaluate the area of incorporative uteropexy in order to assess newly formed tissue adhesions as well as to assess the vitality of fetus. It is necessary to follow the lambing process of ewes with incorporated uterus, and to provide medical assistance to the animals if complications occur during the lambing time.

Uterine Transplantation with Robot-assisted Uterus Retrieval from Living Donor: First Case in Brazil.

OBJECTIVE: To present the first robot-assisted uterus retrieval from a living donor for uterine transplantation in Brazil. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: A uterine transplantation was performed in a 33-year-old patient with Mayer-Rokitansky-Küster-Hauser syndrome. The donor was a 50-year-old woman who underwent a robotic-assisted uterus retrieval. The procedure was held at Barretos Cancer Hospital, Barretos, Sao Paulo, Brazil. INTERVENTIONS: After approval from the national and local institutional review board, the protocol was submitted to ClinicalTrials.gov (NCT04249791), and the first case was performed. The screening of the patients was done. The uterus was retrieved through a Pfannenstiel incision to avoid complications to the uterine vessels. Uterus was transplanted in the recipient by end-to-end anastomosis of the internal iliac arteries and end-to-side anastomosis of the external iliac vein with a gonadal vein from the infundibulopelvic ligament. Surgical intraoperative parameters were measured. The docking time was 4 minutes. Robotic donor surgery took 400 minutes, bench surgery took 62 minutes, and laparotomic recipient surgery was completed in 240 minutes. There were no intraoperative complications. The donor patient was discharged from the hospital in 48 hours and the recipient patient in 5 days. CONCLUSION: To the best of our knowledge, this is the first case in Brazil of uterine transplantation with a living donor. Traditionally, patients who undergo uterine transplantation by minimally invasive surgery are managed by laparoscopy. This video demonstrates a feasible robotic approach to uterine transplantation with superior imaging affording a 3-dimensional vision and stabilization of instruments allowing wrist-like movements.

Uterus transplantation in a sheep model: novel surgical technique with long-term survival and uterus vitality. First case series in Argentina.

OBJECTIVE: To develop a sheep autologous uterus transplantation (UT) program with an innovative surgical technique and assess long term uterus vitality and animal survival. METHODS: A novel surgical technique consisting of the procurement of the complete uterus and the two ovaries, back table vascular reconstruction, and subsequent implantation in the same animal, performing only two arterial and two venous anastomoses. RESULTS: Four autologous transplantations were performed; anesthesia and surgery were well tolerated by all the animals without complications. Direct observation and Doppler US performed a week after UT and laparoscopy performed three months later confirmed uterus vitality. All animals were alive more than a year after transplantation. CONCLUSIONS: Our study was the first to describe a novel surgical technique for sheep uterus autologous transplantation in Latin America, showing long-term survival and uterus vitality.

Endometrial angiogenesis induced by uterine insufflation with an oxygen-ozone gas mixture in mares.

Ozone (O3 ) therapy has been used to improve peripheral tissue oxygenation in humans and domestic animals. The goal of the present study was to characterize histological changes in the endometria of healthy equines following tissue exposure to gas mixtures enriched with different concentrations of O3 . Cycling mares without endometrial degeneration were divided into three groups according to treatment (n = 9 mares/group). The uteri from the O3 , ½O3 and control groups were insufflated for 3 min with gas containing 42, 21 and 0 µg O3 ml-1 , respectively. Treatments were performed every three days from D0 to D6. Endometrial samples were collected immediately before the first treatment and 24 hr after the last treatment. The following nine histological parameters were evaluated: (i) the number of endometrial blood vessels, (ii) endometrial vascular degree (EVD), (iii) increase rate of blood vessels, (iv) increase rate of EVD, (v) glandular total area, (vi) glandular lumen area, (vii) intraglandular secretion area, (viii) glandular epithelial height and (ix) luminal epithelial height. In the O3 group, a positive effect from treatment (p < .01) was detected for all vascular parameters (i, ii, iii and iv), glandular total area, intraglandular secretion area and glandular epithelial height. Compared to the control group, the ½O3 group had greater (p < .01) EVD (84.1 ± 12%) and a higher increase rate of blood vessels (151.9 ± 47.1%). Uterine insufflation with low or intermediate concentrations of the O2 -O3 gas mixture induced endometrial angiogenesis. Morphometry, but not morphology, of the endometrial glands was affected by local O3 therapy. These findings would be of great significance for the development of new therapies for infertility in mares.

Uterine transposition for gynecological cancers.

OBJECTIVE: Uterine transposition has emerged as an alternative for fertility preservation in women with pelvic malignancies that require radiotherapy. The goal of this study was to evaluate the short-term outcomes of patients undergoing uterine transposition after trachelectomy for cervical cancer or before chemoradiation for vaginal cancer. METHODS: We retrospectively evaluated patients with early stage cervical cancer after radical trachelectomy or with vaginal cancer with indication for pelvic radiation who had uterine transposition performed as fertility sparing strategy. RESULTS: Four patients with cervical cancer and one patient with vaginal cancer were included. Median age was 32 years (range 28-38). All patients had squamous cell carcinomas. All patients with cervical cancer had radical trachelectomies with sentinel lymph node dissection (SLN). Two of these patients also had pelvic lymphadenectomies. Indications for adjuvant radiotherapy was due to Sedlis criteria in two patients and to lymph node metastasis in the other two patients. The patient with stage IIB vaginal cancer was recommended primary chemoradiation. All patients underwent uterine transposition before radiotherapy. The median uterine transposition surgical time was 90 min (range 80-205) and no early complications (30 days) occurred. Average time from uterine transposition to start of radiotherapy was 16 days (10-28). After radiation, the uterus along with the ovaries and tubes were repositioned and the residual cervix sutured to the vagina. One patient declined uterine reimplantation after radiation and underwent a hysterectomy. After a median follow-up of 25 months (range 1-30), all patients were without evidence of disease. All patients with preserved uterus have normal menses after treatment. One patient has attempted to conceive with IVF techniques without success. CONCLUSIONS: Uterine transposition may be an option in selected patients with cervical and vaginal cancers who want to preserve fertility. However, further studies that address its oncological safety and obstetrical outcomes are encouraged.

Herlyn-Werner-Wunderlich syndrome: clinical considerations and management.

Herlyn-Werner-Wunderlich syndrome (HWWS), defined by the triad of uterus didelphys, obstructed hemivagina and ipsilateral renal agenesis, is a rare Mullerian duct malformation, usually diagnosed after menarche, when symptoms related to haematocolpos arise. We report a case of a 14-year-old patient who presented to the emergency department complaining of proctalgia and pelvic pain treated in our medical centre. Ultrasound and abdomino-pelvic MRI imaging studies confirmed the diagnosis. Treatment was surgical incision of the vaginal septum. At the follow-up visit, after the initial procedure, excess vaginal tissue was excised using a hysteroscopic approach during diagnostic vaginoscopy. Vaginoscopy-assisted treatment of the patient proved to be a safe and effective minimally invasive treatment modality that resulted in symptomatic relief and fertility preservation. In conclusion, although premenarche is asymptomatic in the vast majority of cases, HWWS would be optimally diagnosed in childhood to avoid acute late complications, although it is usually first diagnosed after menarche as a result of haematocolpos. Gynaecologists should consider the syndrome in the presence of pelvic mass, renal agenesis, menstrual changes and cyclic pelvic pain.