Junctional zone thickening: an endo-myometrial unit disorder.

Adenomyosis is a disease defined by histopathology, mostly of hysterectomy specimens, and classification is challenged by the disagreement of the histologic definition. With the introduction of Magnetic Resonance Imaging (MRI) and two- and three-dimensional ultrasound, the diagnosis of adenomyosis became a clinical entity. In MRI and US, adenomyosis ranges from thickening of the inner myometrium or junctional zone to nodular, cystic, or diffuse lesions involving the entire uterine wall, up to a well-circumscribed adenomyoma or a polypoid adenomyoma. The absence of an accepted classification and the vague and inconsistent terminology hamper basic and clinical research. The sub-endometrial halo seen at US and MRI is a distinct entity, differing from the outer myometrium by its increased nuclear density and vascular structure. The endometrium and the sub-endometrial muscularis or archimetra are of Müllarian origin, while the outer myometrium is non-Mullerian mesenchymal. The junctional zone (JZ) is important for uterine contractions, conception, implantation, and placentation. Thickening of the JZ can be considered inner myometrium adenomyosis, with or without endometrial invasion. Changes in the JZ should be considered a different entity than myometrial clinically associated with impaired conception, implantation, abnormal uterine bleeding, pelvic pain and obstetrical outcome. Pathology of the basal endometrium and JZ is a separate entity and should be identified as an endo-myometrial unit disorder (EMUD).

From complication to litigation: The importance of non-technical skills in the management of complications.

Complications do occur in daily clinical life and can sometimes lead to litigation, which adversely affect the entire health care system, leading to a loss of confidence in medical providers, an increase in defensive medical practice and high professional indemnity insurance costs. Some complications are inevitable but can be minimised by completing a structured training programme. The likelihood of litigation can be reduced when adequate and clear information is given to the patient preoperatively. Non-technical skills are essential in complication management and crucial if confronted with litigation. Checklists and documentation of medication and surgical steps should be routine in all surgeries. Awareness of the complexity of the planned operation, theatre set-up and equipment are important in preventing complications. Mental preparation of surgeons is of the utmost importance in order to be able to confront any problem. When complications occur, remaining calm, calling for assistance, effective team leadership and harmony in the team are important in managing the situation. Good and effective communication with the patient and relatives, offering explanations, apologies and timely intervention without delays reduce the risk of litigation and strengthen any defence in court.

Simulation and Training of Gynaecological Skills.

In order to offer our patients, the "state of the art" treatment in gynaecology, we need a structured teaching program for trainees concerning the gynaecological skills. In recent years, training and education in endoscopic surgery has been critically reviewed. Clinicians, both surgeons as gynaecologists who perform endoscopic surgery without proper training of the specific psychomotor skills, are at higher risk to increased patient morbidity and mortality. The traditional apprentice-tutor model is no longer valid for developing all skills necessary in gynaecological surgery, particularly in endoscopy. Endoscopic training should happen at both the theoretical and the practical skill level. The acquisition of the correct knowledge regarding general laparoscopy, hysteroscopy and standard level procedures is as important as learning the necessary psychomotor skills to successfully perform endoscopic manipulations. Training in the operating room can only start when it is proven that knowledge and skills are present. To learn and train total abdominal hysterectomy by laparotomy there are inexpensive simple models that can be used, which are easy to reproduce. The development, construction, cost, and utility of a low-cost and anatomically representative vaginal hysterectomy simulator also has been described. The complexity of modern surgery has increased the demands and challenges to surgical education and the quality control.

Prevention and Management of Complications in Laparoscopic Myomectomy.

Myomectomy aims to preserve fertility, treat abnormal uterine bleeding, and alleviate pain. It should cause minimal damage to the endometrium, while being tolerable and durable, and reduce the incidence of myoma recurrence and complications including bleeding, hematoma, adhesions, and gravid uterus perforation. Training and experience are crucial to reduce complications. The surgical strategy depends on imaging information on the myomas. The position of the optical and secondary ports will determine the degree of ergonomic surgery performance, time and difficulty of myoma enucleation, and the suturing quality. Appropriate hysterotomy length relative to myoma size can decrease bleeding, coagulation, and suturing times. Bipolar coagulation of large vessels, while avoiding carbonization and myometrium gaps after suturing, may decrease the risk of myometrial hematoma. Quality surgery and the use of antiadhesive barriers may reduce the risk of postoperative adhesions. Slow rotation of the beveled morcellator and good control of the bag could reduce de novo myoma and endometriosis. Low intra-abdominal CO2 pressure may reduce the risk of benign and malignant cell dissemination. The benefits a patient gains from laparoscopic myomectomy are greater than the complication risks of laparoscopic morcellation. Recent publications on laparoscopic myomectomies demonstrate reduced hospitalization stays, postoperative pain, blood loss, and recovery compared to open surgery.

Benign and malignant pathology of the uterus.

The diagnosis of a uterine myoma size and location can be very precise when a 3D sonograph and knowledge are available. The majority of fibroids are asymptomatic, and expectant management is recommended. In young patients, fibroids cause infertility and in middle-aged women, abnormal uterine bleedings. Laparoscopic myomectomy is the preferred way of surgery for IM and SS fibroids, versus hysteroscopy for SM fibroids. In both cases, the size, number of fibroids and the surgeon's experience determine the limitations of the MIGS. Medical treatments provide only temporary tumor reduction and symptom alleviation. Leiomyosarcoma risk is higher in older women usually carrying fibroids larger than 8 cm. There are no other pathognomonic parameters ruling out a sarcoma. In case of suspected fibroid malignancy, the best treatment option is laparotomy and total hysterectomy. Myomectomy complications can be reduced when MIGS is performed by a surgeon with proper training and experience.

Vaginal lichen sclerosus: report of two cases.

BACKGROUND: Lichen sclerosus most commonly affects the genital area. Contrarily to lichen planus, the involvement of the oral or vaginal mucosa is rare. Only four cases of vaginal lichen sclerosus have been described in the literature. CASE REPORT: The authors report two cases of postmenopausal women with a history of vulvar pruritus and burning. Both presented with lesions of the vaginal mucosa compatible with lichen sclerosus, and genital prolapse. Vaginal biopsies confirmed the diagnosis. Initial treatment with topical clobetasol was effective in one of the patients, but in the other patient line therapy with pimecrolimus, triamcinolone, and retinoids was needed. CONCLUSION: Vaginal lichen sclerosus may be underdiagnosed and genital prolapse may favour the development of vaginal lesions.

Uncommon presentations of an uncommon entity: OHVIRA syndrome with hematosalpinx and pyocolpos.

Müllerian malformations result from defective fusion of the Müllerian ducts during development of the female reproductive system. The least common form of these malformations is Herlyn-Werner-Wunderlich syndrome characterized by obstructed hemivagina and ipsilateral renal anomaly (OHVIRA). The most common presentation of this syndrome is a mass secondary to hematocolpos, pain, and dysmenorrhea. Clinical diagnosis is very challenging and requires imaging studies in which ultrasound and MRI play an essential role in the diagnosis, classification and treatment plan. We report two cases of this syndrome, featuring two very rare clinical presentations: hematosalpinx and pyocolpos. The clinical course of the pathology is not standard and each patient is treated accordingly.

From Clinical Symptoms to MR Imaging: Diagnostic Steps in Adenomyosis.

Adenomyosis or endometriosis genitalis interna is a frequent benign disease of women in fertile age. It causes symptoms like bleeding disorders and dysmenorrhea and seems to have a negative effect on fertility. Adenomyosis can be part of a complex genital and extragenital endometriosis but also can be found as a solitary uterine disease. While peritoneal endometriosis can be easily diagnosed by laparoscopy with subsequent biopsy, the determination of adenomyosis is difficult. In the following literature review, the diagnostic methods clinical history and symptoms, gynecological examination, 2D and 3D transvaginal ultrasound, MRI, hysteroscopy, and laparoscopy will be discussed step by step in order to evaluate their predictive value in the diagnosis of adenomyosis.

Implementation of minimal invasive gynaecological surgery certification will challenge gynaecologists with new legal and ethical issues.

The introduction of a certification / diploma program in Minimal Invasive Surgery (MIS) is expected to improve surgical performance, patient's safety and outcome. The Gynaecological Endoscopic Surgical Education and Assessment programme (GESEA) and the ESHRE Certification for Reproductive Endoscopic Surgery (ECRES) provides a structured learning path, recognising different pillars of competence. In order to achieve a high level of competence a two steps validation is necessary: (a) the individual should be certified of having the appropriate theoretical knowledge and (b) the endoscopic psychomotor skills before entering in the diploma programme reflecting the surgical competence. The influence of such an educational and credentialing path could improve safety and offer financial benefits to the hospitals, physicians and healthcare authorities. Moreover the medicolegal consequences can be important when a significant amount of surgeons possess the different diplomas. As the programs are becoming universally accessible, recognised as the best scientific standard, included in the continuous medical education (CME) and continuous professional development (CPD), it is expected that a significant number of surgeons will soon accomplish the diploma path. The co-existence and practice of both non-certified and certified surgeons with different degrees of experience is unavoidable. However, it is expected that national health systems (NHS), hospitals and insurance companies will demand and hire doctors with high and specific proficiency to endoscopic surgery. When medico-legal cases are under investigation, the experts should be aware of the limitations that individual experience provides. The court first of all examines and then judges if there is negligence and decides accordingly. However, lack of certification may be considered as negligence by a surgeon operating a case that eventual faces litigation problems. Patients' safety and objective preoperative counselling are mandatory, directly connected to MIS certification while eliminating any dispute of surgeons' credibility.

The comprehensiveness of the ESHRE/ESGE classification of female genital tract congenital anomalies: a systematic review of cases not classified by the AFS system.

STUDY QUESTION: How comprehensive is the recently published European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) classification system of female genital anomalies? SUMMARY ANSWER: The ESHRE/ESGE classification provides a comprehensive description and categorization of almost all of the currently known anomalies that could not be classified properly with the American Fertility Society (AFS) system. WHAT IS KNOWN ALREADY: Until now, the more accepted classification system, namely that of the AFS, is associated with serious limitations in effective categorization of female genital anomalies. Many cases published in the literature could not be properly classified using the AFS system, yet a clear and accurate classification is a prerequisite for treatment. STUDY DESIGN, SIZE AND DURATION: The CONUTA (CONgenital UTerine Anomalies) ESHRE/ESGE group conducted a systematic review of the literature to examine if those types of anomalies that could not be properly classified with the AFS system could be effectively classified with the use of the new ESHRE/ESGE system. An electronic literature search through Medline, Embase and Cochrane library was carried out from January 1988 to January 2014. Three participants independently screened, selected articles of potential interest and finally extracted data from all the included studies. Any disagreement was discussed and resolved after consultation with a fourth reviewer and the results were assessed independently and approved by all members of the CONUTA group. PARTICIPANTS/MATERIALS, SETTING, METHODS: Among the 143 articles assessed in detail, 120 were finally selected reporting 140 cases that could not properly fit into a specific class of the AFS system. Those 140 cases were clustered in 39 different types of anomalies. MAIN RESULTS AND THE ROLE OF CHANCE: The congenital anomaly involved a single organ in 12 (30.8%) out of the 39 types of anomalies, while multiple organs and/or segments of Müllerian ducts (complex anomaly) were involved in 27 (69.2%) types. Uterus was the organ most frequently involved (30/39: 76.9%), followed by cervix (26/39: 66.7%) and vagina (23/39: 59%). In all 39 types, the ESHRE/ESGE classification system provided a comprehensive description of each single or complex anomaly. A precise categorization was reached in 38 out of 39 types studied. Only one case of a bizarre uterine anomaly, with no clear embryological defect, could not be categorized and thus was placed in Class 6 (un-classified) of the ESHRE/ESGE system. LIMITATIONS, REASONS FOR CAUTION: The review of the literature was thorough but we cannot rule out the possibility that other defects exist which will also require testing in the new ESHRE/ESGE system. These anomalies, however, must be rare. WIDER IMPLICATIONS OF THE FINDINGS: The comprehensiveness of the ESHRE/ESGE classification adds objective scientific validity to its use. This may, therefore, promote its further dissemination and acceptance, which will have a positive outcome in clinical care and research. STUDY FUNDING/COMPETING INTERESTS: None.

The European Academy laparoscopic "Suturing Training and Testing'' (SUTT) significantly improves surgeons' performance.

UNLABELLED: The efficiency of suturing training and testing (SUTT) model by laparoscopy was evaluated, measuring the suturingskill acquisition of trainee gynecologists at the beginning and at the end of a teaching course. During a workshop organized by the European Academy of Gynecological Surgery (EAGS), 25 participants with three different experience levels in laparoscopy (minor, intermediate and major) performed the 4 exercises of the SUTT model (Ex 1: both hands stitching and continuous suturing, Ex 2: right hand stitching and intracorporeal knotting, Ex 3: left hand stitching and intracorporeal knotting, Ex 4: dominant hand stitching, tissue approximation and intracorporeal knotting). The time needed to perform the exercises is recorded for each trainee and group and statistical analysis used to note the differences. Overall, all trainees achieved significant improvement in suturing time (p < 0.005) as measured before and after completion of the training. Similar significantly improved suturing time differences (p < 0.005) were noted among the groups of trainees with different laparoscopic experience. In conclusion a short well-guided training course, using the SUTT model, improves significantly surgeon's laparoscopic suturing ability, independently of the level of experience in laparoscopic surgery. KEY WORDS: Endoscopy, laparoscopic suturing, psychomotor skills, surgery, teaching, training suturing model.

Computer-aided diagnosis in hysteroscopic imaging.

The paper presents the development of a computer-aided diagnostic (CAD) system for the early detection of endometrial cancer. The proposed CAD system supports reproducibility through texture feature standardization, standardized multifeature selection, and provides physicians with comparative distributions of the extracted texture features. The CAD system was validated using 516 regions of interest (ROIs) extracted from 52 subjects. The ROIs were equally distributed among normal and abnormal cases. To support reproducibility, the RGB images were first gamma corrected and then converted into HSV and YCrCb. From each channel of the gamma-corrected YCrCb, HSV, and RGB color systems, we extracted the following texture features: 1) statistical features (SFs), 2) spatial gray-level dependence matrices (SGLDM), and 3) gray-level difference statistics (GLDS). The texture features were then used as inputs with support vector machines (SVMs) and the probabilistic neural network (PNN) classifiers. After accounting for multiple comparisons, texture features extracted from abnormal ROIs were found to be significantly different than texture features extracted from normal ROIs. Compared to texture features extracted from normal ROIs, abnormal ROIs were characterized by lower image intensity, while variance, entropy, and contrast gave higher values. In terms of ROI classification, the best results were achieved by using SF and GLDS features with an SVM classifier. For this combination, the proposed CAD system achieved an 81% correct classification rate.

Color multiscale texture classification of hysteroscopy images of the endometrium.

The objective of this study was to investigate the diagnostic performance of a Computer Aided Diagnostic (CAD) system based on color multiscale texture analysis for the classification of hysteroscopy images of the endometrium, in support of the early detection of gynaecological cancer. A total of 416 Regions of Interest (ROIs) of the endometrium were extracted (208 normal and 208 abnormal) from 45 subjects. RGB images were gamma corrected and were converted to the YCrCb color system. The following texture features were extracted from the Y, Cr and Cb channels: (i) Statistical Features (SF), (ii) Spatial Gray Level Dependence Matrices (SGLDM), and (iii) Gray Level Difference Statistics (GLDS). The Probabilistic Neural Network (PNN), statistical learning and the Support Vector Machine (SVM) neural network classifiers were also applied for the investigation of classifying normal and abnormal ROIs in different scales. Results showed that the highest percentage of correct classification (%CC) score was 79% and was achieved for the SVM models trained with the SF and GLDS features for the 1x1 scale. This %CC was higher by only 2% when compared with the CAD system developed, based on the SF and GLDS feature sets computed from the Y channel only. Further increase in scale from 2x2 to 9x9, dropped the %CC in the region of 60% for the SF, SGLDM, and GLDS, feature sets, and their combinations. Concluding, a CAD system based on texture analysis and SVM models can be used to classify normal and abnormal endometrium tissue in difficult cases of gynaecological cancer. The proposed system has to be investigated with more cases before it is applied in clinical practise.

Color based texture--classification of hysteroscopy images of the endometrium.

The objective of this study was to develop a CAD system for the classification of hysteroscopy images of the endometrium based on color texture analysis for the early detection of gynaecological cancer. A total of 416 Regions of Interest (ROIs) of the endometrium were extracted (208 normal and 208 abnormal) from 40 subjects. RGB images were gamma corrected and were converted to the HSV and YCrCb color systems. The following texture features were extracted for each channel of the RGB, HSV, and YCrCb systems: (i) Statistical Features, (ii) Spatial Gray Level Dependence Matrices and (iii) Gray Level Difference Statistics. The PNN statistical learning and SVM neural network classifiers were also investigated for classifying normal and abnormal ROIs. Results show that there is significant difference (using the Wilcoxon Rank Sum Test at a=0.05) between the texture features of normal and abnormal ROIs of the endometrium. Abnormal ROIs had higher gray scale median, variance, entropy and contrast and lower gray scale median and homogeneity values when compared to the normal ROIs. The highest percentage of correct classifications score was 79% and was achieved for the SVM models trained with the SF and GLDS features for differentiating between normal and abnormal ROIs. Concluding, a CAD system based on texture analysis and SVM models can be used to classify normal and abnormal endometrium tissue. Further work is needed to validate the system in more cases and organs.

Texture-based classification of hysteroscopy images of the endometrium.

The objective of this study was to classify hysteroscopy images of the endometrium based on texture analysis for the early detection of gynaecological cancer. A total of 418 regions of interest (ROIs) were extracted (209 normal and 209 abnormal) from 40 subjects. Images were gamma corrected and were converted to gray scale. The following texture features were extracted: (i) statistical features, (ii) spatial gray level dependence matrices (SGLDM), and (iii) gray level difference statistics (GLDS). The PNN and SVM neural network classifiers were also investigated for classifying normal and abnormal ROIs. Results show that there is significant difference (using Wilcoxon rank sum test at a=0.05) between the texture features of normal and abnormal ROIs for both the gamma corrected and uncorrected images. Abnormal ROIs had lower gray scale median and homogeneity values, and higher entropy and contrast values when compared to the normal ROIs. The highest percentage of correct classifications score was 77% and was achieved for the SVM models trained with the SF and GLDS features. Concluding, texture features provide useful information differentiating between normal and abnormal ROIs of the endometrium.

The effect of color correction of endoscopy images for quantitative analysis in endometrium.

The objective of this study was to develop a standardized protocol for the capturing and analysis of endoscopy digital images for subsequent use in a Computer Aided Diagnosis (CAD) system in gynaecological cancer. Images were captured at optimum illumination and focus at 720x576 pixels using 24 bits color in the following cases: (i) for a variety of testing targets from a color palette with known color distribution, (ii) different viewing angles and distances from calf endometrium, and (iii) images from the human endometrium. Images were then gamma corrected and their classification performance was compared against that of nonqamma corrected images. No significant difference in texture features was found between the close up and panoramic views, and between angles, either before or after gamma correction. There was significant difference in certain texture features between normal and abnormal endometrium, both before and after gamma correction. Our findings suggest that proper color correction can significantly impact CAD system performance, and we recommend its application prior to quantitative texture analysis in gynaecological endoscopy.

H19 and IGF2 gene expression in human normal, hyperplastic, and malignant endometrium.

We examined H19 and insulin-like growth factor 2 (IGF2) gene expression in normal endometrium (12 cases), hyperplasia (27 cases), and cancer (27 cases) by non-radioactive in situ hybridization. H19 was not expressed in the epithelium of normal endometrium, but its frequency of expression was 15% in hyperplastic and 60% in neoplastic epithelium. In stroma cells, H19 frequency of expression was 75% in normal endometrium, 55% in hyperplasia, and 37% in carcinoma. According to the grade of endometrial cancer cell differentiation, H19 showed increased frequency and level of expression in the epithelium from well to moderately and poorly differentiated tissues. Our results indicate that H19 expression in epithelial cells of endometrial hyperplasia and cancer merits further investigation and could be useful as a complementary histopathologic and prognostic marker among other modalities in endometrial cancer. IGF2 expression did not appear useful for diagnostic or prognostic purposes.

Transvaginal laparoscopy proposed as an investigation procedure for patients at high-risk for ovarian cancer.

Transvaginal laparoscopy (TVL) was performed in 23 patients at high risk for ovarian cancer (OC). The patients were placed in the lithotomy position after sedation and a veres needle was inserted in the posterior vaginal vault. A trocar followed and warm normal saline was injected into the pelvis. The needle was removed and a telescope connected to a light source and monitor was introduced. Excellent visualization was achieved in all cases examined and the average time of TVL was 30 min. All patients except one found TVL a simple and painless procedure. TVL helped in the diagnosis of six benign ovarian lesions and ruled out OC in the other 17 cases. TVL is an easy method to learn with reliable results. TVL can reduce the number of unnecessary laparoscopies and/or laparotomies and it seems to be useful in ruling out OC.