Dienogest alone or dienogest combined with estrogens in the treatment of ovarian endometriomas, that is the question. A retrospective cohort study.

PURPOSE: to compare the effects of Dienogest 2 mg (D) alone or combined with estrogens (D + ethinylestradiol 0.03 mg, D + EE; D + estradiol valerate 1-3 mg, D + EV) in terms of symptoms and endometriotic lesions variations. METHODS: This retrospective study included symptomatic patients in reproductive age with ultrasound diagnosis of ovarian endometriomas. Medical therapy for at least 12 months with D, D + EE or D + EV was required. Women were evaluated at baseline visit (V1) and after 6 (V2) and 12 months (V3) of therapy. RESULTS: 297 patients were enrolled (156 in the D group, 58 in the D + EE group, 83 in the D + EV group). Medical treatment leaded to a significant reduction in size of endometriomas after 12 months, with no differences between the three groups. When comparing D and D + EE/D + EV groups, a significant decrease of dysmenorrhea was detected in the D group than in D + EE/D + EV group. Conversely, the reduction of dysuria was more significative in the D + EE/D + EV groups rather than in the D group. Regarding tolerability, treatment associated side effects were reported by 16.2% patients. The most frequent one was uterine bleeding/spotting, significantly higher in the D + EV group. CONCLUSION: Dienogest alone or associated with estrogens (EE/EV) seems to be equally effective in reducing endometriotic lesions mean diameter. The reduction of dysmenorrhea was more significative when D was administered alone, while dysuria seems to improve more when D is associated with estrogens.

Endometriosis in the time of internet: how web navigation affects women with endometriosis.

OBJECTIVES: Patients often search for health-related information on the internet allthough this trend may have some benefits, it also has some risks, such as misinformation. The aim of this study is to evaluate how Internet information seeking affect the level of anxiety in patients with endometriosis. MATERIALS AND METHODS: This prospective observational study was conducted at our outpatient clinic between March 2019 and December 2020. We enrolled We enrolled all patients with a confirmed sonographic diagnosis of endometriosis who had sought information about the disease prior to our visit. We divided them into two groups based on the source of information (Internet only vs multiple sources). Before the visit, we asked women to fill-in validated questionnaires about anxiety, such as the Generalized Anxiety Disorder-7 (GAD) and the Spielberg State Trait Anxiety Inventory (STAI- Y6) and the Endometriosis Health Profile (EHP) - 5. After the visit, the STAI-Y6 was resubmitted to each woman. RESULTS: We enrolled 200 women who filled-in the questionnaires: 46 reported the Internet as the only source of information, 52 sought information also from medically qualified sources, 74 consulted only healthcare professionals, and 28 resorted to medical journals. Women who used the Internet as their exclusive source of information were younger on average and their STAI-Y6 score after the visit was significantly lower compared to other group (34.1 ± 11.5 vs 42.1 ± 14.7, p = .001). Moreover, the difference between the STAI-Y6 scores before and after our assessment was higher in these women (-18.3 ± 14.7 vs -10.3 ± 16.5, p = .003). CONCLUSIONS: Women who sought information online were younger, had lower levels of state trait anxiety after our medical evaluation, and a had a greater reduction in anxiety levels after our examination compared to women who consulted other sources to learn more about endometriosis.KEY MESSAGESWomen using only Internet are younger than those who use other sources of information.Women who researched symptoms online showed higher pre-examination anxiety levels.Patients with severe pain symptoms consulted both the internet and professionals.

Detection of Non-Hodgkin Lymphoma Within Ovarian Tissue.

This case report describes the detection of non-Hodgkin lymphoma (NHL) within ovarian tissue after cryopreservation. The 27-year-old woman presented no gynecological symptoms such as pelvic pain or abnormal uterine bleeding. During laparoscopy for ovarian tissue cryopreservation, the ovaries appeared markedly modified and some solid content cysts were highlighted. Microscopically the cysts revealed the presence of lymphoid infiltrate, whereas the histological assessment of some fragments of the ovarian cortical tissue revealed no evidence of pathological lymphoid infiltration. This case report describes the presence of pathological lymphoid infiltration in ovarian cysts but not in the cortical tissue of a young woman with secondary NHL. Despite the absence of the positivity in cortical tissue it was recommended to avoid the cryopreserved ovarian tissue transplantation to reduce the risk of reseeding of the malignancy in the woman.

Effects of Pelvic Floor Muscle Physiotherapy on Urinary, Bowel, and Sexual Functions in Women with Deep Infiltrating Endometriosis: A Randomized Controlled Trial.

Background and Objectives: Endometriosis is a chronic and recurrent disease defined as the presence and proliferation of endometrial glands and stroma outside the uterine cavity. It affects up to 6-10% of women of reproductive age and can be classified into superficial, ovarian, and deep infiltrating endometriosis (DIE). Deep infiltrating endometriosis can be associated with pain symptoms and pelvic floor muscle hypertone. Moreover, it may be responsible of bowel, urinary, and sexual dysfunctions with impairment of women's quality of life. Few studies have investigated the role of physiotherapy in women with DIE. Here, we aimed first to evaluate the effects of pelvic floor physiotherapy (PFP) on urinary, bowel, and sexual functions. Secondly, we aimed to evaluate the effects of ultrasound visual feedback during PFP on pelvic floor and subjective modifications in the frequency of sexual intercourse. Materials and Methods: This randomized controlled trial was conducted between June 2018 and December 2019 at our tertiary center. Nulliparous women with DIE and superficial dyspareunia were enrolled. At first examination, levator hiatal area (LHA) assessed with 3D/4D transperineal ultrasound, pain symptoms, urinary, bowel, and sexual functions were evaluated. Then, women were randomly assigned to no intervention (control group) or treatment with five individual sessions of PFP (experimental group), and after four months women underwent a second examination. Urinary, bowel, and sexual functions were assessed with validated questionnaires at first and second examinations. In particular, the Bristol Female Lower Urinary Tract Symptoms questionnaire was used to evaluate urinary symptoms, the Knowles-Eccersley-Scott-Symptom questionnaire to assess the presence of constipation, and the Female Sexual Function Index to investigate sexual function. Study outcomes were the comparisons among groups in terms of differences in actual changes in median of questionnaire scores between first and second examinations. Results: Thirty women (17 in the experimental group and 13 in the control group) completed the study. No significant differences were found between the two groups regarding urinary, bowel, and sexual functions, although women in the experimental group showed a tendency towards an improvement in constipation symptoms. Conclusion: In women with DIE, PFP does not appear to affect urinary, bowel, and sexual functions. Therefore, despite the improvement in superficial dyspareunia, chronic pelvic pain, and PFM relaxation with high treatment satisfaction, women should be informed about the unclear impact of PFP on urinary, bowel, and sexual functions. Larger studies are necessary to further investigate the impact of PFP on these functions.

Three-Dimensional Ultrasound Evaluation of Pelvic Floor Muscle Contraction in Women Affected by Deep Infiltrating Endometriosis: Application of a Quick Contraction Scale.

OBJECTIVES: Using transperineal 3D/4D ultrasound, we evaluated the prevalence of the various categories of a 4-point pelvic contraction scale among women affected by ovarian endometriosis (OE), deep infiltrating endometriosis (DIE), and healthy controls. METHODS: This prospective study was conducted on nulliparous women scheduled for surgery to remove endometriosis, and nulliparous healthy volunteers who did not show any clinical or sonographic signs of endometriosis, who served as controls. Patients were subjected to 3D/4D transperineal ultrasound obtaining measurements of the antero-posterior diameter (APD), both at rest and during maximal pelvic floor muscle (PFM) contraction (PFMC). The difference of APD from rest to maximal PFMC was then calculated as percent change from baseline (ΔAPD) and patients were thus categorized using the 4-point pelvic contraction scale. RESULTS: One hundred sixty-four patients were considered for the study. Mean difference in APD between relaxed state and maximal PFMC was 23.3 ± 7.9% (range 2.4-40.0) in controls, 20.5 ± 9.0% (range 0.0-37.3) in patients with OE, and 14.6 ± 10.4% (range 0.0-37.1) in patients with DIE (F-test = 19.5, P-value < .001). A significant negative correlation was found between the contraction scale and dyspareunia (rs = -0.17, P = .032), and it appeared to be stronger among patients with DIE (rs = -0.20, P = .076). CONCLUSIONS: PFM function in endometriotic patients could be assessed reliably through this 4-point scale. The rapid identification of women suffering from PFM dysfunction, along with deep dyspareunia, could enable gynecologists to offer them additional therapies, such as PFM rehabilitation.

Evaluation of Women's Age and Ultrasonographic Features to Choose Surgical Treatment for Endometriosis Associated with Ovarian Cancer.

Adequate surgical management of malignant endometriosis remains a clinical challenge in gynecology. Age, sonography variables, and tumor biomarkers have been reported as candidates in the clinical decision. This study aims were to analyze the factors of women's age, body mass index, ultrasound features, and tumor biomarkers to predict endometriosis-associated ovarian cancer in a large series of endometriomas and to study the surgical treatment performed in this cohort. In this retrospective study, we reviewed the medical records of patients with ultrasound diagnosis of ovarian cyst classified as endometrioma (benign as well as with risk of malignancy), surgically treated in the endometriosis unit of Hospital Universitario La Paz (Madrid, Spain) between January 2019 and July 2021. According to the final histology examination, the women were clustered as non-endometriosis-associated ovarian cancer (OE, benign endometriomas, n = 59) and endometriosis-associated ovarian cancer (EAOC) (n = 17). Demographic, clinical, and surgical data were collected from these women. International Ovarian Tumor Analysis (IOTA) criteria were assessed for the ultrasound examination. The age of the women in the EAOC group was 50.0 [43.0; 63.0] years, which was significantly higher than OE (39.0 [34.0; 46.0] years; p-value < 0.001). In addition, the body mass index for the OE group (24.9 ± 5.3 kg/m2) was significantly higher than for the EAOC group (23.3 ± 4.6 kg/m2; p-value < 0.001). However, the tumor biomarker levels (CA 125, CA 19.9 and He4) were not significantly different among the groups. We performed 51.4% cystectomies and 48.6% adnexectomies, with an association between the adnexectomy and EAOC group (p-value < 0.001). In addition, a significant association was found between ultrasound features suspicious for malignancy and the EAOC group. Conclusively, women's age and ultrasound features, such as papillary projections, septa, and positive echo-Doppler, were the main factors to consider when evaluating the malignancy risk associated with endometriosis.

Pelvic floor dysfunction at transperineal ultrasound and chronic constipation in women with endometriosis.

OBJECTIVE: To assess the association between sonographic findings at transperineal ultrasound (TPU) and chronic constipation (CC) in women with endometriosis. METHODS: An observational prospective cohort study was performed by enrolling all women with endometriosis scheduled for surgery between September 2019 and October 2020. Women underwent TPU at rest and during Valsalva maneuver evaluating levator-hiatal-area (LHA), antero-posterior diameter (APD), and levator ani muscle (LAM) coactivation. Ultrasound findings were compared between women with and without CC in the whole study population, and subsequently in two subgroups (only ovarian endometriosis and deep infiltrating endometriosis [DIE]). RESULTS: In all, 87 women were enrolled: 29 (33%) with CC and 58 (67%) without CC. Women with endometriosis and CC showed a smaller LHA during Valsalva, less LHA and APD enlargement from rest to maximum Valsalva, and a higher prevalence of LAM coactivation compared with women without CC. In the ovarian subgroup, women with CC had smaller LHA at Valsalva, less enlargement of LHA and APD from rest to maximum Valsalva, and higher prevalence of LAM coactivation compared with non-CC patients. In the DIE subgroup, TPU did not significantly differ between CC and non-CC patients. CONCLUSION: TPU signs of pelvic floor muscle hypertonia are more frequent in endometriosis patients with CC compared with those without constipation, particularly in women affected by isolated ovarian endometriosis.

Cost-effectiveness analysis of ovarian tissue cryopreservation and transplantation for preservation of fertility in post-pubertal oncological women submitted to high-risk gonadotoxic chemotherapy.

OBJECTIVE: To study the economic impact of ovarian tissue cryopreservation and transplantation (OTC) in post-pubertal patients who underwent high-risk gonadotoxic chemotherapy. METHODS: A decision tree model was used to determine the live birth rate and cost-effectiveness of OTC versus non-OTC. The incremental cost-effectiveness ratio (ICER) was calculated. A sensitivity analysis was performed under the assumption that the costs of ovarian cortex retrieval, cryopreservation, and storage for patients with cancer might be covered by the national health system or health insurance. RESULTS: Patients had the greatest probability of achieving live birth after high-risk chemotherapy when they underwent OTC versus non-OTC. Although cryopreservation of ovarian tissue results in higher live birth rates, it is always more expensive. Cost-effectiveness increases when the majority of patients completes the path of tissue cryopreservation plus transplantation after 5 years. CONCLUSION: Although OCT has been demonstrated as a procedure for effective fertility preservation in fertility-age women with cancer, no cost-effectiveness analysis has been performed until now. This model could help healthcare systems to allocate coverage for OCT.

Comparison between Laparoscopic and Robotic Approach for Sentinel Lymph Node Biopsy in Endometrial Carcinoma Women.

Robotic surgery has been approved as an alternative to laparoscopy to improve surgical outcomes. There is neither a consensus nor a systematic assessment of the literature about the superiority of the robotic approach over the laparoscopic one for sentinel lymph node (SLN) biopsy in endometrial carcinoma (EC) women. Therefore, a systematic review and meta-analysis was performed to compare the laparoscopic and robotic approaches for SLN biopsy in EC patients. Five electronic databases were queried from their inception to May 2022 for peer-reviewed studies, comparing such approaches in SLN biopsy in EC patients. The rate of detected SLN, dissected SLN, intraoperative and postoperative complications, conversion to laparotomy, number of dissected SLN, and SLN identification and dissection time were compared between the laparoscopic and robotic approaches for SLN biopsy in EC patients. Odds ratios with 95% confidence intervals were calculated when possible. Two studies with 660 EC women (364 who had undergone laparoscopy, and 296 who had robotic surgery) were included. No assessed outcome showed significant differences between the two approaches. In conclusion, the laparoscopic and robotic approaches for SLN biopsy in EC patients appeared to not differ, in terms of SLN detection, intraoperative and postoperative complications, conversion to laparotomy, number of dissected SLN, and SLN identification and dissection time.

Preoperative ureteral stenting in women with deep posterior endometriosis and ureteral involvement: Is it useful?

OBJECTIVE: Systematic placement of a ureteral stent before surgery for posterior deep infiltrating endometriosis (DIE) was previously recommended, but it could increase perioperative complications. We evaluate the role of preoperative ureteral stent in women requiring surgery for ureteral involvement (UI) with large posterior DIE nodules and/or grade I-II hydronephrosis. METHODS: Women undergoing minimally invasive surgery for DIE with UI having posterior nodules >3 cm and/or grade I-II hydronephrosis from 2014 to 2019 were retrospectively included. We progressively changed our strategy from a systematic pre-operative stent insertion (S-PS, up to 2016) to a non-systematic one (NS-PS, from 2016). RESULTS: Eighty-eight women in the S-PS group and 96 in the NS-PS were included. Low urinary tract infections (UTI) were higher in the S-PS group (13.6% vs 2.1%, P = 0.003). Hospital stay was longer in women with S-PS (9.8 ± 5.3 days vs 6.7 ± 2.5 days, P < 0.001). Logistic regression analysis confirmed a significant association between NS-PS and low UTI (adjusted OR 0.20, 95% CI 0.05-0.81, P = 0.024). CONCLUSION: Systematic placement of a ureteral stent before surgery in women requiring surgery does not reduce overall perioperative complication rate, but it is associated with a longer duration of hospitalization and a higher low UTI rate.

Comparison of perioperative outcomes between standard laparoscopic and robot-assisted approach in patients with rectosigmoid endometriosis.

INTRODUCTION: Robot-assisted laparoscopic surgery (RALS) has gained widespread application in several surgical specialties. Previous studies on the feasibility and safety of RALS vs standard laparoscopy (S-LPS) for rectosigmoid endometriosis are limited and reported conflicting data. This study aims to compare S-LPS and RALS in patients with rectosigmoid endometriosis in terms of perioperative surgical and clinical data. MATERIAL AND METHODS: This is a multicentric, observational, prospective cohort study including 44 patients affected by rectosigmoid endometriosis referred to two tertiary referral centers for endometriosis from September 2018 to September 2019. Patients were divided into two groups: 22 patients underwent S-LPS, and 22 underwent RALS. Our primary outcome was to compare operative time (from skin incision to suture) between the two groups. Secondary outcomes included: operative room time (patient entry into operative room and patient out), estimated blood loss, laparotomic conversion rate, length of hospital stay, perioperative complications, and evaluation of endometriosis-related symptoms at 12-month follow up. RESULTS: The two groups were comparable regarding preoperative and surgical data, except for higher rates of hysterectomies and bilateral uterosacral ligament removal procedures in the RALS group. Also after adjusting for these discrepancies, operative time was similar between S-LPS and RALS. Operative room time was statistically longer in the RALS group compared with that of S-LPS. No statistically significant difference was found concerning other study outcomes. Pain and bowel symptoms improved in both groups at 12-month follow up. CONCLUSIONS: If performed by expert teams, RALS provides similar perioperative outcomes compared with S-LPS in rectosigmoid endometriosis surgical treatment, except for longer operative room time.

Ureteral endometriosis, the hidden enemy: multivariable fractional polynomial approach for evaluation of preoperative risk factors in the absence of ureteral dilation.

OBJECTIVE: To determine whether it is possible to predict the risk of ureteral endometriosis (UE) using a mathematical model based on preoperative findings. DESIGN: Prospective observational study conducted between January 2017 and April 2020. SETTING: Tertiary-level academic referral center. PATIENT(S): Three hundred consecutive women of reproductive age with a diagnosis of posterior deep infiltrating endometriosis (DIE) scheduled for laparoscopic surgery. INTERVENTION(S): Before surgery, anamnestic data and the severity of endometriosis-related symptoms were evaluated, and all patients underwent a complete gynecological examination. Transvaginal and transabdominal ultrasound were performed to map the endometriotic lesion. Ureteral involvement was surgically and histologically confirmed. MAIN OUTCOME MEASURE(S): To select important risk factors for UE and determine a suitable functional form for continuous predictors, we used the multivariable fractional polynomial. RESULTS: UE was surgically found in 145 women (48.3%). Based on our multivariable polynomial mathematical model, UE was significantly associated with adenomyosis, parametrial involvement, and previous surgery for endometriosis. A posterior DIE nodule with a transverse diameter >1.8 cm was associated with a higher probability of ureteral involvement. CONCLUSIONS: Posterior DIE nodule with a transverse diameter >1.8 cm, adenomyosis, parametrial involvement, and previous surgery for endometriosis appear to be good predictors of UE.

Long-Term Medical Therapy after Laparoscopic Excision of Ovarian Endometriomas: Can We Reduce and Predict the Risk of Recurrence?

OBJECTIVES: Up to 32% of women experience anatomic recurrence after conservative surgery for endometriomas, while pain recurs in 10-40% of cases. Long-term postoperative hormonal therapy is recommended to prevent disease recurrence. We evaluated the efficacy of long-term therapy with estroprogestins (EPs) or progestins (Ps) in preventing endometrioma recurrence, as identifiable cysts and subjective symptoms, after laparoscopic excision. DESIGN: This retrospective cohort study included 375 women submitted to laparoscopic endometrioma excision. Women were followed up at 6 and 12 months and then yearly after surgery. Based on postoperative medical therapy, women were divided into 4 groups: nonusers, cyclic EP users, continuous EP users, and progestogen users. Materials, Setting, Methods: Anamnestic and anthropometric characteristics were collected as well as clinical and surgical data. Gynecological examination, and transvaginal and transabdominal ultrasound scans were performed. Pain (numerical rating score >5) and endometrioma recurrence at ultrasound (ovarian cyst with typical sonographic features ≥10 mm in mean diameter) were recorded at each examination. The reoperation rate in women with recurrence was investigated. RESULTS: The median follow-up was 3.7 years with a maximum of 16.7 years. Most patients used EPs (119 cyclic and 61 continuous users), 95 used P, and 100 were nonusers. In 135 women (36%), endometriotic cyst recurrence was diagnosed, with a mean diameter of 18.7 ± 10.8 mm (range 10-55 mm). The median recurrent cyst-free time was 7.9 years (95% CI 5.8-10.8). Dysmenorrhea was the first symptom to reappear, affecting 162 patients (43.2%). Upon multivariable regression analysis, continuous users had a lower risk of relapse (OR 0.56, 95% CI 0.32-0.99), in terms of both cysts and symptom recurrence, than patients who received no medications. The reoperation rate was 16.2%. LIMITATIONS: The main limitation of this study is its retrospective design. Also, women switching therapies throughout the follow-up period were sorted into one of the study groups based on the longest treatment taken, without considering the discontinuation rates. CONCLUSIONS: Long-term EPs, administered in a continuous regimen and starting immediately after conservative surgery for endometriomas, seem to reduce the disease recurrence risk.

Indocyanine Green Fluorescence Angiography after Full-thickness Bowel Resection for Rectosigmoid Endometriosis-A Feasibility Study.

STUDY OBJECTIVE: To evaluate feasibility of near-infrared (NIR)-indocyanine green (ICG) imaging for bowel vascularization assessment after full-thickness bowel resection for rectosigmoid endometriosis (RSE). DESIGN: This is a prospective, single-center, preliminary study on consecutive patients who were symptomatic submitted to discoid or segmental resection for RSE and NIR-ICG evaluation for vascular assessment of the anastomotic line from May 2018 to January 2020. SETTING: Tertiary university hospital. PATIENTS: Thirty-two women with RSE meeting eligibility criteria were included for study analysis. INTERVENTIONS: NIR-ICG evaluation of anastomotic line vascularization after RSE removal. MEASUREMENTS AND MAIN RESULTS: Fluorescence degree of the anastomotic line was assessed with a 0 to 2 Likert scale, as follows: 0 or "absent" (no fluorescence observed), 1 or "irregular" (not uniform distribution or weak fluorescence), and 2 or "regular" (uniform distribution of fluorescence and similar to the proximal colon). In all the patients included in the study (100%), NIR-ICG imaging allowed the evaluation of fluorescence degree of the anastomotic line. No adverse reaction related to ICG use was recorded. The protocol did not greatly lengthen operating time (median, 4 [range, 3-5] minutes). Excellent interoperator agreement was observed. Most of the patients (31 of 32, 96.9%) showed regular fluorescence on the anastomotic line; in 1 patient with irregular fluorescence at NIR-ICG after discoid excision, the anastomotic suture was reinforced through interrupted stitches. We had 1 case of anastomotic leakage after segmental resection with intraoperative good fluorescence at NIR-ICG evaluation. CONCLUSION: NIR-ICG imaging for anastomotic perfusion assessment after discoid or segmental resection for RSE seems to be a feasible, safe, and reproducible method.

Use of Indocyanine Green for Intraoperative Perfusion Assessment in Women with Ureteral Endometriosis: A Preliminary Study.

STUDY OBJECTIVE: To evaluate the feasibility, safety, and potential usefulness of near-infrared imaging (NIR) with indocyanine green (ICG) to assess ureteral perfusion after conservative surgery (ureterolysis or nodule removal) for ureteral endometriosis. Any changes to the surgical plan regarding intraoperative ureteral stent placement after NIR-ICG evaluation and early postoperative outcomes were recorded. DESIGN: Prospective case series study. SETTING: Tertiary level referral center for endometriosis and minimally invasive gynecology. PATIENTS: Consecutive symptomatic women scheduled for laparoscopic conservative ureteral surgery for ureteral endometriosis. INTERVENTIONS: After ureterolysis or nodule removal, residual perfusion of the ureters with regular caliber and peristalsis was evaluated through NIR-ICG imaging. Ureteral perfusion grade was defined as absent, irregular, or regular. Time required for NIR-ICG assessment, interoperator agreement regarding ureteral perfusion grade, any changes to the surgical plan after NIR-ICG evaluation, perioperative complications, and clinical-radiologic outcomes at early follow-up were recorded. MEASUREMENTS AND MAIN RESULTS: A total of 31 ureters were examined with NIR-ICG imaging after conservative ureteral procedures. ICG assessment required 5.4 + 2.3 minutes. No complications related to fluorescence imaging were observed. Local ischemia supporting ureteral stent placement was suspected in 5 ureters (16.1%) at white light. Of these, 2 (40.0%) presented regular fluorescence; thus, ureteral stent placement was avoided. In the remaining 3 (60.0%), NIR-ICG confirmed irregular or absent fluorescence, requiring ureteral stent placement. Interoperator agreement regarding NIR-ICG evaluation was high. At a 3-month follow-up, all procedures were clinically and radiologically successful. CONCLUSION: NIR-ICG imaging after conservative surgery for ureteral endometriosis seems to be a feasible, safe, and useful tool to assess ureteral perfusion and guide surgical decision, together with other visual cues at white light. However, this approach needs to be validated by further larger and controlled studies.

Comparison of fertility outcomes after laparoscopic myomectomy for barbed versus nonbarbed sutures.

OBJECTIVE: To assess the impact on women's reproductive outcomes of barbed sutures to repair uterine breaches during laparoscopic myomectomy compared with traditional smooth sutures. DESIGN: Retrospective, monocentric cohort study, with information on subsequent pregnancies prospectively acquired for some women. SETTING: Tertiary-level academic referral center. PATIENT(S): Women older than 18 years who had undergone a laparoscopic myomectomy and had sought pregnancy afterward, divided into two groups based on type of suture used to repair the uterine wall: group A (nonbarbed) and group B (barbed). INTERVENTION(S): Laparoscopic removal of FIGO types 3, 4, 5, and 6 uterine leiomyomas by use of either only barbed sutures or only traditional smooth sutures to reconstruct the uterine defect. MAIN OUTCOME MEASURE(S): Pregnancy achievement rates, delivery modes, main pregnancy complications, perioperative complications for both kinds of suture, and the trend of the use of barbed sutures over time at our center. RESULT(S): Of 164 patients included, 83 were in group A and 81 in group B. Ninety-one patients (55.5%) experienced at least one postoperative pregnancy, with no differences between the groups (group A 60.5%; group B 50.6%). Of the 103 recorded postoperative pregnancies, 70 (68%) resulted in live births, 29 (28.1%) in first-trimester miscarriages, and 4 (3.9%) were ongoing. CONCLUSION(S): Barbed sutures have a similar impact on reproductive outcomes as smooth conventional threads, both in terms of pregnancy and obstetric complication rates, after laparoscopic myomectomy.

Transperineal Ultrasound Visual Feedback Assisted Pelvic Floor Muscle Physiotherapy in Women With Deep Infiltrating Endometriosis and Dyspareunia: A Pilot Study.

A prospective study with the aim to evaluate the effects of pelvic floor physiotherapy was conducted among women with deep infiltrating endometriosis (DIE) and associated dyspareunia. At initial evaluation superficial and deep dyspareunia were assessed using a numerical rating scale, and levator hiatus area (LHA) was assessed with 3-D/4-D transperineal ultrasound. Women underwent five individual sessions of ultrasound visual feedback assisted pelvic floor physiotherapy. One month after the therapy, dyspareunia and LHA were reassessed and compared with pre-therapy data. Pelvic floor physiotherapy seems to improve both superficial and deep dyspareunia and pelvic floor muscle relaxation in women with DIE.

Feasibility and safety of laparoscopic approach in obese patients with endometriosis: a multivariable regression analysis.

PURPOSE: To evaluate the feasibility and safety of laparoscopic excision of endometriotic lesions in obese women. METHODS: Retrospective analysis of prospectively collected data involving consecutive women scheduled for complete laparoscopic removal of macroscopic endometriotic lesions between January 2012 and November 2018. Operative time, laparotomic conversion rates, complication rates, and length of hospital stay were recorded. RESULTS: One thousand two hundred thirty women were enrolled and divided into two main groups, according to the World Health Organization classification of obesity, obese (body mass index ≥ 30 kg/m2) and non-obese (body mass index < 30 kg/m2). During the study period, 91 (7.4% of overall study cohort) obese women underwent surgery. At univariate analyses, significant differences between the two groups were found in terms of age, rates of severe endometriosis, American Society of Anesthesiologists physical status classification ≥ III, and different surgical procedures. Significant differences in terms of median operative time [125 (interquartile range (IQR) 85-165) in obese group vs 110 min (IQR 75-155) in non-obese group, P = 0.04] were observed. There were no significant differences between the obese and non-obese groups with respect to the other variables of interest. After adjusted multivariable regression models for potential confounders, difference in operating time (coefficient of 13.389; 95% CI 1.716, 25.060) was still found to be significant. CONCLUSION: In our tertiary care referral center, laparoscopic removal of endometriosis is feasible and safe, except for a slight increase of operative time and conversion rate.

Rectosigmoid Endometriosis Vascular Patterns at Intraoperative Indocyanine Green Angiography and their Correlation with Clinicopathological Data.

Introduction. The objective of the study was to evaluate the presence of different rectosigmoid endometriosis (RSE) vascular patterns using intraoperative indocyanine green (ICG) angiography and their correlation with clinicopathological data. Material and Methods. A prospective pilot study on 30 consecutive symptomatic women affected by RSE and scheduled for minimally invasive surgery between May 2018 and January 2019. ICG was used for the intraoperative evaluation of RSE vascularization. Perfusion grade was classified as follows: 0-1 = no or low fluorescence (hypovascular pattern); 2 = regular fluorescence, similar to healthy surrounding rectosigmoid tract (isovascular pattern); and 3-4 = diffuse or abundant fluorescence (hypervascular pattern). Results. Thirty women were intravenously injected with ICG after nodule exposure. No adverse effects related to ICG use were noted. After a 5- to 50-s latency from ICG injection, the real-time direct visualization of RSE perfusion showed diffuse or abundant fluorescence in 12/30 (40%) women, while in the remaining 18/30 (60%), fluorescence was poor or absent. No statistical differences were observed between the 2 groups regarding preoperative, intraoperative, and histological variables analyzed, except for a maximum diameter of bowel lesions and microvessel density (MVD). Hypovascular nodules had a larger maximum diameter (39.5 ± 15.6 mm vs 30.3 ± 11.4 mm, P < .05) and lower MVD (154.6+/43.6 vs 281.1+/-77.4, P < .05) than hypervascular ones. Conclusions. ICG angiography is a feasible and safe technique to intraoperatively assess RSE vascularization. The majority (60%) of endometriotic nodule presented a hypovascular pattern. The hypovascular pattern seems to be associated with a larger nodule size and lower MVD.

Adenomyosis and endometriosis in adolescents and young women with pelvic pain: prevalence and risk factors.

AIM: To evaluate the prevalence of ultrasound diagnosis of adenomyosis and endometriosis in young women complaining of pelvic pain and to find the symptoms and clinical characteristics associated with these diseases in young women. METHODS: Cross-sectional study, including 100 young women (14-24 years) with a history of chronic pelvic pain. Women were asked detailed medical hystory and pain symptoms scores (Visual Analogue Scale) and underwent gynecological examination and ultrasound evaluation. RESULTS: The prevalence of endometriosis and adenomyosis in young women amounted to 25.0% and 46.0%, respectively. A significant correlation was found between ovarian endometriosis and adenomyosis. Dysmenorrhea and dyspareunia were risk factors for adenomyosis. Dyschezia, dyspareunia, chronic pelvic pain, presence of sonographic soft markers suggestive of pelvic adhesions, being a worker and having a previous surgery were risk factors for endometriosis. Young women (20-24 years) had a higher incidence of both adenomyosis and endometriosis than adolescents (14-19 years). CONCLUSIONS: Our outcomes strengthen the hypothesis of a progressive and common course of the natural history of endometriosis, which initially may manifest with symptoms, then with signs of pelvic adhesions and finally as adenomyosis, ovarian endometriomas or deep infiltrating endometriosis.