The Application of Shear Wave Elastography to Determine the Elasticity of the Levator Ani Muscle and Vaginal Tissue in Patients With Pelvic Organ Prolapse.

OBJECTIVES: The changes of the extracellular matrix of the connective tissue have significantly contributed to the incidence of pelvic organ prolapse (POP). It seems reasonable that sonoelastography could be a useful tool to evaluate the elasticity of pelvic floor tissue in patients with POP and compare it to those without POP. The main aim of this pilot study was to determine if there are differences in the elasticity of the levator ani muscle (LAM) and vaginal tissue between patients with and without POP. METHODS: Prospective observation study, including 60 patients (30 with POP and 30 without POP). Sonoelastography was performed to evaluate the elasticity (in kilopascals, kPa) of the following regions of interest: vagina at the level of middle third of the urethra; vagina at the level of the bladder trigone; vagina in the anterior and posterior fornix; vagina at the level of middle third of the anorectal canal; posterior third of the LAM. RESULTS: A total of 60 patients completed the study (30 with POP, 30 without POP). In the POP group, 18/30 (60%) had an anterior vaginal wall prolapse, 3/30 (10%) a uterine prolapse, 15/30 (50%) a rectocele, and 6/30 (20%) a enterocele. Patients with POP had higher elasticity in all anatomical study areas, with statistically significant differences in the anterior fornix (13.6 vs 11.2 kPa; P: .012). A multiple regression (controlling age, menopausal stage, and parity) allowed to detect statistically significant differences in the elasticity of the middle third of the urethra (P: .03) and the middle third of the anorectal canal (P: .019). CONCLUSION: It is possible to evaluate the elasticity of the LAM and vaginal tissue using sonoelastography, detecting a higher elasticity in patients with POP than in those without POP.

Is the Presence of Levator Ani Muscle Avulsion Relevant for the Diagnosis of Uterine Prolapse?

OBJECTIVE: To determine if the addition of the assessment of levator ani muscle (LAM) avulsion to the measurement of the difference in the pubis-uterine fundus distance between rest and with the Valsalva maneuver could increase the diagnostic capacity of ultrasound for uterine prolapse (UP). METHODS: This multicenter, observational and prospective study included 145 patients. Ultrasound assessment was performed, establishing the diagnosis of UP as a difference between the pubic-uterine fundus distance at rest and during the Valsalva maneuver ≥15 mm (standard technique), while LAM avulsion was defined as an abnormal LAM insertion in three central slices using multislice ultrasound. A binary multivariate logistic regression model was made using nonautomated methods to predict surgical UP (general population, premenopausal, and postmenopausal patients), including the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver as well as LAM avulsion. RESULTS: A total of 143 patients completed the study. The addition of LAM avulsion criteria to the standard dynamic distance-based protocol for the diagnosis of UP resulted in a higher sensitivity for the general population (79.7 vs 68.1%) as well as for premenopausal (89.3 vs 79.9%) and postmenopausal patients (76 vs 66.1%). In contrast, the standard technique showed a higher specificity than the model based on the standard technique associated with LAM avulsion for the general population (89.2 vs 74.3%) and premenopausal women (91.7 vs 63.2%). For postmenopausal patients, the model based on the standard technique associated with LAM avulsion had a higher sensitivity (76 vs 66.1%) and specificity (91.7 vs 86.8%) than the ultrasound diagnosis of UP. CONCLUSION: The implementation of the assessment of LAM avulsion in the ultrasound diagnosis of UP is useful in postmenopausal patients, increasing sensitivity and specificity relative to the ultrasound assessment based only on the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver.

Analysis of correlation of pre-therapeutic assessment and the final diagnosis in endometrial cancer: role of tumor volume in the magnetic resonance imaging.

Objective: To evaluate whether the introduction of tumor volume as new parameter in the MRI assessment could improve both concordance between preoperative and postoperative staging, and the identification of histological findings. Methods: A retrospective observational study with 127 patients with endometrial cancer (EC) identified between 2016 and 2021 at the Juan Ramon Jimenez University Hospital, Huelva (Spain) was carried out. Tumor volume was measured in three ways. Analyses of Receiver Operating Characteristic (ROC) curve and the area under the curve (AUC) were performed. Results: Although preoperative MRI had an 89.6% and 66.7% sensitivity for the detection of deep mucosal invasion and cervical stroma infiltration, preoperative assessment had an intraclass correlation coefficient of 0.517, underestimating tumor final stage in 12.6% of cases, with a poor agreement between preoperative MRI and postoperative staging (κ=0.082) and low sensitivity (14.3%) for serosa infiltration. The cut-off values for all three volume parameters had good/excellent AUC (0.73-0.85), with high sensitivity (70-83%) and specificity (64-84%) values for all histopathological variables. Excellent/good agreement was found all volume parameters for the identification of deep myometrial invasion (0.71), cervical stroma infiltration (0.80), serosa infiltration (0.81), and lymph node metastases (0.81). Conclusion: Tumor volume measurements have good predictive capacity to detect histopathological findings that affect final tumor staging and might play a crucial role in the preoperative assessment of patients with endometrial cancer in the future.

Assessment of late on-set fetal growth restriction using SMI (superb microvascular imaging) Doppler.

Background: The identification of late-onset fetal growth restriction (FGR) fetuses remains a challenge, given the difficulty to distinguish them from healthy small for gestational age (SGA) fetuses. Given the limitations of conventional Doppler for the identification of placental insufficiency, the appearance of superb microvascular imaging (SMI) Doppler seems promising. Our main objective was to evaluate the diagnostic capability of SMI Doppler for the detection of placental insufficiency findings. Methods: A prospective observational study was conducted at a tertiary care center, including 51 patients who had been diagnosed with late on-set SGA or FGR. A placental ultrasonographic evaluation was carried out using SMI Doppler. Patients were sorted into two groups attending to the histologic evaluation of the placentas after delivery: Group 1 (21 cases), Normal group; and Group 2 (30 cases), FGR group. Results: Placentas in the FGR group had lower peak systolic velocity (PV) values of the chorionic plate. The PV of the other vessels were consistently lower in the FGR group that in the normal group, although without reaching statistical significance. Conclusions: The PV of the chorionic plate measured with SMI Doppler, have the capacity to identify placental insufficiency findings. Ultrasonographic placental assessment using SMI Doppler appears to be a useful technique for the evaluation of suspected late on-set placental insufficiency.

Is It Possible to Diagnose Surgical Uterine Prolapse With Transperineal Ultrasound? Multicenter Validation of Diagnostic Software.

OBJECTIVES: To validate an ultrasound software that uses transperineal ultrasound to diagnose uterine prolapse (UP). METHODS: Multicenter, observational and prospective study with 155 patients that had indications for surgical intervention for dysfunctional pelvic floor pathology. Each patient underwent an examination with Pozzi tenaculum forceps was performed in the operating room with the patient anesthetized, followed by surgical correction of stages II-IV UP. Transperineal ultrasound was used to assess the difference in the pubis-uterine fundus measurement. With a multivariate logistic regression binary model (with the measurement ultrasound at rest, the Valsalva maneuver and age) using nonautomated methods to predict UP. With the purpose of evaluating the model, a table with coordinates of the receiver operating characteristic (ROC) curve, after which sensitivity and specificity were assessed. RESULTS: A total of 153 patients were included (73 with a diagnosis of surgical UP). It was obtained from the AUC (0.89) of the probabilities predicted by the model (95% confidence interval, 0.84-0.95; P < .0005). Based on the ROC curve for the model, obtaining a sensitivity of 91.8% and a specificity of 72.7%, values that were superior to those for the clinical exam for surgical UP (sensitivity: 80.8%; specificity: 71.3%). CONCLUSIONS: We validated software that uses transperineal ultrasound of the pelvic floor and patient age to generate a more reliable diagnosis of surgical UP than that obtained from clinical examinations.

Transvaginal ultrasonography predictive model for the detection of pelvic congestion syndrome.

Background: The diagnosis of pelvic congestion syndrome (PCS) remains a challenge given the lack of universally accepted criteria. Although venography (VG) is the current gold standard for the diagnosis of PCS, non-invasive techniques like transvaginal ultrasonography (TVU) appear to be a valid alternative. The aim of this study was to design a predictive model for the venographic diagnostic of PCS using the parameters identified by TVU in patients with clinical suspicion of PCS, in order to individually assess the need to perform an invasive diagnostic and therapeutic technique such as VG. Methods: An observational and cross-sectional prospective study was conducted including 61 consecutively recruited patients with clinical suspicion of PCS, who were referred by the Pelvic Floor, Gynecology and Vascular Surgery Units, who were distributed in two groups: 18 belonging to the normal group and 43 to the PCS's group. We implemented and compared 19 binary logistic regression models, including the parameters that showed statistical significance in the prior univariate analysis. We evaluated individual predictive values with a receiver operating characteristic (ROC) curve and the area under the curve (AUC). Results: The selected model, based on the presence of pelvic veins or venous plexus of 8 mm or larger, observed by transvaginal ultrasound, had an AUC of 0.79 (95% CI: 0.63-0.96; P<0.001), with a sensitivity of 0.90 and specificity of 0.69, while the VG had a sensitivity of 86.05%, a specificity of 66.67%, and a positive predictive value of 86.05%. Conclusions: This assessment presents a feasible alternative that could potentially be added to our usual gynecological practice.

Can Intrapartum Ultrasonography Improve the Placement of the Vacuum Cup in Operative Vaginal Deliveries?

Although the fetal head position has traditionally been evaluated by digital examination (DE), it has a failure rate ranging between 20 and 70%; hence, intrapartum transabdominal ultrasonography (TUS) has become relevant. We aimed to evaluate the utility of the TUS to identify the fetal head positions in vacuum-assisted deliveries. We performed a prospective observational study including 101 pregnant patients in active labor who required a vacuum-assisted delivery. The fetal head position was assessed by a DE and a TUS prior to vacuum cup placement. After delivery, the optimal vacuum cup placement was evaluated as the distance between the chignon and the flexion point ≤2 cm. The general concordance rate between the DE and TUS was 72.2%, with the poorest concordance rate for occiput posterior positions at 46.1%. In five cases (4.9%), it was not possible to determine the fetal head position through the DE. The correlation was higher in low and medium planes, with 77% and 68.1% concordance rates, respectively, while it was lower in high planes (60%). In 90.1% of cases, the vacuum cup placement was optimal. Our findings show that intrapartum transabdominal ultrasonography is a useful technique to identify the fetal head position allowing optimal placement of the vacuum cup necessary for correct vacuum-assisted delivery.

Angiomixoma agresivo vulvar en mujer joven. Reporte de un caso / Aggressive vulvar angiomyxoma in a young woman. A case report

Resumen ANTECEDENTES: El angiomixoma agresivo profundo perineal es un tumor mesenquimatoso de muy limitada aparición que se origina debido a un crecimiento tumoral del tejido conjuntivo que se expande a pesar de su naturaleza benigna; se caracteriza por un comportamiento agresivo. CASO CLÍNICO: Paciente de 38 años, con un nódulo genital de 3 cm en el labio mayor izquierdo, con sospecha clínica de quiste de la glándula de Bartolino. Durante la intervención para su drenaje se objetivó una tumoración blanda, de aspecto mesenquimal, pediculado. El análisis histológico confirmó que se trataba de un angiomixoma agresivo profundo perineal. Posterior al estudio de extensión negativo, se completó la vulvectomía simple izquierda, con un posoperatorio favorable. CONCLUSIONES: La obtención de una biopsia inicial es decisiva, sobre todo en casos de tumores mesenquimales agresivos, como el angiomixoma agresivo perineal profundo. De esta manera puede establecerse un plan de tratamiento individual en función del diagnóstico histológico definitivo.

Abstract BACKGROUND: Aggressive deep perineal angiomyxoma is a mesenchymal tumor of very limited occurrence that originates due to a tumorous growth of connective tissue that expands despite its benign nature; it is characterized by an aggressive behavior. CLINICAL CASE: 38-year-old patient with a 3 cm genital nodule on the left labium majus, with clinical suspicion of Bartholin's gland cyst. During the intervention for its drainage, a soft, mesenchymal, pedunculated tumor was observed. Histological analysis confirmed that it was an aggressive deep perineal angiomyxoma. Following a negative extension study, a simple left vulvectomy was completed, with a favorable postoperative course. CONCLUSIONS: Obtaining an initial biopsy is critical, especially in cases of aggressive mesenchymal tumors, such as deep perineal aggressive angiomyxoma. In this way an individual treatment plan can be established based on the definitive histologic diagnosis.

Malformación arteriovenosa uterina como causa de hemorragia puerperal tardía / Uterine arteriovenous malformation as a cause of late puerperal hemorrhage

Resumen ANTECEDENTES: Las malformaciones arteriovenosas uterinas constituyen una causa infrecuente de hemorragia puerperal, en la bibliografía solo se encontraron 150 casos. Su conocimiento es importante porque son potencialmente mortales y porque se ha registrado un aumento en los últimos años. Suelen estar relacionadas con intervenciones en el útero: legrados, cesáreas o miomectomías o asociadas con neoplasias (enfermedad trofoblástica gestacional o adenocarcinoma endometrial), aunque otras son congénitas. CASO CLÍNICO: Paciente de 32 años, con una conización cervical y ablación de un mioma uterino mediante radiofrecuencia como únicos antecedentes de interés. A los 15 días posteriores a un parto eutócico, que fue el primero en su historial, tuvo un episodio de abundante metrorragia. En el puerperio inmediato tuvo una hemorragia abundante que requirió la transfusión de dos concentrados de hematíes. En la ecografía transvaginal el útero se observó de 22 x 44 mm, que podría corresponder a un cotiledón retenido. Ante la persistencia del sangrado se colocó un taponamiento intracavitario con una sonda de Foley con lo que se consiguió el cese del sangrado. Luego de descartar la embolización de las arterias uterinas debido al gran tamaño de la malformación arteriovenosa, se procedió a la histerectomía total simple por vía laparotómica. CONCLUSIÓN: Las malformaciones arteriovenosas uterinas, aunque son una causa infrecuente de hemorragia puerperal, deben ser sospechadas en virtud de ser potencialmente mortales.

Abstract BACKGROUND: Uterine arteriovenous malformations are a rare cause of puerperal hemorrhage, with only 150 cases reported in the literature. Their knowledge is important because they are life-threatening and because there has been an increase in recent years. They are usually related to interventions in the uterus: curettage, caesarean section or myomectomy or associated with neoplasms (gestational trophoblastic disease or endometrial adenocarcinoma), although others are congenital. CLINICAL CASE: A 32-year-old patient with a cervical conization and ablation of a uterine myoma by radiofrequency as the only history of interest. Fifteen days after a euthecological delivery, which was the first in her history, she had an episode of abundant metrorrhagia. In the immediate postpartum period, she had a heavy hemorrhage that required the transfusion of two red blood cell concentrates. Transvaginal ultrasound showed a uterus measuring 22 x 44 mm, which could correspond to a retained cotyledon. In view of the persistent bleeding, intracavitary tamponade was placed with a Foley catheter, which led to cessation of bleeding. After ruling out embolization of the uterine arteries due to the large size of the arteriovenous malformation, a simple total hysterectomy by laparotomy was performed. CONCLUSION: Uterine arteriovenous malformations, although an infrequent cause of puerperal hemorrhage, should be suspected because they are potentially fatal.

Attempted vaginal birth after cesarean: assessment of morbidity and predictors of success / Parto tras cesárea anterior: análisis de la morbimortalidad materno-fetal

Objective: Determining the appropriate approach for delivery after previous cesarean is a very controversial issue. Our objective was to establish whether pregnant women with a previous cesarean have an increased maternal and fetal morbidity and mortality after attempting vaginal delivery as well as to determine which factors may influence the achievement of a vaginal birth after cesarean. Materials and methods: A retrospective observational cohort study including 390 patients (196 cesarean group and 194 nulliparous group) was carried out. We compared neonatal and maternal outcomes between groups. Afterward, a multivariate logistic regression was applied for our second objective. Results: There were higher rates of uterine rupture (2% vs. 0%, p: 0.045) and puerperal hemorrhage (9.7% vs. 3.1%, p: 0.008) in the cesarean group and lower vaginal delivery rate (58.2% vs. 77.8%, p < 0.0005). We found that the induced onset of labor (OR = 2.9) and new born weight (OR = 1.0001) were associated with an increased risk of cesarean section. Conclusions: Our findings stress the need for further investigations in this field, which might provide a basis for a better management of patients with a previous cesarean.

Objetivo: Determinar el abordaje adecuado del tipo de parto tras una cesárea previa es un tema muy controvertido. Nuestro objetivo fue establecer si las gestantes con cesárea previa presentan mayor morbimortalidad materna y fetal tras intentar parto vaginal, así como determinar qué factores pueden influir en conseguir un parto vaginal posterior a la cesárea. Material y métodos: Estudio observacional de cohortes retrospectivo incluyendo 390 pacientes (196 con cesárea previa, 194 nulíparas). Comparamos los datos sobre los resultados neonatales y maternos. Posteriormente se aplicó un modelo de regresión logística multivariante. Resultados: Hubo mayores tasas de ruptura uterina (2% vs. 0%; p = 0.045) y hemorragia puerperal (9.7% vs. 3.1%, p: 0.008) en el grupo de cesárea anterior, así como una tasa de parto vaginal mas baja (58.2% vs. 77.8%, p < 0.0005). La inducción del parto (OR = 2,9) y el peso del recién nacido (OR = 1.0001) se asociaron a un mayor riesgo de cesárea. Conclusión: La probabilidad de parto vaginal en estas pacientes disminuye cuanto mayor sea el peso del recién nacido y con partos inducidos.

Does a High-Risk (>1/50) Result for First-Trimester Combined Screening Always Entail Invasive Testing? Which Patients from This Group Might Benefit from cfDNA Testing?

Currently, cell-free DNA (cfDNA) is offered as part of a contingent screening for patients with a first-trimester combined test (FCT) risk between 1/50 and 1/250. However, most aneuploidies are within the group of patients with a risk above 1/10. An observational, retrospective, and multi-centric study was carried out, to evaluate the theorical performance of lowering the cut-off point for the high-risk group from 1/50 to 1/10. Out of the 25,920 patients included, 25,374 (97.9%) consented to the cfDNA contingent screening for aneuploidies. With the proposed strategy, knowing that the detection rate (DR) of cfDNA testing for trisomy 21 is 99.7%, the DR for trisomy 21 would have stayed in a 93.2%, just as it was with the current strategy. In this instance, 267 (1.1%) invasive tests would have been performed, while the current strategy had a total of 307 (1.2%). The false positive rate (FPR) rate would have stayed at 5.2% in both scenarios. In conclusion, the contingent screening of aneuploidies based in the result of the FCT, offering the analysis of cfDNA to patients with an intermediate risk after lowering the cut-off point from 1/50 to 1/10, is a valid alternative that might maintain the current detection rates and avoid the complications associated with invasive testing.

Combination of mifepristone and misoprostol vs misoprostol monotherapy for treatment of second-trimester pregnancy loss.

OBJECTIVE: Our main goal was to evaluate whether a treatment protocol based on the combination of mifepristone and misoprostol for second-trimester foetal loss was more effective than misoprostol monotherapy. METHODS: This was an observational, retrospective, cross-sectional two-centre study of women receiving treatment for second-trimester pregnancy loss. Patients were recruited in two centres that used different treatment protocols: combined mifepristone-misoprostol treatment or misoprostol monotherapy. RESULTS: A total of 99 patients were included in the study: 41 in the mifepristone-misoprostol combined treatment group and 58 in the misoprostol monotherapy group. The combined treatment group had shorter times to expulsion and shorter hospitalisations, as well as higher rates of hospital discharge within 24 h and complete abortion within the first 6 h and 12 h. There were no differences regarding secondary effects and complication rates. CONCLUSION: A combination of mifepristone and misoprostol appears to be a feasible option for the treatment of second-trimester pregnancy loss.

Identification of Pelvic Congestion Syndrome Using Transvaginal Ultrasonography. A Useful Tool.

The gold standard for the diagnosis of pelvic congestion syndrome (PCS) is venography (VG), although transvaginal ultrasound (TVU) might be a noninvasive, nonionizing alternative. Our aim is to determine whether TVU is an accurate and comparable diagnostic tool for PCS. An observational prospective study including 67 patients was carried out. A TVU was performed on patients, measuring pelvic venous vessels parameters. Subsequentially, a VG was performed, and results were compared for the test calibration of TVU. Out of the 67 patients included, only 51 completed the study and were distributed in two groups according to VG results: 39 patients belonging to the PCS group and 12 to the normal group. PCS patients had a larger venous plexus diameter (15.1 mm vs. 12 mm; p = 0.009) and higher rates of crossing veins in the myometrium (74.35% vs. 33.3%; p = 0.009), reverse or altered flow during Valsalva (58.9% vs. 25%; p = 0.04), and largest pelvic vein ≥ 8 mm (92.3% vs. 25%). The sensitivity and specificity of TVU were 92.3% (95% CI: 78.03-97.99%) and 75% (95% CI: 42.84-93.31%), respectively. In conclusion, transvaginal ultrasonography, with the described methodology, appears to be a promising tool for the diagnosis of PCS, with acceptable sensitivity and specificity.

Mini-resectoscope vs morcellator for in-office hysteroscopic myomectomy: Evaluation of results and patient satisfaction.

INTRODUCTION: The development of hysteroscopic techniques has led to an advance in submucous myoma treatment, offering a safe and effective minimally invasive alternative. Our objective was to compare the results of hysteroscopic myomectomy when using whether the mini-resectoscope or the MyoSure morcellator, as well as patient satisfaction after the procedure. MATERIAL AND METHODS: A prospective, cross-sectional, observational study including 80 patients distributed into two groups: Mini-Resectoscope group (MRG) or MyoSure group (MSG), depending on the instrument used for the in-office hysteroscopic myomectomy. Resection time, pain during entry, pain during resection, number of resections required, complete resection, and total satisfaction were recorded. RESULTS: MSG had statistically significant shorter time of entrance. There were no other statistically significant differences between groups. CONCLUSIONS: In-office hysteroscopic myomectomy is associated with high levels of patient satisfaction, without differences between the mini-resectoscope or the MyoSure, allowing high rates of complete resection using both instruments. Thus, it is a feasible technique which could be performed with both instruments, depending on the operator's expertise.

Evaluación de la efectividad y satisfacción de las pacientes tras miomectomía histeroscópica en consulta / Evaluation of effectiveness and patient satisfaction of hysteroscopic myomectomy in office

OBJETIVO: Analizar la efectividad de las miomectomías histeroscópicas en consulta realizadas con minirresector y conocer si hay factores relacionados con el grado de satisfacción de las pacientes. MÉTODO: Estudio observacional, transversal y prospectivo, de mujeres sometidas a miomectomía histeroscópica en consulta durante el año 2018. Las pacientes recibieron medicación para la preparación cervical, analgesia oral y anestesia paracervical. La miomectomía se realizó con un minirresector de 5.8 mm. Se registraron el tiempo y el dolor en una escala visual analógica (EVA) durante la entrada y la resección, así como la satisfacción de las pacientes a los 3 meses con el cuestionario validado CSQ-8. RESULTADOS: El estudio incluyó 59 pacientes. El tiempo medio de entrada fue menor de 1 minuto (47,93 segundos) y el de resección fue de 13,51 minutos. El dolor referido por las pacientes en la EVA durante la entrada y la resección puntuó en torno a 3 y 4, respectivamente. Se consiguió un 74.6% de resecciones completas de los miomas y la puntuación media de satisfacción de las pacientes fue de 27.17. La resección completa del mioma se asoció con una mayor satisfacción total de las pacientes. CONCLUSIONES: La miomectomía histeroscópica en consulta llevada a cabo con un minirresector de 5.8 mm con analgesia paracervical obtiene buenos resultados clínicos, con buena satisfacción de las pacientes. Esta última se relaciona con una resección completa del mioma, sin que influyan el tiempo necesario para su exéresis ni el dolor.

OBJECTIVE: To analyze the effectiveness of hysteroscopic myomectomy in office performed with mini-resectoscope, and to know if there is any variable related with patient satisfaction. METHOD: Observational and prospective transversal study, which included all women who underwent a hysteroscopic myomectomy in office in 2018. Patients received drugs for cervical preparation and pain management, as well as paracervical block. We used the 5.8 mm mini-resectoscope. We kept record of time and AVS pain during entrance and resection, as well as patient satisfaction 3 months after the procedure using the CSQ-8. RESULTS: The study included 59 patients. Mean entrance time was less than 1 minute (47.93 seconds), while mean resection time was 13.51 minutes. AVS pain during entrance and resection was around 3 and 4, respectively. We achieved 74.6% rate of complete resection. Mean patient satisfaction rate was 27.17 points. We found that a complete myoma resection is related to higher patient satisfaction. CONCLUSIONS: Hysteroscopic myomectomy in office performed with the 5.8 mm mini-resectoscope, using cervical block, achieves good clinical results and a good patient satisfaction. Patient satisfaction is associated with a complete resection of the myoma, without any influence of pain experienced or time required.

Evaluation of Placental Micro-vascularization by Superb Micro-vascular Imaging Doppler in Cases of Intra-uterine Growth Restriction: A First Step.

Superb micro-vascular imaging (SMI) Doppler has proven to be a valid method to assess normal placental micro-vascularization. In this study, we present the application of SMI Doppler to assess placental micro-vascularization in cases of placental insufficiency. We observed fewer secondary and tertiary villi in cases of intra-uterine growth restriction, as well as a lower pulsatile index of secondary villi. The observations made in our study stress the diagnostic potential of SMI Doppler in placental insufficiency.

Differential diagnosis of middle compartment pelvic organ prolapse with transperineal ultrasound.

INTRODUCTION AND HYPOTHESIS: The objective was to identify the best parameter (pubis-cervix measurement, pubis-uterine fundus measurement or pubis-pouch of Douglas measurement) on transperineal ultrasound, based on the difference between measurements taken at rest and with the Valsalva maneuver, for presurgical differential diagnosis between uterine prolapse (UP) and cervical elongation (CE) without UP. METHODS: A prospective observational study of 60 consecutively recruited patients who underwent corrective surgery of the middle compartment (UP or CE without UP). A transperineal ultrasound was performed, and the descent of the pelvic organ was measured in relation to the posteroinferior margin of the pubis in the midsagittal plane, referencing the uterine fundus, pouch of Douglas and the cervix at rest and with the Valsalva test. RESULTS: Receiver operating characteristic (ROC) curves were constructed for the three evaluated measures, based on the difference between rest and Valsalva, for the diagnosis of UP. For the pubis-cervix distance, an area under the curve (AUC) of 0.59 was obtained; for the pubis-uterine fundus distance, the AUC was 0.81; and for the pubis-pouch of Douglas distance, the AUC was 0.69. Based on the best AUC (the difference in the pubis-uterine fundus distance at rest and with the Valsalva maneuver), a cut-off point of 15 mm was established for the diagnosis of UP (sensitivity: 75%; specificity: 95%; positive predictive value: 86%; and negative predictive value: 89%). CONCLUSION: A difference of ≥15 mm in the pubis-uterine fundus distance at rest and with the Valsalva maneuver is useful for differentiating UP from CE without UP by ultrasound.