Findings from the Use of Spinal Anesthesia in the Laparoscopic Treatment of Extrauterine Pregnancy: Could It Represent an Alternative to General Anesthesia?

INTRODUCTION: Minimally invasive procedures performed in laparoscopy, such as salpingectomy for ectopic pregnancy, can be combined with a minimally invasive anesthesia. The aim of this study was to assess the feasibility and the intraoperative and postoperative outcomes of laparoscopic surgery for ectopic pregnancy under spinal anesthesia (SA) compared to general anesthesia (GA) from the point of view of the surgeon, anesthesiologist, and patient. METHODS: A retrospective cohort study was performed at DAI Materno Infantile of AOU Federico II of Naples, analyzing all medical records of women who met the inclusion criteria between April 2020 and April 2023. Eighty-two women (35 under SA in group A and 47 under GA in group B) undergone elective or emergency laparoscopic salpingectomy for ectopic tubal or ovarian pregnancy were included. RESULTS: Patients in group A reported less pain at 0 h (adjusted mean difference: -1.5; 95% CI: -2.3 to -0.7; p < 0.001) and after 6 h (adjusted mean difference: -1.1; 95% CI: -2.0 to -0.3; p = 0.01) while no statistically significant differences between the two groups at 12 and 24 h after surgery. No differences were observed among the type of analgesic and during the postoperative observation time, except for paracetamol at 0 h in group B. A faster resumption of bowel motility, patient's mobilization, and a shorter hospital stay were observed in group A compared to group B. Also greater odds of returning faster to daily activities emerged in group A (adjusted OR: 5.39; 95% CI: 1.77-16.37). A greater number of patients in group A were satisfied with the entire procedure compared to those of group B (33 [94.3%] vs. 37 [78.7%]). The general surgeon satisfaction was always very good or excellent in group A. Finally, all surgical steps were well tolerated in group A. CONCLUSION: In specific settings, SA is a feasible and safe procedure for the laparoscopic treatment of ectopic pregnancy.

Ultra-low-impact laparoscopy: a new concept for a minimally invasive surgery.

INTRODUCTION: Minimally invasive surgery is considered the gold standard for the treatment of gynecological diseases. Our study aims to assess the effectiveness of the new concept of ultra-low-impact laparoscopy as a combination of low-impact laparoscopy, consisting in the use of miniaturized instruments through 3-5mm ports and low-pressure pneumoperitoneum, with regional anesthesia to evaluate the perioperative outcomes. METHODS: A cross-sectional study was performed from May 2023 to December 2023, to enroll 26 women affected by benign gynecological disease and threated by mini-invasive surgical approach. The surgical procedures were performed following the low-impact laparoscopy protocol and the regional anesthesia protocol. The postoperative pain, nausea, and vomiting and the antiemetic/analgesic intake were evaluated. Postoperative surgical and anesthesiological variables were analyzed. RESULTS: Operative time was within 90 min (41.1 ± 17.1 mean ± standard deviation (SD)) and no conversion to laparotomy or general anesthesia was required. According to VAS score, the postoperative pain during the whole observation time was less than 3 (mean). Faster resumption of bowel motility (6.5 ± 2.1 mean ± SD) and women's mobilization (3.1 ± 0.7 mean ± SD) were observed as well as low incidence of post-operative nausea and vomit. Early discharge and patient's approval were recorded. Intraoperatively pain score was assessed on Likert scale during all stages. CONCLUSION: Ultra-low-impact laparoscopy showed to provide a satisfying recovery experience for patients in terms of short hospital stays, cosmetic result, and pain relief, without compromising surgical outcomes. The encouraging results lead us to recruit a greater number of patients to validate our technique as a future well-established produce.

C-section technique vs minilaparotomy after minimally invasive uterine surgery: a retrospective cohort study.

PURPOSE: Uterine leiomyomas are benign uterine tumors. The choice of surgical treatment is guided by patient's age, desire to preserve fertility or avoid "radical" surgical interventions such as hysterectomy. In laparotomy, the issue of extracting the fibroid from the cavity does not arise. However, in laparoscopy and robotic surgery, this becomes a challenge. The aim of the present study was to determine the optimal surgical approach for fibroid extraction following laparoscopic or robotic myomectomy in terms of postoperative pain, extraction time, overall surgical time, scar size, and patient satisfaction. METHODS: A total of 51 patients met the inclusion criteria and were considered in our analysis: 33 patients who had undergone the "ExCITE technique" (Group A), and 18 patients a minilaparotomy procedure (Group B), after either simple myomectomy, multiple myomectomy, supracervical hysterectomy, or total hysterectomy. The diagnosis of myoma was histologically confirmed in all cases. RESULTS: Regarding the postoperative pain evaluation, at 6 h, patients reported 4 [3-4] vs 6 [5.3-7] on the VAS in Group A and B, as well as at 12 h, 2 [0-2] vs 3.5 [2.3-4] in Group A and B, respectively: both differences were statistically significant (p < 0.001). No statistically significant difference at 24 h from surgery was found. All patients in Group A were satisfied with the ExCITE technique, while in Group B only 67% of them. The length of the hospital stay was significantly shorter in Group A as compared to Group B (p = 0.007). In terms of the operative time for the extraction of the surgical specimen, overall operative time, and the scar size after the surgery, there was a statistically significant difference for those in Group A. CONCLUSION: The ExCITE technique does not require specific training and allows the surgeon to offer a minimally invasive surgical option for patients, with also an aesthetic result. It is a safe and standardized approach that ensures tissue extraction without the need for mechanical morcellation.

Uterine Tumors Resembling Ovarian Sex Cord Tumors (UTROSCTs): A Scoping Review of 511 Cases, Including 2 New Cases.

Uterine Tumors Resembling Ovarian Sex Cord Tumors (UTROSCTs) are rare uterine mesenchymal neoplasms with uncertain biological potential. These tumors, which affect both premenopausal and postmenopausal women, usually have a benign clinical course. Nevertheless, local recurrences and distant metastases have been described. By analyzing 511 cases retrieved from individual reports and cases series, we provide here the most comprehensive overview of UTROSCT cases available in the literature, supplemented by two new cases of UTROSCTs. Case 1 was an asymptomatic 31-year-old woman who underwent a laparoscopic resection of a presumed leiomyoma. Case 2 was a 58-year-old postmenopausal woman with abnormal vaginal bleeding who underwent an outpatient hysteroscopic biopsy of a suspicious endometrial area. In both cases, immunohistochemical positivity for Calretinin and Inhibin was noted, typical for a sex cord differentiation. In both cases, total laparoscopic hysterectomy with bilateral salpingo-oophorectomy was performed. In light of the available literature, no pathognomonic clinical or imaging finding can be attributed to UTROSCT. Patients usually present with abnormal uterine bleeding or pelvic discomfort, but 20% of them are asymptomatic. In most cases, a simple hysterectomy appears to be the appropriate treatment, but for women who wish to become pregnant, uterus-preserving approaches should be discussed after excluding risk factors. Age, tumor size, lymphovascular space invasion, nuclear atypia, and cervical involvement are not reliable prognostic factors in UTROSCT. The current research suggests that aggressive cases (with extrauterine spread or recurrence) can be identified based on a distinct genetic and immunohistochemical phenotype. For instance, UTROSCTs characterized by GREB1::NCOA1-3 fusions and PD-L1 molecule expression appear to be predisposed to more aggressive behaviors and recurrence, with GREB1::NCOA2 being the most common gene fusion in recurrent tumors. Hence, redefining the criteria for UTROSCTs may allow a better selection of women suitable for fertility-sparing treatments or requiring more aggressive treatments in the future.

Surgical management of endocervical and decidual polyps during pregnancy: systematic review and meta-analysis.

PURPOSE: To evaluate the impact of endocervical and decidual polypectomy on obstetrical outcomes of pregnant women. METHODS: MEDLINE, Scopus, ClinicalTrials.gov, Scielo, EMBASE, Cochrane Library at the CENTRAL Register of Controlled Trials, and LILACS were searched from inception to April 2021. No language or geographical restrictions were applied. Inclusion criteria regarded observational studies concerning pregnant women with a cervical lesion who underwent cervical polypectomy. Co-primary outcomes were incidence of late pregnancy loss and preterm birth in women with endocervical or decidual polypectomy as well as polypectomy versus expectant management. Random effect meta-analyses to calculate risk ratio (RR) with 95% confidence interval (CI) were performed. Quality assessment of included papers was performed using Newcastle-Ottawa Scale criteria. RESULTS: Three studies, with data provided for 3097 women, were included in quantitative analysis, with comparisons between endocervical and decidual polyps extracted from two studies and 156 patients. After a first trimester endocervical or decidual polypectomy, no significant differences were found for late pregnancy losses (RR 0.29 [95% CI 0.05, 1.80], I2 = 11%). Risk for preterm birth was significantly higher for decidual polyps' removal (RR 6.13 [95% CI 2.57, 14.59], I2 = 0%). One paper compared cervical polypectomy vs expectant management, with increased incidence of late pregnancy loss (4/142 vs 5/2799; p < 0.001) and preterm birth (19/142 vs 115/2799; p < 0.001) in women subjected to polypectomy. CONCLUSIONS: Evidence regarding the removal of cervical polyps in pregnancy is extremely limited. However, the removal of either decidual or endocervical polyps seems associated with increased risk of pregnancy loss and preterm birth, with increased preterm birth risk following endocervical rather than decidual polypectomy.

Unicornuate Uterus with Noncommunicating Rudimentary Horn (Class U4aC0V0/ESHRE/ESGE Classification) and a Communicating Bladder Endometriotic Nodule.

STUDY OBJECTIVE: To describe the diagnostic workup and laparoscopic management of a noncommunicating left uterine rudimentary horn (class U4aC0V0 European Society of Human Reproduction and Embryology/European Society of Gastrointestinal Endoscopy Classification) with communicating endometriotic bladder nodule. DESIGN: Step-by-step description of the surgical treatment. PATIENT: A 33-year-old woman with unicornuate uterus and a left-side noncommunicating rudimentary horn affected by primary infertility, mild dysmenorrhea (visual analog scale score 6), severe catamenial dysuria (visual analog scale score 10), and catamenial hematuria. SETTING: Noncommunicating rudimentary horns are rare Müllerian anomalies present in 20% to 25% of women with a unicornuate uterus. It is associated with severe dysmenorrhea, pelvic pain, subfertility, and poor obstetric outcomes and usually presents with cyclic pelvic pain that starts early after the menarche. Endometriotic bladder nodules are present in 1% to 2% of patients with endometriosis. In the literature, there are no reported cases of noncommunicating rudimentary horn with communicating endometriotic bladder nodules. Surgical excision of the rudimentary horn is the treatment of choice. In our case, the 2-dimensional/3-dimensional ultrasound revealed a right unicornuate uterus with a left noncommunicating rudimentary horn with hematometra. The uterine fundus presented «gamma sign¼ vascularization. In addition, a bladder endometriotic nodule (16 × 15 mm) communicating with hematometra was displayed. Magnetic resonance imaging demonstrated no additional malformations. Diagnostic hysteroscopy revealed a single cervix without vaginal malformation and small right uterine cavity with single tubal ostium. At laparoscopy, using hysteroscopic transillumination, a clear plane of dissection was identified between the rudimentary horn and the uterus confirming the presence of a noncommunicating horn. Evaluation of the abdominal cavity showed bilateral normal adnexa with normal ovaries. Chromopertubation showed a patent right Fallopian tube and obstructed left tube. INTERVENTIONS: A left salpingectomy using bipolar and the ultrasonic energy was performed. The utero-ovarian ligament was transected, and the left ovary was preserved. The left ovary was suspended at the pelvic wall, the retroperitoneum was opened, the ureter was identified, and the left uterine artery was temporary occluded. The left round ligament was transected and the left paravesical space was developed. With a lateromedial approach, we opened the vesicouterine septum to dissect the bladder from the rudimentary horn. The endometriotic bladder nodule was gently detached from the uterine horn with a lateromedial approach. The left uterine artery was coagulated and dissected at level of the cervix. A solution of vasopressin was injected between the uterine horn and the uterus. Resection of the rudimentary horn was performed. The peritoneum was closed. The temporary occlusion of the uterine artery was removed. The specimen was placed in a bag and removed using an extracorporeal tissue extraction technique. CONCLUSION: The late clinical presentation of our patient with only mild dysmenorrhea could be explained by the drainage of the hematometra from the noncommunicating horn into the endometriotic bladder nodule. The bladder symptoms in patients with Müllerian anomalies should be carefully investigated. The laparoscopic removal of rudimentary horn with mobilization of communicating bladder nodule when present is a safe and feasible method to improve symptomatology.

Spinal Anesthesia versus General Anesthesia in Gynecological Laparoscopic Surgery: A Systematic Review and Meta-Analysis.

INTRODUCTION: In the last years, spinal anesthesia (SA) has been emerging as an alternative to general anesthesia (GA) for the laparoscopic treatment of gynecological diseases, for better control of postoperative pain. The aim of the review is to compare the advantages of SA compared to GA. METHODS: MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Cochrane Library, and CINAHL were searched from inception until March 2021. Randomized controlled trials (RCTs) and non-randomized studies (NRSs) about women underwent SA and GA for gynecological laparoscopic surgery were analyzed. Relevant data were extracted and tabulated. RESULTS: The primary outcomes included the evaluation of postoperative pain (described as shoulder pain), postoperative nausea and vomiting, and operative times. One hundred and eight patients were included in RCTs, 58 in NRSs. The qualitative analysis had conflicting results and for the most of parameters (hemodynamic variables, nausea, and postoperative analgesic administration) no statistically significant differences were observed: in the NRSs, contradictory results regarding the postoperative pain in SA and GA groups were reported. Regarding the quantitative analysis, in the RCTs, women who received SA had not significantly lower operative times (relative risk [RR] -4.40, 95% confidence interval [CI] -9.32-0.53) and a lower incidence of vomiting (RR 0.51, 95% CI 0.17-1.55); on the other hand, in the NRS, women who received SA had longer operative times (RR 5.05, 95% CI -0.03-10.14) and more episodes of vomiting (RR 0.56, 95% CI 0.10-2.97) compared to those with GA: anyway, the outcomes proved to be insignificant. CONCLUSIONS: Current evidence suggests no significant advantages to using SA over GA for laparoscopic treatment of gynecological diseases.

Minimally invasive anesthesia for laparoscopic hysterectomy: a case series.

PURPOSE: Regional anesthesia (RA) is considered as a "minimally invasive technique" to achieve anesthesia. To assess the feasibility and the perioperative outcomes of laparoscopic hysterectomy in regional anesthesia from the point of view of the surgeon, anesthesiologist and patient. METHODS: A retrospective search was performed to identify patients who underwent laparoscopic hysterectomy under RA from April 2020 to September 2021. Five patients affected by benign gynecological disease (atypical endometrial hyperplasia or uterine leiomyomas) were included. RESULTS: The postoperative pain, nausea, and vomiting (PONV) and the antiemetic/analgesic intake were evaluated. Postoperative surgical and anesthesiological variables were recorded. Duration of surgery was 84 ± 4.18 and no conversion to GA was required. According to VAS score, the postoperative pain during the whole observation time was less than 4 (median). A faster resumption of bowel motility (≤ 9 h) and patient's mobilization (≤ 4 h) were observed as well as a low incidence of post-operative nausea and vomit. Early discharge and greater patient's satisfaction were recorded. Intraoperatively pain score was assessed on Likert scale during all the stages of laparoscopy in RA, with only 2 patients complaining scarce pain (= 2) at pneumoperitoneum. CONCLUSION: RA showed to have a great impact on surgical stress and to guarantee a quicker recovery without compromising surgical results. RA technique could be a viable option for patients undergoing laparoscopic hysterectomy.

Diagnostic and prognostic role of TFF3, Romo-1, NF-кB and SFRP4 as biomarkers for endometrial and ovarian cancers: a prospective observational translational study.

PURPOSE: This study aimed to evaluate trefoil factor 3 (TFF3), secreted frizzled-related protein 4 (sFRP4), reactive oxygen species modulator 1 (Romo1) and nuclear factor kappa B (NF-κB) as diagnostic and prognostic markers of endometrial cancer (EC) and ovarian cancer (OC). METHODS: Thirty-one patients with EC and 30 patients with OC undergone surgical treatment were enrolled together with 30 healthy controls in a prospective study. Commercial ELISA kits determined serum TFF-3, Romo-1, NF-кB and sFRP-4 concentrations. RESULTS: Serum TFF-3, Romo-1 and NF-кB levels were significantly higher in patients with EC and OC than those without cancer. Regarding EC, none of the serum biomarkers differs significantly between endometrial and non-endometrioid endometrial carcinomas. Mean serum TFF-3 and NF-кB levels were significantly higher in advanced stages. Increased serum levels of TFF-3 and NF-кB were found in those with a higher grade of the disease. Regarding OC, none of the serum biomarkers differed significantly among histological subtypes. Significantly increased serum levels of NF-кB were observed in patients with advanced-stage OC than those with stage I and II diseases. No difference in serum biomarker levels was found between those who had a recurrence and those who had not. The sensibility and specificity of these four biomarkers in discriminating EC and OC from the control group showed encouraging values, although no one reached 70%. CONCLUSIONS: TFF-3, Romo-1, NF-кB and SFRP4 could represent new diagnostic and prognostic markers for OC and EC. Further studies are needed to validate our results.

Prevalence and associated psychological risk factors of postpartum depression: a cross-sectional study.

This cross-sectional study aimed to evaluate the prevalence of postpartum depression and the associated risk factors in a sample of Italian women at three months after delivery. Eighty women were screened by completing the Edinburgh Postnatal Depression Scale (EPDS). Women with a score ≥10 were evaluated as positive and other variables were detected through the administration of the Postpartum Depression Predictors Inventory.The prevalence of postpartum depression in the sample was 11.25% (EPDS score >10). A statistically significant relationship was found between the predisposition to postnatal depression and various risk factors such as prenatal depression, stressful life experiences marital problems. Furthermore, strong emotional and instrumental support from the partner and a good economic status can represent protective factors. It is essential to promote an integrated approach to postpartum affective disorders in which psychosocial risk factors are taken into account, and adequate screening programs are implemented.Impact StatementWhat is already known on this subject? Pregnancy can cause emotional stress for women with consequent development, in some cases, of mood disorders such as postpartum depression.What do the results of this study add? According to this study, women suffering from postpartum depression showed a significant tendency to anxiety and depression, low perceived support from the partner, and low socio-economic status.What are the implications of these findings for clinical practice and/or further research? It would be desirable to promote an integrated approach to postpartum affective disorders in which psychosocial risk factors are taken into account and adequate screening programs are implemented.

Ovarian Drilling: Back to the Future.

Polycystic ovary syndrome (PCOS) is the leading cause of anovulatory infertility. The complex metabolic dysregulation at the base of this syndrome often renders infertility management challenging. Many pharmacological strategies have been applied for the induction of ovulation with a non-negligible rate of severe complications such as ovarian hyperstimulation syndrome and multiple pregnancies. Ovarian drilling (OD) is currently being adopted as a second-line treatment, to be performed in case of medical therapy. Laparoscopic ovarian drilling (LOD), the contemporary version of ovarian wedge resection, is considered effective for gonadotropins in terms of live birth rates, but without the risks of iatrogenic complications in gonadotropin therapy. Its endocrinal effects are longer lasting and, after the accomplishment of this procedure, ovarian responsiveness to successive ovulation induction agents is enhanced. Traditional LOD, however, is burdened by the potential risks of iatrogenic adhesions and decreased ovarian reserve and, therefore, should only be considered in selected cases. To overcome these limits, novel tailored and mini-invasive approaches, which are still waiting for wide acceptance, have been introduced, although their role is still not well-clarified and none of them have provided enough evidence in terms of efficacy and safety.

Uterine fibroids morcellation: a puzzle topic.

The laparoscopic approach for the treatment of uterine leiomyoma is increasingly practiced. The necessity to remove large specimens from the small laparoscopic incision has always been one of the main limits of this procedure. The unrestricted use of morcellation, to overtake this weak point of minimally invasive surgery, has opened in recent years a broad debate, especially on the risk of unintended dissemination of cells that could in some cases lead to extremely negative repercussions. This review analyzes these aspects and the principal recommendations from the major gynecological society on this topic surveying their effects. Furthermore, the purpose of this article is to provide an overview of the different morcellation techniques and how they are performed, evaluating their advantages and disadvantages. Contained morcellation seems to overcome many limits; however, based on recent data, an appropriate evaluation and selection of patients, as well as complete counseling before the surgery, are mandatory.

The Invisible External Cervical Os. Tips and Tricks to Overcome this Challenge during In-Office Hysteroscopy.

OBJECTIVE: Hysteroscopy is considered the gold standard technique for the diagnosis and management of intrauterine pathology allowing to "see and treat" patients in 1 session if desired [1-3]. Pain and the inability to enter the uterine cavity are the most common limitations of hysteroscopy, especially when performed in an office setting [4-7]. Cervical stenosis is a common hysteroscopic finding frequently encountered in postmenopausal women, especially in patients with a history of cervical procedures such as cone biopsy [8]. It represents a challenge even for the most expert hysteroscopist. Overcoming the stenosis of the external cervical os is technically more demanding than facing the obliteration of the internal os. The aim of this video article is to illustrate the use of simple techniques that allow the hysteroscopist to safely identify the location of the external cervical os and to overcome the difficulties in entering the uterine cavity during in-office hysteroscopy in patients with severe cervical stenosis including those with complete obliteration of the external cervical os. These techniques are easy to adopt and can be used in different clinical situations in which the hysteroscopic evaluation of the uterine cavity is needed in women with severe cervical stenosis. DESIGN: A series of videos of challenging cases with severe cervical stenosis with complete obliteration of the external cervical os are presented that demonstrate maneuvers to properly identify and enter the cervical canal, unfolding key aspects of the procedure. Tips and tricks to facilitate the adoption of these useful maneuvers into clinical practice are highlighted. SETTING: In-office diagnostic hysteroscopy was performed using a 5-mm rigid continuous flow operative hysteroscope. Patients were placed in a dorsal lithotomy position. The vaginoscopy "no touch" technique was used [9]. No anesthesia or sedation was administered to any of the patients. Normal saline was used as distention media. INTERVENTIONS: Taking advantage of the magnification provided by the hysteroscope, the location of the external cervical os was determined. In cases in which the external cervical os was not clearly recognized, the cervix was gently probed with the use of the uterine palpator, grasper, or scissors (Fig. 1). Recognition of the landmarks of the cervical canal provides reassurance of the adequate identification of the external cervical os and facilitates the use of the correct plane of dissection that leads into the uterine cavity (Fig. 2). Additional maneuvers that are useful to navigate the endocervical canal to overcome stenosis of the internal cervical os are also illustrated. CONCLUSION: The combination of a delicate technique and operator experience aids in overcoming the challenge of cervical stenosis in an office setting. Adopting the presented tips and tricks to enter the uterine cavity in the presence of severe cervical stenosis will reduce the rate of failed hysteroscopic procedures, decreasing the need to take patients to the operating room and the use of general anesthesia.

Cancer-related cognitive impairment (CRCI), depression and quality of life in gynecological cancer patients: a prospective study.

PURPOSE: Cancer-related cognitive impairment (CRCI) has been reported in non-central nervous system neoplasms survivors. The purpose of this study was to evaluate the perception of cognitive decrement in patients undergoing surgical and / or medical therapy for gynecological cancers. METHODS: All women diagnosed with primary gynecological cancer and undergoing active medical treatment have been enrolled in a prospective study. Before starting treatment (T1) and 6 months after the end of treatment (T2), patients were interviewed to evaluate the effects of cancer treatment on perceived cognitive function (using FACT-Cog -version 3), on depression (using Beck Depression Inventory-II test) and on quality of life (using EORTC-QLQC-30). Age, education level, marital status, lifestyle, menopausal state at diagnosis, cancer type, cancer FIGO stage, treatment modality was also recorded. The differences between baseline and post-treatment results have been evaluated with Student's t test. The results have been stratified by the menopausal state at diagnosis, type of tumor (endometrial, cervical, ovarian, vulvar) disease stage and type of treatment (chemotherapy or radiotherapy). RESULTS: Seventy-three patients were included. A significant reduction in perceived cognitive impairments was demonstrated at T2 (CogPCI: 61.35 ± 13.83 vs 55.05 ± 16.56; p < 0.05). On the contrary, a significant improvement was shown in depression state (BDII: 21.14 ± 11.23 vs 12.82 ± 12.33, p < 0.005). The menopausal state at surgery, tumor site, stage and treatment modality seem to influence the variables analyzed. CONCLUSION: CRCI is a true risk also in gynecological cancer survivors. The cognitive impairment does not seem to be dependent on depression state after treatment or to a menopausal condition. Assessing cognitive decline in cancer survivorship is essential for ensuring the optimum quality of life and functioning.

Fertility-Sparing Approach in Women Affected by Stage I and Low-Grade Endometrial Carcinoma: An Updated Overview.

Endometrial cancer (EC) is a deleterious condition which strongly affects a woman's quality of life. Although aggressive interventions should be considered to treat high-grade EC, a conservative approach should be taken into consideration for women wishing to conceive. In this scenario, we present an overview about the EC fertility-sparing approach state of art. Type I EC at low stage is the only histological type which can be addressed with a fertility-sparing approach. Moreover, no myometrium and/or adnexal invasion should be seen, and lymph-vascular space should not be involved. Regarding the pharmaceutical target, progestins, in particular medroxyprogesterone acetate (MPA) or megestrol acetate (MA), are the most employed agent in conservative treatment of early-stage EC. The metformin usage and hysteroscopic assessment is still under debate, despite promising results. Particularly strict and imperious attention should be given to the follow-up and psychological wellbeing of women, especially because of the double detrimental impairment: both EC and EC-related infertility consequences.

Microbiome and PCOS: State-of-Art and Future Aspects.

Polycystic ovary syndrome (PCOS) is a complex and heterogeneous endocrine disease. The hypothesis that alterations in the microbiome are involved in the genesis of PCOS has been postulated. Aim of this review is to summarize the available literature data about the relationship between microbiome and PCOS. A search on PubMed and Medline databases was performed from inception to November 20Most of evidence has focused on the connection of intestinal bacteria with sex hormones and insulin-resistance: while in the first case, a relationship with hyperandrogenism has been described, although it is still unclear, in the second one, chronic low-grade inflammation by activating the immune system, with increased production of proinflammatory cytokines which interfere with insulin receptor function, causing IR (Insulin Resistance)/hyperinsulinemia has been described, as well as the role of gastrointestinal hormones like Ghrelin and peptide YY (PYY), bile acids, interleukin-22 and Bacteroides vulgatus have been highlighted. The lower genital tract microbiome would be affected by changes in PCOS patients too. The therapeutic opportunities include probiotic, prebiotics and synbiotics, as well as fecal microbiota transplantation and the use of IL-22, to date only in animal models, as a possible future drug. Current evidence has shown the involvement of the gut microbiome in PCOS, seen how humanized mice receiving a fecal transplant from women with PCOS develop ovarian dysfunction, immune changes and insulin resistance and how it is capable of disrupting the secondary bile acid biosynthesis. A future therapeutic approach for PCOS may involve the human administration of IL-22 and bile acid glycodeoxycholic acid.

Uterine arteries prophylactic occlusion balloon placement in pregnancies with placenta praevia.

INTRODUCTION: To evaluate the feasibility of uterine arteries prophylactic occlusion balloon placement (POBP) to reduce hemorrhagic complications associated with placenta praevia. MATERIAL AND METHODS: A retrospective analysis was carried out from January 2014 to November 2018. Only women with a diagnosis of placenta praevia and gestational age at delivery between 33 and 40 weeks were included. All women were diagnosed using transvaginal ultrasound scan (TVS) and confirmed with magnetic resonance imaging (MRI). All women underwent uterine arteries POBP before caesarean delivery (CD). All patients underwent clinical and instrumental follow-up with semestral outpatient TVS for 2 years after the surgery. RESULTS: Forty-eight pregnant women were recruited and analyzed. 32/48 patients (66%) had positive anamnesis for previous CDs. Mean blood loss was 510 ± 222 mL. 15/48 patients (31.6%) were supported with RBC concentrate transfusion. In 10 (20.8%) cases, an intrauterine haemostatic balloon (Bakri-Balloon, Cook Medical, Spencer, USA) was used to control the intra-operative hemorrhage. Hysterectomy was performed in eight cases (16.6%). No cases of hemodynamic instability or urinary complications were reported. No postoperative complications occurred. During follow-up, no long-term complications were observed and nine patients had a successful pregnancy. CONCLUSIONS: Uterine arteries POPB is a promising technique that may be adopted in women with placenta praevia to prevent hemorrhagic complications.

Evaluation and treatment of infertile women with Asherman syndrome: an updated review focusing on the role of hysteroscopy.

Asherman syndrome is a rare acquired clinical condition resulting in the obliteration of the uterine cavity causedby the presence of partial or complete fibrous intrauterine adhesions involving at least two-thirds of the uterine cavity potentially obstructing the internal cervical orifice. Common reported symptoms of the disease are alterations of the menstrual pattern with decreased menstrual bleeding leading up to amenorrhoea and infertility. Hysteroscopy is currently considered the gold standard diagnostic and therapeutic approach for patients with intrauterine adhesions. An integrated approach, including preoperative, intraoperative and postoperative therapeutic measures, however, are warranted owing to the complexity of the syndrome. This review aims to summarize the most recent evidence on the recommended preoperative, intraoperative and postoperative procedures to restore the uterine cavity and a functional endometrium, as well as on the concomitant use of adjuvant therapies to achieve optimal fertility outcomes.

Dioxin and endometriosis: a new possible relation based on epigenetic theory.

Endometriosis is a chronic disease characterized by the growth of endometrial-like glands and stroma outside the uterine cavity. Nowadays, the exact etiology of endometriosis is unclear and the interaction between a variety of environmental physical and chemical compounds may potentially promote the disease in women with an individual susceptibility. The first demonstration of a relation between an environmental factor and endometriosis was obtained with the chronic dietary exposure of a primate colony to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). Besides the well-known dioxin's pathway of action, several papers are focusing on the role of epigenetic mechanisms, a way through which the genome responds to the environment and can lead to permanent changes in gene expression until affecting the phenotypes or cause disease. In this review, we focus on the possible role of dioxin epigenetics modification in endometriosis.

Breast metastasis two years after pelvic surgery and adjuvant chemotherapy for serous ovarian cancer.

Ovarian cancer is considered the leading cause of death among gynecologic neoplasias. Breast metastases from primary ovarian cancer have been reported in only 0.03-0.6% of all breast cancers. A 38-year-old female, multipara, affected by advanced ovarian cancer and undergone a total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, and pelvic peritonectomy two years earlier, was discovered to have a breast metastasis. She underwent a quadrantectomy (QSI) with an open biopsy of nodularity attached to the pectoral muscle fascia: on definitive histological characterization the breast lesions showed a high-grade invasive carcinoma, with papillary serum differentiation, and the immunohistochemistry study of breast lesion showed positivity for cytokeratin 7 and an extensive positivity for Wilm's tumor (WT)-1 and paired box 8 (PAX8). These aspects are indicative of mammary metastasis from carcinoma of ovarian origin. Despite their rarity, metastases to breast from ovarian cancer should be considered possible because their recognition and differentiation compared to primary tumors are crucial for prognosis. Future clinical studies on MOCB should be performed to discover new specific markers for a more accurate histopathological diagnosis and to establish the real need of surgical treatment.