Publications by authors named "Alessandro Arena"

49 Publications

The unbearable burden of endometriosis: Results from a large cohort about anxiety reduction during the first outpatient evaluation.

J Psychosom Res 2021 May 18;147:110512. Epub 2021 May 18.

Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Via Massarenti, 13, IRCCS, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

Objective: To evaluate the impact of the first outpatient evaluation on anxiety levels in women with suspected endometriosis. Secondarily, we investigated which individual characteristics exerted the greatest influence on distress levels.

Methods: Women referred to our academic center between January 2019 and March 2020 on the suspicion of endometriosis were enrolled in this prospective, observational study. Before the visit, participants answered questionnaires such as the Generalized Anxiety Disorder-7 (GAD) and the Spielberg State Trait Anxiety Inventory (STAI) Y6. After the visit, the STAI-Y6 was resubmitted to each woman, along with the Patient Global Impression of Improvement (PGII) questionnaire. Women's and physicians' satisfaction with the visit were also evaluated using a 5-point scale.

Results: One hundred and four women were enrolled. Anxiety levels decreased after the evaluation (STAI-Y6 60.0 ± 15.0 vs 40.8 ± 14.2, P < .001). Higher reductions were noted in patients who had higher baseline anxiety levels (est. change -24.3; 95% CI -29.2, -19.5; P < .001), had previously sought information online (est. change -15.9; 95% CI -21.4, -10.5; P < .001), and when endometriosis was not confirmed, but not in those waitlisted for surgery (est. change 1.7; 95% CI -5.9, 9.2; P 0.659). Most patients' mood improved after the examination (67%) and were satisfied with the visit (98%).

Conclusions: Anxiety levels are reduced after medical examination in women with higher baseline distress and who sought information online. To create a trustful relationship with women, providing them with tailored counselling, seems essential to improve their psychological wellbeing.
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http://dx.doi.org/10.1016/j.jpsychores.2021.110512DOI Listing
May 2021

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

Acta Obstet Gynecol Scand 2021 May 17. Epub 2021 May 17.

Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC), IRCCS, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

Introduction: Robot-assisted laparoscopic surgery (RALS) has gained widespread application in several surgical specialties. Previous studies on the feasibility and safety of RALS versus 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.
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http://dx.doi.org/10.1111/aogs.14170DOI Listing
May 2021

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

Fertil Steril 2021 May 4. Epub 2021 May 4.

Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.

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.
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http://dx.doi.org/10.1016/j.fertnstert.2021.03.027DOI Listing
May 2021

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

Gynecol Obstet Invest 2021 13;86(1-2):170-176. Epub 2021 Apr 13.

Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.

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.
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http://dx.doi.org/10.1159/000514310DOI Listing
April 2021

Perioperative blood loss after abdominal myomectomies: new solutions to an old problem.

Fertil Steril 2021 Mar;115(3):609-610

Division of Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 13, 40138 Bologna, Italy.

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http://dx.doi.org/10.1016/j.fertnstert.2021.01.002DOI Listing
March 2021

Transvaginal ultrasound features of normal uterosacral ligaments.

Fertil Steril 2021 Jul 12;116(1):275-277. Epub 2021 Feb 12.

Division of Obstetrics and Gynecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.

Objective: To show a step-by-step technique to assess normal uterosacral ligaments (USLs) during transvaginal ultrasound. Uterosacral ligaments represent the most common location of deep infiltrating endometriosis (DIE) in the posterior compartment and their involvement significantly increases the risk of ureteral lesions. The ultrasonographic diagnosis of DIE involving USLs is characterized by a wide range of accuracies described between studies, probably due to variations in the examination technique, quality of ultrasound equipment, and experience of the operators. Although described as a new classification system of DIE involving USLs, the technique for visualizing normal USLs has not yet been described.

Design: Stepwise demonstration of the technique with narrated video footage.

Setting: Academic tertiary hospital.

Patient(s): The video shows a 33-year-old nulliparous woman scheduled for laparoscopic removal of a para-ovarian cyst of approximately 6 cm. Procedural steps were repeated and confirmed in another four patients submitted to laparoscopy for benign diseases (Table 1). Moreover, we here show the case of a 29-year-old woman with an isolated DIE nodule of the right USL with a comparison of laparoscopic and ultrasound findings. To better point out the technique applied in a clinical setting we show also cases of infiltrated USLs (Table 2) during the ultrasound scan in women scheduled for endometriosis surgery. Informed consent was obtained from all of the patients. The study protocol was approved by the local institutional Ethics Committee (580/2018/Oss/AOUBo).

Intervention(s): To understand correctly the right position of USLs we performed an ultrasound during a surgical procedure; in this way it was possible to recognize the area of interest while the surgeon filled the pouch of Douglas with fluid and highlighted the anatomical area with pliers. Uterosacral ligaments can be seen in the mid-sagittal and transverse view of the uterus.

Main Outcome Measure(s): Description of appearance of normal USLs during transvaginal ultrasound.

Result(s): Uterosacral ligaments, at transvaginal ultrasound, appear as hyperechoic stripes starting from the cervix and pointing laterally in a semi-horizontal direction.

Conclusion(s): We provided a step-by-step technique (Table 3) that may be a useful tool to see accurately both the USLs at transvaginal ultrasound.
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http://dx.doi.org/10.1016/j.fertnstert.2020.11.019DOI Listing
July 2021

Uterine Fundus Remodeling after Hysteroscopic Metroplasty: A Prospective Pilot Study.

J Clin Med 2021 Jan 12;10(2). Epub 2021 Jan 12.

Gynecology and Human Reproduction Physiopathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy.

The septate uterus is the most common congenital uterine malformation and is treated by hysteroscopic metroplasty. There are few studies on the fundal uterine changes that occur after surgery. We designed a pilot prospective observational study to evaluate by three-dimensional transvaginal ultrasound (3D-TVS) the changes not only of the internal fundal uterine profile, but also of the external one, after hysteroscopic metroplasty. Sixty women who underwent hysteroscopic metroplasty for partial or complete uterine septum (U2a and U2b subclasses of ESHRE/ESGE classification) were enrolled. We performed 3D-TVS after surgery confirming optimal removal of the septum. However, at ultrasound follow-up after three months, we observed a significant increase ( < 0.001) in the residual septum (Zr) (3.7 mm (95% CI: 3.1-4.4)), the myometrial wall thickness (Y) (2.5 mm (95% CI: 2.0-3.0)) and the total fundal wall thickness (Y + Zr) (6.2 mm (95% CI: 5.5-6.9)). Forty-three patients (72%) required a second step of hysteroscopic metroplasty. Moreover, the shape of uterine fundus changed in 58% of cases. We actually observed a remodeling of the uterine fundus with modifications of its external and internal profiles. Therefore, we propose to always perform a second ultrasound look at least three months after the metroplasty to identify cases that require a second- step metroplasty.
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http://dx.doi.org/10.3390/jcm10020260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828148PMC
January 2021

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

J Minim Invasive Gynecol 2021 Jun 11;28(6):1225-1230. Epub 2021 Jan 11.

Division of Gynaecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC), IRCCS Azienda Ospedaliero-Universitaria di Bologna, S. Orsola Hospital, University of Bologna, Bologna, Italy (all authors).

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.
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http://dx.doi.org/10.1016/j.jmig.2020.12.017DOI Listing
June 2021

Fertility Sparing Treatment of Endometrial Cancer with and without Initial Infiltration of Myometrium: A Single Center Experience.

Cancers (Basel) 2020 Nov 29;12(12). Epub 2020 Nov 29.

Gynecology and Human Reproduction Physiopathology Unit, IRCCS Policlinico di Sant'Orsola, DIMEC, University of Bologna, 40138 Bologna, Italy.

Endometrial cancer (EC) is the fourth largest female cancer in Europe and North America. In 5% of cases, the diagnosis is made in women who wish to become pregnant. In our retrospective study, we reported our experience about fertility sparing treatment of G1 endometrioid endometrial cancer (G1 EEC) or atypical endometrial hyperplasia/endometrial intraepithelial neoplasm (AEH/EIN) in young women desiring pregnancy treated in our Center. Conservative treatment was based on operative hysteroscopy and hormone therapy with megestrol acetate (160 mg/die for 9 months). For the first time we included women with G1 EEC with minimal myometrial infiltration. The minimum follow-up period was two years and consisted of serial outpatient hysteroscopies with endometrial biopsies. Among the 36 women with G1 EEC we observed one case of disease persistence and four recurrences and four recurrences among the 46 women diagnosed with AEH/EIN. To date, 35 live births were obtained in both groups. Our results advance the hypothesis that conservative treatment can represent a safe and feasible alternative to propose to young women with desire for pregnancy. Further randomized and multicentric studies are needed to arrive at unambiguous and standardized guidelines on the surgical and medical treatment of young women with EEC or AEH/EIN.
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http://dx.doi.org/10.3390/cancers12123571DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7760930PMC
November 2020

Laparoscopic cervicopexy for correction of apical genital prolapse in 10 steps: a pilot study.

Int Urogynecol J 2021 May 25;32(5):1313-1316. Epub 2020 Sep 25.

Gynaecology and Human Reproduction Physiopathology, DIMEC, S. Orsola Hospital, University of Bologna, Bologna, Italy.

Introduction: Surgical repair of pelvic organ prolapse is one of the most frequent gynecological procedures, and its frequency is expected to increase as the population is gradually aging. Mesh use in urogynecological surgery should be limited because of important and life-treating complications. Sacral mesh-less and lateral procedures have been described as safe and effective to treat apical compartment prolapse. In this video, we describe a new laparoscopic mesh-less cervicopexy in women with symptomatic uterovaginal prolapse who did not desire uterine preservation.

Methods: Eleven women with symptomatic uterovaginal prolapse [stage 2 or higher according to the Pelvic Organ Prolapse Quantitative (POP-Q) classification system] underwent laparoscopic mesh-less cervicopexy to the sacrum and transverse fascia between May 2018 and June 2019. We performed application of the right uterosacral ligament starting from the sacrum and two semicontinous sutures including the transverse fascia, round ligament, prevescical peritoneum, pubocervical fascia and cervix that were subsequently knotted.

Results: At 6-month follow-up, the objective success rate for apical prolapse (POP-Q score C > -1) was 90.9% (10/11 women). Only one woman presented stage 3 apical prolapse recurrence with vaginal buldge.

Conclusion: Laparoscopic mesh-less cervicopexy for uterovaginal prolapse seems to be a feasible surgical technique at 6-month follow-up.
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http://dx.doi.org/10.1007/s00192-020-04536-6DOI Listing
May 2021

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

Fertil Steril 2021 01 12;115(1):248-255. Epub 2020 Sep 12.

Gynaecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), S. Orsola Hospital, University of Bologna, Bologna, Italy.

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.
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http://dx.doi.org/10.1016/j.fertnstert.2020.07.036DOI Listing
January 2021

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

J Sex Marital Ther 2020 24;46(7):603-611. Epub 2020 Jun 24.

Gynaecology and Human Reproduction Physiopathology Unit, DIMEC, S. Orsola Hospital, University of Bologna, Bologna, Italy.

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.
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http://dx.doi.org/10.1080/0092623X.2020.1765057DOI Listing
May 2021

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

Minerva Pediatr 2020 Jun 16. Epub 2020 Jun 16.

Gynecology and Human Reproduction Pathophysiology, DIMEC, S. Orsola Hospital, University of Bologna, Bologna, Italy.

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.
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http://dx.doi.org/10.23736/S0026-4946.20.05842-9DOI Listing
June 2020

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

Arch Gynecol Obstet 2020 09 6;302(3):665-670. Epub 2020 Jun 6.

Department of Obstetrics and Gynecology, DIMEC, S. Orsola Hospital, University of Bologna, Massarenti, 13, 40138, Bologna, Italy.

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/m) and non-obese (body mass index < 30 kg/m). 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.
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http://dx.doi.org/10.1007/s00404-020-05629-9DOI Listing
September 2020

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

Surg Innov 2020 Oct 5;27(5):474-480. Epub 2020 Jun 5.

Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), 18508Sant'Orsola Hospital, University of Bologna, Italy.

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. 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). 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, < .05) and lower MVD (154.6+/43.6 vs 281.1+/-77.4, < .05) than hypervascular ones. 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.
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http://dx.doi.org/10.1177/1553350620930147DOI Listing
October 2020

Laparoscopic surgery for benign adnexal conditions under spinal anaesthesia: Towards a multidisciplinary minimally invasive approach.

J Gynecol Obstet Hum Reprod 2020 Sep 16;49(7):101813. Epub 2020 May 16.

Gynaecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), S. Orsola Hospital, University of Bologna, Via Massarenti 13, 40138 Bologna, Italy.

Background: Laparoscopic gynaecological surgery is commonly performed under general anaesthesia with endotracheal intubation. In general surgery, locoregional anaesthesia was applied to laparoscopic procedures, increasing minimally invasive surgery advantages.

Aims: To assess and compare postoperative pain after laparoscopic adnexal procedures for benign conditions under spinal anaesthesia (SA) versus general anaesthesia (GA). Furthermore, anaesthesiologic, surgical and clinical data were evaluated in both groups.

Materials And Methods: This is a prospective cohort study performed in a tertiary level referral centre for minimally invasive gynaecological surgery (Gynaecology and Human Reproduction Physiopathology, University of Bologna). Women scheduled for adnexal laparoscopic surgery for benign conditions between February and May 2019 were assigned to receive either SA or GA with endotracheal intubation. A sample size of 13 women per group was needed to detect a 2-point difference in pain scores.

Main Findings: 13 women were enrolled in the SA arm, 15 in the GA arm. In the SA cohort, the most common intraoperative adverse event was shoulder pain, reported by 3/12 women. At 1, 8, 12, 24 and 48 h after surgery pain was significantly lower in the SA arm (p < .05). Patients submitted to SA experienced no need for opioid drugs administration, unlike those receiving GA. Patients' mobilization and return of bowel function were noted significantly earlier in the SA group (p < .05).

Conclusions: SA is a feasible, safe and effective anaesthesiologic technique for laparoscopic gynaecological procedures for benign conditions, allowing a better control of postoperative pain. Women undergoing SA achieve earlier mobilization and bowel canalization. During the Covid-19 pandemics, SA could be useful in reducing the need for invasive procedures on respiratory tract.
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http://dx.doi.org/10.1016/j.jogoh.2020.101813DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7229474PMC
September 2020

Acute abdominal pain in non-pregnant endometriotic patients: not just dysmenorrhoea. A systematic review.

J Obstet Gynaecol 2021 Jan 21;41(1):7-20. Epub 2020 Apr 21.

Gynaecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), S. Orsola Hospital, University of Bologna, Bologna, Italy.

Endometriosis, defined as the presence of functional endometrial tissue outside the uterine cavity, presents mainly with pelvic pain and infertility. Acute abdominal pain in non-pregnant patients with endometriosis might be minimised as a typical feature of the disease, while endometriosis is rarely considered in the differential diagnosis of acute abdominal pain. Our objective was to conduct a systematic review of the current literature of cases of acute abdomen/acute abdominal pain in non-pregnant endometriotic patients. We performed a PubMed/MEDLINE search of studies published from January 1990 to December 2018, selecting English language reports and series of non-pregnant patients with acute abdomen and histological confirmation of endometriosis. The studies were revised by two independent authors. Data were abstracted and compiled for analysis. Fifty articles reporting 62 patients were identified. The complications were classified according to anatomical sites in bowel, urinary tract, and genital organs emergencies. Rarely was the first diagnostic hypothesis endometriosis, misdiagnosis was frequent. The time frame from symptoms onset to management was often long. This is the first systematic review evaluating acute abdomen/acute abdominal pain in non-pregnant endometriotic patients. These conditions are rare but possibly life-threating and require prompt diagnosis and emergent medical or surgical treatment.
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http://dx.doi.org/10.1080/01443615.2019.1700946DOI Listing
January 2021

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

J Minim Invasive Gynecol 2021 01 10;28(1):42-49. Epub 2020 Apr 10.

Unit of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, S. Orsola Hospital, University of Bologna, Bologna, Italy (Drs. Raimondo, Borghese, Arena, Ambrosio, Del Forno, Degli Esposti, Casadio, Mattioli, Mastronardi, and Seracchioli).

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.
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http://dx.doi.org/10.1016/j.jmig.2020.04.004DOI Listing
January 2021

Unicornuate uterus with noncommunicating functional horn: diagnostic workup and laparoscopic horn amputation.

Fertil Steril 2020 04;113(4):885-887

Gynaecology and Human Reproduction Physiopathology, Department of Obstetrics and Gynecology, DIMEC, Sant'Orsola Academic Hospital, University of Bologna, Bologna, Italy.

Objective: To describe the diagnosis and the management of hematometra in a patient with unicornuate uterus with noncommunicating functional horn (hemi uterus and rudimentary uterine hemicavity).

Design: Video case report.

Setting: Minimally invasive gynaecology unit.

Patient(s): Sixteen-year-old nulliparous woman admitted to the gynaecologic emergency department with pelvic pain during menses.

Intervention(s): Two-dimensional transvaginal ultrasound, magnetic resonance imaging, and laparoscopic rudimentary horn resection.

Main Outcome Measure(s): Description of a case of anomaly of the female reproductive tract treated by laparoscopy.

Result(s): After pain reduction and stabilization of clinical condition, ultrasound and magnetic resonance were performed, which detected a hemi uterus with a right rudimentary uterine hemicavity and a hematosalpinx. The removal of the right rudimentary uterine horn was successfully performed. The patient was in good health at the 3-month follow-up visit.

Conclusion(s): Laparoscopic amputation of a functional rudimentary horn is considered the basic and traditional surgical option for women with hemiuterus. A detailed diagnostic evaluation should be performed to avoid misdiagnoses of other anomalies with blind hemicavity, which may be treated by hysteroscopy. Laparoscopic surgery with minimally invasive approach could be an essential tool to treat these cases, achieving optimal results with low postsurgical pain and a short hospital stay.
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http://dx.doi.org/10.1016/j.fertnstert.2019.12.003DOI Listing
April 2020

Question Mark Sign and Transvaginal Ultrasound Uterine Tenderness for the Diagnosis of Adenomyosis: A Prospective Validation.

J Ultrasound Med 2020 Jul 7;39(7):1405-1412. Epub 2020 Feb 7.

Department of Gynecology and Human Reproduction Pathophysiology, Saint'Orsola Hospital, University of Bologna, Bologna, Italy.

Objectives: To evaluate the diagnostic accuracy of the classic ultrasound (US) signs of adenomyosis, the question mark sign and transvaginal ultrasound (TVUS) uterine tenderness, in the diagnosis of adenomyosis.

Methods: This was a prospective study including 78 patients waiting for hysterectomy for uterine benign diseases and undergoing preoperative US examinations to evaluate all criteria for US diagnosis of adenomyosis as reported by the consensus statement of the Morphological Uterus Sonographic Assessment group. A US diagnosis of adenomyosis was made in the presence of 2 or more Morphological Uterus Sonographic Assessment features. Moreover, the question mark sign and TVUS uterine tenderness were evaluated. Ultrasound features were compared with the histologic examination, which was considered the reference standard for the diagnosis of adenomyosis. The Cohen κ coefficient was used to measure the accordance between US and histologic results. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of each US feature were calculated.

Results: The prevalence of adenomyosis in the sample was 33.3%. The sensitivity, specificity, PPV, NPV, and accuracy of TVUS in the diagnosis of adenomyosis were 77%, 96%, 91%, 89%, and 90%, respectively. Myometrial heterogeneity was the most frequently encountered feature (100%) but showed low specificity (7%). The question mark sign and TVUS uterine tenderness showed sensitivity, specificity, PPV, NPV, and accuracy of 41%, 96%, 83%, 77%, and 69% and 69%, 65%, 66%, 81%, and 67%.

Conclusions: The question mark sign and TVUS uterine tenderness are useful tools for the diagnosis of adenomyosis.
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http://dx.doi.org/10.1002/jum.15237DOI Listing
July 2020

Frequency and clinical impact of Dolichocolon in women submitted to surgery for rectosigmoid endometriosis.

J Gynecol Obstet Hum Reprod 2020 Apr 1;49(4):101697. Epub 2020 Feb 1.

Department of Obstetrics and Gynecology, DIMEC, S. Orsola Hospital, University of Bologna, Italy.

Introduction: Rectosigmoid endometriosis and Dolichocolon can both present with a triad of chronic abdominal pain, constipation and bloating. The relationship between these two pathologies is unknown. The present study aims to determine the frequency of DC in women with rectosigmoid endometriosis and its possible impact on pre- and post-operative symptoms.

Material And Methods: We conducted a retrospective cohort study on 113 consecutive patients submitted to magnetic resonance imaging enema and subsequent complete surgical removal for symptomatic rectosigmoid endometriosis between June 2015 to June 2018. Dolichocolon is an anatomic variant characterized by redundancies and lengthening of the colon. We divided our study population according to its presence or absence. The two groups were compared in terms of demographic data, surgical findings and pre- and post-operative clinical variables. Pain symptoms were assessed through numerical rating scale from 0 to 10. Bowel complaints included constipation, bloating and diarrhea.

Results: Thirty-five patients (31 %) presented a dolichocolon at magnetic resonance imaging enema. The two groups were comparable in terms of demographic data, pre-operative clinical variables and surgical findings. At 6-month follow-up, there was a significant improvement of symptoms, except for constipation and bloating in dolichocolon group. In particular, we observed with a statistical difference (p < .05) the persistence of constipation and bloating in dolichocolon group compared to non-dolichocolon group.

Conclusions: Dolichocolon was observed in one third patients with rectosigmoid endometriosis and could influence surgical outcomes for rectosigmoid endometriosis in terms of relief of bowel symptoms.
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http://dx.doi.org/10.1016/j.jogoh.2020.101697DOI Listing
April 2020

Transvaginal Ultrasound and Doppler Features of Intraligamental Myomas.

J Ultrasound Med 2020 Jul 16;39(7):1253-1259. Epub 2020 Jan 16.

Department of Obstetrics and Gynecology, S. Orsola Malpighi Hospital, University of Bologna, Bologna, Italy.

Objectives: To describe the ultrasound (US) features of intraligamental myomas (IMs) using Morphological Uterus Sonographic Assessment group standardized terminology.

Methods: This was a retrospective monocentric study. A total of 125 consecutive women with a preoperative US diagnosis of a myoma located close to the uterine isthmus (International Federation of Gynecology and Obstetrics stages 5, 6, and 7) from 2016 to 2019 who underwent laparoscopic or laparotomic myomectomy or hysterectomy were included for study analyses. The US data were retrieved from US reports and stored digital images by 2 authors. Ultrasound features of myomas were described according to Morphological Uterus Sonographic Assessment terminology. Clinical data for the study population were retrieved from the patients' records.

Results: Nineteen women with a surgical confirmation of an IM were included in the study group; the remaining population constituted the control group (n = 106). Non-uniform echogenicity was detected in 17 of 19 (89%) of IMs compared to 26 of 106 (25%) fibroids in the control group (P < .001). The presence of shadowing was detected in 12 of 19 (63%) IMs compared to 94 of 106 (89%) cases in the control group (P = .004). Intraligamental myomas were more vascularized tumors compared to myomas in the control group (P = .004). Transvaginal US showed high specificity for the diagnosis of an IM (0.93; 95% confidence interval, 0.87-0.96).

Conclusions: On US imaging, IMs appear as vascularized solid tumors with nonuniform echogenicity; cones of shadows were less frequent in IMs than the control group, and this finding can help in the differential diagnosis. Knowledge of their specific US features could help sonographers make an accurate diagnosis, allowing them to plan correct surgery and avoid severe complications.
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http://dx.doi.org/10.1002/jum.15213DOI Listing
July 2020

Impact of Temporary Protective Ileostomy on Intestinal Function and Quality of Life after a 2-Year Follow-up in Patients Who Underwent Colorectal Segmental Resection for Endometriosis.

J Minim Invasive Gynecol 2020 Sep - Oct;27(6):1324-1330. Epub 2019 Oct 28.

From the Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC), Sant'Orsola Hospital, University of Bologna, Bologna, Italy (all authors).

Study Objective: To compare 2-year follow-up intestinal function and quality of life (QoL) between women with temporary protective ileostomy (PI) and recanalization and women without PI after colorectal segmental resection for deep infiltrating endometriosis (DIE).

Design: Prospective observational exploratory study.

Setting: Tertiary level referral center for minimally invasive gynecologic surgery.

Patients: Consecutive patients who underwent laparoscopic colorectal resection and PI because of DIE between January 2015 and January 2018; an equal number of women without PI were matched according to age and anamnestic findings to serve as controls.

Interventions: Realization of a PI or immediate recanalization in patients who underwent laparoscopic colorectal resection.

Measurements And Main Results: Thirty-six patients were considered for the analyses: 18 in the PI group and 18 in the non-PI group. Baseline intestinal function and QoL were evaluated using 2 validated questionnaires. The main reasons for ileostomy were colpotomy (66.7%), ultralow bowel anastomosis (27.8%), concomitant ureteroneocystostomy, and positive Michelin test result (5.6%). The mean interval between first and second surgery in the PI group was 3.7 ± 1.7 months. Perioperative severe complications included 1 stenosis of colorectal anastomosis in 1 woman in the PI group and 1 perianastomotic abscess in the non-PI group; overall the complications were comparable between the 2 groups. At the 2-year follow-up from recanalization, bowel function and QoL improved from baseline, with no statistical differences between the groups (Knowles-Eccersley-Scott-Symptom delta: 5.9 ± 9.3 in the PI group vs 7.7 ± 10.2 in the non-PI group, p = .6; Gastrointestinal Quality of Life Index delta: 16.0 ± 27.5 vs 19.2 ± 24.7, p = .7).

Conclusion: Temporary PI after colorectal resection for DIE does not seem to influence patients' bowel function and QoL at a median follow-up from recanalization at 2 years.
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http://dx.doi.org/10.1016/j.jmig.2019.10.017DOI Listing
February 2021

Liver function, tolerability and satisfaction during treatment with ulipristal acetate in women with fibroids: a single center experience.

Gynecol Endocrinol 2020 May 24;36(5):445-447. Epub 2019 Oct 24.

Gynecology and Human Reproduction Physiopathology, DIMEC, S. Orsola Hospital University of Bologna, Bologna, Italy.

The aim of the study was to evaluate liver function in women treated with ulipristal acetate (UPA) and to assess the tolerability and satisfaction during treatment. This Cross-sectional study included women with symptomatic uterine fibroids subjected to one or more 3-month treatment courses of 5 mg UPA daily. Following European Medical Agency's prescriptions, women were asked about symptoms potentially related to liver damage and had blood tests done, to assess serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Data on side effects, tolerability and satisfaction with the therapy were obtained during a phone interview. A total of 162 women completed the study with a mean treatment duration of 1.8 ± 0.9 cycles. No increased AST and ALT serum levels were detected and no woman reported symptoms suggestive of liver injury. The majority of women reported improvement of fibroids-related symptoms and a high degree of satisfaction with treatment. More than half of women had side effects, in most cases not as severe as to discontinue therapy. Ulipristal acetate did not worsen liver function or cause severe organ injury and showed high tolerability and satisfaction profiles. Therefore, we believe that it can still be considered a valuable option in the treatment of uterine fibroids.
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http://dx.doi.org/10.1080/09513590.2019.1680626DOI Listing
May 2020

Painful Love: Superficial Dyspareunia and Three Dimensional Transperineal Ultrasound Evaluation of Pelvic Floor Muscle in Women with Endometriosis.

J Sex Marital Ther 2020 15;46(2):187-196. Epub 2019 Oct 15.

Gynaecology and Human Reproduction Physiopathology, DIMEC, S. Orsola Hospital, University of Bologna, Bologna, Italy.

We conducted an observational study between March 2015 and March 2018 in our academic center. Symptomatic, sexually active women with clinical and sonographic diagnosis of deep infiltrating endometriosis (DIE) or isolated ovarian endometriosis were enrolled. Women were asked to rank endometriosis-related symptoms, especially superficial and deep dyspareunia. Moreover, 3D transperineal ultrasound was performed to assess the levator hiatus area (LHA) evaluating pelvic floor muscle (PFM) morphometry. Women with endometriosis seem to have a high prevalence of superficial dyspareunia and three-dimensional transperineal ultrasound seems to be a viable technique to assess PFM morphometry in these women.
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http://dx.doi.org/10.1080/0092623X.2019.1676852DOI Listing
November 2020

The Impact of Hormonal Replacement Treatment in Postmenopausal Women with Uterine Fibroids: A State-of-the-Art Review of the Literature.

Medicina (Kaunas) 2019 Aug 30;55(9). Epub 2019 Aug 30.

Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), S. Orsola Hospital, University of Bologna, Via Massarenti, 13-40138 Bologna, Italy.

: Hormonal replacement therapy (HRT) is effective in treating many debilitating symptoms of menopause. However, its use in women with uterine fibroids is widely debated, based on the susceptibility of these tumors to sexual steroids. This review aims to ascertain the effects of HRT on leiomyomas development and growth in postmenopausal women. : Electronic databases (i.e., MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Sciencedirect, the Cochrane Library at the CENTRAL Register of Controlled Trials, Scielo) were searched from January 1990 until May 2019. All English-written studies evaluating the impact of various HRT regimens on uterine leiomyomas were selected. : Seventeen papers, considering a total of 1122 participants, were included. Fifteen of these were prospective trials, of which nine were randomized controlled trials. The remaining two works were a retrospective observational trial and a retrospective case series respectively. Five studies evaluated the effects of tibolone, also comparing it with various estrogen/progestin combinations, while two were about raloxifene. Thirteen studies compared different combinations of estrogens/progestins, the most common being transdermal estrogens (used in nine studies) and medroxyprogesterone acetate at different doses (used in 10 studies). : For women with uterine fibroids, the choice of the most appropriate HRT regimen is crucial to avoid leiomyomas growth and the symptoms possibly related to it. Available data are conflicting, but suggest that uterine fibroids might be influenced by HRT, without representing an absolute contraindication to hormonal replacement therapy. Women with uterine fibroids subjected to HRT should be periodically examined and hormonal treatment should be discontinued if leiomyomas appear to increase in size. Moreover, the minimal effective dose of progestin should be employed.
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http://dx.doi.org/10.3390/medicina55090549DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6780684PMC
August 2019

First Impressions Can Be Deceiving: Surgical Outcomes of Laparoscopic Myomectomy in Patients Pretreated with Ulipristal Acetate.

J Minim Invasive Gynecol 2020 Mar - Apr;27(3):633-638. Epub 2019 Aug 13.

Department of Obstetrics and Gynecology, DIMEC, Sant'Orsola Hospital, University of Bologna (Drs. Frascá, Arena, Degli Esposti, Raimondo, Del Forno, Moro, Zanello, Mabrouk, and Seracchioli), Italy.

Study Objective: To compare enucleation time, total operative time, and perioperative complications during laparoscopic myomectomy in patients pretreated with ulipristal acetate (UPA) compared with untreated patients.

Design: Prospective, observational pilot study.

Setting: Tertiary referral center of minimally invasive gynecologic surgery, Sant'Orsola Academic Hospital, Bologna, Italy.

Patients: Seventy-four of 108 patients scheduled for laparoscopic myomectomy from January to November 2017 were enrolled.

Interventions: Laparoscopic myomectomy following pretreatment with UPA or no hormonal pretreatment therapy.

Measurements And Main Results: Of the 74 patients who were enrolled, 29 were pretreated with UPA (UPA group), and 45 did not receive any hormonal therapy before surgery (control group). Surgeons, blinded to patient pre-operative treatment, completed a 3-item questionnaire after each procedure to evaluate surgical difficulty. Based on surgeon response, myomas in the UPA group appeared softer and more difficult to enucleate because of less clear cleavage planes than the control group. The overall difficulty of myoma detachment from the myometrium was judged considerably higher in the UPA group. Despite this, enucleation time, total operative time, and perioperative complications were not statistically different in the 2 groups.

Conclusion: Myomas in patients pretreated with UPA are subjectively less easy to enucleate; however, surgical times and perioperative outcomes are not affected by pretreatment with UPA.
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http://dx.doi.org/10.1016/j.jmig.2019.04.026DOI Listing
October 2020

Hormonal Replacement Therapy in Menopausal Women with History of Endometriosis: A Review of Literature.

Medicina (Kaunas) 2019 Aug 14;55(8). Epub 2019 Aug 14.

Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), S. Orsola Hospital, University of Bologna, Via Massarenti 13, 40138 Bologna, Italy.

Hormonal replacement therapy (HRT) is effective in treating the symptoms of menopause. Endometriosis is defined as the presence of functional endometrial tissue outside the uterine cavity with a tendency towards invasion and infiltration. Being an estrogen-dependent disease, it tends to regress after menopause. Nevertheless, it affects up to 2.2% of postmenopausal women. Conclusive data are not available in the literature on the appropriateness of HRT in women with endometriosis or a past history of the disease. The hypothesis that exogenous estrogen stimulation could reactivate endometriotic foci has been proposed. The aim of this state-of-the-art review was to revise the current literature about endometriosis in perimenopause and menopause and to investigate the possible role of HRT in this setting of patients. An electronic databases search (MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Sciencedirect, the Cochrane Library at the CENTRAL Register of Controlled Trials, Scielo) was performed, with the date range of from each database's inception until May 2019. All of the studies evaluating the impact of different HRT regimens in patients with a history of endometriosis were selected. 45 articles were found: one Cochrane systematic review, one systematic review, five narrative reviews, two clinical trials, two retrospective cohort studies, 34 case reports and case series. Some authors reported an increased risk of malignant transformation of endometriomas after menopause in patients assuming HRT with unopposed estrogen. Low-quality evidence suggests that HRT can be prescribed to symptomatic women with a history of endometriosis, especially in young patients with premature menopause. Continuous or cyclic combined preparations or tibolone are the best choices. HRT improves quality of life in symptomatic post-menopausal women, who should not be denied the replacement therapy only due to their history of endometriosis. Based on low-grade literature evidence, we recommend to prescribe combined HRT schemes; tibolone could be considered.
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http://dx.doi.org/10.3390/medicina55080477DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723930PMC
August 2019

Deep Infiltrating Endometriosis and Spontaneous Hemoperitoneum: A Life-Threatening Situation Treated by Laparoscopy.

J Minim Invasive Gynecol 2020 Mar - Apr;27(3):579. Epub 2019 Jul 31.

Gynaecology and Human Reproduction Physiopathology, Department of Obstetrics and Gynecology (all authors), DIMEC, S. Orsola Hospital, University of Bologna, Bologna, Italy; Department of Obstetrics and Gynecology, Faculty of Medicine (Dr. Mabrouk), University of Alexandria, Alexandria, Egypt; Cambridge Endometriosis and Endoscopic Surgery Unit (CEESU) (Dr. Mabrouk), Cambridge University Hospitals, Cambridge, United Kingdom.

Objective: To describe a case of spontaneous hemoperitoneum in a woman affected by deep infiltrating endometriosis (DIE).

Design: Technical video showing laparoscopic management of a spontaneous hemoperitoneum in a patient with DIE.

Setting: Minimally Invasive Gynecological Unit, Sant'Orsola Academic Hospital, Bologna, Italy.

Intervention: A 35-year-old nulliparous woman was admitted to our gynecologic emergency room because of pelvic pain and a fainting sensation. She had a history of DIE and had been followed for 6 months by our outpatient clinics. The patient underwent an immediate laparoscopy because of the rapid worsening of clinical conditions. After blood suction and difficult adhesiolysis, a vascular lesion with a huge blood flow, close to the left utero-ovarian ligament, was detected. Selective coagulation was performed with good results. During the follow-up visit after 1 month, the patient reported good health. Written informed consent was obtained from the patient for publication of this case report.

Conclusion: Spontaneous hemoperitoneum represents a rare and life-threatening complication associated with endometriosis. In patients with hemoperitoneum and a history of endometriosis, it is important to pay attention to the possible presence of uncommon bleeding localizations. Laparoscopy was useful and effective in this challenging situation, identifying the bleeding source and performing selective coagulation.
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http://dx.doi.org/10.1016/j.jmig.2019.07.020DOI Listing
October 2020

Dienogest or Norethindrone acetate for the treatment of ovarian endometriomas: Can we avoid surgery?

Eur J Obstet Gynecol Reprod Biol 2019 Jul 2;238:120-124. Epub 2019 May 2.

Gynaecology and Human Reproduction Physiopathology, DIMEC, S. Orsola Hospital, University of Bologna, Italy.

Objective: To compare the effects of Dienogest (D) and Norethindrone acetate (N) in symptomatic women with ovarian endometriomas, analyzing the efficacy in reducing endometrioma size and symptom relief and drug tolerability.

Study Design: Retrospective study including 135 symptomatic women with ultrasonographic diagnosis of ovarian endometrioma. Women were divided into two groups: 1) women who received D 2 mg/day (group D); 2) women who received N 2.5 mg/day (group N). Women were evaluated at therapy prescription and after 6 and 12 months of treatment: transvaginal ultrasound was performed to assess the mean diameter of endometriomas, a Visual Analogue Scale was used to rank endometriosis related symptoms (dysmenorrhea, dyspareunia, chronic pelvic pain). The main outcome measure was the comparison between the 2 groups in terms of variations in endometrioma size and endometriosis related symptoms during the follow-up. Drug tolerability was also analyzed in terms of side effects.

Results: A reduction in ovarian endometrioma size was observed during treatment in both groups, with no significant differences between groups D and N. Endometriosis related symptoms decreased in both groups, but the decrease was significantly higher in group D than in group N for all symptoms, both at 6 and 12 months of treatment. Regarding drug tolerability, uterine bleeding/spotting and weight gain were reported more frequently by women in the group N than women in the group D, both at 6 and 12 months of treatment.

Conclusion: Progestin therapy with D or N appears to be effective in reducing the size of endometriomas and related symptoms, with a greater effect on symptoms relief and higher tolerability in women treated with D.
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http://dx.doi.org/10.1016/j.ejogrb.2019.04.010DOI Listing
July 2019