Publications by authors named "Artur Ludwin"

61 Publications

CD133 Expression in the Nucleus Is Associated with Endometrial Carcinoma Staging and Tumor Angioinvasion.

J Clin Med 2021 May 15;10(10). Epub 2021 May 15.

Institute of Pediatrics, Department of Transplantation, Faculty of Medicine, Jagiellonian University Medical College, 30-663 Krakow, Poland.

Background: (1) Endometrial cancer is one of the most common cancers affecting women, with a growing incidence. To better understand the different behaviors associated with endometrial cancer, it is necessary to understand the changes that occur at a molecular level. CD133 is one of the factors that regulate tumor progression, which is primarily known as the transmembrane glycoprotein associated with tumor progression or cancer stem cells. The aim of our study was to assess the impact of subcellular CD133 expression on the clinical course of endometrial cancer. (2) Methods: CD133 expression in the plasma membrane, nucleus, and cytoplasm was assessed by immunohistochemical staining in a group of 64 patients with endometrial cancer representing FIGO I-IV stages, grades 1-3 and accounting for tumor angioinvasion. (3) Results: Nuclear localization of CD133 expression was increased in FIGO IB-IV stages compared to FIGO IA. Furthermore, CD133 expression in the nucleus and plasma membrane is positively and negatively associated with a higher grade of endometrial cancer and angioinvasion, respectively. (4) Conclusions: Our findings suggest that positive nuclear CD133 expression in the tumor may be related to a less favorable prognosis of endometrial carcinoma patients and has emerged as a useful biomarker of a high-risk group.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/jcm10102144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8156002PMC
May 2021

Resection of a uterine septum in a normal uterus: Whoa Nellie.

Fertil Steril 2021 May 3;115(5):1140-1142. Epub 2021 Apr 3.

Wright State University Boonshoft School of Medicine, Dayton, Ohio; Center for Reproductive Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2021.03.010DOI Listing
May 2021

Oxytocin and Misoprostol With Diclofenac in the Preparation for Magnetic Resonance-Guided High-Intensity Ultrasound Treatment of Symptomatic Uterine Fibroids: A Prospective Cohort Study.

Ultrasound Med Biol 2021 Jun 28;47(6):1573-1585. Epub 2021 Mar 28.

Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, Warsaw, Poland.

Uterine fibroids (UFs) are very common benign tumors of the female reproductive tract. According to recent reports, magnetic resonance-guided high-intensity ultrasound (MR-HIFU) appears to be a well-tolerated and efficient treatment option for UFs. However, MR-HIFU still presents several limitations. The treatment is rarely associated with achieving complete non-perfused volume (NPV). Not all patients are qualified for a final procedure, and selected women obtain very good results in such treatment. The primary objective of this experimental study was to assess the effect of transvaginal misoprostol and intravenous oxytocin preparation on UF volume change, sonication time and NPV after MR-HIFU procedure in women of reproductive age with symptomatic UFs. Secondary outcomes included the effect on the peri-procedural effectiveness of misoprostol and oxytocin. This study enrolled 247 women with symptomatic UFs; based on gynecologic examinations and magnetic resonance imaging (MRI) scans, 128 women qualified for MR-HIFU without pharmacologic treatment, 57 women qualified for the misoprostol/diclofenac group and 62 women qualified for the oxytocin group. Pharmacologic pre-treatment improved NPV compared with non-pharmacologic treatment (average NPV: controls 61.9% ± 25.8%; oxytocin 76.8% ± 20.7%; misoprostol/diclofenac 85.2% ± 15.1%; average sonication time: controls 120 min ± 56.4%; oxytocin 111 min ± 45.4%; misoprostol/diclofenac 80 min ± 47.7%). Statistical analysis did not reveal significant intergroup differences in UF volume changes after 6 mo (controls: n = 40, 37.4% ± 27.5%; oxytocin n = 25, 45.8% ± 31%; misoprostol/diclofenac n = 19, 33.4% ± 23.2%). The misoprostol/diclofenac group, which achieved the highest NPV immediately after the MR-HIFU procedure, was characterized by the lowest UF volume change percentages 6 mo later. The administration of vasoconstrictor drugs (oxytocin and misoprostol/diclofenac) to support MR-HIFU in UF treatment is a new issue that may improve the total effectiveness of this method. Randomized controlled trials are necessary to estimate the real effect of vasoconstrictors on MR-HIFU.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ultrasmedbio.2021.02.018DOI Listing
June 2021

Terminology for describing normally sited and ectopic pregnancies on ultrasound: ESHRE recommendations for good practice.

Hum Reprod Open 2020 16;2020(4):hoaa055. Epub 2020 Dec 16.

Department of OB/GYN, University College Hospital, London, UK.

Study Question: What recommendations can be provided to improve terminology for normal and ectopic pregnancy description on ultrasound?

Summary Answer: The present ESHRE document provides 17 consensus recommendations on how to describe normally sited and different types of ectopic pregnancies on ultrasound.

What Is Known Already: Current diagnostic criteria stipulate that each type of ectopic pregnancy can be defined by clear anatomical landmarks which facilitates reaching a correct diagnosis. However, a clear definition of normally sited pregnancies and a comprehensive classification of ectopic pregnancies are still lacking.

Study Design Size Duration: A working group of members of the ESHRE Special Interest Group in Implantation and Early Pregnancy (SIG-IEP) and selected experts in ultrasound was formed in order to write recommendations on the classification of ectopic pregnancies.

Participants/materials Setting Methods: The working group included nine members of different nationalities with internationally recognised experience in ultrasound and diagnosis of ectopic pregnancies on ultrasound. This document is developed according to the manual for development of ESHRE recommendations for good practice. The recommendations were discussed until consensus by the working group, supported by a survey among the members of the ESHRE SIG-IEP.

Main Results And The Role Of Chance: A clear definition of normally sited pregnancy on ultrasound scan is important to avoid misdiagnosis of uterine ectopic pregnancies. A comprehensive classification of ectopic pregnancy must include definitions and descriptions of each type of ectopic pregnancy. Only a classification which provides descriptions and diagnostic criteria for all possible locations of ectopic pregnancy would be fit for use in routine clinical practice. The working group formulated 17 recommendations on the diagnosis of the different types of ectopic pregnancies on ultrasound. In addition, for each of the types of ectopic pregnancy, a schematic representation and examples on 2D and 3D ultrasound are provided.

Limitations Reasons For Caution: Owing to the limited evidence available, recommendations are mostly based on clinical and technical expertise.

Wider Implications Of The Findings: This document is expected to have a significant impact on clinical practice in ultrasound for early pregnancy. The development of this terminology will help to reduce the risk of misdiagnosis and inappropriate treatment.

Study Funding/competing Interests: The meetings of the working group were funded by ESHRE. T.T. declares speakers' fees from GE Healthcare. The other authors declare that they have no conflict of interest.

Trial Registration Number: N/A.

Disclaimer: This Good Practice Recommendations (GPR) document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and where relevant based on the scientific evidence available at the time of preparation. ESHRE's GPRs should be used for informational and educational purposes. They should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. Furthermore, ESHRE's GPRs do not constitute or imply the endorsement, recommendation or favouring of any of the included technologies by ESHRE.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/hropen/hoaa055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738750PMC
December 2020

Tubal Flushing Treatment for Unexplained Infertility.

Semin Reprod Med 2020 Jan 18;38(1):74-86. Epub 2020 Dec 18.

Department of Reproductive Medicine, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.

Tubal patency testing was initially introduced as a diagnostic test. However, it has been observed that some tubal patency tests also have a therapeutic effect. This therapeutic effect can be influenced by the contrast medium used during tubal flushing. In this review, we discuss current evidence associated with different methods for tubal flushing and their potential impact on reproductive outcomes in women with unexplained infertility. Furthermore, we discuss their diagnostic accuracy, safety, and cost-effectiveness.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0040-1721720DOI Listing
January 2020

Reunification of the unicornuate uterus and the remnant horn- proceed with caution!

Fertil Steril 2020 11 13;114(5):981-982. Epub 2020 Oct 13.

Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, Ohio.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2020.09.136DOI Listing
November 2020

Longitudinal vaginal septum: a proposed classification and surgical management.

Fertil Steril 2020 10 18;114(4):899-901. Epub 2020 Aug 18.

Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland; Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland; Centermed Private Hospital and Clinic, Krakow, Poland.

Objective: To demonstrate various types of longitudinal vaginal septa (LVS), their classification, and the surgical management of typical and unique morphologic conditions of LVS.

Design: Video presentation of clinical appearance and surgical techniques for treatment of LVS.

Setting: University hospital and two private.

Patient(s): Representative cases from 121 consecutive women treated from 2013 to 2018 with LVS as a part of complex uterovaginal malformations or in isolated forms with [1] typical morphologic configuration of LVS, [2] rarer variants, or [3] specific anatomic restrictions.

Intervention(s): Resection of LVS performed as a main surgical procedure in cases with didelphys and bicornuate uterus in symptomatic women and as a part of corrective surgery of complete septate uterus. The three main nonsuturing techniques used were speculoscopy and septum excision using three different electrosurgical modalities; speculoscopy with laparoscopic devices; and vaginoscopy with hysteroscopic instruments.

Main Outcome Measure(s): Clinical appearance and suggested classification, feasibility of surgery, and perioperative and anatomic results in a short follow-up period (3 months).

Result(s): We identified distinct types of longitudinal vaginal septa. Considering clinical appearance, we suggest classification of LVS based on four main features: [2] completeness of vaginal division: partial and complete type; [2] the symmetricity: symmetric and asymmetric position (with dominant left and right side); [3] association with the cervix: merged and isolated forms; and [4] concomitant vaginal openings: normal, and narrow openings: vaginal stenosis and hymen persistent (Fig. 1). Vaginoscopic techniques by hysteroscope were successful in atraumatic treatment of women with substantial anatomic restrictions, and all of the presented techniques can be effectively used for typical LVS. However, vessel-sealing systems allow for bloodless surgery in contrast with other methods. This study was based on previously acquired data during large prospective study approved by the local ethics committee, and written informed consent to participate in the prospective study and permit publishing anonymous data regarding the medical images, videos of procedures, and results was obtained from all patients.

Conclusion(s): A new classification of longitudinal vaginal septum allows better characterization compared with the currently available classification systems. Different surgical modalities are discussed with their respective advantages and disadvantages. Vaginoscopic incision using resectoscope is a reasonable alternative for women with an intact hymen and vaginal stenosis. The impact of vaginal septum resection on obstetric, reproductive, and sexual outcomes should be assessed in randomized controlled trials and large well-designed studies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2020.06.014DOI Listing
October 2020

Septum resection does not improve reproductive outcomes: truly?

Authors:
Artur Ludwin

Hum Reprod 2020 07;35(7):1495-1498

Department of Gynecology and Oncology, Jagiellonian University, Krakow 31-501, Poland.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/humrep/deaa142DOI Listing
July 2020

Saline-Air Hysterosalpingo-Contrast Sonography Is Equivalent to the Modified Hysterosalpingogram Following Hysteroscopic Sterilization.

Ultrasound Q 2020 Jun;36(2):138-145

Department of Obstetrics and Gynecology, University of Wisconsin Madison, WI.

Purpose: To estimate the diagnostic efficacy of saline-air hysterosalpingo-contrast sonography (SA-HyCoSy) compared with the modified hysterosalpingogram (mHSG) for confirmation of both coil location and tubal occlusion following hysteroscopic sterilization.

Methods: This study included 19 women who underwent both SA-HyCoSy and mHSG where 1 test was followed by the other. Sensitivity, specificity, and positive and negative predictive values for tubal occlusion against the mHSG were calculated for each fallopian tube by 2 independent interpreters. Interrater reliability was assessed using Cohen κ statistic. Procedure time and pain level by 11-point numeric rating scale of SA-HyCoSy and mHSG were also compared.

Results: Thirty-eight fallopian tubes were evaluated. Tubal occlusion was noted in 97.3% of tubes for both interpreters with the mHSG compared with 92.1% and 94.7% with SA-HyCoSy. The positive and negative predictive values for tubal occlusion were 100%/100% and 50%/33%, respectively, with an overall agreement of 97.4% and 95.7%, κ = 0.48, P < 0.01. Saline-air HyCoSy changed interpretation of coil insert location in 50% and 44.7% for each interpreter, being downgraded from optimal to satisfactory in 42.9% (9/21) and 36% (9/25) and upgraded to optimal in 58.8% (10/17) and 61.5% (8/13), respectively. There were no statistically significant differences in procedural time (7.5 vs 9.4 minutes, P > 0.05) or maximum pain scores (2.3 vs 3.1, P > 0.05) for the mHSG compared with SA-HyCoSy.

Conclusions: Our findings revealed a high degree of diagnostic accuracy with SA-HyCoSy for tubal occlusion, although coil location changed in nearly half of cases. Avoidance of radiation and patient convenience/compliance with SA-HyCoSy may outweigh the drawbacks.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/RUQ.0000000000000488DOI Listing
June 2020

Unicornuate uterus and the noncommunicating functional horn: continued debate on the diagnosis, classification, and treatment.

Fertil Steril 2020 04 5;113(4):772-773. Epub 2020 Mar 5.

Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, Ohio; Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2020.01.006DOI Listing
April 2020

From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis.

Arch Gynecol Obstet 2020 01 27;301(1):33-52. Epub 2020 Jan 27.

Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy.

Purpose: To investigate the effectiveness and risks of different surgical therapies for isthmocele in symptomatic women with abnormal uterine bleeding, infertility, or for the prevention of obstetric complications, considering safety and surgical complications.

Methods: PubMed/MEDLINE, Scopus, Embase, Science Direct, and Cochrane Library were systematically searched (n° CRD4201912035) for original articles on the surgical treatment of isthmocele published between 1950 and 2018. Data synthesis was completed using MedCalc 16.4.3. The body of evidence was assessed using the GRADE methodology.

Results: We retrieved 33 publications: 28 focused on a single surgical technique, and five comparing different techniques. Meta-analysis showed an improvement of symptoms in 85.00% (75.05-92.76%) of women after hysteroscopic correction, 92.77% (85.53-97.64%) after laparoscopic/robotic correction, and 82.52% (67.53-93.57%) after vaginal correction. Hysteroscopic surgery was associated with the lowest risk of complications (0.76%, 0.20-1.66%).

Conclusions: We found adequate evidence supporting the use of surgery for the treatment of symptomatic isthmocele, as it was found to improve the bleeding symptoms in more than 80% of patients. Differently, we found a lack of evidence regarding the role of surgery with the purpose of improving fertility or reducing the risk of obstetric complications in women with asymptomatic isthmocele. The hysteroscopic correction of isthmocele may be the safest and most effective strategy in those patients with adequate residual myometrial thickness overlying the isthmocele. Laparoscopic and vaginal surgeries may be the preferred options for patients with a thinner residual myometrium over the defect (< 2.5 mm) and when hysteroscopic treatment is inconclusive.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00404-020-05438-0DOI Listing
January 2020

Innovations in hysteroscopic surgery: expanding the meaning of "in-office".

Minim Invasive Ther Allied Technol 2021 Jun 23;30(3):125-132. Epub 2020 Jan 23.

Obstetrics, Gynecology and Reproductive Sciences Department, University of Miami, Miami, FL, USA.

Surgical innovations in hysteroscopic surgery have radically changed the way of treating intrauterine pathologies, throughout the advent of the 'see-and-treat' philosophy, which transferred the advantages of inpatient surgery to the office setting. However, in-office operative hysteroscopy was mainly limited to minor pathology as a supplement to its diagnosis, whereas commonly larger abnormalities were left to be treated in the operating room. Nowadays, pre-surgical assessment of uterine pathology is based on modern ultrasound evaluation and the evolving role of in-office hysteroscopy as a well-planned treatment modality for larger lesions and more complex procedures. Office operative hysteroscopy has been accepted as a feasible, cost-effective, practical way to treat almost any intrauterine disease. Despite the growing role of other imaging tools in the proper evaluation of benign uterine diseases, especially extended beyond to direct hysteroscopic visualization, diagnostic hysteroscopy remains a valuable tool of direct endometrial sampling and may be used as the first line in the diagnosis of endometrial cancer and hyperplasia. Our aim is to describe the most recent innovations and future perspectives in the field of outpatient operative hysteroscopy: mini-resectoscopes, intrauterine morcellators, tissue retrieval systems, diode laser, new miniaturized mechanical instruments, endometrial ablation devices and portable and entry-level hysteroscopes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/13645706.2020.1715437DOI Listing
June 2021

Societal pressures and procreative preferences for gay fathers successfully pursuing parenthood through IVF and gestational carriers.

Reprod Biomed Soc Online 2019 Dec 26;9:1-10. Epub 2019 Oct 26.

Bioethics Institute Ghent, Ghent University, Department of Philosophy and Moral Science, Gent, Belgium.

This retrospective study surveyed decision-making and challenges among 78 gay cisgender male couples utilizing in-vitro fertilization (IVF) and a gestational carrier. While most couples (67.1%) found the decision to actively pursue fertility treatment 'not difficult', 32.9% felt that it was 'somewhat difficult' or 'very or extremely difficult'. Almost 30% of couples had not undertaken financial planning for treatment, which introduced delays of > 2 years for 25.3% of participants. Conceiving twins was 'important to very important' in 52.3% of couples, and 84.2% of couples chose to transfer two embryos to 'increase the odds' or reach an ideal family size in a single attempt despite increased complications with multiple pregnancies. Paternal leave was granted for one partner in 47.3% of couples, and for both partners in 43.2% of couples. One-third of couples reported experiencing discrimination, prompting a partner to seek employment, and 38% changed jobs or careers. For 80.3% of couples, the estimated cost exceeded US$100,000. Couples where one partner was aged > 50 years were significantly more likely to find the decision to actively pursue fertility treatment 'very or extremely difficult' (28.6%), and less likely to agree on becoming parents (64.3%). Gay male couples undergoing assisted reproduction face challenges regarding decision-making, lack of infertility benefits and discrimination, which appear to be influenced by age and country of residence. Policy and educational changes are needed, including broader fertility benefits, more egalitarian parental leave, and greater awareness of risks inherent to multiple gestation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.rbms.2019.09.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6951275PMC
December 2019

The outcome of magnetic resonance-guided high-intensity ultrasound for clinically symptomatic submucosal uterine fibroid performed accidentally in very early pregnancy: a case report.

Int J Hyperthermia 2019 ;36(1):975-979

Second Department of Obstetrics and Gynecology, The Center of Postgraduate Medical Education , Warsaw , Poland.

This is a report of an unintended application of MR-HIFU therapy of uterine fibroids (UFs) in a woman in early pregnancy and should be treated as the first description of such an event. A 37-year-old nullipara with confirmed UFs, who suffered from excessive uterine bleeding and dysmenorrhea, was qualified for MR-HIFU therapy to reduce UF-related symptoms. The procedure took place 2 months later. No complications occurred and the patient was discharged home in good overall condition. About 5 weeks after the procedure the patient was diagnosed with viable intrauterine pregnancy. Basing on early pregnancy ultrasound it was calculated that at the time of MR-HIFU procedure the patient was about 10 (+/- 3 days) days after the conception. Later, the pregnancy was uncomplicated and she gave birth to a healthy neonate. Physical examinations did not reveal any abnormalities in her child. Symptoms associated with UFs significantly decreased after the therapy and pregnancy. Despite the fact that the pregnancy being subjected to MR-HIFU treatment had further uncomplicated course, the presented case indicates that counseling/management in women at reproductive age should be standardized to avoid unknown consequences of such unrecommended procedures for the fetus. According to current standards MR-HIFU procedures to treat UFs should never be performed without a negative pregnancy test.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/02656736.2019.1660002DOI Listing
February 2020

Reproductive surgery for müllerian anomalies: a review of progress in the last decade.

Fertil Steril 2019 09;112(3):408-416

Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York. Electronic address:

Disorders of development, fusion, or resorption of paired müllerian ducts and urogenital sinus may cause various congenital malformations of the corpus uteri, cervix, vagina, and fallopian tubes. Classification systems have been developed to better characterize these anomalies, and each has advantages and disadvantages. Clinical correlation of classification of anomalies with pre- and postsurgical outcomes is needed to better direct treatment. Methods to evaluate these anomalies are primarily radiologic studies, with diagnostic surgery rarely used. Treatment of müllerian anomalies used to focus on relief of symptoms. Now, as diagnostic and surgical options have expanded, preservation or improvement of reproductive potential is a primary goal. As a consequence, controversies in surgical management have also developed. Future directions in this field include better-quality studies with the use of consistent diagnostic criteria to evaluate impacts of treatment on clinical outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2019.07.005DOI Listing
September 2019

Overdiagnosis, overdetection, and overdefinition of the septate uterus: reexamination of the ASRM and ESHRE-ESGE criteria is urgently needed.

Fertil Steril 2019 09 29;112(3):448-449. Epub 2019 Jul 29.

Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, Ohio.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2019.05.026DOI Listing
September 2019

T-shaped uterus and subtle uterine variances: a need for reliable criteria.

Fertil Steril 2019 08 4;112(2):248-249. Epub 2019 Jul 4.

Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, Ohio; Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2019.05.024DOI Listing
August 2019

Overcoming the Challenging Cervix: Identification and Techniques to Access the Uterine Cavity.

Obstet Gynecol Surv 2018 Nov;73(11):641-649

Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH.

Importance: Cervical stenosis is a challenging clinical entity that requires prompt identification and management in order to avoid iatrogenic injury at the time of endocervical canal cannulation.

Objective: The aim of this study was to identify cervical stenosis and discuss associated etiologies, risk factors, and review medical and surgical approaches for overcoming cervical stenosis.

Evidence Acquisition: Computerized searches of MEDLINE and PubMed were conducted using the key words "cervix", "cervical stenosis," "embryo transfer," "hysteroscopy complications," "misoprostol," and "ultrasound." References from identified sources were manually searched to allow for a thorough review. Data from relevant sources were compiled to create this review.

Results: Transcervical access to the uterine cavity is frequently required for procedures such as hysteroscopy, dilation and curettage, endometrial biopsy, sonohysterogram, hysterosalpingogram, intrauterine insemination, embryo transfer in those undergoing in vitro fertilization, and insertion of intrauterine devices. These procedures can become complicated when difficult cannulation of the endocervical canal is encountered. Management strategies include preprocedural use of cervical-ripening agents or osmotic dilators, ultrasound guidance, no-touch vaginoscopy, manual dilatation, and hysteroscopic resection of the obstructed endocervical canal.

Conclusions And Relevance: Cervical stenosis is associated with iatrogenic complications that can result in significant patient morbidity. In patients undergoing in vitro fertilization, difficult embryo transfer is associated with lower pregnancy rates. The clinician should carefully consider the patient's menopausal status, risk factors, and symptoms in order to anticipate difficult navigation of the endocervical canal. Various medical and surgical management strategies, including hysteroscopic resection, can be used to overcome the stenotic cervix.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/OGX.0000000000000614DOI Listing
November 2018

Occult uterine leiomyosarcoma in women undergoing abdominal and minimally invasive surgeries for myomas.

Ginekol Pol 2018 ;89(10):546-552

Department of Gynecology and Oncology, Jagiellonian University, Krakow, 31 501 Krakow, Poland.

Objectives: To estimate (i) the incidence of occult uterine leiomyosarcoma (LMS) in patients operated on for presumedmyomas, and (ii) the proportion of occult LMS to preoperatively diagnosed LMS in a tertiary center.

Material And Methods: An Institutional Review Board-approved retrospective cohort study was performed. The electronicdatabase of 30,476 patients was searched for women who had undergone surgery due to presumed myomas (N = 2675) as well as those with uterine LMS recognized via histology (N = 10) between January 2010 and December 2016.

Results: Six of the 2675 treated women had occult LMS (incidence 1:446; 0.002; CI 0.0-0.013), and one underwent power morcellation (incidence 1:951; 0.001; CI 0.0-0.006). Parallel searching revealed that 6 of the 10 cases (60%) with uterine LMS recognized via histology were diagnosed postoperatively, whereas 4 of the 10 (40%) were diagnosed preoperatively. The incidence of LMS morcellation during laparoscopy was 1:951 and, when all MIS cases were included, 1:1178. The patient who underwent LMS morcellation was operated in the general surgery ward 5 years after laparoscopy (omental recurrence).

Conclusions: These results are similar to the first and recent conservative FDA estimations, but two-times lower for procedures with laparoscopic morcellation and all MIS procedures than for abdominal. Because above half of LMS may be recognized after surgery, the risk of occult LMS and the delay of targeted surgical treatment should be included in all informed consent forms for conservative management of presumed myomas without histology.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5603/GP.a2018.0093DOI Listing
April 2019

Immunoexpression of DNA fragmentation factor 40, DNA fragmentation factor 45, and B-cell lymphoma 2 protein in normal human endometrium and uterine myometrium depends on menstrual cycle phase and menopausal status.

Arch Med Sci 2018 Oct 31;14(6):1254-1262. Epub 2017 Jul 31.

Department of Gynecology and Oncology, Jagiellonian University Medical College, Krakow, Poland.

Introduction: DNA fragmentation factors 40 and 45 (DFF40 and DFF45) are final executors of apoptosis, and B-cell lymphoma 2 (Bcl-2) is a well-recognized apoptosis inhibitor. We aimed to evaluate DFF40, DFF45 and Bcl-2 immunoexpression in the normal human endometrium with respect to the glandular and stromal layer and in uterine myometrium.

Material And Methods: DFF40, DFF45, and Bcl-2 expression was assessed via immunohistochemistry in the endometrium and myometrium collected postmenopausally and premenopausally during the proliferative and secretory phases of the menstrual cycle.

Results: Compared to the myometrium and stroma, endometrial glands showed the highest DFF40 and DFF45 expression in pre- and postmenopausal specimens. DFF45, but not DFF40, glandular expression dependent on menstrual cycle phase and DFF40 and DFF45 scoring was significantly lower in postmenopausal specimens. Significantly higher Bcl-2 expression was observed in proliferative glandular endometrium compared to secretory and postmenopausal specimens. No cycle- or menopause-dependent changes were reported for stromal or myometrial DFF40, DFF45 or Bcl-2 expression. DFF40, DFF45 and Bcl-2 expression was independent of age, age at menarche and menopause, BMI, menstrual cycle and menses lengths, parity and gravidity.

Conclusions: The study provides important evidence regarding menstrual cycle-dependent changes in the expression of DFF40, DFF45 and Bcl-2 in the normal human endometrium, especially in the glandular layer, and shows that their levels are stable in the normal uterine myometrium.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5114/aoms.2017.69383DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6209718PMC
October 2018

Occult uterine malignancy during laparoscopic supracervical hysterectomy.

Ginekol Pol 2018 ;89(9):467-474

Department of Gynecology and Oncology, Jagiellonian University, Krakow, 31 501 Krakow, Poland.

Objectives: To estimate the incidence of occult uterine malignancies during laparoscopic supracervical hysterectomy (LSH).

Material And Methods: Retrospective cohort study based on archival data (2010-2016) of the Department of Gynecology and Oncology, Jagiellonian University.

Results: Medical records of 696 women, who underwent LSH were analyzed. Two occult sarcomas (2/696; 0.29%, 0.003, 95% CI: 0.001 to 0.01), including one case of low-grade endometrial stromal sarcoma (ESS) with co-occurring atypical endometrial hyperplasia (AH) and one case of high-grade ESS were found postoperatively. One case of invasive primary fallopian tube cancer (1/696; 0.14%, 0.001, 95% CI: 0.00 to 0.008) and additional three cases of AH (3/696; 0.57%, 0.004, 95% CI: 0.001 to 0.013) were also identified. No case of EC was documented. One hundred sixty nine (24.3%) women of 696 had an endometrial sampling prior LSH including these with ESS. We did not observe worsening of the prognosis and all patients with confirmed malignancy are still alive and free from recurrence in 2-5 years of observations.

Conclusions: Most commonly the occult malignancy would have not been recognized if the surgery had not been conducted. When appropriate diagnostics is conducted, rare incidents of malignant tissue morcellation should not be considered as a professional misconduct but as a possible adverse event. Patients should be informed about the risk of malignancy according to available estimations and that endometrial sampling cannot eliminate such a risk. A consensus regarding safe indications, required diagnostics, and justifiability of mandatory use of contained morcellation for LSH should be developed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5603/GP.a2018.0080DOI Listing
April 2019

Virginity-sparing management of blind hemivagina in obstructed hemivagina and ipsilateral renal anomaly syndrome.

Fertil Steril 2018 10;110(5):976-978

Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, Dayton, Ohio.

Objectives: To demonstrate the hymen-sparing management of a blind hemivagina in obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome with the use of transrectal ultrasound (TRUS)-guided vaginoscopic septoplasty supported by pre- and postoperative diagnostics with the use of a novel ultrasound technique: 3-dimensional saline-solution infusion contrast sonovaginocervicography (3D-SVC) with virtual speculoscopy.

Design: Video presentation of surgical and ultrasound techniques.

Setting: University hospital and two private centers.

Patient(s): We are demonstrating four cases with blind hemivagina as a component of OHVIRA syndrome and varying level and features of obstruction including: 1) hemihydrocolpos; 2) hemihematocolpos; 3) "old blood" deposits in small hemivagina; and 4) narrow hymenal opening.

Interventions(s): The patients were diagnosed preoperatively by means of 3D-SVC with the use of TRUS. Surgery was planned according to available data from ultrasound and 3D-SVC, and the place of incision of the vaginal septum and blinded hemivagina with cervix were performed with the use of TRUS guidance. Wide septal incision was performed with the use of a monopolar or bipolar resectoscope with needle Collin electrode, and after incision the occult second of double cervix or part of septate cervix was visualized, and the septum was excised with the use of a loop electrode. In narrow hymenal opening, a small diagnostic sheath was used for wide septal incision. Anatomic results in the vagina were assessed with the use of 3D-SVC 2 months after surgery.

Main Outcome Measure(s): Agreement between imaging from preoperative diagnostics with the use of 3D-SVC and intraoperative findings, and anatomic (hymenal integrity, obstruction, status of vagina and cervix) and clinical outcomes (pain).

Result(s): In these four cases, 3D-SVC accurately recognized the morphology of blind hemivagina, oblique vaginal septa, and double or septate cervix. Successful minimally invasive wide septoplasty with preservation of hymen were performed with the use of hysteroscope and TRUS guidance. Concomitant laparoscopy was performed if endometriosis and hematosalpinx were present. No peri- or late postoperative complications occurred. Patients were discharged within 3 hours or within 12 hours in case of laparoscopy. Anatomic results were optimal (lack of septum) or suboptimal (wide opening) after septum resection and incision, respectively, without recurrence of obstruction according to 3D-SVC. Pain was not noticed 2 months after the primary surgery.

Conclusion(s): 3D-SVC is a useful and accurate technique in diagnosis, surgery planning, and postoperative assessment in women with blind hemivagina and intact hymen. TRUS-guided vaginoscopic septoplasty is a reasonable alternative to traditional vaginal surgery and allows hymen preservation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2018.07.007DOI Listing
October 2018

Pre-, intra-, and postoperative management of Robert's uterus.

Fertil Steril 2018 09;110(4):778-779

Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, Ohio.

Objectives: To demonstrate a minimally invasive approach and management in three different types of Robert's uterus.

Design: Video presentation of surgical and ultrasound techniques.

Setting: University hospital and two private centers.

Patients: Patients with three types of Robert's uterus; a rare form of septate uterus consisting of non-communicating hemicavity, a contralateral unicornuate uterine cavity in a single uterine body with normal fundus: with large hematometra in the blind hemi-cavity and acute pelvic pain; with an inactive blind hemi-cavity without hematometra and recurrent miscarriages; and with small hematometra in the blind hemi-cavity.

Interventions: Three-dimensional ultrasound with saline infusion sonohysterography and automatic volume calculation software (SonoHySteroAVC) were used for differential diagnosis and surgical planning. Transrectally guided hysteroscopic metroplasty, a incision of myometrium between two parts of cavities by resectoscope and Collin's electrode, were performed and recorded. Sequentional balloon anti-adhesion therapy and three-dimensional ultrasound with saline infusion sonohysterography with SonoHysteroAVC were used in post-operative management.

Main Outcome Measures: Pre-, intra- and postoperative findings regarding uterine morphology, feasibility of surgery and anatomical and clinical outcomes.

Results: A successful unification of non-communicating and communicating uterine cavity parts during surgery, better shape and several times higher volume of uterine cavity, and total elimination of pain associated with obstruction after healing period were recorded.

Conclusions: Three-dimensional ultrasound techniques seem to be the best tool for complex pre- and postoperative management of Robert's uterus. Minimally invasive ultrasound-guided hysteroscopic metroplasty should be considered as the first choice of treatment because of the potential for normalization of uterine morphology and function.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.fertnstert.2018.05.033DOI Listing
September 2018

"Y Sign" at the Level of the 3-Vessel and Trachea View: An Effective Fetal Marker of Aortic Dextroposition Anomalies in the First Trimester.

J Ultrasound Med 2018 Aug 27;37(8):1869-1880. Epub 2017 Dec 27.

Dobreusg Ultrasound Group Practice, Krakow, Poland.

Objectives: The "Y sign" at the level of the 3-vessel and trachea view corresponds to thinning of main pulmonary artery and arterial duct and a dilated transverse aortic arch. The purpose of this study was to evaluate the Y sign for the diagnosis of aortic dextroposition anomalies at the time of the first-trimester scan and to assess the screening performance of only the Y sign, only abnormal left axis deviation (axis sign), and their combination for the diagnosis of aortic dextroposition anomalies.

Methods: A prospective evaluation of 6025 pregnant women undergoing first-trimester ultrasonography was conducted. The cardiac axis was measured in all examined patients and considered abnormal (positive axis sign) at greater than 57 °. The frequency of the Y sign and the axis sign was assessed for this population, and their screening performance for the diagnosis of aortic dextroposition anomalies was calculated.

Results: A total of 5775 patients fulfilled the inclusion criteria. Aortic dextroposition anomalies were diagnosed in 17 cases (tetralogy of Fallot in 8 and Fallot-like double-outlet right ventricle in 9). The Y sign was found in 18 of 5775 (0.3%) fetuses examined, of which 7 of 18 were confirmed with tetralogy of Fallot, 9 of 18 with a Fallot-like double-outlet right ventricle, and 2 of 18 with pulmonary stenosis. A positive axis sign of greater than 57 ° was found in 20 fetuses, including 4 with normal heart anatomy. The sensitivity values of the Y sign, the axis sign, and their combination were 94%, 76%, and 94%, respectively.

Conclusions: Visualization of the Y sign should increase the suspicion of aortic dextroposition anomalies in the late first trimester. The screening performance of the Y sign alone and in combination with an abnormal cardiac axis was high and may aid in the early diagnosis of aortic dextroposition anomalies in the fetus.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jum.14533DOI Listing
August 2018

Inter-Rater Reliability of Air/Saline HyCoSy, HyFoSy and HyFoSy Combined With Power Doppler for Screening Tubal Patency.

Ultraschall Med 2019 Feb 12;40(1):47-54. Epub 2017 Dec 12.

Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil.

Purpose:  To estimate the inter-observer reliability and agreement of offline analyses of three different ultrasound techniques for assessing tubal patency.

Methods:  100 tubes (n = 100) in 50 women were evaluated for tubal patency between November 2013 and July 2015 using ultrasound as index tests and laparoscopy as the reference standard. Three different ultrasound techniques were applied: two-dimensional grayscale ultrasound using air + saline as the contrast media (2D-HyCoSy); two- and three-dimensional grayscale ultrasound using foam as the contrast media (2 D/3D-HyFoSy); and the same technique but adding bi-directional power Doppler (2 D/3D-Doppler-HyFoSy). The videos containing full standardized exams using these three techniques were split into three parts, anonymized, encoded, randomized and reassessed in Nov. 2015 by two observers who assessed tubal patency using standardized criteria. These observers were blinded to any clinical information and each other's results. Proportions of observed agreement (po) and Cohen's Kappa (κ) including the 95 % confidence intervals (CI) were calculated.

Results:  The inter-observer reliability/agreement in 2 D/3D-Doppler-HyFoSy (po = 0.99, κ = 0.95, 95 % CI: 0.93 - 0.97) was higher compared to 2D-air/saline-HyCoSy (po = 0.83, κ = 0.55, 95 % CI: 0.40 - 0.68) and 2 D/3D-HyFoSy (po = 0.92, κ = 0.67, 95 % CI: 0.54 - 0.76).

Conclusion:  The inter-observer reliability and agreement of the diagnosis of tubal patency evaluating stored videos are improved when foam and power Doppler are used during acquisition. Therefore, this technique may be preferred to minimize misclassification and misdiagnosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0043-120111DOI Listing
February 2019

Laparoscopic Intervention in Acute Crohn's Disease Involving an Ovary.

J Minim Invasive Gynecol 2017 Sep - Oct;24(6):1040-1045. Epub 2017 May 27.

Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland; Ludwin and Ludwin Gynecology, Krakow, Poland. Electronic address:

Crohn's disease (CD) is a chronic inflammatory disorder that may involve any part of the gastrointestinal tract. Acute manifestations in female internal reproductive organs are rare and have been described in only a few cases. A 27-year-old nulligravida woman diagnosed with CD presented with pelvic pain, fever, and a palpable mass (confirmed by ultrasound) in the right lower quadrant of the abdomen. She underwent diagnostic laparoscopy because of worsening symptoms suggestive of a tubo-ovarian abscess. The right adnexa were excised after adhesiolysis. Pathologic examination revealed an ovarian granuloma consistent with CD. This case shows that a laparoscopic approach is possible for active CD, with all the benefits of a minimally invasive approach. Although the involved ovary was removed, similar to previous reports using laparotomy, conservative therapy should be considered if preoperative diagnosis can be made. Improvements in preoperative diagnosis and development of management guidelines is critical for ovarian preservation and conservative treatment options.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jmig.2017.04.028DOI Listing
March 2018

Pain Intensity During Ultrasound Assessment of Uterine Cavity and Tubal Patency With and Without Painkillers: Prospective Observational Study.

J Minim Invasive Gynecol 2017 May - Jun;24(4):599-608. Epub 2017 Feb 1.

Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland; Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland. Electronic address:

Study Objective: To determine the pain intensity and incidence of mild to severe pain during the ultrasound assessment of the uterine cavity and tubal patency using saline, air and saline, and foam as contrasts with and without painkiller.

Design: Prospective observational study (Canadian Task Force classification II-1).

Setting: Private clinic.

Patients: Three hundred infertile women who were consecutively submitted to uterine cavity and tubal patency assessment by ultrasound using saline, air, and foam in single exam between October 2012 and November 2013.

Interventions: No painkillers were used until March 2013 when we started offering an effervescent codeine tablet containing paracetamol 500 mg and codeine phosphate 30 mg approximately 1 hour before the procedure.

Measurements And Main Results: Pain intensity measured with an 11-point (0-10) numerical rating scale and incidence of moderate/severe levels of pain (numerical rating scale > 3) during the main components of the procedure (speculum insertion, catheter insertion, saline infusion, air and saline infusion, foam infusion, and after the procedure [0 minutes, 15 minutes, 30 minutes, and 24 hours]) were assessed. The incidence of moderatesevere pain was significantly lower in women using painkillers considering any moment of the procedure: 49 of 175 (28%) versus 65 of 125 (52%); relative risk, .54; 95% confidence interval, .40-.72; p < .001; number needed to treat, 4. Less women presented with moderate/severe pain during air and saline compared with foam infusion: 31 of 300 (10%) versus 75 of 300 (25%); p < .001; relative risk, .41, 95% confidence interval, .28-.61.

Conclusion: The incidence of moderate/severe pain during the ultrasound assessment of the uterine cavity and tubal patency is common. Our results suggest that using paracetamol + codeine before the procedure reduces the pain level, but randomized controlled trials are required.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jmig.2017.01.015DOI Listing
December 2017

Endometrial cancer and hyperplasia rate in women before menopause with abnormal uterine bleeding undergoing endometrial sampling.

Przegl Lek 2017;74(4):139-43.

Introduction: Abnormal uterine bleeding (AUB) is the most common symptom of endometrial cancer (EC) and endometrial hyperplasia with (AH) or without (EH) atypia. Risk of malignancy and hyperplasia is significantly lower in premenopausal than in postmenopausal women. Only 10% of EC occurs before menopause. Obesity and age are well-recognized risk factors of endometrial cancer. Endometrial sampling is recommended in women at high risk of endometrial malignancy. The primary objective was to determine the incidence of EC, AH and EH in premenopausal women undergoing dilation and curettage (D&C) because of AUB. Additional objective of the study was to estimate the risk of EC and AH in overweight and obese women with two types of AUB: heavy menstrual bleeding (AUB-HMB) and intermenstrual bleeding (AUB-IMB), according to PALM-COEIN classification.

Material And Methods: Retrospective study in the population of women undergoing D&C in tertiary hospital because of AUB between Jan-2016 and Dec-2016. The incidence of EC, AH, EH was established. The influence of the variables: age, BMI, AUBHMB/ AUB-IMB on the occurrence of abnormal histology (EC, AH, EH) was evaluated. Finally, the model built by using backward stepwise regression and mechanism of v-fold cross-validation, showed no statistically significant relationship.

Results: EC was detected in 2/213 cases (0.9%; 95% CI 0.0003 to 0.036), AH in 3/213 cases (1.4%), giving a total of 5/213 (2.3%) women with AH or EC. EH was detected in 16/213 (7.5%) women. High BMI raises the chance of AH diagnosis: OR 1.16 (95% CI 1.05- 1.28). The presence of HMB compared to IMB reduces the chance of EH: OR 0.24 (95% CI 0.07-0.9). IMB increases the chance for the diagnosis of EH 4.11 times compared to HMB (OR 4.1, 95% CI 1.1-14.9; p = 0.016).

Conclusions: EC in premenopausal women with AUB undergoing D&C is rare. There is a need to search for more effective methods of selection of patients than commonly used. Age and BMI do not seem to be factors that should be used to select patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
June 2018