Publications by authors named "Paolo Casadio"

51 Publications

Prognostic value of myometrial invasion and TCGA groups of endometrial carcinoma.

Gynecol Oncol 2021 Jun 1. Epub 2021 Jun 1.

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, Via Massarenti 13, Bologna 40138, Italy.

Background: 2021 ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma (EC) encourage molecular classification and propose a new prognostic risk stratification based on both pathologic and molecular features. Although deep myometrial invasion (DMI) has been considered as a crucial risk factor in EC, it is unclear if its prognostic value is independent from The Cancer Genome ATLAS (TCGA) groups.

Aim: To assess if the prognostic value of DMI is independent from the TCGA groups in EC patients.

Materials And Methods: A systematic review and meta-analysis was performed by searching through 5 electronic databases, from their inception to March 2021, for all studies that allowed to assess DMI as a prognostic factor independent of the TCGA groups in EC patients. Pooled hazard ratio (HR) of DMI for overall survival (OS) and disease-free survival (DFS) was calculated at multivariable analyses including TCGA groups as a variable. Superficial myometrial invasion (<50% of myometrial thickness) was considered as a reference. In DFS analyses, locoregional and distant recurrence were separately considered for one study.

Results: Five studies with 2469 patients were included in the systematic review and 3 studies with 1549 patients in the meta-analysis. Pooled HR of DMI was 1.082 (CI 95% 0.85-1.377; p = 0.524) for OS, 1.709 (CI 95% 1.173-2.491; p = 0.005) for DFS, 1.585 (CI 95% 1.154-2.178; p = 0.004) for DFS additionally considering locoregional recurrence for one study, and 1.701 (CI 95% 1.235-2.344, p = 0.001) for DFS additionally considering distant recurrence for the same study.

Conclusions: DMI does not appear as an independent prognostic factor for OS in EC patients; instead, it seems to affect the risk of recurrence independently from the TCGA groups. Further studies are necessary to confirm these findings and to assess the prognostic impact of DMI separately in each TCGA group.
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http://dx.doi.org/10.1016/j.ygyno.2021.05.029DOI Listing
June 2021

Laparotomic versus robotic surgery in elderly patients with endometrial cancer: A systematic review and meta-analysis.

Int J Gynaecol Obstet 2021 May 27. Epub 2021 May 27.

Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy.

Background: Although robotics has shown to improve outcomes in some high-difficulty surgical category of patients, it is unclear if such approach may improve outcomes in endometrial carcinoma (EC) elderly patients.

Objective: To compare robotic and laparotomic surgery in the treatment and staging of EC elderly patients.

Materials And Methods: A systematic review and meta-analysis was performed assessing the risk of overall, intra-operative and peri-operative complications associated to the surgical approach (laparotomic vs robotic) for EC elderly patients by relative risk (RR). Pooled means ± standard deviation (SD) of length of stay were compared with the unpaired T test. Subgroup analyses for overall complications were performed based on different age cut-offs (>70, >65 and >75 years) and severity of complications (minor and major). A p-value<0.05 was considered significant.

Results: 5 studies with 7,629 EC patients were included. Pooled RR for robotic compared to laparotomic surgery was 0.40 (p<0.00001) for overall, 0.46 (p=0.18) for intra-operative, and 0.43 (p<0.00001) for peri-operative complications. Pooled difference between means ± SD of length of stay for robotic vs laparotomic surgery was -3.34 (p<0.00001). At subgroup analyses, pooled RR of overall complications for robotic surgery vs laparotomic surgery was 0.34 (p<0.00001) in the "70 years", 0.51 (p<0.0001) in the "65 years", 0.20 (p =0.12) in the "75 years", 0.50 (p=0.1) in the "minor complications", and 0.42 (p=0.002) in the "major complication" subgroups.

Conclusion: Robotics might be a viable alternative to laparotomic approach for EC elderly patients since it significantly decreases the risk of overall and peri-operative complications (mainly major complications), and the length of stay when compared to laparotomy. The decrease in risk of overall complication is greater with increasing patient age.
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http://dx.doi.org/10.1002/ijgo.13766DOI Listing
May 2021

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

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

Tumor-infiltrating lymphocytes and POLE mutation in endometrial carcinoma.

Gynecol Oncol 2021 May 12;161(2):621-628. Epub 2021 Mar 12.

Division of Gynaecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC). IRCCS Azienda Ospedaliero-Univeristaria di Bologna. S. Orsola Hospital. University of Bologna, Via Massarenti 13, Bologna 40138, Italy.

Background: Polymerase-ε (POLE)-mutated endometrial carcinomas (ECs) have displayed an increased number of tumor-infiltrating lymphocytes (TIL) compared to POLE-wild-type ECs. However, it is unclear if TIL may aid in identifying POLE-mutated ECs when molecular data are unavailable. The identification of a POLE mutation surrogate may be crucial to translate TCGA/ProMisE risk assessment in the clinical practice.

Aim: To assess TIL as histological surrogate of POLE mutation in EC.

Materials And Methods: Seven electronic databases were searched from their inception to September 2020 for studies that allowed data extraction about TIL and TCGA/ProMisE groups of EC. We calculated pooled sensitivity, specificity, positive and negative likelihood ratios (LR+ and LR-), diagnostic odds ratio (DOR) and area under the curve (AUC) on SROC curves of TIL in distinguishing POLE-mutated from i) POLE-wild-type, ii) no specific molecular profile (NSMP), iii) POLE-wild-type/MMR-proficient, iii) MMR-deficient ECs.

Results: 10 studies assessing 1169 women were included in the qualitative analysis. TIL-high pattern showed: sensitivity = 0.65, specificity = 0.63, LR + =2.06, LR- = 0.48, DOR = 4.39, AUC = 0.7532 for POLE-mutant vs POLE-wild-type ECs; sensitivity = 0.85, specificity = 0.73, LR + =2.80, LR- = 0.22, DOR = 15.17 for POLE-mutant vs NSMP ECs; sensitivity = 0.85, specificity = 0.66, LR + =2.49, LR- = 0.25, DOR = 10.30 for POLE-mutant vs POLE-wild-type/MMR-proficient ECs; sensitivity = 0.68, specificity = 0.44, LR + =1.38, LR- = 0.64, DOR = 2.68, AUC = 0.6694 for POLE-mutant vs MMR-deficient ECs.

Conclusion: TIL-high pattern shows a moderate accuracy in distinguishing POLE-mutated from POLE-wild-type ECs after the exclusion of MMR-deficient cases. TIL might be considered in an integrate algorithm to identify POLE-mutated ECs when sequencing is unavailable. Further studies are necessary in this regard.
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http://dx.doi.org/10.1016/j.ygyno.2021.02.030DOI Listing
May 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

Prenatal diagnosis of congenital heart defects and voluntary termination of pregnancy.

Am J Obstet Gynecol MFM 2020 11 15;2(4):100207. Epub 2020 Aug 15.

Obstetric Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy.

Background: The prenatal diagnosis of an isolated congenital heart defect is a matter of concern for parents. The decision of whether to terminate the pregnancy according to the different types of congenital heart defects has not been investigated yet.

Objective: This study aimed to evaluate the frequency of voluntary termination of pregnancy after the prenatal diagnosis of a congenital heart defect in a tertiary care center.

Study Design: This was a retrospective study of patients who were referred to our center from January 2013 to December 2019, underwent fetal echocardiography, and were counseled by a perinatologist and a pediatric cardiologist. The following data were collected: prenatal diagnosis, including genetic testing; gestational age at diagnosis; and outcome of pregnancy. The diagnoses were stratified retrospectively according to the type of congenital heart defect and its severity (low complexity, moderate complexity, and high complexity) by a perinatologist and a pediatric cardiologist.

Results: Of 704 women who received a diagnosis of fetal congenital heart defect, 531 (75.4%) were seen before 23 weeks' gestation, which is the upper limit imposed for the termination of pregnancy by the Italian legislation. Congenital heart defects were apparently isolated in 437 of 531 cases (82.3%). Overall, 108 of 531 patients (20.3%) requested a termination of pregnancy. The rate of termination of pregnancy was found to vary according to the severity of congenital heart defects: low complexity, 0%; moderate complexity, 12.1%, and high complexity, 33.2% (P<.001). The presence or absence of associated anomalies or the ethnicity of the couples was not found to have an influence on women's decisions.

Conclusion: In our population, the decision to terminate a pregnancy after the diagnosis of a fetal congenital heart defect is influenced by the surgical complexity of the congenital heart defect itself. However, most patients, including those with the most severe forms of congenital heart defect, decided to continue the pregnancy.
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http://dx.doi.org/10.1016/j.ajogmf.2020.100207DOI Listing
November 2020

Total laparoscopic vs. conventional open abdominal nerve-sparing radical hysterectomy: clinical, surgical, oncological and functional outcomes in 301 patients with cervical cancer.

J Gynecol Oncol 2021 Jan 27;32(1):e10. Epub 2020 Nov 27.

Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy.

Objective: Total laparoscopic nerve-sparing radical hysterectomy (TL-NSRH) has been considered a promising approach, however, surgical, clinical, oncological and functional outcomes have not been systematically addressed. We present a large retrospective multi-center experience comparing TL-NSRH vs. open abdominal NSRH (OA-NSRH) for early and locally-advanced cervical cancer, with particular emphasis on post-surgical pelvic function.

Methods: All consecutive patients who underwent class C1-NSRH plus bilateral pelvic + para-aortic lymphadenectomy for stage IA2-IIB cervical cancer at 4 Italian gynecologic oncologic centers (Negrar, Varese, Bologna, Avellino) were enrolled. Patients were divided into TL-NSRH and OA-NSRH groups and were investigated with preoperative questionnaires on urinary, rectal and sexual function. Postoperatively, patients filled a questionnaire assessing quality of life, taking into account sexual function and psychological status. Oncological outcomes were analyzed using Kaplan-Meyer method.

Results: 301 consecutive patients were included in this study: 170 in the TL-NSRH group and 131 in the OA-NSRH group. Patients in the OA-NSRH group were more likely to experience urinary incontinence and (after 12-months follow-up) urinary retention. No patient in the TL-NSRH group vs. 5 (5.5%) in the OA-NSRH group had complete urinary retention (at the >24-month follow-up [p=0.02]). A total of 20 (11.8%) in the TL-NSRH and 11 (8.4%) patients in the OA-NSRH had recurrence of disease (p=0.44) and 14 (8.2%) and 9 (6.9%) died of disease during follow-up, respectively (p=0.83).

Conclusion: Our study shows that TL-NSRH is feasible, safe and effective and conjugates adequate radicality and improvement in post-operative functional outcomes. Oncological outcomes of laparoscopic procedures deserve further investigation.
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http://dx.doi.org/10.3802/jgo.2021.32.e10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7767655PMC
January 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

The use of lung ultrasound during the COVID-19 pandemic: A narrative review with specific focus on its role in pregnancy.

J Popul Ther Clin Pharmacol 2020 15;27(S Pt 1):e64-e75. Epub 2020 Oct 15.

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

The novel coronavirus disease (COVID-19) is a challenge to every health system. Unfortunately, it is unlikely that this pandemic will disappear soon. No health system, with its present resources and workflow, is capable enough to deal with a full-blown wave of this pandemic. Acquisition of specific new skills may be fundamental in delivering appropriate health care for our patients. The gold standard for diagnosis of the COVID-19 infection is real-time reverse transcription polymerase chain reaction. Radiological investigations (chest X-ray or high-resolution computerized tomography [CT]) can be helpful both for diagnosis and management, but they have many limitations. Ultrasound has been suggested as a reliable and accurate tool for assessing the lungs in COVID-19 patients. Lung ultrasound (LUS) can show specific signs of interstitial pneumonia, which is characteristic of COVID-19 pulmonary infection. In addition, nonradiologist specialists with experience in ultrasound can be trained on LUS with a relatively rapid learning curve. In pregnancy, LUS can be particularly useful due to the avoidance of exposure to ionizing radiation. In this review, we present the advantages, techniques, and limitations of the use of LUS during the COVID-19 pandemic, with specific focus on pregnancy.
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http://dx.doi.org/10.15586/jptcp.v27iSP1.743DOI Listing
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

The dynamic change of the anteroposterior diameter of the levator hiatus under Valsalva maneuver at term and labor outcome.

Neurourol Urodyn 2020 11 31;39(8):2353-2360. Epub 2020 Aug 31.

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

Aim: The aim of the present study was to evaluate the correlation between the proportional change of anteroposterior diameter (APD) of levator hiatus from rest to maximum Valsalva maneuver in nulliparous women at term and labor outcome.

Methods: We prospectively recruited nulliparous women at term before the onset of labor. Women underwent a two-dimensional transperineal ultrasound, measuring the APD of the levator hiatus at rest and under maximum Valsalva's maneuver. APD change from rest to maximum Valsalva was described both in terms of absolute figures and proportional change. Correlation of APD change with the mode of delivery and with labor durations was assessed.

Results: Overall, 486 women were included in the analysis. No significant association between change in APD and the mode of delivery. We found a significant negative correlation between change of APD from rest to Valsalva and the duration of active second stage both in terms of absolute change (Pearson's r = -0.138, P = .009) and in terms of proportional change (Pearson's r = -0.154, P = .004). Survival outcomes based on Cox-regression model showed that APD was independently associated with the duration of active second stage of labor after adjusting for epidural analgesia, maternal age and body mass index (hazard ratio, 1.008; 95% confidence interval, 1.001-1.016; P = .04) CONCLUSION: Women with higher increase of the anteroposterior diameter of the levator hiatus from rest to Valsalva have a shorter active second stage of labor.
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http://dx.doi.org/10.1002/nau.24494DOI Listing
November 2020

Lung Ultrasound Is Not a Useful Screening Tool for Severe Acute Respiratory Syndrome Coronavirus 2 in Pregnant Women: A Pilot Study.

J Ultrasound Med 2021 01 27;40(1):215. Epub 2020 Aug 27.

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

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http://dx.doi.org/10.1002/jum.15451DOI Listing
January 2021

Fertility-sparing treatment for intramucous, moderately differentiated, endometrioid endometrial cancer: a Gynecologic Cancer Inter-Group (GCIG) study.

J Gynecol Oncol 2020 Sep;31(5):e74

Department of Gynecologic Oncology, Istituto Nazionale Tumori, IRCSS, "Fondazione G. Pascale", Naples, Italy.

Objective: 'The Endometrial Cancer Conservative Treatment (E.C.Co.). A multicentre archive' is a worldwide project endorsed by the Gynecologic Cancer Inter-Group, aimed at registering conservatively treated endometrial cancer (EC) patients. This paper reports the oncological and reproductive outcomes of intramucous, G2, endometrioid EC patients from this archive.

Methods: Twenty-three patients (Stage IA, G2, endometrioid EC) were enrolled between January 2004 and March 2019. Primary and secondary endpoints were, respectively, complete regression (CR) and recurrence rates, and pregnancy and live birth rates.

Results: A median follow-up of 35 months (9-148) was achieved. Hysteroscopic resection (HR) plus progestin was adopted in 74% (17/23) of cases. Seventeen patients showed CR (median time to CR, 6 months; 3-13). Among the 6 non-responders, one showed persistence and 5 progressed, all submitted to definitive surgery, with an unfavorauble outcome in one. The recurrence rate was 41.1%. Ten (58.8%) complete responders attempted to conceive, of whom 3 achieved at least one pregnancy with a live-birth. Two out of the 11 candidate patients underwent definitive surgery, while the remaining 9 have so far refused. To date, 22 patients show no evidence of disease, and one is still alive with disease.

Conclusions: Fertility-sparing treatment seems to be feasible even in G2 EC, although caution should be kept considering the potential pathological undergrading or non-endometrioid histology misdiagnosis. The low rate of attempt to conceive and of compliance to definitive surgery underline the need for a 'global' counselling extended to the follow-up period.
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http://dx.doi.org/10.3802/jgo.2020.31.e74DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7440989PMC
September 2020

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

Metformin metabolic and vascular effects in normal weight hyperinsulinemic polycystic ovary syndrome patients treated with contraceptive vaginal ring. A pilot study.

Gynecol Endocrinol 2020 Dec 16;36(12):1062-1069. Epub 2020 Jun 16.

Department of Obstetrics and Gynecology "P. Fioretti" University of Pisa, Italy.

Purpose: The aim of this longitudinal, controlled, and retrospective pilot study was to assess how metformin, associated with a contraceptive vaginal ring, may influence lipid and carbohydrate metabolism, and surrogate markers of arterial function in normal weight polycystic ovary syndrome patients.

Material And Methods: Among 28 lean patients, 15 were treated with vaginal ring plus metformin and 13 women with only vaginal ring. The effects were assessed after six months. The patients were submitted to evaluation of lipid and carbohydrate metabolism; Doppler analysis of ophthalmic artery; brachial artery flow-mediated vasodilatation; and oral glucose tolerance test.

Results: After six months, the fasting insulin, glucose/insulin ratio, and homeostatic model assessment estimates for insulin resistance were significantly improved in metformin group. The ophthalmic artery pulsatility index did not significantly improve in either group. The brachial artery vasodilation was better in metformin treated patients.

Conclusion: Metformin, associated with vaginal ring, improves the insulin and carbohydrate metabolism. This, associated with the significant improvements of surrogate markers of arterial function, may be responsible of a slight possible cardiovascular and cerebrovascular protective effect.
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http://dx.doi.org/10.1080/09513590.2020.1770213DOI Listing
December 2020

Comparison of Hysteroscopic Cesarean Scar Defect Repair with 26 Fr Resectoscope and 16 Fr Mini-resectoscope: A Prospective Pilot Study.

J Minim Invasive Gynecol 2021 02 6;28(2):314-319. Epub 2020 Jun 6.

Gynecology and Human Reproduction Physiopathology Unit, S. Orsola Hospital, University of Bologna (Drs. Casadio, Morra, Talamo, Magnarelli, Paradisi, and Seracchioli).

Study Objective: Several studies have been published on hysteroscopic treatment of cesarean scar defect using the 26 Fr resectoscope. This study compared the effects of the 26 Fr resectoscope with those of the 16 Fr mini-resectoscope in terms of efficacy, safety profile, and peri- and postoperative complications.

Design: A prospective cohort study.

Setting: Tertiary care university hospital (S. Orsola-Malpighi, Bologna, Italy).

Patients: Three hundred and nine women having symptoms and with a cesarean scar defect diagnosis were divided into 2 groups according to a temporal criterion: from March 2012 to March 2015, 155 consecutive women (control group) underwent isthmoplasty with the 26 Fr resectoscope (Karl Storz, Tuttlingen, Germany), whereas from April 2015 to March 2018, 154 consecutive women (study group) underwent isthmoplasty with the 16 Fr mini-resectoscope (Gubbini system, Tontarra Medizintechnik, Tuttlingen, Germany).

Interventions: One hundred and fifty-five women (control group) underwent isthmoplasty with the 26 Fr resectoscope, and 154 women (study group) underwent isthmoplasty with the 16 Fr mini-resectoscope. The so-called "channel-like" 360° endocervical resection technique was applied.

Measurements And Main Results: The isthmoplasty time with the 2 resectoscopes, excluding cervical dilatation, was similar (p = .25), whereas the overall surgical time was shorter in the case of the mini-resectoscope. The use of the 16 Fr mini-resectoscope was significantly associated with a reduced volume of distension medium used (p <.001) and a lower fluid absorption (p <.001). A significant increase (p = .01) in postoperative complications in the control group (9/155; 5.8%) compared with the study group (1/154; 0.7%) was also found. No significant reduction in discharge time was observed between the 2 groups (p = .13). Patient satisfaction immediately after surgery was significantly higher (p <.001) in the study group than in the control group.

Conclusion: Isthmoplasty with a 16 Fr mini-resectoscope seems to be as effective as isthmoplasty with a 26 Fr resectoscope in reducing postmenstrual abnormal uterine bleeding and suprapubic pelvic pain. It is associated with a significant reduction in overall surgical time owing to the non-necessity of performing cervical dilatation. The 16 Fr mini-resectoscope facilitates surgery in small anatomical spaces such as the cervical canal and reduces the complication rate linked to blind maneuvers not respecting the uterine anatomy.
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http://dx.doi.org/10.1016/j.jmig.2020.06.002DOI Listing
February 2021

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

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

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

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

Conservative hysteroscopic treatment of stage I well differentiated endometrial cancer in patients with high surgical risk: a pilot study.

J Gynecol Oncol 2019 Jul 22;30(4):e62. Epub 2019 Apr 22.

Department of Obstetrics, Gynecology and Reproductive Biology, DIMEC, S.Orsola Hospital, University Alma Mater Studiorum of Bologna, Bologna, Italy.

Objective: To report hysteroscopic treatment combined with levonorgestrel-releasing intrauterine device (LNG-IUD) to treat women with early well differentiated endometrial cancer (EC) at high surgical risk.

Methods: Nine women diagnosed with stage IA, grade 1 endometrioid EC which was contraindicated or refused standard treatment with external beam radiation therapy with or without brachytherapy were enrolled in our prospective study. Endo-myometrial hysteroscopic resection of the whole uterine cavity and the placement of LNG-IUD for 5 years was performed. Response rate, perioperative complications, and recurrence of disease were evaluated.

Results: None had intra or post-operative complications and all were discharged no later than the third day of hospitalization. After 6 months from surgery, all the women showed a complete regression of the lesion. All the women completed the 5 years follow-up and in no case was detected sign of recurrence. Two women died for causes unrelated to the tumor or the ongoing therapy.

Conclusion: The alternative treatment with endo-myometrial hysteroscopic resection and LNG-IUD in women with stage IA, grade 1 endometrioid EC showed initial encouraging outcomes in terms of effectiveness and safety.
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http://dx.doi.org/10.3802/jgo.2019.30.e62DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6543116PMC
July 2019

Channel-like 360° Isthmocele Treatment with a 16F Mini-Resectoscope: A Step-by-step Technique.

J Minim Invasive Gynecol 2019 Nov - Dec;26(7):1229-1230. Epub 2019 May 3.

Gynecology and Human Reproduction Physiopathology Unit (Drs. Morra, Paradisi, and Seracchioli), Sant'Orsola Hospital, University of Bologna, Bologna, Italy.

Study Objective: To show the technique of hysteroscopic channel-like 360° repair of a cesarean scar defect performed with a Gubbini 16F miniresectoscope (GUBBINI system; Tontarra Medizintechnik, Tuttlingen, Germany).

Design: A step-by-step demonstration of the surgical technique using slides, pictures, and a video (an instructive video [Video 1]).

Setting: A university hospital (Bologna University Hospital, Sant'Orsola-Malpighi Polyclinic, Bologna, Italy).

Patients: A 35-year-old woman with a history of a previous cesarean section complaining of pelvic pain and postmenstrual spotting.

Interventions: With the vaginoscopic approach, the isthmocele was localized; a high-frequency 90° angled circular loop electrode and pure cutting current of 100 W were used to resect the fibrotic tissue of the proximal (step 1) and distal (step 2) part of the niche. We performed resection not only of the fibrotic tissue underneath the niche but also of the inflamed tissue placed around the niche and on the opposite site (the so-called channel-like 360° endocervical ablation). A high-frequency angled ball electrode was used to obtain focused coagulation of all residual inflamed tissue still present on the niche surface and on the cervical canal walls (step 3); the aim of this step is to facilitate the re-epithelialization of the cervical canal walls by the paraphysiological endocervical epithelium. The procedure was ended by controlling any bleeding of the endocervical vessels by reducing the inflow and pressure of the distending medium and by focused electrocauterization with a ball electrode (step 4).

Measurements And Main Results: The operative time was 14 minutes. The small diameter of a 16F resectoscope and the use of a miniaturized loop without cervical dilation allow the operative procedures to be performed without cervical dilation and without anatomic distortion of the defect, reducing the risk of complications. The small diameter of the sheaths also makes the surgical gesture faster with an easier and faster approach to the niche compared with isthmocele hysteroscopic standard surgery.

Conclusion: The presence of a uterine scar defect is usually asymptomatic or refers to postmenstrual spotting with dark red or brown discharge, dysmenorrhea, dyspareunia, chronic pelvic pain, infertility, or a dull sensation after menstruation. Several factors may play a role in isthmocele development such as a low uterine incision, a deficient suturing technique of the uterine incision, and patient-related factors that impair wound healing or increase inflammation or adhesion formation. Different techniques were used as reconstructive therapies of the cesarean scar defect including laparoscopic or robot-assisted laparoscopic excision, vaginal repair, or hysteroscopic treatment. All of these procedures remove or ablate the niche fibrotic tissue with the aim of relieving symptoms. Asymptomatic cases should not be treated. According to the most recent literature, hysteroscopic repair of a cesarean scar represents an effective and safe surgical option in cases of a symptomatic isthmocele. The persistence of symptoms has been reported in up to 18% of cases, so adequate counseling should be performed before the procedure.
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http://dx.doi.org/10.1016/j.jmig.2019.04.024DOI Listing
May 2020

Prevalence of Infections After In-Office Hysteroscopy in Premenopausal and Postmenopausal Women.

J Minim Invasive Gynecol 2019 May - Jun;26(4):733-739. Epub 2018 Aug 21.

Department of Obstetrics and Gynecology, University of Naples "Federico II," Naples, Italy (Drs. Santangelo and Di Spiezio Sardo).

Study Objective: To estimate the incidence of infection after diagnostic and operative hysteroscopic procedures performed in an in-office setting with different distension media (saline solution or CO).

Design: Prospective, multicenter, observational study (Canadian Task Force classification II-2).

Setting: Tertiary women's health centers.

Patients: A total of 42,934 women who underwent hysteroscopy between 2015 and 2017.

Interventions: Of the 42,934 patients evaluated, 34,248 underwent a diagnostic intervention and 8686 underwent an operative intervention; 17,973 procedures used CO and 24,961 used saline solution as a distension medium. Patients were contacted after the procedure to record postprocedure symptoms suggestive of infection, including 2 or more of the following signs occurring within the 3 weeks after hysteroscopy: fever; lower abdominal pain; uterine, adnexal, or cervical motion tenderness; purulent leukorrhea; vaginal discharge or itchiness; and dysuria. Vaginal culture, clinical evaluation, transvaginal ultrasound, and histological evaluation were completed to evaluate symptoms.

Measurements And Main Results: Operative hysteroscopies comprised polypectomies (n = 7125; 82.0%), metroplasty (n = 731; 15.0%), myomectomy (n = 378; 7.8%), and tubal sterilization (n = 194; 4.0%). Twenty-five of the 42,934 patients (0.06%) exhibited symptoms of infection, including 24 patients (96%) with fever, 11 (45.8%) with fever as a single symptom, 7 (29.2%) with fever with pelvic pain, and 10 (41.7%) with fever with dysuria. In 5 patients with fever and pelvic pain, clinical examination and transvaginal ultrasound revealed monolateral or bilateral tubo-ovarian abscess. In these patients, histological examination from surgical specimens revealed the presence of endometriotic lesions.

Conclusion: The present study suggests that routine antibiotic prophylaxis is not necessary before hysteroscopy because the prevalence of infections following in-office hysteroscopy is low (0.06%).
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http://dx.doi.org/10.1016/j.jmig.2018.06.021DOI Listing
August 2019