Outcomes of monopolar versus bipolar endometrial ablation on uterine bleeding and psychophysical wellbeing

BACKGROUND

To compare outcomes of endometrial ablation with monopolar versus bipolar resection on uterine bleeding and psychophysical wellbeing.

METHODS

In a prospective randomized study, 100 perimenopausal patients, without desire of pregnancy and with no response to pharmacological treatment, underwent endometrial ablation from 2012 to 2014. They were randomly divided in two groups: 50 patients treated with monopolar electrode resection loop (group A) and 50 patients treated with bipolar electrode resection loop (group B). Operative parameters were immediately assessed. Menstrual outcome parameters and psycho-physical well-being parameters were evaluated after 12 months.

RESULTS

No significant difference in operating time was recorded between the two groups. No serious hysteroscopic complication occurred with a similar immediate cumulative complication rate but two cases of intravasation were recorded in group A. The late cumulative complication rate was higher in group A than group B (44% vs. 24%). Cycle was overall controlled in over the 80% of the cases in the two groups without significant difference. The analysis of Short Form-36 showed an improvement of all assessed items after the endometrial ablation without significant difference.

CONCLUSIONS

Hysteroscopic endometrial ablation performed with bipolar loop electrode is as effective as resectoscopy with unipolar loop electrode regarding menstrual and psychophysical wellbeing outcomes. Endometrial ablation with bipolar electrode loop is safer but more expansive than monopolar electrode loop.

Resectoscope versus small diameter hysteroscopy for endometrial polypectomy in patients with "unfavorable" cervix

BACKGROUND

The aim of this study was to compare resectoscopic and small-diameter hysteroscopic techniques for endometrial polypectomy in patients with "unfavorable" cervix.

METHODS

Eighty women with a single 2-4 cm sized endometrial polyp, with unfavorable cervical anatomical conditions were enrolled in the study. Forty patients were treated with a 26F resectoscope requiring cervical dilatation (group A), forty patients were treated with a 5-mm hysteroscope requiring vaginoscopic approach (group B). Operative time, fluid absorption, complications, instrument failure, postoperative pain, overnight stay were analyzed. Operative visualization, operative difficulty and overall surgeon's satisfaction were assessed with a Visual Analogue Scale (VAS).

RESULTS

Operative time was significantly longer in group A than in group B (18.3±7.4 vs. 11.3±5.2 minutes), the cumulative complication rate and the need of postoperative analgesics were higher in group A than in group B. VAS of surgical difficulty and surgeon's satisfaction were higher in group B than in group A.

CONCLUSIONS

The small-diameter hysteroscopy is a safe and effective approach for endometrial polyp up to 4 cm in patients with unfavorable cervical canal at risk of cervical injury.

Fertility-sparing management of low-grade endometrial stromal sarcoma: analysis of an institutional series and review of the literature

OBJECTIVE

Low-grade endometrial stromal sarcoma (LG-ESS) is a rare malignancy, often occurring before menopause. There is no consensus regarding its optimal management. Total hysterectomy and bilateral salpingo-oophorectomy precludes future fertility and may thus be undesirable by women wishing to maintain their reproductive potential. However, experience of fertility-sparing management in LG-ESS is very limited. In this paper, the disease outcome is presented in six young women with LG-ESS conservatively treated by combined hysteroscopic resection and hormonal therapy.

STUDY DESIGN

From October 2009 to February 2013, at the Gynecologic Oncology Department of the National Cancer Institute of Naples, six women, with early-stage LG-ESS aged 18-40 years who desired childbearing and/or retaining their fertility, were enrolled into a pilot study of fertility-sparing management. Diagnosis of LG-ESS was made on specimens from hysteroscopic resection performed on a presumed benign lesion. All patients were planned to be treated with adjuvant megestrol acetate for two years. Hormonal therapy was started within 6 weeks from the hysteroscopic resection, with orally megestrol acetate at 40mg daily, increasing gradually according to patient's tolerance to the recommended total dose of 160mg daily.

RESULTS

All patients were submitted to hysteroscopic resection in a one-step procedure. Five patients started megestrol acetate within 6 weeks from the hysteroscopic resection (one patient did not start hormonal therapy because of early pregnancy after the hysteroscopic resection). Hormonal therapy was well tolerated; one patient stopped megestrol acetate after 12 months because of self-supporting strong desire to conceive; the other four patients regularly completed the hormonal therapy. To date, all patients show no evidence of disease.

CONCLUSIONS

Although fertility-sparing management is not the current standard of care for young women with early-stage LG-ESS, our preliminary data are promising. Larger series with a longer follow-up are needed to further assess safety and efficacy of combined hysteroscopic resection and hormonal therapy.

Ovarian fibrosarcoma: case report and latest trends in diagnostic and therapeutic management

The authors describe a rare case of primary ovarian fibrosarcoma and the latest trends in diagnosis and therapy. The rarity of this dis-ease and the scarce number of reported cases pose serious problems in differentiating it from other fibrous forms. A 58-year-old woman presented intermittent pelvic pain and a demarcated, mobile, and solid lump in the right adnexa. Diagnostic imaging revealed a solid- cystic inhomogeneous mass occupying the right adnexa and the CA125 level was elevated. The patient underwent total hysterectomy with bilateral salpingo-oophorectomy and infracolic omentectomy. Histological findings with immunomarkers led to the final diagnosis of low-grade malignant mesenchymal neoplasm derived from the ovarian stroma compatible with fibrosarcoma. Twenty-four months follow-up showed no recurrence of disease. Ovarian fibrosarcoma is very uncommon neoplasm with a poor prognosis. Despite the efforts of several authors in reporting morphological, histological, and immunohistochemical features of this neoplasm, nowadays, the diagnosis, treatment, and prognosis are unresolved issues. The present case highlights the important role of immunohistochemistry to define histological type and differential diagnosis. As demonstrated by the authors' experience, they believe that surgery is curative in the early stages with low immunohistochemical positivity for ki67 and that chemotherapy should be reserved in advanced stages with regimens in use for the treatment of sarcomas.

The possible role of zinc in the etiopathogenesis of endometriosis

PURPOSE OF INVESTIGATION

Aim of the study was to evaluate the possible involvement of zinc in the complex pathogenic process behind the onset and perpetuation of endometriotic lesions. To study the level of zinc serum between a group of patients affected by endometriosis and a group of healthy patients.

MATERIALS AND METHODS

The study included 86 women: 42 patients whose histodiagnosis had revealed pelvic endometriosis and 44 healthy patients. The authors measured the serum zinc concentration for all patients.

RESULTS

The group of patients with endometriosis presented serum zinc concentration of 1010 +/- 59.24 microg/l. The observation group presented a serum zinc concentration of 1294 +/- 62.22 microg/l.

CONCLUSION

The results showed that serum zinc levels in women with endometriosis are decreased and this seems to actually confirm that this microelement can possibly affect the multifactorial pathogenesis of the disease. As a matter of fact, zinc interferes with many biological processes, among which inflammation and immunity, which seem to be the base of the development of the lesions. Therefore, the authors believe that this hypothesis requires more attention and further investigation to determine its reasonableness. If the results are confirmed, this study opens up future prospects as for the treatment of endometriosis, taking into account also the role of zinc in the onset of male sterility and the development of testicles. Zinc could in fact be used as marker to detect women at high risk of endometriosis and for the elaboration of a new treatment for sterility, from which these women often suffer.

Arterial hypertension and female sexual dysfunction in postmenopausal women

PURPOSE

To evaluate female sexual dysfunction in hypertensive postmenopausal women and the effects of antihypertensive therapy.

MATERIALS AND METHODS

Female sexual dysfunction was assessed by the Female Sexual Function Index (FSFI) in three groups of postmenopausal patients: normotensive women (group A: 240 women), hypertensive women without therapy (group B: 220 women), hypertensive women on therapy (group C: 80 women).

RESULTS

The incidence of female sexual dysfunction was increased in group B compared to groups A and C. Healthy patients showed higher FSFI scores compared to hypertensive patients (groups B and C). Hypertensive-treated patients accounted for higher scores in all items compared to hypertensive patients without therapy.

CONCLUSIONS

Essential hypertension significantly affects female sexual function. Physicians should recognize and properly manage FSD in hypertensive women.

An apparently benign vulvar mass: possibly a rare malignancy

BACKGROUND

Vulvar dermatofibrosarcoma is a rare fibrous tumor of intermediate grade malignancy, with a tendency for local recurrence, and rarely metastasizes. Management should be multidisciplinary. This is a report of an apparently benign vulvar mass with delayed diagnosis of vulvar dermatofibrosarcoma.

CASE REPORT

A 42-year-old woman was referred to our hospital because of a vulvar tumor lasting 16 years, although several gynecological procedures and a total laparoscopic hysterectomy had been performed two years before. During this long period the lesion did not change morphological features and remained asymptomatic. Only a benign vulvar mass was diagnosed. Then, the swelling became evident showing erythematous skin with an aspect of "peau d'orange", leading the patient to consult a specialist. A firm vulvar swelling was observed in the anterior third of right labia majora continuing with about 3 cm of cord on top, quite movable above the underlying tissue but not on the overlying tissue. A wide excision was performed. The pathological examination showed positive margins. One month later an extensive deeper excision was performed. Histology confirmed a diagnosis of dermatofibrosarcoma. Immunohistochemistry was strongly positive for CD34.

CONCLUSION

Vulvar lesions always require complete pathologic examination even in case of features of benign tumor to exclude a dermatofibrosarcoma. The role of the pathologist is essential to ensure negative microscopic margins and to avoid local recurrence.

Long-term safety and efficacy of raloxifene in the prevention and treatment of postmenopausal osteoporosis: an update

The integrity of bone tissue and its remodeling that occurs throughout life requires a coordinated activity of osteoblasts and osteoclasts. The decreased estrogen circulating level during postmenopausal transition, with a prevalence of osteoclastic activity over osteoblastic activity, represents the main cause of bone loss and osteoporosis. Osteoporosis is a chronic disease requiring long-term therapy and it is important to evaluate the efficacy and safety of treatments over several years, as the fear of health risks is a common reason for discontinuing therapy. Raloxifene is a selective estrogen receptor modulator (SERM) leading to estrogen-agonist effects in some tissues and estrogen-antagonist effects in others. Raloxifene is effective to prevent and treat postmenopausal vertebral osteoporosis, with reduction of spine fractures and, in post-hoc analyses, non-spine fractures in high-risk subjects. Moreover, raloxifene reduces the risk of invasive breast cancer and improves the levels of serum lipoprotein but with an increased risk of venous thromboembolism and fatal stroke, without significant change in the incidence of coronary events. For these reasons the overall risk-benefit profile is favorable. Therefore, when considering the use of raloxifene in a postmenopausal woman, we should take into account the osteoporosis-related individual risk and weigh the potential benefits, skeletal and extra-skeletal, against the health risks.

Perineal ultrasound evaluation of urethral mobility after the TVT-O procedure

AIMS

The aim of study was to assess, by means of perineal ultrasound (US), women treated with the trans-obturator suburethral sling procedure for urinary stress incontinence (USI).

METHODS

Twelve women with USI and urethral hypermobility were enrolled. Static and dynamic perineal US of urethral mobility was performed before and after tension-free vaginal tape opturator (TVT-O) procedure: US parameters evaluated were pubis-urethra distance and inclination angle of the urethral axis.

RESULTS

The Valsalva stress US evaluation showed a return to normal range of the pubic urethral distance in all cases (p = 0.0001); also a correction of the angle of inclination of the urethral axis occurred in all patients (p < 0.0001).

CONCLUSIONS

Our results propose the use of perineal US for patients with USI as an additional diagnostic tool and a means for postsurgical follow-up.

Therapeutic alternatives in Behçet's syndrome

Behçet's Syndrome (BD) is a chronic, relapsing, recurrent systemic vasculitis with an unknown cause. The disease affects all organs of the body concurrently or consecutively. Its various clinical manifestations result from ubiquitous small-vessel vasculitis, which is the underlying pathology. An Italian study has reported an increased association of the extended haplotype B51-DR5-DQw3. Without a known etiology BD syndrome has no uniformly acceptable therapy. Our study addresses therapeutic alternatives for the treatment of BD, with the systemic use of interferon alpha-2a., which has antiviral. immunomodulatory, antiproliferative, and antitumoral properties. Ten patients diagnosed with BD were referred from September 2002 to September 2005 to the Department of Gynaecology, Obstetrics and Reproduction of the Second University of Naples. The International Study Group (ISG) Criteria for Behçet's Disease (27) was applied. Patients were treated with oral prednisone; sulfasalazine; clobetasol; and interferon alpha-2a. Every month all patients had a complete blood count, platelet count, and liver function test. Biopsies of genital ulcerations identified small vessel vasculitis with mononuclear cell and lynphocytic infiltrates. HLA-B27 and B5 were positive in three subjects. The pathergy test was positive in all patients. Today the therapy is still ongoing, and none of the patients in therapy with our protocol present clinical symptoms of BD or intolerance. Laboratory findings are in a normal range and none have had neurological failure. Our findings may be attributable to less severe disease in a patients, to our smaller number of patients, or to other unknown factors. Nonetheless, these findings remain to be confirmed in a larger number of patients.

Surgical approach to appendiceal mucocele mimicking an adnexal complex mass: case report

Mucocele of the vermiform appendix is a rare disease of the appendix caused by mucoid substance retention in its lumen, due to obstruction or hyperproduction due to appendiceal retention cysts, mucosal hyperplasia, mucinous cystadenomas and cystadenocarcinomas. Therefore, also appendiceal malignancy can be the underlying cause, making accurate preoperative diagnosis imperative, even if this disease is often asymptomatic and an early diagnosis still remains very difficult on imaging studies. In women, appendiceal mucoceles can sometimes present on clinical and instrumental findings as a right adnexal mass mimicking an ovarian neoplasm. A rare case of appendiceal mucocele in a 36-year-old women with a right-sided painful pelvic mass is presented. The mucocele was misdiagnosed as a cystic complex mass of the right adnexa both clinically and ultrasonographically. Serum levels of CEA and CA19-9 were increased. Explorative laparoscopy was performed revealing an enlarged vermiform appendix with the uterus and adnexa macroscopically normal, and no signs of intraperitoneal metastasis or adnexal torsion. Laparotomic appendectomy followed. Histological examination revealed a mucinous cystadenoma of the vermiform appendix. This clinical entity of appendiceal mucocele should always be considered by gynaecologists as well as gastroenterologists in the differential diagnosis of patients presenting a right-sided adnexal mass on ultrasound in order to choose the best surgical approach.

A rare case of female pelvic mass: angioleiomyoma of the broad ligament

Angioleiomyoma is a benign mesenchymal neoplasm composed of smooth muscle cells and thick-walled vessels. It is usually found in the skin of the lower extremities. Angioleiomyoma is a very rare tumor among the ever-expanding repertoire of growth variants described in benign uterine leiomyoma. More rare is a solitary tumor of the broad ligament. Thus angioleiomyoma of the broad ligament is an extremely rare benign tumor of the female pelvis. In this report a 52-year-old woman with a one-year history of abdominal pain was admitted to our hospital. Gynaecological and ultrasonography exams showed a large mass with increased vascularization in the right adnexal region. The patient underwent total hysterectomy and bilateral salpingo-oophorectomy. The site of the benign mass was the left broad ligament of the uterus. On pathologic examination of the specimen, the tumor was diagnosed as angioleiomyoma. We present a case of angioleiomyoma of the broad ligament because of its extreme rarity and the large size of the tumor.

Raloxifene therapy interacts with serum osteoprotegerin in postmenopausal women

OBJECTIVES

Osteoprotegerin (OPG) is a protein expressed by osteoblasts that, linking the receptor activator of nuclear factor kappaB (RANK) ligand (RANKL), produced by osteoblasts, blocks the process of osteoclastic differentiation and modulates osteoclastic apoptosis. Raloxifene (RAL) stimulates the production of OPG from osteoblasts, as demonstrated in vitro, carring out their antiresorption activity, at least in part, as means of the OPG/RANK/RANKL system. The aim of this study was to evaluate in vivo if the RAL treatment of postmenopausal women was associated to changes in serum OPG; moreover, to evaluate the serum changes of bone turnover modulators interleukin-6 (IL-6) and C-telopeptides of type-1 collagen (CrossLaps).

METHODS

A prospective, randomized, placebo-controlled study was designed. A group of consecutive healthy postmenopausal women (n=40) referred to II Menopause Centre of the Department of Gynaecology of Second University of Naples for climacteric syndrome was enrolled and divided in two groups: (n=20) postmenopausal women received for 6 months oral raloxifene (60 mg/day) versus (n=20) postmenopausal women received placebo tablets.

RESULTS

Serum OPG levels in postmenopausal women after RAL treatment are statistically significant increased (P<0.001) versus baseline (P=0.007) versus placebo.

CONCLUSIONS

These in vivo data demonstrate that RAL could improve osteoporosis, also through an increase of OPG production by osteoblasts.

A new approach to vulvar squamous cell carcinoma: two-year follow-up of a case report

BACKGROUND

Vulvar carcinoma is relatively rare gynaecologic malignancy. The most prevalent vulvar cancer is squamous cell carcinoma. It is not uncommon for patients to delay seeking medical attention or for physicians to delay diagnosing the condition. This delay results in many cases being diagnosed in advanced stage. The sentinel lymph node "concept" is attractive in vulvar cancer because it has the potential to avoid a radical vulvectomy associated with uni- or bilateral inguinofemoral lymphadenectomy and, thus, to avoid the morbidity associated with formal groin dissection.

CASE REPORT

A case of an 88-year-old woman with advanced local vulvar cancer is presented. A study of the inguinal-femoral lymph nodes was also conducted with intraoperative vital blue dye peritumoral injection and as the sentinel node was found to be negative for malignant metastasis, a radical vulvectomy without bilateral inguinofemoral lymphadenectomy and without additional treatment (chemotherapy and/or radiotherapy) was performed. Follow-up was performed at one, three, six, nine, 12, 18 and 24 months. No local recurrence or distant metastasis was found.

CONCLUSION

The sentinel lymph node procedure allows a less aggressive treatment to be carried out in patients with invasive vulvar cancer thus reducing the complications and morbidity of treatment. Moreover, reducing the operative stress can change the overall survival and reduce the mortality linked to complications and postoperative stress.

A therapeutic algorithm for early-stage endometrial cancer: indications, patient selection, and feasibility

Endometrial cancer is the most widely spread gynaecologic neoplasm in industrial countries. Mode of spread includes direct extension, lymphatic and haematic diffusion. Lymphatic involvement, particularly, is a topic of wide debate due to the strong therapeutic implications associated with it. In this regard, anatomic-surgical staging is better in that it corresponds to real conditions whereas clinical-instrumental staging is still today incomplete.

Third stage ovarian carcinoma--case report: the necessity of a multidisciplinary approach to treatment

Ovarian carcinoma, part of a heterogeneous group of tumours, is the main cause of death by gynaecological neoplasms. The diagnosis, in general, is delayed. Multiorgan diffusion, the necessity of a surgical operation and strong chemotherapy, and the eventual pathology due to patient age are all factors that require a multidisciplinary approach. In fact the case, here reported, refers to a patient who came under our observation for a bilateral ovarian mass discovered casually during an abdominal ultrasound exam carried out for renal colic. Excellent cytoreduction with peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy (Figure 2), bilateral pelvic lymphadenectomy, total omentectomy, removal of nodules from the mesentery, the colon and three nodules in the abdominal wall thickness was executed. The histological report was G3, angioinvasive bilateral ovarian endometrioid adenocarcinoma. Metastasis was found only in one left obturator lymph node out of 17 lymph nodes removed. All of the removed abdominal, mesenteric and intestinal nodules were neoplastic. It is concluded that the complexity of similar cases always requires a multidisciplinary approach as in our case, involving an oncologist, hematologist, surgeon, gynaecologist, radiologist, anaesthesiologist, and nursing staff in the management of third stage ovarian cancer patients to obtain the best treatment thus guaranteeing a higher survival rate and better quality of life.

Local estrogen replacement therapy in postmenopausal atrophic vaginitis: efficacy and safety of low dose 17beta-estradiol vaginal tablets

PURPOSE OF INVESTIGATION

To verify the effectiveness and safety of low-dose 17beta-estradiol vaginal tablets in the treatment of the postmenopausal atrophic vaginitis.

PATIENTS AND METHODS

325 postmenopausal women with atrophic vaginitis in estrogenic replacement therapy with 0.025 mg 17beta-estradiol vaginal tablets, one application each day for two weeks, and a single application two times a week for the following 22 weeks (total treatment period: 24 weeks).

RESULTS

Most of the women reported an improvement of symptoms just after two weeks and minimal incidence of adverse reactions. No patients showed abnormal endometrial thickness and no one had to interrupt the treatment for abnormal uterine bleeding because of systemic absorption.

CONCLUSION

Low-dose 17beta-estradiol vaginal tablets in the treatment of the postmenopausal atrophic vaginitis constitutes an extremely valid approach in terms of effectiveness and safety.

Bilateral pelvic ganglioneuroma: clinico-pathological findings: a case report

Ganglioneuroma is a rare benign neurogenic tumor originating from the autonomic nervous system, and is considered the benign counterpart of neuroblastoma, lacking the immature neuroblastic cells. A case of pelvic ganglioneuroma with bilateral pelvic spread is described.

Haematosalpinx of fallopian tube: isolated torsion with congenital abnormal vascularisation

We report a case of haematosalpinx due to torsion of the Fallopian tube with congenital abnormal blood supply in a girl. The symptoms were not specific and the first diagnosis was a pelvic complex mass like a tumour. The authors discuss the possible aetiology.

Pelvic lipomatosis complicating ovarian cyst removal: a case report

Pelvic lipomatosis consists of an abdominal capsulated mass containing lipidic tissue, generally with remarkable dimensions, responsible for urinary tract disturbances. Here we describe the first case to our knowledge of accidental intraoperative diagnosis associated to an ovarian cyst in absence of objective symptoms and signs.

Methotrexate treatment for tubal pregnancy. Criteria for medical approach

AIM

The purpose of this retrospective study is to underline the indications for the use of systemic methotrexate (MTX) in tubal pregnancies.

METHODS

One hundred and four (n=104) consecutive women were treated in our Department for tubal pregnancy. The database analysis showed that after careful respect for inclusion criteria, the treatment chosen was the intravenous administration of MTX in 68 patients, whereas laparoscopy constituted the primary treatment in 36 patients. A single dose of MTX was intravenously administered, diluted in saline solution, with a dosage of 50 mg/m2 of body surface. Close serum beta-hCG monitoring was performed, and in the case of a short fall, a 2nd dose of methotrexate was submitted.

RESULTS

The overall success rate of MTX treatment was 91%; the 2nd dose of MTX was used in 12% of patients, whereas in only 6 out of 68 patients included in the medical treatment group a surgical approach for suspected tubal rupture was necessary.

CONCLUSION

Treatment with methotrexate is effective and safe in the presence of these criteria: patient hemodynamically stable, absence of tubal rupture sign and hemoperitoneum, an adnexal mass with a diameter < or = 5 cm, an amenorrhea < or = 6 weeks and HCG levels < or = 10,000 mIU/ml. Laparoscopy is indicated in diagnostic uncertainty, when MTX is not suggested, when adnexal mass is > 5 cm, or in patients in which beta-hCG levels was > 10,000 mIU/ml.

Premature ovarian failure. Clinical evaluation of 32 cases

AIM

Premature menopause, also termed premature ovarian failure (POF), is characterized by cessation of menstruation before the age of 40 years. Pathogenetic mechanisms are not so clear, particularly genetic implications of cellular apoptosis. Diagnostic approach is multifactorial and therapy depends on the pregnancy wish.

METHODS

Eight hundred and thirty patients approached the Menopausal Center of the University Department of Gynaecological, Obstetrical and Reproductive Sciences of the Second University of Naples between October 1998 and October 2002. All patients were clinically investigated and selected on the basis of menopausal age, pregnancy wish and menopausal syndrome.

RESULTS

Menopausal mean age was 48.31+/-4.62 years and 32 patients (4%) were affected by premature ovarian failure because of menopausal appearance before the age of 40. Three of these patients were treated to have a pregnancy; the remaining 29 required medical treatment to reduce menopausal symptoms. The osteoporosis risk for premature menopause patients was similar to the other women. The cardiovascular risk was increased because of an increase in risk factors in premature ovarian failure patients. No breast or endometrial pathology was revealed and therapy compliance was satisfactory without any drop-out.

CONCLUSION

Premature ovarian failure has a varied etiology, pathogenetic aspects, clinical evolution and therapeutical approach. Adequate treatment of premature menopause women presents good compliance, resolution of infertility when required and a successful resolution of menopausal symptoms.

Alcohol sclerosis of endometriomas after ultrasound-guided aspiration

AIM

We investigate the possibility to use ultrasound-guided aspiration and alcohol sclerosis in patients with endometrioma.

METHODS

Ten patients with endometriotic ovarian cysts, mean diameter <70 mm, CA125 <35 UI, persistence of cyst after medical therapy and refusal of surgical therapy have been studied. The patients were submitted to ultrasound-guided aspiration of endometriomas. Fifty per cent of aspirated fluid was replaced with pure ethanol, which was left in situ for 10 to 20 minutes. No medical therapy was employed after aspiration and ethanol treatment.

RESULTS

In 9 patients no recurrence was observed at ultrasound after 21.2+/-6.62 months of follow-up. In 1 case only, after 6 months, a recurrence of the endometrioma in the same site was observed.

CONCLUSION

Ultrasound-guided alcoholic sclerotherapy of the endometriotic ovarian cysts is effective and safe. We speculate that this procedure could be indicated in patients refusing standard surgical therapy.

Ovarian hyperstimulation syndrome: distinction between local and systemic disease

The ovarian hyperstimulation syndrome (OHSS) is an iatrogenic, unpredictable and potentially life-threatening complication in patients submitted to pharmacological ovarian stimulation. Information on risk factors, etiopathogenetic mechanisms, prevention strategies and therapeutic management is continuously updated. The present study retrospectively analyzed 123 women affected by different grades of OHSS as a result of pharmacological ovulation induction. Hospital admission was suggested in 14 patients with severe OHSS, whereas patients with moderate or mild OHSS were followed in the out-patient section of our department. The results confirmed the efficacy of the therapeutic scheme adopted. The syndrome is localized to the ovaries at the time that the condition is triggered; when organs different from the ovaries become involved, OHSS assumes systemic aspects. The different clinical signs are the basis of a proposal of a local and systemic classification.

[Indications for hormone replacement therapy]

BACKGROUND

The purpose of the present study is to evaluate indications and contraindications, advisability and compliance of hormone replacement therapy (HRT) in women in the climacteric who, owing to the cessation of ovarian activity, face loss of the state of present and future wellbeing.

METHODS

A series of 602 women who have attended the Menopause Centre of the II Division of the Department of Gynaecology and Obstetrics of the Second University of Naples in the period from 1/12/1998 to 10/4/2001. The diagnostic methodology adopted is outlined and the reasons for the prescription of HRT indicated. Patients who do not present contraindications were assessed in relation to the gravity of the climacteric syndrome and the likelihood of a future pathology bound up with the lack of estrogens. The intensity of the symptomatology was assessed on the basis of Kuppermann's nomogram.

RESULTS

The cessation of ovarian activity occurred between the ages of 40 and 45 in 16.9% of cases while the percentage was 5.9% prior to the age of 40. Cases in which a climacteric syndrome was present numbered 147, or 24.2%. Women who present a cardiovascular risk represent a noteworthy percentage (27.1%). A high number of women are at osteoporotic risk: 223, or 37.0%. Although it has a great number of indications, HRT is only prescribed in about half the patients. Stress is laid on the caution exercised by physicians in prescribing HRT and the diffidence of women in accepting it. Of the well-known contraindications to HRT the most common are those relative to the mammary risk.

CONCLUSIONS

HRT was only prescribed for about half the women who came to our attention both as a result of the caution of the physicians who consider even relative contraindications peremptory, and because of the diffidence of a percentage of women with regard to such therapy. Alternative therapies to HRT are in fact a second valid choice, especially in the prevention of osteoporosis.

[Pelvic actinomycosis and sub-acute abdomen]

An interesting case of pelvic actinomycosis with paculiar clinical manifestation is presented. A 42 years-old patient came to our emergency service for an abdominal pelvic pain and fever. Past history showed IUD in situ for over 15 years. The patient was submitted to a ultrasonographic scan and a complete hematological screening was performed. The diagnosis was of subacute abdomen, and an exploratory laparotomy was carried out. During laparotomy an atypical reactive tissue and a suppurative cavity were found. The histological finding of tissue biopsy showed pelvic actinomycosis. On the basis of these findings the conclusion is drawn that a better prevention of pelvic actinomycosis is necessary of its diffusion in the last years due to sexual habit changes.

Restitutio ad integrum of myometrium after myomectomy. Different results in pregnant and non-pregnant patients

BACKGROUND

The aim of this study is to check whether there exists a difference in restitutio ad integrum of the uterus after myomectomy performed during Caesarean section and out of pregnancy.

METHODS

Two different groups are considered: Group A (n=8) that underwent myomectomy during Caesarean section; Group B (n=10) in which myomectomy was performed out of pregnancy. All patients were followed with serial scan evaluations.

RESULTS

The results showed a much more complete and faster absorption of hyperplasia and hypertrophy surrounding fibroid nodules when myomectomy was performed during Caesarean section.

CONCLUSIONS

A later pregnancy in patients who underwent myomectomy during Caesarean section might have a favourable outcome, possibly reaching a term gestation and vaginal delivery.

Electro-cautery of myomas during caesarean section--two case reports

Myomectomy is a surgical procedure not usually performed during caesarean section because associated with high risk of haemorrhage and other complications. The goal of our study is to evaluate the feasibility of myomectomy during caesarean section, the outcome, and try to establish the favourable conditions to perform a myomectomy during the same surgical event. Electro-cautery of intramural-subserous myomas was performed on two different patients. Only the myomas of little or middle size were treated. Both patients had multiple fibroids, a firm contraindication for myomectomy during caesarean section. After 10 and 13 months since myoma electro-cautery, all uterine fibroids treated were completely reabsorbed. These preliminary results regard the fibroids of middle size. It could be interesting evaluating the electro-cautery on bigger fibroids.

[Vena cava filter in patients with gynecologic cancer complicated by pulmonary embolism and progressive hypercoagulability]

The aim of the study was to verify the validity of placement of a vena cava filter in patients with gynecologic cancer complicated by pulmonary embolism and progressive persistent hypercoagulability. The authors discuss two patients with pulmonary embolism. In this study, a gynecologic tumor was diagnosed, one presented endometrial carcinoma and the other ovarian papillary carcinoma, after the position of vena cava filter and treatment with urokinasi (2.800.000 UI/ml) it was possible to do surgery followed by radiation therapy in the first case and chemotherapy in the second. In these cases there are indications for the placement of a vena cava filter. This has enabled surgery and anticoagulation therapy and has prevented the movement of any other emboli, which were later dissolved by fibrinolytic agents, and the effectiveness result was the arrest of progressive hypercoagulability moved by tumor cell. The serious conditions that were related to prior embolism and to a persistent thrombotic state characterized by progressive hypercoagulability did not make it possible to perform surgery or any other type of therapy because of absolute contraindications. The decision to place the filter could thus become the first step towards subsequent improvements, that are also tied to the possibility of performing surgery for removing tumor, arrest of progressive hypercoagulability due to tumor cell, allow chemotherapy or radiation treatment.

[Cesarean section according to Stark]

BACKGROUND

The aim of this paper is to compare cesarean section according to Stark to cesarean section according to conventional technique in order to evaluate advantages and limits.

METHODS

PLACE

Second University of Study of Naples, Department of Obstetrics and Gynaecology, during the period from March 1996 to March 1999.

PATIENTS

One hundred and two cesarean sections according to Stark were performed. These interventions have been compared with others performed, during the same period, according to the conventional technique.

INTERVENTION

Comparison between cesarean section according to Stark and cesarean section according to conventional technique.

RESULTS

For each case, several parameters have been compared: extraction time, total time, number of suture threads, canalization time, blood loss and fetal Apgar.

CONCLUSIONS

Cesarean section according to Stark is an evolution of the conventional surgical technique, which can be applied for particular indications such as maternal, fetal and anesthesiologic conditions.

[A case of atypical bicornate unicollis uterus treated with metroplasty according to Jones]

The aim of the study is to report on the result achieved on uterus bicornate unicollis that after hysterosalpingography proved atypical in the isthmic section of the left horn because it was filiform and had irregular walls. The metroplasty technique was performed, applying the Jones technique, on a patient affected by infertility for six years, with uterine malformation. Hysterosalpingography evidenced an atypical malformation: a unicollis-bicornis uterus that was atypical in the isthmic section of the left horn, treated with the technique of Jones because it was filiform. Diagnostic laparoscopy visualized two symmetrical and separated horns. Metroplasty was performed applying Jones technique, by removing the isthmic miometrium of the left horn in order to widen the communication with the upper part. The result of postoperative hysterosalpingography, performed 10 months after intervention, showed a single uterine cavity with irregular walls that allowed the evolution of a pregnancy that was prematurely concluded after thirty-two weeks on the birth of a live, vital fetus. Infertility is probably associated with the complexity of uterine malformation. We can, therefore, underline that laparotomic metroplasty is an effective technique that can be performed in particular cases.

[Ovarian function after total simple hysterectomy]

BACKGROUND

The aim of this prospective study is to evaluate the ovarian function and its duration after total simple hysterectomy.

METHODS

This research was carried out on thirty regularly menstruating patients who underwent simple hysterectomy. Ovarian function has been evaluated by measuring FSH, E2, PP at 6 and 24 months from hysterectomy or from the first observation at the beginning of the study.

RESULTS

None of the patients showed ovarian failure at 6 months. Nine patients (average age: 48,8 years) showed ovarian failure at 24 months.

CONCLUSIONS

The conclusion is drawn that the cessation of ovarian activity is not influenced by hysterectomy: it rather depends on the age of the patient.

Pelvic actinomycosis in menopause: a case report

OBJECTIVE

To examine the association between the use of intra uterine device (IUD) and the risk of actinomycosis in postmenopausal women.

METHODS

We report a case of pelvic actinomycosis in a postmenopausal woman who was wearing an IUD for 14 years until 20 months after the beginning of menopause. In the last 5 years the patient had been suffering occasionally from pain, abdominal tension and rectal tenesmus. The disease was revealed clearly 18 months after removing the intrauterine device.

RESULTS

The diagnosis of pelvic actinomycosis was only possible after hysterectomy, bilateral oophorectomy and multiple biopsies. At histological features a focus with actynomycetes colonies was evident.

CONCLUSIONS

This study supports the previously reported association between the pelvic location of actinomycosis and the use of the IUD. The removal of IUD should be mandatory in postmenopausal women.

[Exploration of the uterine cavity in the gynecologic preoperative diagnosis]

BACKGROUND

The diagnostic accuracy of dilatation and curettage (D & C) was studied comparing retrospectively the results of histologic findings of D & C with the correspondent specimen from hysterectomy.

METHODS

During five years, at the Institute of Gynecology and Obstetrics, II University of Studies in Naples, 260 women underwent hysterectomy, 160 of which underwent D & C prior to hysterectomy. The histologic findings were classified in: a) physiological endometrium; b) hyperplasia; c) polyps; d) atrophia; e) adenomatous hyperplasia; f) adenocarcinoma. During the period January 1989-October 1993, 260 patients underwent hysterectomy. The age was between 32 and 65 years. The indications to the intervention were: menometrorrhagia, hypogastric pains, dysmenorrhea, metrorrhagia, genital prolapse, urinary incontinence, anemia. Two hundred-sixty patients underwent hysterectomy, 160 of which underwent D & C prior to hysterectomy. Curettage was performed using a right size curette after dilatation of the uterine cervix using Hegar's metallic dilatator. Patients were submitted to general anesthesia. Histologic tissues were fixed with formalin and were sent to the Institute of Anatomopathology for examinations.

RESULTS

The histologic results obtained by cavitary exploration have been compared with those reached by the analysis of the surgical samples. The results obtained confirm the reliability of D & C for the identification of endometrial lesions.

CONCLUSIONS

Therefore, the diagnostic utility of cavitary exploration before hysterectomy is confirmed, particularly in selected cases.

Contribution to the choice of therapy in abdominal pregnancy

The goal of our study was to offer our contribution to the selection of the most suitable therapy to treat abdominal pregnancy. We discuss three patients affected with this pathology, which was diagnosed early by laparoscopy. The patients were treated with 50 mg/m2 of methotrexate administered intravenously. The abdominal pregnancy was terminated in all three patients. Since the outcome involved termination of the pregnancy, it is important to emphasize that methotrexate therapy, must be considered elective. Operative laparoscopy can be limited only to cases in which the ovum has not become implanted in the intestinal interstices and is not near sites susceptible to complications.