O-309 Surgery versus IVF/ICSI in infertile women with rectosigmoid endometriosis: the FERTILITY-RECTOSIGMOID study

Study question

To compare the live birth rate in infertile patients with rectosigmoid endometriosis treated by surgery or IVF/ICSI.

Summary answer

In infertile women with rectosigmoid endometriosis, IVF/ICSI is associated with a higher live birth rate and a shorter time to conceive than first-line surgery.

What is known already

The choice between surgery and IVF/ICSI is based on several variables including concomitant infertility factors, presence of (sub)occlusive symptoms, preference of patients. Until now, there is no evidence to favor first-line IVF/ICSI or first-line surgery in women affected by rectosigmoid endometriosis wishing to conceive.

Study design, size, duration

This was a prospective patient’s preference study enrolling infertile women with rectosigmoid endometriosis who underwent first-line surgery or IVF/ICSI. Symptoms and fertility outcomes were compared between the two groups.

Participants/materials, setting, methods

Rectosigmoid endometriosis was diagnosed by transvaginal ultrasonography and magnetic resonance enema. All study patients underwent computed tomographic colonography (CTC) to assess the degree of stenosis of the intestinal lumen. Inclusion criteria were infertility; bilateral tubal patency; age < 40 years. Exclusion criteria were history of surgery for endometriosis; previous IVF/ICSI cycles; oocyte donation or vitrified oocyte procedures; poor ovarian reserve; estimated bowel stenosis > 70% at CTC; (sub)occlusive symptoms; oligospermia (sperm count < 15 million/mL).

Main results and the role of chance

Two hundred twenty-nine patients underwent IVF/ICSI. Patients underwent up to 4 IVF/ICSI cycles. Overall, 128 women had a live birth (55.9%; 95% C.I., 49.2%-62.4%). Two bowel sub occlusions occurred during IVF-ICSI. 198 patients underwent surgical treatment of rectosigmoid endometriosis. Nine patients have postoperative complications: four rectovaginal fistula, two anastomotic leakage, two pelvic abscess and one postoperative bleeding. At a median follow-up of 23 months after surgery (range, 12-56 months), 91 women had a live birth (44.9%; 95% C.I., 38.0%-56.1%). The live-birth rate was significantly higher in patients who underwent IVF/ICSI than in those who underwent surgery (p = 0.047). The time to conception that resulted in live birth was significantly shorter in patients who underwent IVF/ICSI (mean ± SD, 11.9 ± 7.6 months) than in those who underwent surgery (18.5 ± 8.1 months; p = 0.037). Six months after surgery or first IVF/ICSI cycle, there was a higher improvement of pain (p < 0.001) and intestinal symptoms (p < 0.001) in women surgically treated. No bowel endometriosis-related complication occurred during pregnancy. There was no difference in perinatal outcomes between the two groups.

Limitations, reasons for caution

The nonrandom allocation to treatments and the relatively small sample sized limits the strength of our results.

Wider implications of the findings

IVF/ICSI is associated with a higher live birth rate and a shorter time to conceive than surgery. The disadvantages of IVF/ICSI are potential endometriosis-related complications during the procedure and persistence of symptoms. Surgery improves symptoms but it has a higher risk of postoperative complications, which may negatively impact spontaneous conception.

Trial registration number

CE Liguria - ID 10766 - n. 394 (Approval: 10/2020)

Cervical re-injection of indocyanine green to improve sentinel lymph node detection in endometrial cancer

OBJECTIVES

To evaluate the role of cervical re-injection of indocyanine green (ICG) to increase the detection rate of sentinel lymph node (SLN) in patients with endometrial cancer (EC) who underwent robotic-assisted surgical staging.

METHODS

We retrospectively identified consecutive EC patients undergoing robotic-assisted staging with SLN biopsy at our Institution between June 2016 and April 2020. Patients were excluded if they had open abdominal surgical approach, neoadjuvant chemotherapy, and advanced stage [International Federation of Gynecology and Obstetrics (FIGO) stage III-IV] at diagnosis. According to our SLN protocol, in case of either unilateral or no SLN detection, we performed an ipsilateral or bilateral cervical re-injection of ICG.

RESULTS

In total, 251 patients meeting inclusion criteria were included in the analysis. At first injection, bilateral detection was achieved in 184 (73.3%), unilateral detection in 57 (22.7%), and no detection in 10 (4.0%) patients. Cervical re-injection was performed in 51 of 67 patients with failed bilateral mapping. After cervical re-injection, bilateral detection rate increased to 94.5% (222/235), while unilateral and no detection were 5.1% (12/235) and 0.4% (1/235), respectively.

CONCLUSIONS

Our results suggest that cervical re-injection of ICG, in case of failed bilateral mapping of SLN, brings about a significant improvement in SLN detection rates, therefore reducing the number of side-specific required lymphadenectomies.

Tertiary cytoreductive surgery in recurrent epithelial ovarian cancer: A multicentre MITO retrospective study

OBJECTIVES

To evaluate the impact of tertiary cytoreductive surgery (TCS) on survival in recurrent epithelial ovarian cancer (EOC), and to determine predictors of complete cytoreduction.

METHODS

A multi-institutional retrospective study was conducted within the MITO Group on a 5-year observation period.

RESULTS

A total of 103 EOC patients with a ≥6month treatment-free interval (TFI) undergoing TCS were included. Complete cytoreduction was achieved in 71 patients (68.9%), with severe post-operative complications in 9.7%, and no cases of mortality within 60days from surgery. Multivariate analysis identified the complete tertiary cytoreduction as the most potent predictor of survival followed by FIGO stage I-II at initial diagnosis, exclusive retroperitoneal recurrence, and TCS performed ≥3years after primary diagnosis. Patients with complete tertiary cytoreduction had a significantly longer overall survival (median OS: 43months, 95% CI 31-58) compared to those with residual tumor (median OS: 33months, 95% CI 28-46; p<0.001). After multivariate adjustment the presence of a single lesion and good (ECOG 0) performance status were the only significant predictors of complete surgical cytoreduction.

CONCLUSIONS

This is the only large multicentre study published so far on TCS in EOC with ≥6month TFI. The achievement of postoperative no residual disease is confirmed as the primary objective also in a TCS setting, with significant survival benefit and acceptable morbidity. Accurate patient selection is of utmost importance to have the best chance of complete cytoreduction.

Diginyc partial hydatidiform mole with increased fetal nuchal translucency and ovarian hyperstimulation syndrome

PURPOSE OF INVESTIGATION

Hydatidiform mole (HM) is an abnormal pregnancy characterized by proliferation of cytotrophoblast and syncytiotrophoblast and vesicular swelling of placental villi. The fetus or embryo can be absent or abnormal. HMs can be complete or partial.

CASE REPORT

A case of diginyc partial HM at 12 weeks of gestational age was referred to the present center of prenatal diagnosis. The patient showed ovarian hyperstimulation syndrome. At ultrasonography, increased fetal nuchal translucency (NT) with fetal anomaly was evident, without sonographic signs of placental mole. Pregnancy was terminated with legal abortion.

RESULTS

Partial HM (PHM) was suspected by ultrasonographic fetal markers with ovarian hyperstimulation syndrome, but the diagnosis was performed only with fluorescent in situ hybridization. In particular fetal NT appeared increased also in diginyc mole.

CONCLUSION

In order to improve the detection rate of PHM, routine histological examinations may be associated to fluorescent in situ hybridization in all cases of fetal anomalies.

Sentinel node mapping with radiotracer alone in vulvar cancer: a five year single-centre experience and literature review

PURPOSE OF INVESTIGATION

The pathologic status of lymph node represents the most important prognostic factor in vulvar cancer patients, but a complete groin dissection is associated with high post-operative morbidity. Sentinel lymph node (SLN) could be representative of the totality of regional lymph nodes and consequently its biopsy might have a significant impact on clinical management in vulvar cancer patients.

MATERIALS AND METHODS

From January 2006 to December 2010 45 patients with vulvar carcinoma are evaluated. Preoperative lymphatic mapping with technetium-99m-labeled nanocolloid was performed in all patients, followed by radioguided intraoperative detection. The detection rate is 100% of patients. All the SLNs were dissected separately for histopathological evaluation and a routine inguinofemoral lymphadenectomy was performed.

RESULTS

Nine patients had positive SLNs. In the remaining 36 patients with negative SLNs, one of them showed positive non-SLNs at histological examination. It was the only false negative case in the present series.

CONCLUSIONS

Based on literature review, lymphoscintigraphy and sentinel node biopsy under gamma-detecting probe guidance offer a reliable and careful method to identify sentinel node in early vulvar cancer. Taking certain guidelines, SLN biopsy seems to be a safe alternative to inguinofemoral node dissection in order to reduce morbidity of surgical treatment.

Transvaginal ultrasonography with water-contrast in the rectum in the diagnosis of bowel endometriosis

AIM

The rectosigmoid is the most frequent location of intestinal endometriosis. Although several techniques have been proposed for the diagnosis of intestinal endometriosis, no gold standard is currently available. In this review, we describe in details a new technique for the diagnosis of rectosigmoid endometriosis: rectal water-contrast transvaginal ultrasonography.

METHODS

During transvaginal ultrasonography, an assistant inserts a 6-mm flexible catheter through the anal os into the rectal lumen; the insertion of this catheter is evaluated under ultrasonographic control. Water contrast is instilled slowly in the rectum to permit intestinal distension. The colonic wall evaluation is obtained by positioning the transvaginal probe against a length of the sigmoid colon to obtain either axial or longitudinal images. The injection of the saline solution facilitates the identification of recto-sigmoid endometriotic nodules which appear as rounded or triangular hypoechoic masses, located anterior or lateral to the bowel.

RESULTS

This technique has high sensitivity and specificity in the diagnosis of rectal infiltration in women with rectovaginal endometriosis. The distance between the nodules and the mucosal layer permits to estimate the depth of infiltration of these endometriotic lesions within the intestinal wall. Rectal distensibility can be estimated. The procedure is well tolerated by the patients.

CONCLUSION

Water distension of the rectum facilitates the identification of intestinal endometriosis during transvaginal ultrasonography.

Massive ovarian edema: a case of over 30 cm ovarian mass in young woman

Massive ovarian edema is a rare entity that can be confused with ovarian neoplasm. A 20-year-old nulligravid woman presented with a large solid pelvic mass and abdominal mass. On examination a solid mass was found which extended from the pelvis until over the umbilical transversal line. Abdominal ultrasound revealed a solid non-homogenous mass originating from the right ovary with largest diameter of over 30 cm, fine internal echoes, regular margins, and poor vascularization. The abdominal computed tomography (CT) image was non-contributory. Blood work including hematology and biochemistry was normal. There was no sign of systemic infection and the tumour markers are negative. Unilateral adnexectomy was performed during exploratory laparotomy. Histological examination demonstrated massive ovarian edema. The adnexa weighted 1,585 g. Massive edema of the ovary remains difficult to diagnose before surgery because it may clinically and radiologically mimic an ovarian neoplasm. The majority of cases present with recurrent abdominal pain or a palpable adnexal mass. Nausea with or without vomiting can be present. Menstrual irregularities are common. Some patients have signs of masculinization including hirsutism, clitoromegaly, voice deepening, precocious puberty. However, this entity should be considered in young women presenting with an ovarian mass and abdominal pain. Treatment of massive ovarian edema is controversial.

Modulation of calcium-dependent chloride secretion by basolateral SK4-like channels in a human bronchial cell line

The human bronchial cell line16HBE14o- was used as a model of airway epithelial cells to study the Ca(2+)-dependent Cl(-) secretion and the identity of K(Ca) channels involved in the generation of a favorable driving force for Cl(-) exit. After ionomycin application, a calcium-activated short-circuit current ( I(sc)) developed, presenting a transient peak followed by a plateau phase. Both phases were inhibited to different degrees by NFA, glybenclamide and NPPB but DIDS was only effective on the peak phase. (86)Rb effluxes through both apical and basolateral membranes were stimulated by calcium, blocked by charybdotoxin, clotrimazole and TPA. 1-EBIO, a SK-channel opener, stimulated (86)Rb effluxes. Block of basolateral K(Ca) channels resulted in I(sc) inhibition but, while reduced, I(sc) was still observed if mucosal Cl(-) was lowered. Among SK family members, only SK4 and SK1 mRNAs were detected by RT-PCR. KCNQ1 mRNAs were also identified, but involvement of K(cAMP) channels in Cl(-) secretion was unlikely, since cAMP application had no effect on (86)Rb effluxes. Moreover, chromanol 293B or clofilium, specific inhibitors of KCNQ1 channels, had no effect on cAMP-dependent I(sc). In conclusion, two distinct components of Cl(-) secretion were identified by a pharmacological approach after a Cai2+ rise. K(Ca) channels presenting the pharmacology of SK4 channels are present on both apical and basolateral membranes, but it is the basolateral SK4-like channels that play a major role in calcium-dependent chloride secretion in 16HBE14o- cells.

Characterization of the taurine transport pathway in A6 kidney cells

We investigated the role of taurine in cell homeostasis and characterized the taurine transport pathway in cultured kidney cells (A6). The taurine concentration in A6 cells varies with the osmolarity of the culture medium, suggesting that taurine participates in cell osmolarity. Under isosmotic conditions, 14C-taurine efflux through the apical membranes (aJtaur) was 6-7 times lower than that through the basolateral membranes (bJtaur). Under hyposmotic conditions, aJtaur remained almost unchanged. On the contrary, bJtaur increased 8 times in comparison with isosmotic conditions. In hyposmotic conditions, bJtaur was inhibited by 500 microM DIDS, 50 microM NPPB, 10 microM of the two oxonol derivatives DISBAC(2)3 and WW-791, and 100 microM ketoconazole. Conversely, 100 microM 1,9-dideoxyforskolin, 10 microM tamoxifen, 100 microM niflumic acid and 50 microM verapamil had no inhibitory effects. Cell volume regulation upon hyposmotic stress was also found to be inhibited by DISBAC(2)3 (K0.5 of 5+/-1 microM) and by ketoconazole. Nystatin was used to permeabilize the apical membranes with the aim to further characterize bJtaur. 14C-taurine transepithelial fluxes in nystatin-treated cells were found to be linear over taurine concentrations ranging from 3.5 microM to 35 mM. Clamping the transepithelial voltage at positive values (serosal side) slightly stimulated the 14C-taurine transport. Similar time courses of 14C-taurine, 36Cl and 86Rb transepithelial fluxes were found under osmotic stimulation followed by DIDS inhibition in nystatin-treated cells. In whole cell patch-clamp experiments, DISBAC(2)3 application resulted in a strong and reversible decrease of the global Cl- current which was stimulated by hyposmotic stress. Our study indicates that taurine participates in the control of A6 cell osmolarity and that the transporting taurine pathway (efflux) is on the basolateral membranes. In addition to usual chloride channel blockers, oxonol was found to be a potent blocker of the taurine transport and of the swelling-activated chloride current. Using a pharmacological approach, we could not distinguish between a common or different pathway for Cl- and taurine.

Control of apical membrane chloride permeability in the renal A6 cell line by nucleotides

1. The effect of extracellular nucleotides applied on the apical side of polarised A6 cells grown on permeant filters was investigated by measuring the changes in (i) the 36Cl efflux through the apical membranes, (ii) the intracellular chloride concentrations (aCli, measured with N-(6-methoxyquinolyl) acetoethyl ester, MQAE), (iii) ICl, the short-circuit current in the absence of Na+ transport and (iv) the characteristics of the apical chloride channels using a patch-clamp approach. 2. ATP or UTP (0.1-500 microM) transiently stimulated ICl. The sequence of purinergic agonist potencies was UTP = ATP > ADP >> the P2X-selective agonist beta,gamma-methylene ATP = the P2Y-selective agonist 2-methylthioATP. Suramin (100 microM) as the P2Y antagonist Reactive Blue 2 (10 microM) had no effect on the UTP (or ATP)-stimulated current. These findings are consistent with the presence of P2Y2-like receptors located on the apical membranes of A6 cells. Apical application of adenosine also transiently increased ICl. This effect was blocked by theophylline while the UTP-stimulated ICl was not. The existence of a second receptor, of the P1 type is proposed. 3. ATP (or UTP)-stimulated ICl was blocked by apical application of 200 microM N-phenylanthranilic acid (DPC) or 100 microM niflumic acid while 100 microM glibenclamide was ineffective. 4. Ionomycin and thapsigargin both transiently stimulated ICl; the nucleotide stimulation of ICl was not suppressed by pre-treatment with these agents. Chlorpromazin (50 microM), a Ca2+-calmodulin inhibitor strongly inhibited the stimulation of ICl induced either by apical UTP or by ionomycin application. BAPTA-AM pre-treatment of A6 cells blocked the UTP-stimulated ICl. Niflumic acid also blocked the ionomycin stimulated ICl. 5. A fourfold increase in 36Cl effluxes through the apical membranes was observed after ATP or UTP application. These increases of the apical chloride permeability could also be observed when following aCli changes. Apical application of DPC (1 mM) or 5-nitro-2(3-phenylpropylamino)benzoic acid (NPPB; 500 microM) produced an incomplete inhibition of 36Cl effluxes through the apical membranes in ATP-stimulated and in untreated monolayers. 6. In single channel patch-clamp experiments, an apical chloride channel with a unitary single channel conductance of 7.3 +/- 0.6 pS (n = 12) was usually observed. ATP application induced the activation of one or more of these channels within a few minutes. 7. These results indicate that multiple purinergic receptor subtypes are present in the apical membranes of A6 cells and that nucleotides can act as modulators of Cl- secretion in renal cells.