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We report a case of a primary vaginal adenosarcoma with sarcomatous overgrowth in a postmenopausal 58-year-old woman with recurrent endometriosis. In the past 5 years she underwent several biopsies of a polypoid lesion on the vaginal cuff, and the last histologic examination of the biopsy showed an adenosarcoma with "sarcomatous overgrowth" in a background of endometriosis. There was no evidence of distant metastatic disease on the diagnostic workup, and we performed a laparoscopy to remove the pelvic mass. We reviewed the literature on the electronic databases Medline, Embase, and Science Direct on articles published in English from 1990 to 2015. We identified 5 articles in which the surgical treatment was performed via a laparotomic approach. The present case is the first in the literature to report feasibility of laparoscopic treatment for this kind of pathology with a detailed description of the surgical technique.

Study Objective To create a classification of diaphragmatic endometriosis (DE) in order to better select the surgical treatment of endometriotic nodules, depending on their size and localization. Design All the patients treated for deep infiltrating endometriosis (DIE) with DE between January 2004 and December 2018 were retrospectively reviewed. All the patients underwent surgery by laparoscopic approach or video-assisted thoracoscopic surgery (VATS). Diaphragmatic lesions were classified in three groups according to size, shape and depth of muscular infiltration. Setting Department of Obstetrics & Gynecology, and Thoracic Surgery, IRCCS Sacro Cuore Don Calabria Hospital – Negrar (Verona), Italy. Patients or Participants 150 patients with DE were identified. Interventions 128 patients were treated by laparoscopy, 21 by VATS and 1 of them had VATS combined with laparoscopy. Measurements and Main Results Patients were divided into 3 groups, according to the proposed classification. The first group of 99 patients (66%) included those with superficial lesions ≤ 1 cm. These lesions were called ‘foci' and were treated by diathermocoagulation (DTC) or argon laser vaporization. The second group included 17 patients (11,3%) with lesions called ‘plaques', bigger than 1cm, bidimensional and caused thickening of the involved tissue, without deep infiltration of the muscular layer of the diaphragm. These lesions were usually removed by diaphragmatic stripping. In the last group, the lesions were called ‘nodules', they were larger than 10 mm, and with deep infiltration of the diaphragm These nodules were observed in 34 patients (22,6%) and were removed by laparoscopic excision with diaphragmatic resection or by VATS. Conclusion Diaphragmatic nodules can be easily classified in one of the proposed groups. Considering this classification, different methods of surgical treatments of DE can be chosen, in order to allow a total and safe removal of the lesions, with low complications rate and a significant improvement of patients' symptoms.

Study Objective to prospectively assess the effectiveness and safety of RadioFrequency Thermal Ablation (RFA) for uterine nodular adenomyosis Design all patients with nodular adenomyosis who desired to preserve the uterus and who were selected for RFA were included. Setting third-level Referral Center for Endometriosis Patients or Participants One hundred twenty women with symptomatic nodular adenomyosis, aged 24-51 years, were collected. Interventions All the procedures were carried out by laparoscopic access in order to perform a concomitant surgery for endometriosis (75% of the cases), if preoperatively detected. In order to evaluate the impact of the treatment on the intensity symptoms related to the presence of uterine adenomyosis, the intensity of uterine bleeding and pain during the follow-up was compared to the properative symptomatology, and the ten-point visual analog scale (VAS) was used for pain assessment. Patients were asked about any hormonal or surgical treatments performed during the follow-up period and pregnancies occurred after the radiofrequency thermal ablation. Measurements and Main Results The median number of nodular lesions treated per patient was 1 (range, 1-2). The median reduction in volume was 66%. Follow-up period ranged from 6 to 94 months. A significant progressive improvement in the symptoms score was observed at the follow-up. Conclusion In this study, laparoscopic RFA reduced uterine adenomyosis-related symptoms and volume, with significant improvement on quality of life in the treated patients.

In this review, we assessed the feasibility of total laparoscopic hysterectomy (TLH) in cases of very large uteri weighting more than 500 grams. We compared surgical outcomes and short term follow-up in 149 patients with the uterus weighing less than 350 g (group A: 40-350 g) and 100 patients with the uterus weighing more than 500 g (group B: 500-1550 g). We discovered no statistical difference between the 2 groups in terms of intraoperative complications (group A: 0%; group B: 2%) and postoperative stay (group A: 3.05 +/- 1.89 days; group B: 3.2 +/- 1.28 days). There were statistically significant differences between the 2 groups in terms of operative time (group A: 101.3 +/- 34.3 min; group B: 149.1 +/- 57.2 min.; p.0001) and postoperative hospital stay length (group A: 2.8 +/- 0.7 days; group B: 3.5 +/- 1.7 days; p.0001). No major complications occurred in either group. Postoperative minor complications were more frequent in group B (group A: 8.7%; group B: 18%; p = .03). Median time to well-being was comparable in both groups. In conclusion, TLH is a feasible surgical technique also in cases of very large uteri. An increase in operative time, intraoperative blood loss, hospital stay length, and postoperative minor complications can be expected as the uterine weight increases.

Study Objective: A strong association exists between adenomyosis and endometriosis and a common pathogenetic mecha- nism was proposed. The aim of this study was to evaluate whether and how the presence of concurrent adenomyosis can affect the outcome of laparoscopic excision of deep endometriosis. Design: Data were retrospectively collected from our computerized medical records (Canadian Task Force classification II-3). Setting: General hospital. Intervention: Restrospective evaluation. Patients: From January 2003 through July 2005, 40 consecutive patients affected by concomitant endometriosis and adeno- myosis were included in group A and another 40 affected by endometriosis only were included in group B. Measurements and Main Results: In group A, 20 women required bowel surgery (17 segmental and 3 full-thickness discoid resections) versus 16 patients in the other group (13 segmental bowel resections with end-to-end anastomosis and 3 discoid re- sections). Dysmenorrhea and dyspareunia after treatment improved (p ,.01) in both groups, whereas dyschezia improved only ingroupA.ThepersistenceofmenometrorrhagiawasmorefrequentingroupB(p ,.01).Duringfollow-up,patientsofgroupA underwent medical treatment for a longer time than those of group B (p ,.001). Clinical detection of endometriosis recurrence wasmorefrequentinpatientswithadenomyosis(p ,.01),whereasnodifferenceexistedintheincidenceoftherecurrencedetected byultrasound.Theoverallnumberofpregnanciesaftersurgerywassignificantlylowerinthegroupwithadenomyosis(p 5.03). Conclusion: Complete excision of deep endometriosis is not always feasible because of adenomyosis. For this reason, preop- erative imaging screening for adenomyosis could be included in the preoperative workup when extensive disease is clinically suspected. Journal of Minimally Invasive Gynecology (2008) 15, 566-570 2008 AAGL All rights reserved. Adenomyosis is a benign condition resulting from the presence of heterotopic endometrial glands and stroma in the myometrium with adjacent smooth-muscle hyperplasia. It is a common gynecologic disorder with prevalence up to 61.5% in women undergoing hysterectomy for benign pa- thology (1) and up to 90% in women with endometriosis (2). A strong association exists between adenomyosis and endometriosis (3); therefore, a common pathogenetic mecha- nism was proposed. Adenomyosis occurs mainly in premeno- pausal women, particularly in parous ones. The common symptoms are: menorrhagia (10%-12%), dysmenorrhea (10%-30%), metrorrhagia (10%-12%), dyspareunia, and dyschezia. Adenomyosis could represent an important factor ofsterilityinwomenwithendometriosis,probablybyimpair

STUDY OBJECTIVE: Adequate surgical treatment of severe deep endometriosis requires complete excision of all implants, but the modality of bowel resection is still debated. We describe the results of our experience as a tertiary care endometriosis referral center in complete laparoscopic management of deep pelvic endometriosis with bowel involvement. DESIGN: A prospective single-center study (Canadian Task Force classification II-1). SETTING: In Sacro Cuore General Hospital of Negrar, Italy. PATIENTS: One hundred ninety-two women treated with laparoscopic excision of deep endometriosis and segmental colorectal resections were evaluated. INTERVENTION: From January 2003 through December 2005 we registered all consecutive patients laparoscopically treated for deep endometriosis who also were having segmental bowel resection. MEASUREMENTS AND MAIN RESULTS: Data analysis included age, weight, body mass index, history of endometriosis, preoperative symptoms, parity, infertility, operative procedures, operating time, conversion, intraoperative and postoperative morbidity, recovery of bladder and bowel function, and discharge from hospital. We report our results in terms of feasibility and short-term morbidity. Radicality was achieved in 91.5% of patients. Laparoconversion occurred in 5 cases (2.6%). Major complications that required repeat operation occurred in 20 cases (10.4%): Nine anastomosis leakages (4.7%), 3 uroperitoneum (1.6%), 4 hemoperitoneum (2.1%), 1 pelvic abscess (0.5%), 1 bowel perforation, 1 intestinal obstruction, and 1 sepsis. Minor complications occurred in 50 patients (26%). CONCLUSION: Laparoscopic segmental colorectal resection for endometriosis is feasible and, in hospitals with necessary experience, can be proposed to selected patients who are informed of the risk of complications.