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Objective To compare oncological outcomes in women with lower uterine segment involvement (LUSI) in endometrial carcinoma (EC) stage ≥ II - staged by a minimally invasive surgery (MIS) versus laparotomy. Study design A retrospective multi-center cohort study. Univariate analysis, Kaplan-Meier survival and Cox proportional hazard analysis were performed to compare between women staged by MIS and those staged by laparotomy. Results Over a median follow-up period of 3 years (interquartile range, 1.5–6 years) 212 women were included, 68 (32.1%) were surgically staged by MIS. Stages of disease did not vary between MIS and laparotomy and were 32.1%, 51.9%, and 16.0%, in stages II, III and IV – respectively. Adjuvant radiation and chemotherapy rate did not differ between groups. Overall recurrence rate was comparable (p = 0.084). Locoregional recurrence rate was higher in the MIS group odds ratio 2.17, 95% confidence interval 1.19–4.20). Overall and progression free survival were similar in both groups (log rank test p = 0.08 and p = 0.912 respectively). In Cox regression model adjusting for age, comorbidities, tumor grade, stage and adjuvant therapy, route of surgery (MIS vs. laparotomy) was not associated with overall survival (p = 0.169). Conclusions In women with advanced EC and LUSI, although MIS is associated with locoregional recurrences, survival is comparable to laparotomy.

Objective To compare outcomes of symptomatic and asymptomatic women with endometrial cancer and a preoperative diagnosis of an endometrial polyp. Design An Israel Gynecologic Oncology Group multi-center retrospective cohort study. Methods Of 635 patients with endometrial cancer and a preoperative diagnosis of an endometrial polyp who underwent surgery between 2002 and 2014 in one of 11 centers in Israel were divided into two groups according to the presence of bleeding symptoms. Outcome measures included recurrence-free survival, disease-specific survival and overall survival. Survival data were plotted according to the method of Kaplan and Meier and compared using the log-rank test. Results There were 513 symptomatic and 122 asymptomatic women with endometrial cancer and a preoperative diagnosis of an endometrial polyp. The median follow-up was 52 months (range 12-120 months). There were no differences between patients who experienced bleeding and those who did not in 5-year recurrence-free survival (85.2 % vs. 85.7 %; p=0.83, respectively), disease-specific survival (88.2 % vs. 89.2 %; p=0.71, respectively), or overall survival (80.2% vs. 78.4 %; p=0.97, respectively). Conclusion The diagnosis of endometrial cancer in patients with asymptomatic endometrial polyps is not associated with improved outcomes as compared with patients with bleeding. In the absence of factors indicating a high risk of endometrial cancer, clinical and sonographic follow-up is the advised management strategy for these patients.

Study Objective Most cases of adnexal torsion in pregnancy are currently managed by laparoscopy, which may be associated with increased risks for spontaneous abortion and pre-term delivery. We sought to evaluate the obstetrical outcomes of these women with emphasis on their live birth rate and gestational age at delivery. Design Retrospective cohort study and telephone questionnaire. Setting University-affiliated Obstetrics and Gynecology department. Patients All pregnant women who underwent laparoscopy for adnexal torsion between 2007 and 2017. Their obstetrical outcomes were obtained by retrospective review of medical records and a telephone questionnaire. Interventions Laparoscopy for adnexal de-torsion, with or without cyst drainage or cystectomy. Measurements and Main Results The study cohort included 94 women. Most torsion cases (71, 75.5%) were diagnosed in the first trimester of pregnancy, while 21 (22.3%) were diagnosed in the second trimester, and 2 (2.1%) in the third trimester. Conception was achieved by in-vitro fertilization (IVF) or by ovulation induction (OI) in 45 (47.9%) cases. The information on pregnancy outcomes was available for 93 women. Of those, live birth was reported for 86 (92.5%) pregnancies while 6 (6.5%) women had a spontaneous abortion, and one woman experienced an intrauterine fetal death. Five cases of spontaneous abortion were diagnosed in the first trimester, all within 3 weeks of surgery. Pre-term delivery prior to 37 gestational weeks was reported for 18 (19.4%) pregnancies and was significantly associated with twin pregnancy (p=0.002) and with conception following IVF/OI (p=0.03). On logistic regression analysis, preterm delivery was only associated with twin versus singleton gestation (Odds Ratio=6.7, 95% Confidence Interval 1.3-34.8, p=0.02). Conclusion The obstetrical outcomes of pregnant women who underwent laparoscopy for adnexal torsion are generally favorable. However, there is a risk for preterm delivery which is primarily associated with multiple gestation.

Objectives Primary, to explore correlation between the extent of pelvic lymphadenectomy in the surgical staging of endometrial cancer and the number of nodes with metastasis. Secondary, evaluate survival measures in relation to the number of excised nodes. Methods A retrospective multi-center study of prospectively collected information of 2014 women with endometrial cancer, 1032 of whom underwent lymph node staging. Spearman's rank correlation was used to assess the correlation between the number of pelvic nodes excised and the number of metastatic nodes. Women's data were dichotomized by the median number of excised pelvic nodes. Kaplan-Meier and log rank tests were used to examine the effect of the number of pelvic nodes excised on survival. Results There was no significant correlation between the number of pelvic nodes harvested and the number of metastatic lymph nodes (r = 0.301; p = 0.28). The median number of excised pelvic nodes was 9 (range 1–77). There was no difference between women with up to 9 and women with more than 9 lymph nodes excised in the 5-year recurrence-free survival (82.4% vs. 83.9%; p = 0.90), disease-specific survival (83.6% vs. 86.7%; p = 0.37), or overall survival (75.8% vs. 82.8%; p = 0.11). Conclusions The extent of pelvic lymphadenectomy in the surgical staging of endometrial cancer is not associated with a higher yield of metastatic nodes or with longer survival. Current focus should be on sentinel node procedures that offer women the benefit of accurate staging without the complications associated with extensive lymphadenectomy.

Objective To investigate the rates of intrauterine adhesion following hysteroscopy for removal of RPOC associated with surgical termination of pregnancy. Methods We conducted a retrospective cohort study of all cases of removal by hysteroscopy of RPOC associated with surgical termination of pregnancy carried out at the Yitzhak Shamir (Assaf Harofe) Medical Center from January 2013 to December 2018. The rates of postoperative intrauterine adhesion were assessed by follow-up hysteroscopy. Results Our study involved 85 cases of removal by hysteroscopy of RPOC associated with surgical termination of pregnancy. The mean size of the RPOC was 1.9 ± 0.9 cm, and the mean time from termination of pregnancy to hysteroscopy was 1.5 ± 0.9 months. Two patients (2.4%) were readmitted for postoperative complications (fever). Postoperative follow-up information was available for 49 cases (57.6%). A total of 47 of these women had a normal uterine cavity (95.9%) while 2 women (4.1%) were diagnosed with mild intrauterine adhesions. Conclusions Hysteroscopy for removal of RPOC following surgical termination of pregnancy is associated with low rates of postoperative intrauterine adhesions. Additional studies may determine whether this is the procedure of choice in these cases.

Objective To compare survival measures of women with early-stage endometrial cancer who underwent either hysteroscopy or a non-hysteroscopic procedure as a diagnostic procedure. Study design An Israel Gynecologic Oncology Group multicenter study of 1324 patients with stage I endometrial cancer who underwent surgery between 2002 and 2014. Patients were divided into two groups: hysteroscopy and non-hysteroscopy (curettage or office endometrial biopsy). Clinical, pathological, and survival measures were compared between the groups. Results There were 355 patients in the hysteroscopy group and 969 patients in the non-hysteroscopy group. The median follow-up was 52 months (range 12–120 months). There were no differences between the groups in the 5-year recurrence-free survival (90.2% vs. 88.2%; p = 0.53), disease-specific survival (93.4% vs. 91.7%; p = 0.5), and overall survival (86.2% vs. 80.6%; p = 0.22). Conclusion Our findings affirm that hysteroscopy does not compromise the survival of patients with early-stage endometrial cancer.

Women with cervical cancer who undergo radical hysterectomy are often treated postoperatively with chemoradiation. Patient selection that minimizes adjuvant treatment is valuable. We compared two methods for predicting postoperative adjuvant treatment of women with tumor size ≥2 cm and4 cm.This multicenter retrospective study included 272 women with tumor size ≥2 cm and4 cm. A receiver operating characteristic curve (ROC) analysis was used to determine the optimal tumor cutoff size to predict adjuvant treatment. A second analysis compared the rate of adjuvant treatment between women with and without lymph vascular space involvement (LVSI).According to the ROC, the optimal cutoff value of tumor size for predicting adjuvant treatment was 2.95 cm (sensitivity 0.70, specificity 0.67). Tumors were ≥3.0 cm in 166 (61.0%) women. The rate of adjuvant treatment was higher in women with larger tumor diameter (73.8% vs. 47.9%, p 0.0001). Of the 241 women with a LVSI record, LVSI was present in 81 (34%) women. Among women with LVSI, rates were higher of positive lymph nodes (41.0% vs 14.5%, p 0.0001) and postoperative adjuvant treatment (83.3% vs. 53.7%, p 0.001). Among women with tumor size ≥3.0 cm and LVSI, the rate of adjuvant treatment was 90.0%. In the multivariate analysis, both tumor size ≥3.0 cm and the presence of LVSI were independently associated with adjuvant treatment (OR 3.9, 95% CI 2.1-7.1; p 0.0001 and OR 4.9, 95% CI 2.4-10.0; p 0.0001, respectively).In women with cervical cancer who underwent radical hysterectomy, tumors ≥3 cm were associated with a70% rate of adjuvant treatment, and LVSI was associated with a80% rate. These data should be weighed in multidisciplinary consultation with radiation oncologists when deciding treatment strategy.

To compare the rates of post-operative radiotherapy between two methods of lymph nodes assessment during surgical staging for endometrial cancer (EC).We conducted a comparative study of all consecutive women with endometrial cancer who underwent sentinel lymph node detection and biopsy using blue dye and isotope scan (SLNB) at Kaplan Medical Center and patients from the IGOG database, who underwent staging lymphadenectomy (PLND). The primary outcome was the rate of adjuvant and therapeutic radiation. The secondary outcome was a comparison of disease-free survival (DFS) and overall survival (OS).There were 138 patients in the SLNB group and 1022 women in the PLND group. The detection rate of SLN was 74% for unilateral detection and 54% for bilateral detection. In the PLND group 57% were high risk patients vs. 47% in SLNB group (p = 0.03). 43% of high-risk patients in the PLND group received adjuvant or therapeutic pelvic radiation vs. 28% of high-risk women in the SLNB arm (p = 0.017). No statistically significant difference in recurrence rates nor in death rates had been observed in the high-risk group patients. The 5-years survival in the high-risk PLND group was 80% and the recurrence rate was 19% vs. 75% 5-year survival and 14% recurrence in high-risk SLNB cohort, log-rank p = 0.82 for survival and long-rank p = 0.25 for recurrence.Endometrial cancer patients undergoing lymph node assessment by sentinel lymph node biopsy, receive less pelvic radiotherapy.

Study Objective To compare oncological outcomes of women with stage II -IIIc endometrial cancer (EC) who underwent minimally invasive surgery (MIS) versus laparotomy. Design A retrospective cohort study. Setting Academic multi-center. Patients or Participants Consecutive women with EC treated at 11 Israeli institutions between 2002 and 2017 were recorded in an assimilated database with a median follow-up of 52 months (range 12-120 months). Women with stage II -IIIc were stratified into groups by intentional route of surgery; MIS vs. laparotomy. Clinical, pathological and outcome data were compared. Interventions MIS and laparotomy. Measurements and Main Results Three hundred and four women met criteria: 200 underwent laparotomy and 104 MIS. Women in the MIS group were younger, had lower rate of diabetes and lower CA-125 level. Women who underwent laparotomy had higher grade EC and more advanced stage disease; Odds Ratio (OR) and 95% Confidence Interval (CI) 0.34 (0.21-0.56) and 0.56 (0.34-0.92), respectively. Brachytherapy rate was comparable between groups (p=0.715). In a multivariable analysis, including age, comorbidities, disease stage, tumor grade and lymph-vascular space invasion, MIS was not associated with an increased risk for recurrence, progression or decreased overall survival. However, patients operated by MIS had higher risk to recur locally (vaginal cuff or pelvic) (26.9% vs. 16.5%, p=0.032, OR, 1.86, 95% CI 1.05-3.30). MIS was the only independent factor associated with local recurrence, adjusted OR, 2.09, 95% CI 1.12-3.90. Conclusion In women with stage II-IIIc EC, MIS was associated with an increased risk for local recurrence compared to laparotomy.

Objectives Data on the outcome of stage IIA1 cervical cancer is limited, as these tumors comprise a small percentage of early tumors. NCCN guidelines suggest consideration of surgical management for small tumors with vaginal involvement. Our objective was to evaluate the risk of adjuvant radiotherapy in stage IIA1 cervical cancer and its associated features, in order to improve selection of patients for surgical management. Methods A retrospective cohort study comparing surgically treated cervical cancer patients with stage IB1 and stage IIA1 disease. Women treated between 2000 and 2015 in ten Israeli medical centers were included. Patient and disease features were compared between stages. The relative risk (Fisher's exact test) of receiving post-operative radiation was calculated and compared for each risk factor. A general linear model (GLM) was used for multivariable analysis. Results 199 patients were included, of whom 21 had stage IIA1 disease. Most features were comparable for stage IB1 and stage IIA1 disease, although patients with vaginal involvement were more likely to have close surgical margins (23.8% vs 8.5%, p = 0.03). Patients with stage IIA1 disease were more likely to receive radiation after surgery (76% vs. 46%, RR = 1.65 (1.24–2.2), p = 0.011). Vaginal involvement as well as depth of stromal invasion, LVSI and lymph node metastases were independent predictors of radiation on multivariable general linear modeling. Conclusions Cervical cancer patients with vaginal involvement are highly more likely to require postoperative radiation. We recommend careful evaluation of these patients before surgical management is offered.

Study Objective To compare oncological outcomes of women with high-grade endometrial carcinoma (HGEC) who underwent surgery by minimally invasive surgery (MIS) versus laparotomy. Design A retrospective cohort study. Setting Academic multi-center. Patients or Participants Consecutive women with HGEC cancer treated at 11 Israeli institutions between 2002 and 2017 were accrued in an assimilated database with a median follow-up of 52 months (range 12-120 months). Women with HGEC were stratified into two groups by route of surgery; MIS vs. laparotomy by an intention to treat. Clinical, pathological and outcome data were compared. Interventions MIS and laparotomy. Measurements and Main Results Six hundred and seventy-eight women met the inclusion criteria: 160 underwent MIS and 518 laparotomy. The two groups were comparable in demographic and clinical characteristics. Local recurrence was more common in the MIS group, Odds Ratio (OR) 95% Confidence Interval (CI) 2.80 (1.80-4.36). Disease progression rates were comparable (p=0.537). In a multivariable analysis, including age, comorbidities, disease stage, CA-125 and lymph-vascular space invasion, MIS was not associated with an increased risk for either overall recurrence rate, disease progression, or overall survival. Independent risk factors for local recurrence were diabetes, stage III-IV, LVSI and MIS, adjusted OR 95% CI 3.30 (1.69-6.48). Conclusion In women with HGEC, MIS is associated with higher rates of local recurrence as compared to laparotomy.

Objective The objective was to identify the prevalence of and variables associated with unintended pregnancy among young, unmarried women serving in the Israeli military. Study design We performed a retrospective cohort study of unmarried women drafted by the Israeli military between 2013 and 2015 at the age of 18 years. We used multivariable logistic regression to examine associations between unintended pregnancy and women's education, IQ, immigration status, country of origin, neighborhood socioeconomic status and history of psychiatric illness. Results Most women ( n =127,262) did not become pregnant while serving in the Israeli military. Unintended pregnancy was reported by 2365, with an additional 6 women reporting pregnancy resulting from sexual assault and 5 an intended pregnancy. Annual rates of unintended pregnancy among young women serving in the Israeli military declined from 1.69% in 2013 to 1.56% in 2014 and 1.33% in 2015. In multivariable models, unintended pregnancy was more common among women soldiers who had not graduated from high school (adjusted relative risk [RR], 5.3; 95% confidence interval [CI], 4.69–6.04) and those who were first-generation immigrants (adjusted RR, 2.1; 95% CI, 1.90–2.35). Conclusion Unintended pregnancy is rare among women serving into the Israeli military. Implications Increasing contraceptive use among women who have not graduated from high school may further reduce rates of unintended pregnancy among women serving in the Israeli military.

Study Objective To evaluate the safety and effectiveness of Oxiplex/AP gel (Intercoat) in reducing intrauterine adhesion formation after hysteroscopic treatment because of retained products of conception (RPOC). Design Prospective double-blind, randomized, controlled pilot study (Canadian Task Force classification I). Setting Tertiary medical center. Patients All women who underwent hysteroscopic treatment because of RPOC at our institution between September 2009 and June 2012 were invited to participate. After operative hysteroscopy, participants were randomized to either have their uterine cavity filled with Oxiplex/AP gel (study group, n = 26) or not (control group, n = 26). Interventions Diagnostic office hysteroscopy to assess for adhesion formation was performed after 6 to 8 weeks. Findings were graded according to the American Fertility Society classification. Rates of subsequent pregnancy in the 2 groups were assessed. Measurements and Main Results Intraoperative complication rates were similar between the 2 groups. There were no postoperative complications after Oxiplex/AP gel application. Moderate to severe adhesions developed in 1 woman (4%) in the study group and 3 (14%) in the control group (p = .80). During follow-up of 20 months (range, 2–33 months), 7 women (27%) in the treatment group conceived, compared with 3 (14%) in the control group (p = .50). Conclusion Intrauterine application of Oxiplex/AP gel after hysteroscopic removal of RPOC is safe. In this small sample, the difference in the rate of intrauterine adhesions was not statistically significant. A larger study would enable further establishment of the safety and efficacy of use of this gel.

Incidental ultrasonographic findings in asymptomatic postmenopausal women, such as thickened endometrium or polyps, often lead to invasive procedures and to the occasional diagnosis of endometrial cancer. Data supporting a survival advantage of endometrial cancer diagnosed prior to the onset of postmenopausal bleeding are lacking.To compare the survival of asymptomatic and bleeding postmenopausal patients diagnosed with endometrial cancer.This was an Israeli Gynecology Oncology Group retrospective multicenter study of 1607 postmenopausal patients with endometrial cancer: 233 asymptomatic patients and 1374 presenting with postmenopausal bleeding. Clinical, pathological, and survival measures were compared.There was no significant difference between the asymptomatic and the postmenopausal bleeding groups in the proportion of patients in stage II-IV (23.5% vs 23.8%; P = .9) or in high-grade histology (41.0% vs 38.4%; P = .12). Among patients with stage-I tumors, asymptomatic patients had a greater proportion than postmenopausal bleeding patients of stage IA (82.1% vs 66.2%; P.01) and a smaller proportion received adjuvant postoperative radiotherapy (30.5% vs 40.6%; P = .02). There was no difference between asymptomatic and postmenopausal bleeding patients in the 5-year recurrence-free survival (79.1% vs 79.4%; P = .85), disease-specific survival (83.2% vs 82.2%; P = .57), or overall survival (79.7% vs 76.8%; P = .37).Endometrial cancer diagnosed in asymptomatic postmenopausal women is not associated with higher survival rates. Operative hysteroscopy/curettage procedures in asymptomatic patients with ultrasonographically diagnosed endometrial polyps or thick endometrium are rarely indicated. It is reasonable to reserve these procedures for patients whose ultrasonographic findings demonstrate significant change over time.

Objective To describe the option of ultrasonographic-guided percutaneous transabdominal puncture for ovum pickup in a rare case of Rokitansky syndrome with subcostal located ovaries and a right single kidney. Design Technique and instrumentation. Setting A university-based hospital IVF and Reproductive Medicine Unit. Patient(s) A woman with congenital agenesis of the uterus in a surrogate gestation program. Intervention(s) Ultrasonographic-guided percutaneous transabdominal puncture for oocyte retrieval. Main Outcome Measure(s) Number of oocytes retrieved and fertilized. Result(s) Oocyte retrieval was feasible in four treatment cycles with subsequent embryo transfer to the surrogate mother. Conclusion(s) Ultrasonographic-guided percutaneous transabdominal oocyte collection is a feasible and efficacious procedure for IVF in a case of Rokitansky syndrome with elevated subcostal ovaries and a single kidney.

Background Accessory fallopian tube is a rare anatomical variation, which might rarely cause gynecological complications such as infertility, ectopic pregnancy, cystic swelling, and pyosalpinx. It is usually diagnosed by surgeons during diagnostic laparoscopy for other purposes. We present a rare case of isolated accessory tube torsion in a young adolescent. Case A 16-year-old virgin teen presented with a 24-hour history of aggravating right lower-quadrant abdominal pain and nausea without vomiting or fever. On examination she had right lower quadrant abdominal tenderness with no peritoneal signs. On pelvic ultrasound a right corpus luteum cyst was suspected, but right adnexal torsion could not be ruled out. On laparoscopy, torsion of the right accessory tube was diagnosed. Because of its ischemic and bluish appearance it was removed. The postoperative course was uneventful. Pathology confirmed the diagnosis. Summary and Conclusion Torsion of an accessory fallopian tube is rare. An English literature search showed that the current case is the third reported overall and the first in a young adolescent. Because of the rarity of this congenital variation, and the low suspicion index for its existence, the diagnosis of accessory tube is often missed. Preventive removal of such findings should be considered but weighed against its possible surgical complications.

Objective To present four cases of twin tubal pregnancies and discuss possible etiologies. Twin tubal pregnancies are a rare event, with incidence rates estimated as 1 out of 725–1,580 of tubal pregnancies. Design Case series. Setting Department of obstetrics and gynecology at a tertiary health care facility. Patient(s) All women with twin tubal pregnancy diagnosed and treated in the department during the years 2007–2009, according to electronic files and histologic reports. Intervention(s) None. Main Outcome Measure(s) Artificial reproductive technique preceding twin tubal pregnancies Result(s) We diagnosed four twin pregnancies of 163 tubal pregnancies, an incidence of 2.4%. Of the four cases, two conceived after gonadotropin stimulation and intrauterine insemination. The third conceived following in vitro fertilization and intracytoplasmic sperm injection. The fourth was a spontaneous conception diagnosed as monochorial monoamniotic twin tubal pregnancy. Conclusion(s) Twin tubal pregnancies may not be as rare as previously thought. Three of the four cases indentified during a 2-year period followed artificial reproductive technique. We hope that this report will promote the study of the epidemiology of this event, improve diagnosis, and encourage the development of treatment modalities.