Search

Objectives: Endometrial cancer is the most common gynecologic malignancy in developed countries. The overall risk of recurrence is associated with traditional risk factors., Methods: Machine learning was used to predict recurrence among women who were diagnosed and treated for endometrial cancer between 2002 and 2012 at elven university-affiliated centers. The median follow-up time was 5 years. The following data were retrieved from the medical records and fed into the algorithm: age, chronic metabolic diseases, family and personal cancer history, hormone replacement therapy use, endometrial thickness, uterine polyp presence, complete blood count results, albumin, Ca-125 level, surgical staging, histology, depth of myometrial invasion, LVSI, grade, pelvic washing cytology, and adjuvant treatment. We used XGBoost algorithm, which fits the training data using decision trees, and can also rate the factors according to their influence on the prediction., Results: 1935 women were identified of whom 325 had recurrent disease. On the randomly picked samples, the specificity was 55% and the sensitivity was 98%. Our model showed an operating characteristic curve with AUC of 0.84., Conclusions: A machine learning algorithm presented promising ability to predict recurrence of endometrial cancer. The algorithm provides an opportunity to identify at-risk patients who may benefit from adjuvant therapy, tighter surveillance, and early intervention., Competing Interests: Declaration of Competing Interest The authors whose names are listed in the first page,certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript., (Copyright © 2022. Published by Elsevier Masson SAS.)

Objective: 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 and <4 cm., Study Design: This multicenter retrospective study included 272 women with tumor size ≥2 cm and <4 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)., Results: 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)., Conclusion: In women with cervical cancer who underwent radical hysterectomy, tumors ≥3 cm were associated with a >70% rate of adjuvant treatment, and LVSI was associated with a >80% rate. These data should be weighed in multidisciplinary consultation with radiation oncologists when deciding treatment strategy., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objective: To compare the rates of post-operative radiotherapy between two methods of lymph nodes assessment during surgical staging for endometrial cancer (EC)., Methods: 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)., Results: 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., Conclusion: Endometrial cancer patients undergoing lymph node assessment by sentinel lymph node biopsy, receive less pelvic radiotherapy., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors. Published by Elsevier Inc.)

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., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: Endometrial cancer prognosis is related to stage, histology, myometrial invasion, and lymphovascular space invasion. Several studies have examined the association between pretreatment thrombocytosis and patient outcomes with contrasting results regarding prognosis. Our aim was to evaluate the association of pretreatment platelet count with outcomes in endometrial cancer patients., Methods: This is an Israeli Gynecologic Oncology Group multicenter retrospective cohort study of consecutive patients with endometrial cancer, who underwent surgery between January 2002 and December 2014. Patients were grouped as low risk (endometrioid G1-G2 and villoglandular) and high risk (endometrioid G3, uterine serous papillary carcinoma, clear cell carcinoma, and carcinosarcoma). Those with stage I disease were compared with stages II-IV. Disease stages were reviewed and updated to reflect International Federation of Gynecology and Obstetrics (FIGO) 2009 staging. All patients underwent pelvic washings for cytology and total abdominal or laparoscopic hysterectomy with bilateral salpingo-oophorectomy. Pelvic lymph node assessment was performed in patients with tumors of moderate-high risk histology or deep myometrial invasion. Para-aortic sampling was performed at the surgeon's discretion. Patients were categorized by pretreatment platelet count into two groups: ≤400×10 9 /L and >400×10 9 /L (defined as thrombocytosis). Clinical and pathological features were compared using Student t-test, χ 2 or Fisher's exact test. Survival measures were plotted with the Kaplan-Meier method and compared using the log-rank test. A Cox proportional hazards model was used for multivariable comparison of associations., Results: Of the 1482 patients included, most had stage I disease (961; 74.8%) and most had endometrioid histology (927; 64.1%). A total of 1392 patients (94%) had pretreatment platelet counts ≤400×10 9 /L and 90 (6%) had pretreatment thrombocytosis. Patients with thrombocytosis had a significantly higher rate of high-grade malignancy, advanced stage, lymphovascular space invasion, low uterine segment involvement, and lymph node metastases. They also had shorter 5 year disease-free survival (65% vs 80%, p=0.003), disease-specific survival (63% vs 83%, p<0.05) and overall survival (59% vs 77%, p<0.05). On multivariate analysis, an elevated pretreatment thrombocyte count remained a significant independent predictor for disease-specific survival and overall survival., Conclusions: Pretreatment thrombocytosis is an independent prognostic factor for decreased disease-specific survival and overall survival among patients with endometrial cancer, and can serve as a predictor of poor outcome., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: Ectopic pregnancy implantation on the tubal stump after salpingectomy is a rare location for extrauterine pregnancy, whose pathogenesis is still unknown. The purpose of this study was to examine whether the time interval elapsed from salpingectomy may predispose the embryo to implantation on the tubal stump in the next pregnancy subsequent to tube removal., Methods: Nine women operated for stump pregnancy (study group) between 2008 and 2019 were retrospectively identified. For each case in the study group, 12 consecutive cases that underwent laparoscopic salpingectomy constituted the control group. A sample size of 100 control patients was calculated to achieve statistical power (97.8%) and an α of 0.05. The control groups were triple-matched with the study group for patients' age, indications for salpingectomy (tubal pregnancy or hydrosalpinx prior to in vitro fertilization treatment) and mode of conception of the subsequent pregnancy following salpingectomy., Results: Nine women underwent surgery for stump pregnancy during the study period. All women had a surgical history of laparoscopic salpingectomy. The time interval from prior salpingectomy to subsequent pregnancy was significantly shorter in study group than in the control group (4.3 ± 2.1 months vs. 15.6 ± 13.7 months, respectively, p = 0.016)., Conclusion: A possible association between the short time interval from prior salpingectomy to ectopic implantation on the tubal stump in the subsequent pregnancy was found. The clinical implications of these findings and in particular whether patients should be advised to wait at least 4 months from the salpingectomy to the subsequent pregnancy remain unclear., (© 2021 Japan Society of Obstetrics and Gynecology.)

Study Objective: To describe the incidence of ovarian dermoid cysts associated with paraneoplastic encephalitis syndrome due to N-methyl-D-aspartic acid (NMDA) receptor antibodies among women undergoing surgical resection of dermoid cysts., Design: Retrospective cohort study., Setting: University-affiliated department of obstetrics and gynecology., Patients: All patients with pathology-proven ovarian dermoid cysts who underwent surgical resection in our department between January 2008 and December 2019. Their demographic, clinical, and surgical characteristics are described, with emphasis on cases diagnosed with anti-NMDA receptor encephalitis., Interventions: Ovarian dermoid cyst resection by cystectomy or salpingo-oophorectomy., Measurements and Main Results: A total of 233 patients were operated on for ovarian dermoid cysts, comprising 2 cases diagnosed with anti-NMDA receptor encephalitis (0.85%). Among the women without NMDA receptor encephalitis, the mean age was 33.3 ± 14.9 years, 84.0% were of reproductive age, 5.2% were premenarchal, and 10.8% were menopausal. The mean diameter of the dermoid cyst in this group was 77.3 ± 33.3-mm. The 2 patients diagnosed with anti-NMDA receptor encephalitis were 21 years old and 42 years old. The diameters of their dermoid cysts were 15-mm and 80-mm, respectively. The patients with anti-NMDA receptor encephalitis were managed with laparoscopic resection, plasmapheresis, intravenous immunoglobulins, and corticosteroids; 1 patient also received immunosuppressive treatment. Both recovered without significant neurologic sequela., Conclusion: Paraneoplastic syndrome due to NMDA receptor antibodies is a rare complication of dermoid cysts. This complication may occur in younger or older women, as well as in small- or large-diameter cysts. Thus, a high index of suspicion is required to correctly diagnose and treat women presenting with neurologic symptoms in the presence of dermoid cysts., (Copyright © 2020. Published by Elsevier Inc.)

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., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: We aimed to assess the association of pre-operatively evaluated ultrasonographic endometrial thickness with outcomes of patients with endometrial cancer., Methods: An Israel Gynecologic Oncology Group multicenter retrospective cohort study of consecutive patients with endometrial cancer who underwent surgery between 2002 and 2014 in one of eleven academic centers. Patients were categorized by endometrial thickness into two groups: ≤20 mm and >20 mm. Clinical and pathological features were compared using Student T-test for continuous variables and Chi-square or Fisher's exact test for categorical variables. Survival measures were plotted with the Kaplan-Meier method and compared using the log-rank test. A Cox proportional hazards model was used for multivariable comparison of associations., Results: 1113 patients in whom endometrial thickness data was recorded were the subject of this study and included 2 groups: ≤20 mm (n = 930), >20 mm (n = 183). The median follow-up was 52 months (range 12-120 months). Patients with endometrial thickness >20 mm had significantly lower recurrence-free survival (log rank, p < .0001), disease-specific survival (log rank, p = .01), and overall survival (log rank, p < .0001). On multivariate Cox proportional hazards analysis, endometrial thickness >20 mm remained independently associated with an increased hazard of recurrence and death (HR = 1.77, 95% CI 1.07-2.96, p = .03 for recurrence; and HR = 1.68; 95% CI 1.07-2.65; p = .03 for overall survival)., Conclusion: In patients with endometrial cancer, endometrial thickness>20 mm as measured preoperatively by ultrasound, is independently associated with decreased recurrence-free and overall survival. This finding suggests that thick endometrium may be considered as one of the risk factors for poor prognosis., Competing Interests: Declaration of competing interest The authors report no conflicts of interest., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Objective: During the 2020 COVID-19 pandemic there was a decrease in emergency room arrivals. There is limited evidence about the effect of this change in behavior on women's health. We aimed to evaluate the impact of the COVID-19 pandemic on the diagnosis, treatment and complications of women presenting with a tubal Ectopic Pregnancy (EP)., Study Design: This is a single centre retrospective cohort study. We compared the clinical presentation, treatment modalities and complications of all women presenting in our institution with a tubal EP during the COVID-19 pandemic between 15 March and 15 June 2020, with women who were treated in our institution with the same diagnosis in the corresponding period for the years 2018-2019., Results: The study group included 19 cases of EP (N = 19) that were treated between the 15 March 2020 and 15 June 2020. The control group included 30 cases of EP (N = 30) that were admitted to in the corresponding period during 2018 and 2019. Maternal age, parity, gravity and mode of conception (natural vs. assisted) were similar between the two groups. There was no difference in the mean gestational age (GA) according to the last menstrual period. In the study group more women presented with sonographic evaluation of high fluid volume in the abdomen than in the control group (53 % vs 17 %, P value 0.01). This finding is correlated with a more advanced disease status. In the study group there was a highly statistically significant 3-fold increase in rupture among cases (P < 0.005) and a 4-fold larger volume of blood in the entrance to the abdomen (P < 0.002). We found that there were no cases of ruptured EP in the group of women who were pregnant after assisted reproduction., Conclusion: We found a higher rate of ruptured ectopic pregnancies in our institution during the COVID-19 pandemic. Health care providers should be alerted to this collateral damage in the non-infected population during the COVID-19 pandemic., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Second-trimester and early third-trimester uterine rupture in a nonlaboring woman is a very rare and life-threatening condition for both mothers and newborns. We aimed to present clinical characteristics, prenatal findings, and maternal and neonatal outcomes following second-trimester and early third-trimester spontaneous antepartum uterine rupture in our institute., Method: The medical records of all women with full-thickness second-trimester and early third-trimester uterine rupture treated in our department from 1988 to 2019 were retrieved from the institutional database and reviewed. Small uterine defects, incomplete ruptures, and silent uterine incision dehiscence were excluded., Results: From 1988 to 2019, 213 665 deliveries were recorded in our institute. Of these, 12 patients experienced second-trimester or early third-trimester spontaneous uterine rupture. Obstetric history revealed that 50% of the women in each period had undergone previous classical uterine incisions and 50% had a short interpregnancy (IP) interval. The mean age at diagnosis of uterine rupture was 26.3 ± 5.1 weeks. The ruptures were associated with abnormal placentation in 10 cases (83.3%): placenta previa (n = 7); and placenta previa and percreta (n = 3). No maternal mortality occurred. Seven of the 10 (70%) viable newborns survived., Conclusions: The increasing rates of cesarean births (CB) may lead to iatrogenic complications including midgestational prelabor spontaneous uterine rupture, an obstetric emergency, which is hard to diagnose. Maternal and neonatal outcomes can be optimized by a greater awareness of the risk factors, recognition of clinical signs and symptoms, and the availability of ultrasound to assist in establishing a diagnosis to enable prompt surgical intervention., (© 2020 Wiley Periodicals LLC.)

Introduction: Advanced age is considered an adverse factor in endometrial cancers but may be a surrogate for other conditions that impact outcomes. The study objective was to assess the association of age with endometrial cancer features, treatment and prognosis., Material and Methods: In this multicenter cohort study, consecutive women with endometrial cancer treated at 10 Israeli institutions between 2000 and 2014 were accrued in an assimilated database. Postmenopausal women were stratified into age groups with a cut-off of 80. Clinical, pathological and treatment data were compared using t test or Mann-Whitney test for continuous variables, and Chi-square Test or Fisher's Exact test for categorical variables. Main outcome measures included disease recurrence and disease-specific and overall survival; these were plotted using the Kaplan-Meier method and compared using the log-rank test. The association between age and recurrence and survival, adjusted for other clinical and pathological factors, was assessed using multivariable Cox regression modeling., Results: A total of 1764 postmenopausal women with endometrial cancer were identified. Adverse pathological features were more prevalent in older women, including high-risk histologies (35% vs 27%, P = .025), deep myoinvasion (44% vs 29%, P = .001) and lymphovascular involvement (22% vs 15%, P = .024). Surgical staging was performed less frequently among older women (33% vs 56%; P < .001). Chemotherapy was less often prescribed, even for non-endometrioid histologies (72% vs 45%; P < .001). On multivariable analysis, age remained a significant predictor for recurrence (HR = 1.75, P = .007), death of disease (HR = 1.89, P = .003) and death (HR = 2.4, P < .001)., Conclusions: Older age in women with endometrial cancer is associated with more adverse disease features, limited surgery and adjuvant treatment, and worse outcomes. On multivariable analysis, age remains an independent prognosticator in this population., (© 2020 Nordic Federation of Societies of Obstetrics and Gynecology (NFOG). Published by John Wiley & Sons Ltd.)

Objectives: This work is aimed to summarize the first year of the high-risk human papillomavirus (hrHPV) screening test and compare it to the cytology screening test, regarding positivity rates and premalignant lesions diagnosed in the Israeli population. A specific consideration is for the age group 25-30 that is not considered mandatory for the HPV primary screening testing., Methods: A retrospective study was performed in women who were screened for prevention of cervical cancer in Maccabi HealthCare HMO from March 2017 to March 2019. Screening methods included hrHPV typing for types 16, 18, and the other 12 hrHPV types and the PAP LBC test., Results: A total of 115,807 cervical samples were tested for HPV presence and 91% (105,225) were found negative for hrHPV. The other 9% (10,582) were positive for one or more of the 14 hrHPV types tested, and 37% (3,916) of them showed abnormal PAP LBC results. In the age group of 25-30, 3,104 (17.5%) women were found positive for hr-HPV (825 had hrHPV types 16 and/or 18), of which 42% (1,293) of them showed abnormal PAP LBC results. During the hrHPV versus PAP LBC screening era, 258 more women were diagnosed with precancerous cervical lesions (CIN2/3), 70% increased detection versus cytology screening., Conclusions: The hrHPV screening test is currently the best method for the detection of precancerous cervical lesions and cervical cancer, and it is better started at age 25., (© 2021 S. Karger AG, Basel.)

Background: Adnexal torsion in pregnancy is often associated with functional adnexal cysts, especially in pregnancies conceived by ovulation induction (OI) or in-vitro fertilization (IVF). During laparoscopy for adnexal de-torsion, drainage of the functional cysts can be attempted, although this procedure may cause bleeding., Objectives: To investigate the characteristics of ovarian torsion in pregnancy associated with functional cysts and to compare the rate of torsion recurrence following de-torsion alone versus cyst drainage., Methods: All cases of surgically diagnosed adnexal torsion occurring during pregnancy between January 2007 and April 2019 in our department were retrospectively analyzed. The cases of torsion associated with presumed functional ovarian cysts were selected. The rate of recurrent torsion during the same pregnancy was compared for de-torsion alone versus de-torsion and cyst aspiration., Results: Of the 113 women who experienced adnexal torsion during pregnancy, 71 (67.0%) of torsion cases were caused by presumed functional ovarian cysts. Among women with torsion of functional ovarian cysts, the rate of torsion recurrence was significantly higher in patients who underwent de-torsion alone (n=28) compared to women who underwent aspiration and drainage of the ovarian cysts (n=43) (14.3% vs. 0, P = 0.021). There were no cases of intra- or post-operative bleeding in the study cohort., Conclusions: Functional ovarian cysts are the most common adnexal pathology encountered in pregnant women with torsion. Intra-operative cyst aspiration and drainage may reduce the risk of recurrent torsion. Further multi-center studies are required to validate our data prospectively.

Background: This retrospective study compared perioperative measures, costs, quality of life and survival after open vs. robotic surgery, among obese women diagnosed with low-grade endometrial cancer., Methods: Obese women (body mass index (BMI) ≥ 30) who underwent open or robotic surgery for endometrial cancer, in one of two tertiary medical centers in the center of Israel, 2013-2016, postoperative grade 1-2, were included. Costs per patient, including 30-days post-surgery were calculated. Quality of life was evaluated by Physical and Mental Components of the SF-36 and a recovery from surgery questionnaire. Overall survival outcomes were obtained from patients' files. Surgical outcomes, including operating and anesthesia times, length of hospital stay, and intraoperative and postoperative complications according to the Clavien-Dindo classification scale were reviewed., Results: In all, 138 women with BMI ≥30 underwent open (n = 61) or robotic surgery (n = 77) during the study period. The groups had similar BMI, comorbidities, demographics and tumor characteristics. Robotic surgery was associated with shorter hospital stays (mean 1.7 vs. 4.8 days; P < .0001) and fewer postoperative complications (Clavien-Dindo > 2, 5.2% vs. 19.7%; P = .0008), but longer operating theater time (3.8 vs. 2.8 h; P < .001). Costs are equivalent when at least 350 robotic surgeries are performed annually, not including the initial system costs. Quality of life measures were better after robotic surgery. SF-36 showed better measures for robotic surgery (Physical 56 vs. 39 and Mental 73 vs. 56; P < .01). After robotic surgery, patients tended to recover quicker when compared to open surgery, as they returned to normal activities earlier, with less need for family and governmental assistance (mean recovery time, 23 vs. 70 days; P < 0.006 and mean change in preoperative total functioning score, - 1.5 vs. -3.9: P < 0.05, respectively). Overall, 5-year survival was 89.8% for the open surgery group vs. 94% for the robotic surgery group (log rank, P = 0.330)., Conclusions: Obese women with low-grade endometrial cancer had better quality of life after robotic vs. open surgery. They also had shorter hospital stays and fewer postoperative complications. Centers with high volumes of robotic surgery can achieve similar costs when comparing both methods. These results were achieved without jeopardizing survival. Our results further emphasize the need for the Israeli healthcare system to include specific reimbursement for robotic procedures in the population we studied.

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., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

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 preterm delivery. We sought to evaluate the obstetric 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 obstetric outcomes were obtained by retrospective review of medical records and a telephone questionnaire., Interventions: Laparoscopy for adnexal detorsion, 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, whereas 21 (22.3%) cases and 2 (2.1%) cases were diagnosed in the second and third trimesters, respectively. Conception was achieved by in vitro fertilization or by ovulation induction 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 1 woman experienced an intrauterine fetal death. Five cases of spontaneous abortion were diagnosed in the first trimester, all within 3 weeks of surgery. Preterm delivery before 37 gestational weeks was reported for 18 (19.4%) pregnancies and was significantly associated with twin pregnancy (p = .002) and with conception following in vitro fertilization and ovulation induction (p = .03). On logistic regression analysis, preterm delivery was only associated with twin vs singleton gestation (odds ratio, 6.7; 95% confidence interval, 1.3-34.8; p = .02)., Conclusion: The obstetric 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 gestations., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective: Dermoid cysts (benign mature cystic teratoma) are a relatively common cause of adnexal torsion. We aimed to identify the clinical and surgical characteristics associated with adnexal torsion involving dermoid cysts., Study Design: Retrospective review of all cases of ovarian dermoid cysts (as diagnosed by pathology evaluation) operated in our department between 2008-2019. We collected information on demographic characteristics, clinical presentation, and surgical findings and compared those parameters among women with and without adnexal torsion., Results: The study cohort included 231 patients who were operated for ovarian dermoid cysts. Of these, the surgery was performed urgently for suspected adnexal torsion in 77 (33.3%) cases, while adnexal torsion was surgically diagnosed in 51 (22.1%) cases. Diagnosis of torsion was significantly associated with younger mean age (28.8 ± 14.4 years in torsion cases versus 34.5 ± 14.8 years in non-torsion cases, p = 0.01), but not with the mean cyst diameter (81.9 ± 26.3 mm in the torsion group versus 74.7 ± 35.9 mm in the non-torsion group, p = 0.1). Regarding cyst size, torsion was found in women with cyst diameter ≤ 55 mm (9 cases, 17.7% of torsion cases), 60-90 mm (30 cases, 58.8%), and ≥ 100 mm (12 cases, 23.5%) (p = 0.1 for comparison between all groups and p = 0.05 for comparison between the small diameter group versus the intermediate/large diameter groups). Although abdominal pain was reported in most women with and without torsion, patients with adnexal torsion were significantly more likely to present with nausea and/or vomiting (24 cases [47.1%], versus 14 cases [7.8%], respectively, p < 0.001)., Conclusion: Torsion of dermoid cysts is associated with younger age, but not with the mean cyst's diameter. Surgical removal of dermoid cysts should be considered in pre-menarchal girls, adolescents and young women to prevent adnexal torsion., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To assess whether statin use by endometrial cancer patients was associated with a survival advantage., Methods: A retrospective chart review study, by the Israeli Gynecologic Oncology Group, of consecutive endometrial cancer patients who underwent surgery in one of 11 medical centers between 2002 and 2014. Clinical and pathological reports, and measures of survival were compared between statin users and nonusers. Kaplan-Meier and Cox proportional hazard models were used to assess the effect of using statins on survival measures., Results: Over a mean follow-up period of 6.2 years (range, 1-12 years) for 2017 endometrial cancer patients with complete data, 663 (32.8%) used statins prior to diagnosis and 1354 (67.1%) did not. No statistically significant differences between the groups were observed for most demographic and clinical characteristics. There was no difference between statin users and nonusers in 5-year recurrence-free survival (82% vs 83%; P=0.508), disease-specific survival (86% vs 84%; P=0.549), or overall survival (77% vs 75%; P=0.901)., Conclusions: In this large cohort of patients with endometrial cancer, no significant associations were found between use of statins and endometrial cancer survival., (© 2019 International Federation of Gynecology and Obstetrics.)

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., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Study Objective: To investigate whether hysteroscopic features can contribute to the diagnosis of malignancy in endometrial polyps., Design: Retrospective review., Setting: Obstetrics and gynecology department., Patients: All women who underwent operative hysteroscopy for the removal of endometrial polyps between January 2012 and September 2017. Their medical records were reviewed, and information on medical, surgical, and obstetric history and hysteroscopic findings (including the number, size, and vascular appearance of the polyps) were abstracted., Interventions: Operative hysteroscopy with resection or biopsy of endometrial polyps., Measurements and Main Results: Five hundred fifty-six women were included in the study. Their mean age was 55.4 ± 12.4 years, and 322 (57.9%) were menopausal. Endometrial carcinoma was found in 26 (4.7%) cases, whereas endometrial hyperplasia was found in 5 (0.9%) cases. Endometrial carcinoma or hyperplasia was significantly associated with patients' age, menopausal status, increased polyp vascularity on hysteroscopy, and the presence of 3 or more polyps on hysteroscopy (p <.01 for all comparisons). However, the size of the largest polyp was not associated with endometrial carcinoma or hyperplasia. On logistic regression analysis, only increased polyp vascularity was associated with endometrial carcinoma or hyperplasia (odds ratio =13.5; 95% confidence interval, 5.6-32.3; p <.001). The sensitivity, specificity, positive predictive value, and negative predictive value of polyp vascularity for the diagnosis of polyps of nonbenign pathology were 51.6%, 94.3%, 34.8%, and 97.1%, respectively., Conclusion: Hysteroscopic findings of increased vascularity of endometrial polyps and numerous endometrial polyps may suggest the diagnosis of malignant polyps, in addition to demographic parameters such as age and menopausal status., (Copyright © 2019. Published by Elsevier Inc.)

Purpose: Retained products of conception (RPOC) may occur as the result of a morbidly adherent placenta. In these cases, the hysteroscopic removal of RPOC may be technically challenging, and may require more than one hysteroscopic procedure. We sought to compare the clinical, surgical, and postoperative characteristics of cases managed by either a one-step hysteroscopy procedure or a two-step hysteroscopy approach., Methods: A retrospective review of all RPOC cases managed by hysteroscopy from 1/2013 to 3/2018. We included cases of RPOC occurring following delivery and medical or surgical pregnancy terminations. The rates of postoperative intrauterine adhesions were assessed by office hysteroscopy., Results: A two-step procedure was required in 11 (3.9%) of the 358 women who underwent hysteroscopy for removal of RPOC during the study period. Comparison between the two-step and the one-step procedure groups revealed that the women in the two-step group were significantly older and the mean RPOC size was significantly larger (35.5 ± 4.1 years versus 30.7 ± 5.9 years, respectively, p = 0.01, and 38.6 ± 9.8 mm versus 22.3 ± 7.5 mm, p < 0.001, respectively). While the rates of intraoperative complications were similar between groups, readmission for postoperative fever was more common in the two-step group (18.2% versus 2.0%, respectively, p = 0.03). Postoperative intrauterine adhesions were diagnosed in 20.0% and 5.2%, respectively (p = 0.05)., Conclusions: The two-step hysteroscopic approach enabled the complete removal of larger RPOC masses without the use of uterine curettage. The women who underwent the two-step procedure, however, were at increased risk for postoperative fever and postoperative intrauterine adhesions.

Background: Unintended pregnancy is a major public health problem with known risk factors, however, little is known about the prevalence of variables associated with recurrent unintended pregnancy (RUP) among young, unmarried women., Methods: A retrospective cohort study of unmarried women aged 18-21 serving in the Israeli military between 2013 and 2015. Multivariable logistic regression analysis was used to examine associations between RUP and women's education, IQ, immigration status, country of origin, socioeconomic status and history of psychiatric illness., Results: Of 129,638 women drafted by the Israeli military during the study period, 1720 women with unintended pregnancies had a follow up period of at least a year. Three hundred and eighty-nine of them had RUP (22.6%). Multivariable models comparing women with no unintended pregnancies and women with RUP revealed that RUP was more common among (adjusted relative risk; 95% confidence interval) women who had not graduated from high school (6.9; 4.99-9.55), who had low (90-99) IQ scores (3.9; 2.88-5.39) those reporting Africa as the country of origin (2.5; 1.37-4.59) and those from a lower socioeconomic neighborhood (1.6; 1.18-2.05). Multivariate regression modeling comparing women with single unintended pregnancies and women with RUPs showed that recurrent unintended pregnancy was more common among women who had not graduated from high school (3.2; 2.04-4.84) and those who had a low (90-99) IQ score (1.9; 1.32-2.61)., Conclusion: Rate of RUP is high among women serving in the Israeli military. These women have unique epidemiological characteristics. This may serve in identifying populations at high risk and thus may enable policy maker to offer at least to this population Long-Acting Reversible Contraception (LARC) methods. We encourage policy makers to consider the provision of LARC methods to all servicewomen who had an unintended pregnancy.

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., (Copyright © 2018. Published by Elsevier Inc.)

Background: 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., Objective: To compare the survival of asymptomatic and bleeding postmenopausal patients diagnosed with endometrial cancer., Study Design: 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., Results: 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)., Conclusion: 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., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To investigate whether women who were surgically treated for retained products of conception (RPOC) by either suction curettage or hysteroscopy are at risk for recurrent RPOC on their subsequent pregnancies., Study Design: Retrospective analysis of 442 women surgically treated for RPOC following delivery or abortion by suction curettage (N = 63, 14.3%) or hysteroscopy (N = 379, 85.7%). Information on subsequent pregnancies and their outcomes was available for 161 (36.4%) women., Results: One or more live births were reported for 150 (93.2%) of the women for whom information on subsequent pregnancies was available. The overall rate of spontaneous abortions was 31/161 (19.3%). Recurrent RPOC were diagnosed in 25 (15.5%) cases, while third stage of labor placental problems (including retained placenta or cotyledons and placenta accreta) were found in 44 (27.3%) cases. Recurrent RPOC was associated with treatment by suction curettage compared with hysteroscopy for the initial RPOC on multivariate logistic regression analysis (Odds Ratio [OR] = 3.6, 95% Confidence Interval [CI]1.3-10.5, p = 0.01) and with the initial RPOC occurring after delivery compared with after abortion (OR = 8.4, 95%CI 1.8-39.5, p = 0.006)., Conclusion: Women treated for RPOC are at risk for recurrent RPOC and for third stage of labor placental problems on their subsequent pregnancies, especially those who had been managed by suction curettage in comparison with operative hysteroscopy. Clinical and ultrasound follow-up in the early and late postpartum period should be considered in women with a history of RPOC., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Purpose: The aim of this study was to investigate the association of clinical, laboratory and ultrasound findings with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion., Methods: The study included 199 reproductive age women > 16-year-old who underwent urgent laparoscopy for suspected adnexal torsion between January 2008 and December 2014. The association of various parameters with adnexal torsion was analyzed with a multivariate logistic regression analysis and described as odds ratios (OR) ± 95% confidence intervals (CI)., Results: Adnexal torsion was surgically diagnosed in 111/199 (55.8%) cases. On the multivariate logistic regression analysis, complaints of nausea/vomiting (OR 4.5, 95% CI 1.8-11.1), peritoneal irritation signs (OR 100.9, 95% CI 4.2-2421.9), elevated white blood cell count > 11,000 cells/mL (OR 3.7, 95% CI 1.3-10.8), presence of free pelvic fluid on ultrasound (OR 34.4, 95% CI 6.7-177.9), ultrasound findings suggestive of ovarian edema (OR 4.2, 95% CI 1.5-11.6), ultrasound findings suggestive of benign cystic teratoma (OR 7.8. 95% CI 1.2-49.4) and location of the ultrasound pathology on the right side (OR 4.7. 95% CI 1.9-11.9) were positively associated with adnexal torsion, while ultrasound findings suggestive of hemorrhagic corpus luteum cyst (OR 0.04, 95% CI 0.008-0.2) were negatively associated with adnexal torsion. By combining these eight parameters, the ROC curve was calculated, yielding an area under the curve of 0.93, 95% CI 0.90-0.97 (p < 0.0001)., Conclusion: Routine clinical, laboratory and grayscale ultrasound findings may be incorporated into the emergency room workup of women with suspected adnexal torsion. Laparoscopy should be considered in all patients with suspected adnexal torsion.

Background: Endometriosis-associated malignant transformation in abdominal surgical scar (EAMTAS) is a very rare and aggressive phenomenon. Our current article aims to provide a clinical overview, focusing on risk factors affecting survival., Methods: We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review based on prior reviews and case reports regarding the phenomenon published as abstracts in English, from January 1980 to November 2016. Overall, we identified 47 cases, and we included another case from our institution. We further contacted previous investigators to receive updated follow-up regarding their patients. We analyzed the data, focusing on risk factors that might affect overall survival., Results: All the patients reported in the literature had a uterine surgery, mainly caesarean section. The median time-lag from first surgery to the diagnosis of cancer was about 19 years. Clear-cell carcinoma (CCC) was the most prevalent histology (67%), followed by endometrioid adenocarcinoma (15%). Most of the patients were treated by extensive surgery and chemotherapy and/or radiation. Overall 5 years survival was about 40%. Median overall survival was 42 months (95% confidence interval of [18.7, 65.3]). Although our review is currently the largest in the literature, we cannot draw any statistical significant results due to the limited number of patients reported. According to univariate Cox-regression models, a tendency toward worse prognosis was shown for 3-year disease-free survival clear cell histologic-type (P = .169), and tumor diameter ≥8 cm in nonclear-cell histology, 18 months postdiagnosis (P = .06)., Conclusion: EAMTAS is a rare and aggressive disease. It is mostly related to cesarean section scars and is diagnosed many years postsurgery. Clear-cell histology tends to endure from the worse prognosis. The treatment is mainly extensive surgery and adjuvant chemotherapy and/or radiotherapy.

Study Objective: To investigate the use of operative hysteroscopy instead of traditional curettage in women with retained products of conception (RPOC) following first trimester medical abortion, with the aim of reducing post-operative intrauterine adhesions., Design: Retrospective study., Setting: Gynecology department in a University affiliated hospital., Patients: All women treated by hysteroscopy for RPOC following first trimester medical abortion using the mifepristone-misoprostol protocol for pregnancy termination or the misoprostol protocol for early missed abortion from January 2013 to August 2016., Intervention: Operative hysteroscopy for removal of RPOC. Post-operative intrauterine adhesions were assessed by diagnostic office hysteroscopy after 6-8 weeks., Measurements and Main Results: 50 cases were identified. The mean time from medication administration to the operative hysteroscopy was 1.7 ± 0.7 months. Operative hysteroscopy with blunt use of the resectoscopic loop was used to remove all specimens, and all procedures were completed without intra-operative complications. Two patients (4.0%) were readmitted for fever. Pathology confirmed the presence of RPOC in 45 (90.0%) cases. On follow-up office hysteroscopy, a normal uterine cavity without evidence of intrauterine adhesions was seen in 29/29 (100%) women., Conclusion: Hysteroscopy for removal of RPOC following medical abortion is associated with low rates of complications and post-operative intrauterine adhesions., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest relevant to this article.

Objective: The aim of this article was to describe the outcome of women diagnosed with cervical intraepithelial neoplasia (CIN) grades 2 or 3 in pregnancy either observed or treated by loop electrosurgical excision procedure (LEEP) in the first 15 weeks of gestation., Methods: Loop electrosurgical excision procedure during the first 15 gestational weeks compared with observation of CIN2/3. This is a retrospective analysis of a nonrandomized study at tertiary, academic, and referring centers in Israel. Ninety-three pregnant women diagnosed with CIN2/3 between 2006 and 2016 were included in this study. Fifty patients with CIN2/3 on cervical biopsy were conservatively followed-up, and 43 patients have undergone LEEP during the first 15 gestational weeks. Main outcome measures were ultimate diagnosis of invasive cancer or CIN, pregnancy outcome, and complications., Results: In 5.4% of CIN2/3 during pregnancy, the final diagnosis was invasive cancer. The postpartum results of 50 women who were conservatively observed were as follows: 3 (6.0%) had cervical cancer and undergone radical hysterectomy, 33 (66.6%) had CIN2/3, and 14 (28%) had CIN1 or normal histology. The diagnoses of the 43 patients who have undergone LEEP were invasive cancer in 2 patients (4.6%) but did not undergo hysterectomy, CIN2/3 or adenocarcinoma in situ (AIS) in 38 patients (88.4%), and 3 women (7%) had CIN1 or normal histology. None of them suffered severe bleeding. Thirty-seven women continued their pregnancy, 34 (91.9%) had term deliveries, 2 (5.4%) gave birth at 34 and 36 weeks, and 1 patient had missed abortion (2.7%)., Conclusions: The LEEP procedure during the first 15 weeks of pregnancy is safe. A total of 5.4% of the women with CIN2/3 during pregnancy were diagnosed with invasive cancer. It is time to reconsider the recommendations about CIN2/3 in early gestation.

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., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Growing evidence suggests that cesarean scar pregnancy (CSP) and morbidly adherent placenta (MAP) may represent a continuum of the same disease., Objectives: To investigate and compare the prior risk factors in women with either CSP or MAP., Methods: The study included 33 women diagnosed with CSP in our department between 2006 and 2014. For each CSP case, two pregnant patients with MAP were matched for hospitalization date from delivery ward records, constituting the control group., Results: In both groups, maternal age, parity, and previous early and late abortions were similar. The rate of conception by assisted reproductive technologies was 9% in both groups. Although the number of previous cesarean sections was statistically different between CSP versus MAP (2.0 ± 1.0 vs. 1.0 ± 1.0, respectively, P = 0.006), the leading indication of previous cesarean section was breech presentation in both groups (28.1% and 27.8%, respectively, P > 0.05)., Conclusions: CSP and MAP share similar prior risk factors. Due to high morbidity in both diseases, further research is needed toward reducing the known etiological factors contributing to the growing number of both complications.

Objective: To assess fetal abnormalities leading to termination of pregnancy (TOP) performed in twin pregnancies., Method: The current study consisted of all women with dichorionic twin pregnancies (study group) who underwent TOP due to fetal abnormalities in our institute from 1999 to 2015. The data were compared to our registry of all parturient women with a singleton pregnancy (control group) that underwent TOP due to fetal anomalies at the same period., Results: There were 2495 cases of TOP because of fetal indications during the study period. Of them, 86 (3.4%) and 2409 (96.6%) were from the study and control group, respectively. Structural anomalies were the leading indication for TOP in twins compared with singleton pregnancies (81.4% versus 50.9%, respectively, p < 0.0001). For twins, the leading indication for TOP was central nervous system (CNS) abnormalities and it was more common compared with singleton pregnancies (26.1% versus 12.2%, respectively, p < 0.0001). This was followed by chromosomal/genetic abnormalities (16.3% versus 40.4%, respectively, p < 0.0001)., Conclusions: We found a different distribution for fetal anomalies leading to TOP in twins versus singleton pregnancies. The main indication for TOP in the study group was structural malformations, with a predominance of CNS abnormalities.

Objective: The present study aims to compare the presence and localization of collagen type IV in the prenasal tissue of fetuses with and without Down syndrome (DS)., Methods: Products of conception were obtained from mid-gestation uterine evacuations of 14 DS fetuses and 15 unaffected controls. Microdissection of the prenasal area and an analysis of the prenasal tissue specimens were performed by a single pathologist, blinded to the karyotype results. Immunohistological presence and localization of type IV collagen were analyzed in the basement membrane (BM), blood vessels, and stroma of the tissues., Results: There were no statistically significant differences in the presence and localization of antibodies for collagen IV in the blood vessels and stroma between the two groups. However, the presence and localization of type IV collagen in the BM of the prenasal skin were significantly higher in DS specimens compared to the control group (P=0.023). When combining both groups altogether, a significant correlation was found between the increased prenasal thickness (PT) and the high presence and location of collagen type IV, irrespective of the karyotype results (Spearman's correlation; R=0.459; P=0.012)., Conclusion: Using the immunohistochemistry technique, we were able to confirm the overexpression of collagen type IV in the BM of the prenasal area. This may explain the sonographic finding of increased PT seen mainly in DS fetuses.

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., (Copyright © 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Objective: To compare adnexal torsion characteristics and torsion recurrence rates in a pre- and postmenarchal pediatric and adolescent population., Design: Retrospective cohort study., Setting: University-affiliated medical center., Patient(s): Females <18 years old with surgically diagnosed adnexal torsion., Intervention(s): Adnexal detorsion, cystectomy, salpingectomy, or salpingo-oophorectomy by laparoscopy or laparotomy. Oophoropexy using the utero-ovarian ligament plication technique was performed in cases of recurrent torsion of normal adnexa., Main Outcome Measure(s): The clinical presentation, laboratory and ultrasound characteristics, surgical findings, surgical procedures, pathologic diagnosis, and torsion recurrence rates were analyzed and compared between pre- and postmenarchal patients., Result(s): Twenty premenarchal and 24 postmenarchal patients were identified. The clinical presentation, laboratory findings, and ultrasound characteristics were similar between the two groups, except for a higher prevalence of paraovarian cysts on preoperative ultrasound in the postmenarchal compared with in the premenarchal group (20.8% vs. 0%). For the whole cohort, torsion of normal adnexa constituted 25.0% (11/44) of cases, while torsion of "pathologic" adnexa constituted 75.0% (33/44) of torsion cases. Torsion recurrence was significantly more common among girls whose first torsion episode occurred in the premenarchal period compared with in postmenarche (35% vs. 4.2%). On multivariate logistic regression analysis, torsion recurrence was significantly associated with premenarchal status (odds ratio [OR] = 12.7; 95% confidence interval [CI], 1.1-152.0) and with torsion involving normal adnexa (OR = 19.1; 95% CI, 2.3-154.5)., Conclusion(s): Recurrent torsion is common in patients whose first torsion episode occurred in the premenarchal period and involved otherwise normal adnexa. Ovarian fixation procedures may be considered in patients at risk for torsion recurrence., (Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to compare the accuracy of multiple sonographic fetal weight estimation models in assessing small-for-gestational-age (SGA) fetuses., Materials and Methods: The cohort included all singleton pregnancies recorded at a single medical center from January 2004 to September 2011, with a minimum of 24 weeks of gestation. SGA was defined as a fetal weight of less than the 10th percentile. We used birth weight (BW) distribution curves for our population, matched according to fetal gender and gestational age. Predicted birth weights were calculated using 26 sonographic fetal weight estimation models, including targeted formulas for SGA fetuses., Results: 1218 cases of SGA fetuses that underwent sonographic fetal weight estimation within one week prior to delivery were found. Prediction of fetal weight was significantly less accurate in SGA fetuses than in the general population. The random error for SGA fetuses ranged from 7.2 % to 13.9 % in different models, while the systematic error ranged from -12.8 % to 26 %. Most non-targeted formulas showed a specificity of over 90 % but a sensitivity of only 20 - 35 % in the detection of SGA fetuses, while most targeted formulas had a low specificity but a high sensitivity. The model by Scott et al. was found to be the most accurate in assessing SGA fetuses in our population., Conclusion: Estimation of fetal weight in SGA fetuses is less accurate than in the general population. Some formulas which are designed for SGA are more accurate than others and their use might increase the sensitivity in identifying SGA fetuses, with only a small decline in specificity., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: We sought to investigate and compare the clinical presentation, ultrasound findings, surgical characteristics, and causes of adnexal torsion among three groups: pediatric and adolescent population, reproductive-age women, and pregnant women., Material and Methods: Two hundred twenty-seven surgically confirmed episodes of adnexal torsion in 199 patients treated in our department from January 2008 to December 2014 were retrospectively analyzed., Results: Abdominal pain duration of >24 hours before emergency room presentation was more common in pediatric and adolescent patients compared with reproductive-age and pregnant women (42.3% vs. 28.4% and 15.5%, respectively, p = 0.04). However, there was no difference between the groups in the time interval from their emergency room admission to surgery. Torsion of "normal adnexa" occurred in 11/44 (25.0%) of pediatric and adolescent patients, 30/99 (30.3%) of reproductive-age patients, and 12/56 (21.4%) of pregnant patients, while torsion involving multicystic ovaries occurred in 0%, 4%, and 32.1%, respectively, torsion involving paraovarian cysts occurred in 20.5%, 14.1%, and 1.8%, respectively, and torsion involving benign dermoid cysts occurred in 4.5%, 15.2%, and 5.4%, respectively (p < 0.001). Torsion involving supposedly functional ovarian cysts occurred in 45.5%, 34.3%, and 69.6%, respectively (p < 0.001). The torsion recurrence rates were 18.2% in the pediatric subjects, 19.2% in reproductive-age women, and 10.7% in pregnant women (p = 0.3)., Conclusions: The presentation of adnexal torsion is similar in pediatric and reproductive-age and pregnant women, although the underlying adnexal pathology may be different. Functional ovarian cysts cause the majority of torsion cases in pregnant women. Recurrence of torsion may occur in any age group.

Objective: To investigate the clinical presentation of women with primary ovarian pregnancy diagnosed in recent years and to compare it to tubal pregnancy., Study Design: Seven women treated for primary ovarian pregnancy from 2002-2013 were retrospectively identified and compared to 42 women with tubal pregnancies (involving either tubal rupture or tubal abortion) operated on during the same period. In the ovarian pregnancy group the pathology examination confirmed primary ovarian pregnancy according to the Spiegelberg criteria., Results: Seven women underwent surgery for primary ovarian pregnancy during the study period. Five women presented with hemodynamic shock. A ruptured ovarian pregnancy was identified in all cases. Wedge resection was performed by laparotomy in 1 case and by laparoscopy in 6 cases. The mean estimated blood loss was significantly higher in those women with ovarian versus tubal pregnancy (1057.1 ± 472.1 mL vs. 250.2 ± 241.5 mL, respectively, p<0.001). Moreover, a statistically significant difference was found when we compared postoperative hospitalization days (2 ± 0.6 vs. 1.3 ± 0.7, respectively; p=0.01) in the ovarian pregnancy group as compared with the tubal pregnancy group., Conclusion: Primary ovarian ectopic pregnancy is still a major challenge for early diagnosis and treatment; it is associated with rupture and massive intraabdominal bleeding.

Campylobacter is a gram-negative, microaerophilic, curved rod and a normal resident of the gastrointestinal flora and may be the cause of disease in animals. Transmission to humans occurs by ingestion of contaminated food or by direct contact with infected animals. In the past few decades, an increasing number of reports have implicated the presence of this organism in human abortions as well. An infectious mechanism due to primary placental inflammatory damage followed by secondary damage to the fetus following placental insufficiency and ischemia was suggested. The most common species of Campylobacter are Campylobacter jejuni and Campylobacter coli, which are classically associated with enteritis in humans. We present a rare case of mid-gestation intrauterine growth restriction (IUGR) associated with maternal bacteremia caused by C. coli infection. Our literature review focuses on Campylobacter infections occurring in the second and third trimesters of pregnancy. In all cases, mild maternal symptoms consisting of fever and weakness were presented. However, associated adverse fetal outcome, including abortions, IUGR or preterm labor may occur more frequently than anticipated. Our report strengthens the importance of awareness to this finding and focuses the need to consume properly cooked meat during pregnancy., (© 2015 John Wiley & Sons, Ltd.)

Background: Despite awareness regarding tubal pregnancy, ovarian pregnancy still remains a diagnostic challenge. The correct diagnosis is most frequently made intraoperatively and requires histopathologic confirmation. Therefore, additional diagnostic measurements are needed for earlier and more accurate detection of ovarian pregnancies which will allow more rapid and efficient treatment., Objectives: To assess the time trends, clinical manifestations, surgical management and post-procedure outcome of 46 primary ovarian pregnancies in a single institution during three time periods., Methods: In this retrospective study we compared 20 patients with primary ovarian pregnancy during the years 1971- 1989 (first period), 19 patients in 1990-2001 (second period) and 7 patients in 2002-2013 (third period). In all cases the pathology examination confirmed primary ovarian pregnancy., Results: The number of tubal ectopic pregnancies almost doubled, from 637 in the first period to 1279 in the third period (P < 0.001). However, there was a significant fall in the number of ovarian ectopic pregnancies, from 20 cases in the first period to 7 cases in the third (P = 0.009). A significant difference was noted when we compared the postoperative hospitalization time (4.06 ± 1.4 vs. 2.0 ± 0.6 days respectively, P = 0.001) in the second versus the third time period., Conclusions: Ovarian pregnancy continues to be a diagnostic challenge, associated with a high rate of circulatory collapse, hemoperitoneum and requirements for blood transfusions, all leading to longer hospitalization.

Repair of injured lungs represents a longstanding therapeutic challenge. We show that human and mouse embryonic lung tissue from the canalicular stage of development (20-22 weeks of gestation for humans, and embryonic day 15-16 (E15-E16) for mouse) are enriched with progenitors residing in distinct niches. On the basis of the marked analogy to progenitor niches in bone marrow (BM), we attempted strategies similar to BM transplantation, employing sublethal radiation to vacate lung progenitor niches and to reduce stem cell competition. Intravenous infusion of a single cell suspension of canalicular lung tissue from GFP-marked mice or human fetal donors into naphthalene-injured and irradiated syngeneic or SCID mice, respectively, induced marked long-term lung chimerism. Donor type structures or 'patches' contained epithelial, mesenchymal and endothelial cells. Transplantation of differentially labeled E16 mouse lung cells indicated that these patches were probably of clonal origin from the donor. Recipients of the single cell suspension transplant exhibited marked improvement in lung compliance and tissue damping reflecting the energy dissipation in the lung tissues. Our study provides proof of concept for lung reconstitution by canalicular-stage human lung cells after preconditioning of the pulmonary niche.

Objective: The objective was to explore the prevalence of and risk factors for inadequate cervical dilation following insertion of a single set of laminaria in women scheduled for dilation & evacuation (D&E) at 14-24 weeks' gestation., Study Design: We retrospectively reviewed all cases of women who underwent pregnancy termination by D&E at 14-24 weeks' gestation between January 2003 and December 2013. All cases in which the surgical procedure was cancelled due to failure to achieve adequate cervical dilation after a single set of laminaria inadequate cervical dilation were included. The control group was women who underwent D&E following adequate cervical dilation after a single set of laminaria, and were matched according to gestational week in a ratio of 1:3., Results: The overall dilation failure rate was 3.2%, with 4.0% among the induced-abortion patients and 1.5% among the patients with fetal demise (p=.002). Patients who had inadequate cervical dilation had lower rates of gravidity (p=.002) and previous spontaneous vaginal delivery (p<.001), along with higher rates of primigravidity, nulliparity (p<.001), previous cesarean section/s (p=.041), previous abdominal surgeries (p=.001) and previous cervical procedures (p=.003), compared to controls. A multivariable logistic regression analysis revealed two risk factors for inadequate cervical dilation following laminaria insertion, namely, previous cesarean section (p=.002) and previous cervical procedure (p<.001), whereas increased gravidity was found to protect against inadequate cervical dilation (p=.002)., Conclusions: Previous cesarean section/s, cervical procedures and primigravidity were found to be risk factors for failure to achieve adequate cervical dilation after a single set of laminaria. Women who are scheduled for D&E, and in whom one of these risk factors exists, might benefit from additional interventions to achieve better cervical preparation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To assess the prevalence and risk factors for intrauterine adhesions (IUAs) after hysteroscopic treatment of retained products of conception (RPOC)., Design: Retrospective cohort study., Setting: Gynecologic endoscopy unit., Patient(s): A total of 167 women referred to our institution from 2009 to 2013., Intervention(s): Operative hysteroscopy for treatment of RPOC and office hysteroscopic follow-up to assess for IUA., Main Outcome Measure(s): We investigated demographic characteristics, obstetrics parameters, and surgical variables to evaluate which factors could be associated with IUA formation., Result(s): Of 167 women treated for RPOC, 84 (50.3%) had undergone a follow-up hysteroscopic evaluation after the operative hysteroscopy and were included in the study. Intrauterine adhesions were found in 16 cases (19.0%), of which only 3 (3.6%) were severe adhesions. Multivariate analysis showed that the presence of IUA was associated with RPOC after cesarean section (5 of 10 [50.5%] developed IUA, vs. 7 of 49 [14.3%] after vaginal delivery). Intrauterine adhesions were also found in 4 of 23 women (17.4%) undergoing hysteroscopy for RPOC after abortion. Patient age, gravidity, parity, and the interval between the index pregnancy and treatment for RPOC were not associated with postoperative IUA., Conclusion(s): Hysteroscopic treatment for RPOC had a 3.6% incidence of severe intrauterine adhesions formation in this descriptive series. Women with RPOC occurring after delivery by cesarean section are particularly at risk for development of IUA., (Copyright © 2015 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Triploidy (69 chromosomes) is the most common chromosomal anomaly encountered in human gestation, occurring in 1% of all conceptions. Most triploidies abort spontaneously during the 1st trimester. In cases that last, it is usually associated with fetal distress that can Lead to many obstetric complications., Objective: To assess the indications for prenatal karyotyping of triploidy during pregnancy in our medical center., Methods: This retrospective cohort study involved all singleton pregnancies diagnosed or referred to our institute because of triploidy, during the years 1998-2011., Results: There were 1879 cases of termination of pregnancies (TOPs). During this period 8 cases of triploidy were aborted. The main indications for prenatal karyotyping in our study group were abnormal sonographic findings during anomaly scans. In addition, in all of the triploidy cases, the NT test was normal. Also, the 1st or 2nd trimester serum markers tests for early diagnosis of trisomy 18 predicted all of the triploidy cases that performed the tests., Discussion: Our findings corresponded with other studies and show that the 1st or 2nd trimester serum markers tests for early diagnosis of trisomy 18, can lead to identification of triploidy pregnancies., Conclusions: The routine screening tests applied in Israel INT, serum markers tests and 2nd trimester anomaly scans) were highly effective in the identification of triploidy pregnancies.

Introduction: Trisomy 18 and 13 are the most common autosomal trisomies, after trisomy 21, and their frequency is rising due to the increased maternal age of pregnant women. The fetuses suffer from multi-organ damage that may lead to many gestational complications as well as short life expectancy., Objective: To assess the indications for prenatal karyotyping of trisomy 13 (T-13, Patau syndrome) and trisomy 18 (T-18, Edwards syndrome) during pregnancy in our medical center., Methods: This retrospective cohort study involved all singleton pregnancies locally diagnosed or referred to our Institute because of T-13 and T-18, during the years 1998-2011., Results: There were 1879 cases of termination of pregnancies (TOPs) because of fetal indications, of them 53 cases of T-18 and 10 cases of T-13. The main indications for prenatal karyotyping in our study group were abnormal sonographic findings during anomaLy scans. In addition, 7 newborns with T-18 and 3 infants with T-13 were born in our hospital during the same period of time. We examined all cases that led to the Live birth of newborns with chromosomal anomalies, stemming from the Lack of extraction of the tests mentioned above and/or ignoring findings that raise suspicion that requires performing prenatal karyotyping during pregnancy., Discussion: Our findings corresponded with other studies and showed that prenatal diagnosis of T-13/T-18 due to abnormal sonographic finding is rising., Conclusions: Our study shows that it was possible to identify the vast majority of T-13/T-18 among the pregnant women who had an increased risk based on a combination of the routine screening tests applied in Israel.

Cancer is a heterogeneous and tissue-specific disease. Thus, the tissue of origin reflects on the natural history of the disease and dictates the therapeutic approach. It is suggested that tissue differentiation, mediated mostly by epigenetic modifications, could guide tissue-specific susceptibility and protective mechanisms against cancer. Here we studied breast specific methylation in purified normal epithelium and its reflection in breast cancers. We established genome wide methylation profiles of various normal epithelial tissues and identified 110 genes that were differentially methylated in normal breast epithelium. A number of these genes also showed methylation alterations in breast cancers. We elaborated on one of them, TRIM29 (ATDC), and showed that its promoter was hypo-methylated in normal breast epithelium and heavily methylated in other normal epithelial tissues. Moreover, in breast carcinomas methylation increased and expression decreased whereas the reverse was noted for multiple other carcinomas. Interestingly, TRIM29 regulation in breast tumors clustered according to the PAM50 classification. Thus, it was repressed in the estrogen receptor positive tumors, particularly in the more proliferative luminal B subtype. This goes in line with previous reports indicating tumor suppressive activity of TRIM29 in estrogen receptor positive luminal breast cells in contrast to oncogenic function in pancreatic and lung cancers. Overall, these findings emphasize the linkage between breast specific epigenetic regulation and tissue specificity of cancer.