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: In this article we provide a very interesting and challenging PCI of unrecognized anomalous left circumflex coronary artery (LCx) arising from right sinus of Valsalva (RSV) after aortic valve replacement (AVR).This case presentation focuses the attention on important criteria for recognition of abnormal LCx coronary artery, that is the most frequent congenital coronary variant. Failure to demonstrate the anomaly can lead to erroneous interpretation of coronary anatomy with fatal complication in case of aortic valve replacement, as a consequence of accidental ligation or compression of the anomalous vessel. This procedure, especially in the presence of a bioprosthesis aortic valve just implanted, constitutes a challenge for the interventional cardiologist and at the same time a question mark regarding the strategy, choice of guiding catheter, guide wire, and type of stent to use.

: In this article, we provide very illustrative images obtained with optical coherence tomography (OCT) of a patient presenting with ST-elevation myocardial infarction and multivessel disease. These patients are referred to the catheterization laboratory without performing any prior noninvasive imaging. This leads very often to diagnostic dilemmas with difficult solutions. Coronary angiography is frequently insufficient or even misleading to guide the interventional cardiologist in the identification and revascularization of the culprit coronary lesion. What makes our case particularly paradigmatic is the fact that without OCT guidance, an erroneous clinical decision-making process would have taken place, leaving untreated the culprit lesion in this patient.

Objectives: The aim of this prospective multicenter study was to identify the optimal approach for simple and fast fractional flow reserve (FFR) computation from radiographic coronary angiography, called quantitative flow ratio (QFR)., Background: A novel, rapid computation of QFR pullbacks from 3-dimensional quantitative coronary angiography was developed recently., Methods: QFR was derived from 3 flow models with: 1) fixed empiric hyperemic flow velocity (fixed-flow QFR [fQFR]); 2) modeled hyperemic flow velocity derived from angiography without drug-induced hyperemia (contrast-flow QFR [cQFR]); and 3) measured hyperemic flow velocity derived from angiography during adenosine-induced hyperemia (adenosine-flow QFR [aQFR]). Pressure wire-derived FFR, measured during maximal hyperemia, served as the reference. Separate independent core laboratories analyzed angiographic images and pressure tracings from 8 centers in 7 countries., Results: The QFR and FFR from 84 vessels in 73 patients with intermediate coronary lesions were compared. Mean angiographic percent diameter stenosis (DS%) was 46.1 ± 8.9%; 27 vessels (32%) had FFR ≤ 0.80. Good agreement with FFR was observed for fQFR, cQFR, and aQFR, with mean differences of 0.003 ± 0.068 (p = 0.66), 0.001 ± 0.059 (p = 0.90), and -0.001 ± 0.065 (p = 0.90), respectively. The overall diagnostic accuracy for identifying an FFR of ≤0.80 was 80% (95% confidence interval [CI]: 71% to 89%), 86% (95% CI: 78% to 93%), and 87% (95% CI: 80% to 94%). The area under the receiver-operating characteristic curve was higher for cQFR than fQFR (difference: 0.04; 95% CI: 0.01 to 0.08; p < 0.01), but did not differ significantly between cQFR and aQFR (difference: 0.01; 95% CI: -0.04 to 0.06; p = 0.65). Compared with DS%, both cQFR and aQFR increased the area under the receiver-operating characteristic curve by 0.20 (p < 0.01) and 0.19 (p < 0.01). The positive likelihood ratio was 4.8, 8.4, and 8.9 for fQFR, cQFR, and aQFR, with negative likelihood ratio of 0.4, 0.3, and 0.2, respectively., Conclusions: The QFR computation improved the diagnostic accuracy of 3-dimensional quantitative coronary angiography-based identification of stenosis significance. The favorable results of cQFR that does not require pharmacologic hyperemia induction bears the potential of a wider adoption of FFR-based lesion assessment through a reduction in procedure time, risk, and costs., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Pressure wire-based fractional flow reserve is considered the standard of reference for evaluation of the ischemic potential of coronary stenoses and the expected benefit from revascularization. Accordingly, its application in daily practice or for research purposes has to be as standardized as possible to avoid technical or operator-related artifacts in pressure recordings. This document proposes a standardized way of acquiring, recording, interpreting, and archiving the pressure tracings for daily practice and for the purpose of clinical research involving a core laboratory. Proposed standardized steps enhance the uniformity of clinical practices and data interpretation., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Fractional flow reserve (FFR) has never been investigated in patients with aortic stenosis (AS). From 2002 to 2010, we identified 106 patients with AS and coronary artery disease with at least one intermediate lesion treated according to FFR guidance. We matched 212 contemporary control patients with AS in which revascularization was decided on angiography only. More patients in the FFR-guided group underwent percutaneous coronary intervention (24% vs 13%; p = 0.019), whereas there was a trend toward less coronary artery bypass grafting (CABG) performed. After FFR, the number of diseased vessels was downgraded within the FFR-guided group (from 1.85 ± 0.97 to 1.48 ± 1; p <0.01) and compared with the angio-guided group (1.48 ± 1 vs 1.8 ± 0.97; p <0.01). Less aortic valve replacement was reported in the FFR-guided group (46% vs 57%; p = 0.056). In patients who underwent CABG, less venous conduits (0.5 ± 0.69 vs 0.73 ± 0.76; p = 0.05) and anastomoses (0.61 ± 0.85 vs 0.94 ± 1; p = 0.032) were necessary in the FFR-guided group. Up to 5 years, we found no difference in major adverse cardiac events (38% vs 39%; p = 0.98), overall death (32% vs 31%; p = 0.68), nonfatal myocardial infarction (2% vs 2%; p = 0.79), and revascularization (8% vs 7%; p = 0.76) between the 2 groups. In conclusion, FFR guidance impacts the management of selected patients with moderate or severe AS and coronary artery disease by resulting into deferral of aortic valve replacement, more patients treated with percutaneous coronary intervention, and in patients treated with CABG, into less venous grafts and anastomoses without increasing adverse event rates up to 5 years., (Copyright © 2016 Elsevier Inc. All rights reserved.)

We evaluated the clinical outcome of patients with moderate/severe aortic stenosis and significant coronary disease not treated according to guidelines, recommending combined aortic valve replacement (AVR) and coronary artery bypass grafting (CABG). From 2002 to 2010, we assessed death up to 5 years in 650 patients with moderate/severe aortic stenosis and at least one coronary lesion (>50 %): 23 % were treated conservatively (MT), 17 % with percutaneous coronary intervention (PCI), 11 % with AVR, and 49 % with combined CABG and AVR. At a median follow-up of 58 months, overall death decreased over the groups (MT, 68 % vs. PCI, 44 % vs. AVR, 34 % vs. CABG and AVR, 23 %, p < 0.01). Compared to the MT group, Cox regression analysis adjusted for potential confounders showed significantly reduced mortality in the PCI, AVR, and CABG and AVR groups. When combined CABG and AVR is not feasible, PCI or AVR alone still improves significantly long-term survival as compared with MT alone.

Objectives: This study sought to assess the impact of a wide range of mean right atrial pressure (Pra) on fractional flow reserve (FFR) measurements., Background: FFR invasively assesses the ischemic potential of coronary stenoses. FFR is calculated as the ratio of mean distal coronary pressure (Pd) to mean aortic pressure (Pa) during maximal hyperemia. The Pra is considered to have little impact if it is within normal range, so it is neglected in the formula., Methods: In 1,676 stenoses of 1,235 patients undergoing left-right heart catheterization for ischemic (642 [52%]) or valvular heart disease (593 [48%]), the authors compared the FFR values calculated without accounting for Pra (FFR= Pd/Pa) to the corresponding myocardial fractional flow reserve (FFRmyo) values accounting for Pra (FFRmyo = Pd - Pra/Pa - Pra)., Results: The median Pra was 7 (interquartile range [IQR]: 5 to 10) mm Hg with a maximum of 27 mm Hg. The correlation and agreement between FFR and FFRmyo was excellent (R(2) = 0.987; slope 1.096 ± 0.003). The median FFR (0.85; IQR: 0.78 to 0.91) was slightly but statistically significantly higher than the median FFRmyo (0.83; IQR: 0.76 to 0.90; p < 0.001) with a median difference of 0.01 (IQR: 0.01 to 0.02). Values of FFR above the cutoff of 0.80 provided an FFRmyo ≤0.80 in 110 (9%) stenoses. No FFR value above 0.80 provided an FFRmyo ≤0.75., Conclusions: The difference between FFR and FFRmyo was minimal even in patients with markedly increased Pra. FFR values above the gray zone (i.e., >0.80) did not yield values below the gray zone (i.e., ≤0.75) in any case, which suggests that the impact of right atrial pressure on FFR measurement is indeed negligible., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The fractional flow reserve (FFR) value of 0.75 has been validated against ischemic testing, whereas the FFR value of 0.80 has been widely accepted to guide clinical decision making. However, revascularization when FFR is 0.76 to 0.80, within the so-called gray zone, is still debatable., Methods and Results: From February 1997 to June 2013, all patients with single-segment disease and an FFR value within the gray zone or within the 2 neighboring FFR strata (0.70-0.75 and 0.81-0.85) were included. Study end points consisted of major adverse cardiovascular events (death, myocardial infarction, and any revascularization) up to 5 years. Of 17 380 FFR measurements, 1459 patients were included. Of them, 449 patients were treated with revascularization and 1010 patients were treated with medical therapy. In the gray zone, the major adverse cardiovascular events rate was similar (37 [13.9%] versus 21 [11.2%], respectively; P=0.3) between medical therapy and revascularization, whereas a strong trend toward a higher rate of death or myocardial infarction (25 [9.4] versus 9 [4.8], P=0.06) and overall death (20 [7.5] versus 6 [3.2], P=0.059) was observed in the medical therapy group. Among medical therapy patients, a significant step-up increase in major adverse cardiovascular events rate was observed across the 3 FFR strata, especially with proximal lesion location. In revascularization patients, the major adverse cardiovascular events rate was not different across the 3 FFR strata., Conclusions: FFR in and around the gray zone bears a major prognostic value, especially in proximal lesions. These data confirm that FFR≤0.80 is valid to guide clinical decision making., (© 2016 American Heart Association, Inc.)

Purpose: Transvaginal hydrolaparoscopy (THL) is a mini-invasive technique, which allows exploration of the posterior pelvis. THL can be carried out as an office procedure and may replace hysterosalpingography and laparoscopy for the diagnosis of infertility. The aim of this study was to assess pain level during each step of THL., Methods: Forty infertile women underwent office THL with local anesthesia and had to score pain on a Likert scale (0-no pain, 5-maximum pain) during five stages of THL: stage 1, introduction of the intrauterine catheter; stage 2, introduction of the Veress needle in the Douglas pouch; stage 3, introduction of the trocar in the pelvis; stage 4, exploration of pelvic organs; stage 5, chromosalpingoscopy. At the end of the study, patients scored their overall satisfaction on a VAS scale (0-not satisfied at all; 10-completely satisfied)., Results: Stage 5 was associated with the highest pain score in comparison with stages 1-4 (p < 0.001), while pain score during stage 4 was significantly higher in comparison with stages 1-3 (p = 0.001)., Conclusions: Office THL seems to be well tolerated by patients. Chromosalpingoscopy was the least tolerated stage but it does not adversely impact on the procedure, which can be adequately accomplished by performing proper counseling.

Objectives: The present study sought to establish the dosage of intracoronary (IC) adenosine associated with minimal side effects and above which no further increase in flow can be expected., Background: Despite the widespread adoption of IC adenosine in clinical practice, no wide-ranging, dose-response study has been conducted. A recurring debate still exists regarding its optimal dose., Methods: In 30 patients, Doppler-derived flow velocity measurements were obtained in 10 right coronary arteries (RCAs) and 20 left coronary arteries (LCAs) free of stenoses >20% in diameter. Flow velocity was measured at baseline and after 8 ml bolus administrations of arterial blood, saline, contrast medium, and 9 escalating doses of adenosine (4 to 500 μg). The hyperemic value was expressed in percent of the maximum flow velocity reached in a given artery (Q/Qmax, %)., Results: Q/Qmax did not increase significantly beyond dosages of 60 μg for the RCA and 160 μg for LCA. Heart rate did not change, whereas mean arterial blood pressure decreased by a maximum of 7% (p < 0.05) after bolus injections of IC adenosine. The incidence of transient A-V blocks was 40% after injection of 100 μg in the RCA and was 15% after injection of 200 μg in the LCA. The duration of the plateau reached 12 ± 13 s after injection of 100 μg in the RCA and 21 ± 6 s after the injection of 200 μg in the LCA. A progressive prolongation of the time needed to return to baseline was observed. Hyperemic response after injection of 8 ml of contrast medium reached 65 ± 36% of that achieved after injection of 200 μg of adenosine., Conclusions: This wide-ranging, dose-response study indicates that an IC adenosine bolus injection of 100 μg in the RCA and 200 μg in the LCA induces maximum hyperemia while being associated with minimal side effects., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The study aimed to evaluate the adequacy and feasibility of the single string bifurcation stenting technique., Background: Double-stent techniques may be required for complex bifurcations. Currently applied methods all have their morphological or structural limitations with respect to wall coverage, multiple strut layers, and apposition rate., Methods: Single string is a novel method in which, first, the side branch (SB) stent is deployed with a single stent cell protruding into the main branch (MB). Second, the MB stent is deployed across this protruding stent cell. The procedure is completed by final kissing balloon dilation. The single string technique was first tested in vitro (n = 20) and next applied in patients (n = 11) with complex bifurcation stenoses., Results: All procedures were performed successfully, crossing a single stent cell in 100%. Procedure duration was 23.0 ± 7.9 min, and the fluoroscopy time was 9.4 ± 3.5 min. The results were evaluated by optical coherence tomography, showing fully apposed struts in 83.0 ± 9.2% in the bifurcation area. Residual area obstruction in the MB was 6.4 ± 5.6% and 25.0 ± 16.9% in the SB, as evaluated by micro computed tomography. All the human cases were performed successfully with excellent angiographic results: the residual area stenosis was 27 ± 8% and 29 ± 10% in the MB and in the SB, respectively, by 3-dimensional quantitative coronary angiography. No relevant periprocedural enzyme increase was observed. During follow-up (6 ± 4 months), no adverse clinical events (death, myocardial infarction, target vessel revascularization) were noted., Conclusions: The single string technique for complex bifurcation dilation was shown to be adequate in vitro and feasible in humans, with favorable results in terms of stent overlap, malapposition rate, and low residual obstruction in both the MB and SB., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Fractional flow reserve (FFR) measurement of intermediate coronary stenoses is recommended by guidelines when demonstration of ischemia by noninvasive testing is unavailable. The study aims to evaluate the penetration of this recommendation into current thinking about revascularization strategies for stable coronary artery disease., Methods and Results: International Survey on Interventional Strategy was conducted via a web-based platform. First, participants' experiences in interventional cardiology were queried. Second, 5 complete angiograms were provided, presenting only focal intermediate stenoses. FFR and quantitative coronary angiography values were known; however, remained undisclosed. Determination of stenosis significance was asked for each lesion. In cases of uncertainty, the most appropriate adjunctive invasive diagnostic method among quantitative coronary angiography, intravascular ultrasound, optical coherence tomography, or FFR needed to be selected. International Survey on Interventional Strategy was taken by 495 participants who provided 4421 lesion evaluations. In 3158 (71%) decisions, participants relied solely on angiographic appearance that was discordant in 47% with the known FFR, using 0.80 as cutoff value. The use of FFR and imaging modalities was requested in 21% and 8%, respectively. Comparing 4 groups of participants according to the experience in FFR, angiogram-based decisions were less frequent with increasing experience (77% versus 72% versus 69% versus 67%, respectively; P<0.001). As a result, requests for FFR were more frequent (14% versus 19% versus 24% versus 28%, respectively; P<0.001) and rates of discordant decisions decreased (51% versus 49% versus 47% versus 43%, respectively; P<0.022)., Conclusions: The findings confirm that, even when all potential external constraints are virtually eliminated, visual estimation continues to dominate the treatment decisions for intermediate stenoses, indicative of a worrisome disconnect between recommendations and current practice., (© 2014 American Heart Association, Inc.)

The role played by glycoprotein (GP) IIb/IIIa inhibitors has continuously evolved from the initial introduction in mid 90 s until the most recent guidelines for treating acute coronary syndromes, and competed with a wider use of ADP inhibitors and novel anticoagulant drugs, to the extent that they stepped down from class I to class II recommendation in the routine setting of acute coronary syndromes. As a consequence, GP IIb/IIIa use was greatly narrowed. The purpose of this review is to define the roles that GP IIb/IIIa inhibitors may still have in acute ischemic settings by explaining why in high risk patients they might be preferable and/or whether they might be added to ADP inhibitors also emphasizing the underlying mechanistic actions. It is concluded that there might be a more extensive use of GP IIb/IIIa inhibitors in patients presenting with acute coronary syndromes, strictly based on the definition for a high risk procedure: complexity, angiographic characteristics and patient's risk profile, regardless whether STEMI or NSTEMI. The positive elements one should appreciate in GP IIb/IIIa inhibitors are: efficacy, rapid onset and reversibility of action, absence of pharmacogenomic variability, pharmacoeconomic considerations and the possibility of intracoronary administration.

The prescription of aspirin (acetylsalicylic acid (ASA)) to patients with a history of hypersensitivity to this drug could prove harmful. The aim of the study was to assess the antiplatelet activity and safety of a combined antiplatelet treatment with indobufen and clopidogrel in acute coronary syndrome (ACS) patients with hypersensitivity to aspirin, undergoing coronary stenting. Forty-two consecutive ACS patients treated with stent implantation were randomly assigned to receive clopidogrel 75 mg daily (loading dose 300 mg) plus indobufen 100 mg twice a day (group A), or clopidogrel 75 mg daily, after 300 mg of loading dose (group B). Platelet activity and safety were monitored in both groups at 1, 3, 6, 12, and 18 months with laboratory and clinical evaluation. A lower value of max % platelet aggregation to arachidonic acid and collagen was found in group A compared to group B (31.79 ± 27.33 vs. 73.67 ± 19.92; p < 0.0001 and 28.53 ± 21.32 vs. 73.58 ± 17.71; p < 0.0001, respectively). There was no difference in max % of platelet inhibition to adenosine diphosphate between the two groups (14.23 ± 18.92 vs. 10.30 ± 18.97; p = 0.23). In the population that was under indobufen treatment, the serum thromboxane B2 (TXB2) production at 1 week and 1 month was very low (2.6 ± 1.6 ng/ml and 3.0 ± 2.7 ng/ml, respectively; p = 0.82). The combined treatment was well tolerated in group A patients. This study suggests that the combined antiplatelet treatment with clopidogrel and indobufen could be a good option in ACS patients with hypersensitivity to aspirin undergoing coronary stenting.

Levosimendan increases the sensitivity of the heart to calcium and consequently exerts positive inotropic effects. Levosimendan is indicated in acutely decompensated severe congestive heart failure. We report that levosimendan infusion may induce myocardial ischemia in patients with acute heart failure.

Adhesions are the most frequent complication of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with considerable morbidity and expense, and an important mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in most patients. There is rising evidence, however, that surgeons can take important steps to reduce the impact of adhesions. A task force of Italian gynecologists with a specialist interest in adhesions having reviewed the current evidence on adhesions and considered the opportunities to reduce adhesions in Italy, have approved a collective consensus position. This consensus paper provides a comprehensive overview of adhesions and their consequences and practical proposals for actions that gynecological surgeons in Italy should take. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be adopted particularly in high risk surgery and in patients with adhesiogenic conditions. Patients also need to be better informed of the risks of adhesions.

Aim and Methods: The treatment of mild-moderate acne with topical drugs in association with appropriate cosmetics is currently the golden standard. The tolerability and efficacy of a cream formulated with a new mix of alpha-hydroxy acids (Hyseac AHA cream) in 248 patients with mild-moderate acne (comedonic, inflammatory, or mixed) have been investigated in a multicenter, non-randomized, open study by 10 dermatologists from different Italian areas during their routine practice. The medication with Hyseac AHA cream was prescribed at first consultation for 60 days, twice a day, either as a monotherapy (49.2% patients) or in association with a pharmacological treatment (50.2%)., Results: The tolerability was good to excellent in 92.3% patients, without significant differences between patients using AHA cream in monotherapy (90.0%) or associated with concomitant pharmacological treatment (97.6%). The efficacy was overall high in 64.2% patients, again without significant differences related to concomitant pharmacological treatment or not (64.8% vs. 63.3%) and/or the acne clinical type (comedonic vs. inflammatory vs. mixed: 69.2% vs. 66.7% vs. 58%)., Conclusion: The results of this study, while confirming the high tolerability and efficacy of this AHA cream in the treatment of mild/moderate acne, reasonably suggest its possible use also in monotherapy. Furthermore, its use can be reasonably hypothesized as a maintenance treatment after specific pharmacological treatment even in more severe acne types.

Ageing is a complex process that negatively impacts the development of the different systems and its ability to function. On the other hand, the rate of ageing in humans is not uniform, due to genetic heterogeneity and the influence of environmental factors. Thus, the ageing rate, measured as the decline of functional capacity and stress resistance, seems to be different in every individual. Therefore, attempts have been made to analyse this individual age, the so-called biological age, in comparison to chronological age. Age-related changes in body function or composition that could serve as a measure of biological age and predict the onset of age-related diseases and/or residual lifetime are termed biomarkers of ageing. Such biomarkers of ageing should help on the one hand to characterise this biological age and, as age is a major risk factor in many degenerative diseases, could be subsequently used on the other hand to identify individuals at high risk of developing age-associated diseases or disabilities. Unfortunately, most of the markers under discussion are related to age-related diseases rather than to age, so none of these markers discussed in literature is a true biomarker of ageing. Hence, we discuss some disease-related biomarkers useful for a better understanding of ageing and the development of new strategies to counteract it, essential for improving the quality of life of the elderly population. Biomarkers discussed are based on immunosenescence, inflammatory responses and oxidative stress, since the review is based on data from author laboratories rather than on an extensive review of the literature. However, this kind of knowledge is useful to anti-ageing strategies aimed to slow ageing and to postpone death by preventing infectious diseases and delaying the onset of age-related diseases.

In the last decade, ''fertiloscopy'', a new mini-invasive diagnostic technique, is becoming more and more popular: it is a good alternative to the diagnostic laparoscopy, a standard procedure but surely not harmless, very often capable to discover pathologies in asymptomatic patients. Fertiloscopy allows the visualization of the posterior pelvis (posterior face of the uterus, ovaries, tubes and intestinal ansae with the rectum), with a technique of introducing an optical device in the pouch of Douglas, through the posterior vaginal fornix, under previous general or local anesthesia. When fertiloscopy is performed under local anesthesia, it can comfortably be carried out in out-patient departments and it is generally well tolerated by patients, who follow the whole procedure on the monitor. Moreover, it is possible to perform small interventions, such as adhesiolysis, ovarian drilling, coagulation of endometriosis spots and to perform chromosalpingoscopy and salpingoscopy, important investigations in the diagnostic iter of unexplained female infertility. With fertiloscopy, the patient, therefore, can avoid a real surgical intervention, such as diagnostic laparoscopy, and also uncomfortable examinations, such as hysterosalpingography.

Autocrosslinked hyaluronic acid gel is useful for preventing postsurgical adhesion formation in infertile patients who have undergone laparoscopic myomectomy, and it increases the pregnancy rate more than laparoscopic myomectomy alone. Moreover, pregnancy rate is significantly higher with the use of subserous sutures.

Objective(s): To compare the long-term effectiveness of two different laparoscopic colposuspension procedures., Study Design: Sixty women affected by genuine stress incontinence (GSI) were enrolled in a prospective randomized controlled trial (RCT) and treated by transperitoneal laparoscopic colposuspension using nonabsorbable sutures (group A) or prolene mesh fixed with tackers or staplers (group B). In each group the subjective and objective failure rates were evaluated at 12, 24, and 36 months after surgery. For the subjective evaluation patients were asked whether they had experienced urine leakage and any urine loss they reported was recorded on a visual analogue scale (VAS). The objective evaluation was performed by means of a clinical examination and multichannel urodynamic studies. The data were analyzed by the intention-to-treat method., Results: The subjective failure rate was significantly (P < 0.05) lower in group A than in group B at 12 months (3.3% versus 13.3%, respectively), 24 months (20.0% versus 36.7%, respectively), and 36 months (33.3% versus 53.3%, respectively) after surgery. The objective failure rate also differed significantly (P < 0.05) between the two groups after 12 (10.7% versus 25.0% for group A and group B, respectively), 24 (29.6% versus 57.7%, respectively), and 36 (42.3% versus 61.5%, respectively) months of follow-up., Conclusion(s): Laparoscopic colposuspension performed with sutures is more effective than laparoscopic colposuspension accomplished with the use of prolene meshes in the long term, and the use of prolene meshes should be avoided in treatment of GSI.

Objective: To evaluate the effectiveness of the injection of bupivacaine plus epinephrine before laparoscopic myomectomy., Methods: Sixty premenopausal women with uterine leiomyomata were enrolled in a randomized controlled design and intraoperatively treated with injection of bupivacaine plus epinephrine (group A) or saline solution (group B) during laparoscopic myomectomy. Uterine size and volume, number of leiomyomata, hematological parameters, total operative time, enucleation time of each myoma, suturing time of the myomectomy, blood loss, degree of surgical difficulty, and postoperative pain were evaluated. Just before and after the injection of vasoconstrictive or saline solution, systolic and diastolic blood pressure and heart rate were recorded in each subject., Results: Blood loss, total operative and enucleation time, and degree of surgical difficulty was significantly (P <.05) lower in group A than in group B. No difference was observed between groups in suturing time of the myomectomy. The number of vials of pain medication used postoperatively was significantly (P <.05) lower in group A than in group B. No differences in systolic and diastolic blood pressure or heart rate was recorded between the 2 groups., Conclusion: The injection of bupivacaine plus epinephrine during laparoscopic myomectomy is effective in reducing blood loss, total operative and enucleation time, degree of surgical difficulty, and postoperative pain.

Background: A prospective, randomized, controlled study was performed to assess the efficacy of auto-crosslinked hyaluronic acid (ACP) gel to prevent the development of de-novo intrauterine adhesions following hysteroscopic surgery., Methods: One hundred and thirty-two patients with a single surgically remediable intrauterine lesion (myomas, polyps and uterine septa, subgroups I-III) completed the study. Patients were randomized to two different groups: group A underwent hysteroscopic surgery plus intrauterine application of ACP gel (10 ml) while group B underwent hysteroscopic surgery alone (control group). The rate of adhesion formation and the adhesion score was calculated for each group and subgroup 3 months after surgery., Results: Group A showed a significant reduction in the development of de-novo intrauterine adhesions at 3 months follow-up in comparison with the control group. Furthermore, the staging of adhesions showed a significant decrease in adhesion severity in patients treated with ACP gel., Conclusions: ACP gel significantly reduces the incidence and severity of de-novo formation of intrauterine adhesions after hysteroscopic surgery.

Study Objective: To assess the long-term effectiveness of presacral neurectomy (PSN) in women with severe dysmenorrhea due to endometriosis treated with conservative laparoscopic surgical intervention., Design: Randomized, controlled trial (Canadian Task Force classification I)., Setting: University-affiliated department of obstetrics and gynecology., Patients: One hundred forty-one sexually active women of reproductive age., Intervention: Conservative laparoscopic surgery without (group A) or with (group B) PSN., Measurements and Main Results: At entry and 24-months after surgical procedures, cure rates; frequency and severity of dysmenorrhea, dyspareunia, and chronic pelvic pain; and quality of life were evaluated. At follow-up visit, the cure rate was significantly (P<0.05) higher in group B (83.3%) than in group A (53.3%). The frequency and severity of dysmenorrhea, dyspareunia, and chronic pelvic pain were significantly (P<0.05) lower in both groups compared with baseline values, and only severity was significantly (P<0.05) lower in group B. A significant (P<0.05) improvement in quality of life was observed after surgery in both groups and was significantly (P<0.05) increased in group B compared with group A., Conclusion: PSN improves long-term cure rates and quality of life in women treated with conservative laparoscopic surgery for severe dysmenorrhea due to endometriosis.

Objective: To assess the efficacy of autocrosslinked hyaluronic gel in postsurgical adhesion prevention after laparoscopic myomectomy., Design: Prospective, randomized, controlled study., Setting: University of Naples "Federico II".Thirty-six infertile women with symptomatic myomas were randomly divided into two groups of 18 patients each., Intervention(s): Laparoscopic myomectomy with subserous sutures or interrupted figure 8 sutures, with (group A) or without (group B) application of autocrosslinked hyaluronic acid (HA) gel., Main Outcome Measure(s): Rate of postsurgical adhesions at 60-90 days of follow-up. The rate of subjects who developed postoperative adhesions was significantly lower in group A in comparison with group B (27.8% vs. 77.8%). In both groups, the rate of adhesions was significantly higher in patients treated with interrupted figure 8 sutures than with subserous sutures., Conclusion(s): Autocrosslinked HA gel is a promising resorbable agent barrier for the reduction of postoperative adhesions after laparoscopic myomectomy. Moreover, the type of suture is a factor influencing the postsurgical adhesion formation.

Objective: To determine the diagnostic value of hysteroscopy in endometrial cancer., Methods: 216 patients underwent hysteroscopy and endometrial biopsy. A comparison was made between hysteroscopic impression and histological examination., Results: Sensitivity of hysteroscopy for diagnosing of endometrial cancer was 83.33%, specificity was 99.04%, positive predictive value was 71.42% and negative predictive value was 99.52%., Conclusion: Hysteroscopy was found to have a very important role in the diagnosis of endometrial cancer.

Background: To evaluate the efficacy of the urinary test "Persona" in the recognition of the fertile period comparing hormonal assay and monitoring the follicular growth by ultrasonography., Methods: Twenty women have used "Persona" for 13 cycles (200 cycles). This device evaluates changes in E-3-G and LH concentrations and estimates the fertile days which are displayed by a red light. Inclusion criteria were: age 22-45, regular menstrual cycles (23-35 days), absence of the polycystic ovary syndrome. The participants underwent vaginal ultrasonography in several days (one of the first 7 "green days", the first "red day", the ovulation day "O", and the first "green day" after ovulation) and determination of blood concentration of LH, in the ovulation day, and progesterone, in the 21st day of cycle., Results: Vaginal ultrasonography was in agreement with predictions of "Persona" in 96% in the first "green days", in 94% in the first "red day", in 95,8% in the ovulation day and in 97,5% in the first "green day" after ovulation. All participants with ultrasonographic evidence of ovulation had a concentration of LH included in 13-71 mUI/ml range and of progesterone included in 12-50 ng/ml range., Conclusions: These results suggest that the "Persona" test is effective in the recognition of the fertile period, but a correct maintenance of the microcomputer is important for the best reliability of method. The method seems to be a wellcome alternative for couples who want to use natural family planning.

Background: The study was designed to compare local anaesthesia and conscious sedation for outpatient bipolar operative hysteroscopy in terms of pain control and patients' satisfaction., Methods: A prospective multicentre randomized study was carried out in university hospitals and in a private endoscopy unit. A total of 166 women with surgically treatable lesions associated with infertility or abnormal uterine bleeding was considered eligible for the study. Patients were randomized, using a computer-generated randomization list, into two groups. Group A (82 patients) underwent operative hysteroscopy with local anaesthesia. Group B (84 patients) received conscious sedation. Operative hysteroscopy was performed with a bipolar electrosurgical device to cut, vaporize and coagulate. Main outcome measures were pain control during the procedure, the post-operative pain score at 15 and 60 min, and at 24 h after the procedure, and patients' satisfaction rate., Results: All procedures were completed within 35 min, the amount of saline used varied from 400-1200 ml. There were no significant differences between local anaesthesia and conscious sedation in terms of pain control during the procedure and in postoperative pain at different intervals. Satisfaction rate was similar in the two groups., Conclusions: Both local anaesthesia and conscious sedation can be used for operative hysteroscopy using a bipolar electrosurgical system without significant differences in terms of pain control and patients' satisfaction.

Objective: To evaluate the satisfaction rate, efficacy, and complication rate of carbon dioxide (CO(2)) versus normal saline as a uterine distension medium for outpatient diagnostic vaginoscopic hysteroscopy in infertile patients., Design: Prospective, randomized multicenter study., Setting: Hysteroscopy units in two university hospitals and in a private center., Patient(s): One hundred eighty-nine infertile women undergoing outpatient hysteroscopy., Intervention(s): Outpatient hysteroscopy was performed with CO(2) (group A) or normal saline (group B) and with endometrial biopsy when indicated., Main Outcome Measure(s): Quality of the visualization of the uterine cavity, procedure time, complications, patient discomfort, and satisfaction rate., Result(s): Significantly lower abdominal and shoulder tip pain and a lower incidence of vasovagal reactions were observed in group B in comparison with group A. A higher satisfaction rate and a lower operative time were obtained in the normal saline group in comparison with the CO(2) group. Moreover, group A required significantly more analgesics after the procedure than group B., Conclusion(s): Uterine distension with normal saline seems to have less adverse effects and is better tolerated by patients. Moreover, it allows operative procedures to be performed with the new bipolar instruments.

Objective: This study was undertaken to compare the relative efficacy and safety of hysteroscopic endometrial resection and laparoscopic supracervical hysterectomy in the treatment of abnormal uterine bleeding., Study Design: One hundred eighty-one patients affected by menometrorrhagia and unresponsive to medical treatment agreed to be randomized to either laparoscopic supracervical hysterectomy or hysteroscopic endometrial ablation. They were monitored for 2 years to evaluate perioperative and postoperative outcomes, resolution of symptoms, and patient satisfaction., Results: Duration of hospitalization, period of convalescence, perioperative complications, and resumption of normal activity were similar between the two groups. Operative time was significantly shorter in the hysteroscopic group, but patient satisfaction was significantly higher in the laparoscopic group., Conclusion: For the treatment of menorrhagia, hysterectomy has the distinct advantage of being curative but the disadvantage of being more invasive than the hysteroscopic approach. However, laparoscopic supracervical hysterectomy preserves the curative effect of hysterectomy without its increased surgical invasiveness, as suggested by the current study.

Background: This comparative study evaluated effectiveness, complications and patient satisfaction following the use of carbon dioxide (CO2) compared with physiological solution for uterine distension during hysteroscopy. The study was motivated by doubts concerning the choice of distension methods and the implications of their use., Methods: The study population included 189 patients attending the outpatient services of the Obstetrics/Gynecological Clinic of the University of Naples for sterility/infertility disorders. Patients were randomly assigned by computer to either of two treatment groups. Both groups underwent hysteroscopy. In Group A (92 patients), uterine distension was performed using carbon dioxide (CO2), while in Group B (97 patients) physiological solution was used. Treatment was assessed for effectiveness, causes of discomfort, patient compliance and satisfaction rate., Results: Compared with carbon dioxide (CO2), the use of physiological solution as a means of uterine distension was demonstrated certain advantages that were statistically significantly for the parameters of operating time, onset of vagal reactions, causes of discomfort, compliance and satisfaction rate, and cost-effectiveness of equipment., Conclusions: The use of physiological solution for uterine distension was observed to enhance patient compliance with hysteroscopy, because the method was better tolerated, more rapid and involved fewer failures.

This prospective randomized, single-blind, placebo-controlled clinical trial was performed to evaluate the efficacy of raloxifene in preventing the bone loss associated with GnRH agonist (GnRH-a) administration. One hundred premenopausal women with uterine leiomyomas were treated with leuprolide acetate depot at a dosage of 3.75 mg/d for 28 d and then randomized into two groups to receive raloxifene hydrochloride at 60 mg/d (group A) or placebo (1 tablet/d; group B). Bone mineral density (BMD) and serum bone metabolism markers were evaluated at admission and after six treatment cycles. Posttreatment BMD differed significantly from baseline BMD in group B but not in group A. BMD was significantly higher in group A than in group B. In group A, serum osteocalcin and bone alkaline phosphatase levels and urinary deoxypyridinoline and pyrilinks-D excretion were unchanged vs. baseline. Differently, posttreatment concentrations of these bone turnover markers were significantly lower in group B compared with baseline and group A values. In conclusion, raloxifene prevents GnRH-a related bone loss in premenopausal women with uterine leiomyomas.

Objective: The purpose of this study was to compare the satisfaction rate and the effectiveness of transcervical hysteroscopic endometrial resection and thermal destruction of the endometrium in the treatment of menorrhagia., Study Design: A prospective randomized trial with 2 years of follow-up was carried out in the Department of Gynecology of the University of Naples. Eighty-two patients who were affected by menorrhagia that was unresponsive to medical treatment were respectively randomized to transcervical hysteroscopic endometrial resection or to thermal destruction of the endometrium. Satisfaction rate, operative time, discharge time, complication rate, reintervention rate, and resumption of normal activity were evaluated in each group., Results: The satisfaction rate was significantly higher in the thermal destruction group. Operative time was significantly shorter in the thermal destruction group (24 +/- 4 minutes vs 37 +/- 6 minutes). Intraoperative blood loss was significantly lower in the thermal destruction group (7.2 +/- 2.8 mL vs 89 +/- 38 mL). Reintervention rates were higher in the transcervical hysteroscopic endometrial resection group, although postoperative pain was not significantly different between the two groups. Discharge time, complication rate, and resumption of normal activity were not significantly different between the two groups., Conclusion: Thermal destruction of the endometrium for the treatment of menorrhagia should be considered an effective therapeutic option because of its acceptability among patients, shorter operative time, and lower blood loss.

This prospective randomized single-blind placebo-controlled clinical trial was carried out to evaluate the effects of raloxifene administration on uterine and leiomyoma sizes in premenopausal women. Ninety healthy premenopausal women affected by asymptomatic uterine leiomyomas were enrolled and treated with raloxifene at the doses of 60 mg/d (group A), 180 mg/d (group B), or placebo (group C). The duration of the treatment was 6 cycles of 28 d each. At entry and after three and six cycles, uterine and leiomyoma sizes were measured by transvaginal ultrasonography. The difference between uterine and leiomyoma volumes (Delta size) was calculated in all subjects. The characteristics of the menstrual cycles and the side effects of the treatments were recorded using a daily diary. The severity of the uterine bleedings was assessed using a rank scale. Throughout the study, no significant changes were observed in uterine and leiomyoma size or in Delta size among the three groups and within each group of treatment. The length and severity of uterine bleedings was not significantly different between the three groups and within each group. In conclusion, raloxifene has no significant effect on uterine and leiomyoma size or on menstrual cycle in premenopausal women.

Objective: To study the bone metabolism in postmenopausal women who have been treated with gonadotropin-releasing hormone agonist (GnRH-a) and tibolone., Design: Prospective, open, controlled clinical trial., Setting: Department of Gynecology and Obstetrics, University of Catanzaro, Catanzaro, Italy., Patient(s): One hundred twenty perimenopausal women with symptomatic uterine leiomyomas (groups A and B), and 40 healthy control women who underwent a normal spontaneous menopause (group C)., Intervention(s): Treatment for 12 months with leuprolide acetate plus tibolone (group A) or hysterectomy with bilateral oophorectomy (group B)., Main Outcome Measure(s): Lumbar spine bone mineral density (BMD) and bone turnover markers at entry into the study, after medical treatment (only group A), and 12 months after discontinuation medical treatment (group A) or after surgery (group B). The same parameters were noted in healthy women before and 12 months after menopause (retrospective control group, group C)., Result(s): At the women's entry into the study, no significant difference in BMD and bone turnover markers was detected between groups A and B. In group A, no significant variation in BMD or bone turnover markers was observed 12 months after medical treatment in comparison with baseline. At 12 months after discontinuation of treatment (in women who had achieved menopause) and after surgery, we observed a statistically significant decrease in BMD and in bone turnover markers in both groups in comparison with baseline. At 12 months after they became menopausal, we also observed a statistically significant reduction in BMD and in bone turnover markers in control group C. At the same 12-month follow-up visit, a statistically significant difference in BMD and in bone turnover markers was detected when comparing groups A and B with group C., Conclusion(s): Women previously treated with GnRH-a and tibolone similar to women who are menopausal as a result of surgery, have higher bone loss after menopause.

Maternal endocrine disorders can have detrimental effects on the fetus and the pregnancy can affect the course of a pre-exisiting endocrinopathy or induce the onset of one of these disorders. Therapies for endocrine disorders are not always safe to administer during pregnancy. Before administering any therapy to the mother, the effects on the fetus, the degree of placental trespassing as well as the potential damaging effects must be assessed. An accurate evaluation of the risks/benefits of any drug to be used on the mother is needed, assessing above all a potential theratogenic effect. In this review, the incidence of the main endocrine disorders, their evolution during pregnancy, their effects on mothers and fetuses and new acquisition on the treatment during pregnancy are discussed.

The use of exogenous gonadotropins, alone or in association with other drugs, is a useful tool in the treatment of anovulation. The first stages of the follicologenesis are gonadotropin independent up to the preantral stage. The final phase of this process begins when follicles grow faster during the luteal phase of the preceding cycle, the so-called gonadotropin-dependent phase. Recent studies confirmed the central role of FSH in follicular and oocyte maturation, but also re-evaluated the actions of LH, in particular during the first phases of these processes. LH induces the physiological development of the follicle, acting only on a limited number of follicles, while FSH protects against atresia. In the absence of FSH the development will be delayed. It seems obvious that both hormones are necessary, that a stimulation protocol may rely only on FSH, but the addition of LH will render it more physiological.

One of the main advances in the field of metabolic control of body weight and obesity treatment was the identification of the OB protein or leptin, that plays an important role in controlling body weight, signalling to the CNS the amount of body fat. Indeed, leptin levels are positively correlated to indices of body fat, namely total fat mass, percent body fat and body mass index (BMI). This protein may be also the signal that indicates the nutritional status to the reproductive axis. Whether this signal is exerted directly on the gonads or through the neuroendocrine axis is still to be determined. A sexual dimorphism between male and female in serum leptin levels has been observed, with the latter showing higher serum leptin levels. This evidence has led to the hypothesis that estrogens might have a stimulatory role in leptin secretion. To evaluate this hypothesis, several authors have determined serum leptin levels in postmenopausal women that have estrogen levels comparable to those present in men. The results of these studies are contradictory and the aim of this article has been the revision of data present in the literature regarding serum leptin levels in menopause and to correlate them to body composition changes taking place during menopause.

Objective: To evaluate the feasibility of a bilateral multiple ovarian biopsy through minilaparoscopy under local anesthesia and conscious sedation and to assess the efficacy of this technique as compared to the traditional laparoscopic approach., Study Design: Twenty-five infertile women with premature ovarian failure underwent bilateral ovarian biopsy plus chromoperturbation. Twelve patients were treated with minilaparoscopy (minilap group) and preoperatively received mepivacaine for subcutaneous local anesthesia and midazolam plus fentanyl for conscious sedation. Following minilaparoscopy, 40 mL of 0.5% intraperitoneal subdiaphragmatic lidocaine and 5 mL of ropivacaine, 7.5 mg/mL, for infiltration of the trocar insertion sites were administered. Thirteen women (control group) were treated with the traditional laparoscopic approach under general anesthesia. If necessary, ketoprofene or intramuscular ketorolac was administered following surgery. Postoperative pain score was evaluated by a 1-10 visual analogic scale immediately after surgery and in the following 24 hours; in addition, the quantity of ovarian biopsy material for the pathologist and the discharge and operative times were evaluated., Results: The minilap group had lower postoperative pain scores postoperatively. Operative time was similar in both groups. The rate of discharge two hours after surgery was significantly higher in the minilap group. In all cases the amount of ovarian tissue was sufficient for diagnosis. Twenty-one patients were affected by premature menopause and four by resistant ovary syndrome. The need for postoperative analgesics was significantly higher in the control group., Conclusion: Minilap allows the performance of bilateral, multiple ovarian biopsy under local anesthesia and conscious sedation in association with chromoperturbation and the obtaining a sufficient amount of ovarian tissue for histopathologic diagnosis. Intraperitoneal lidocaine administration and ropivacaine infiltration of the trocar sites were beneficial for patients undergoing operative minilap in a day-surgery setting. The effect of these drugs was obviously temporary; however, low postoperative pain scores and low additional analgesic requirement permitted early discharge, within two hours after surgery.

Background: To evaluate the feasibility of ovarian drilling using minilaparoscopy under local anesthesia and to determine its efficacy in the surgical treatment of polycystic ovarian syndrome., Methods: Prospective randomized study carried out in an out patient service on 62 women affected by PCOS divided into two groups: 32 patients (group A) underwent bilateral ovarian drilling by minilaparoscopy under local anesthesia and 30 patients (group B) underwent bilateral ovarian drilling by traditional laparoscopy under general anesthesia., Results: Operation times were not different between the two groups. Discharge time was significantly lower in group A in comparison to group B. The rate of patients discharged after 2 hours was significantly higher in group A. The need for additional analgesia was lower in group A in comparison to group B. Serum LH, A and T levels were significantly reduced after surgery in both groups. Pregnancy rate after 1-year follow-up was higher, although not significantly in group A. Ovulation and abortion rates were not different between the two groups., Conclusions: Ovarian drilling in minilaparoscopy under local anesthesia is a new option for gynecologists, allowing similar therapeutical results to those achieved by traditional laparoscopy, but with the benefits of a less invasive technique that can be carried out in an outpatient service without the need for general anesthesia.