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Dear editor With great interest we have read an article by Wu et al1 recently published in the International Journal of Nanomedicine aimed to estimate cytotoxicity, toxicity, and histopathological changes, as well as the postsurgical antiadhesion potential of biodegradable and thermosensitive micelles by combining in vitro and in vivo models. Our congratulations to Wu et al1 for their new, precisely designed, and promising study of nanoparticles used in the prevention of postsurgical adhesions. Even more so when we know that in most clinical studies the adhesion prevention adjuvants have failed. Taking into account medical and financial problems associated with postsurgical adhesions worldwide in the health care system, new developments in this area are welcomed and call for further investigation. We do not question the definite study question and design: the experimental models are precisely formed and trigger correctly described results, a knowledgeable discussion and subsequent reasonable conclusions in line with their achievements. However, in our opinion, for these biodegradable and thermosensitive micelles to be recommended for further clinical applications, experimental studies should be designed examining different doses of nanoparticles in order to establish the optimal dose of micelles, an evaluation of the impact of these materials in different time points after their application, ie, 14, 21, 28 days, as well as their long-term impact after 6 and 12 months. The impact of these particles on embryos in in vivo models should also be evaluated: do these particles last longer or do they have an impact on uterine wall tissue? In the future a personalized adhesion prevention strategy could be developed, with application of state of the art technologies, taking into account genetic and constitutional predisposing factors of the patients undergoing these surgical procedures, with targeted predisposing genetic and constitutional conditions.2 Subsequently, these biodegradable and self-assembling micelles could be designed to contain medication such as recombinant tissue plasminogen activator (rtPA),3 tPA genes, inhibitors of plasminogen activator inhibitor-1 (PAI-1) genes, or other cytokines activating the expression of individually targeted genes at certain times after surgery in order to lyse and remove temporary fibrinogenous adhesions. In conclusion, biodegradable micelles containing certain medications should be a basis for future personalized adhesion prevention strategies.

Ovarian sex-cord stromal tumor (SCST) comprises 5% of the ovarian neoplasm; it occurs as an ovarian mass or hemoperitoneum, and the surgical management of SCST is not well defined at early stage and in adult patients.The authors tested to test the total not radical laparoscopic management of SCST in postmenopausal women at early stage.Three postmenopausal women were admitted in University-affiliated hospitals for pelvic pain, ovarian complex mass and genital bleeding. Preoperative clinical and instrumental examination suspected an ovarian tumor; therefore, a total laparoscopic approach was attempted. All patients underwent laparoscopic oophorectomy with the frozen section, who suggested for ovarian SCST; one woman received a total laparoscopic hysterectomy plus other oophorectomy, two received only the complementary oophorectomy, all without intensive surgical staging by with pelvic and para-aortic lymphadenectomy, appendectomy, peritoneal biopsies, and omentectomy.All patients completed surgery without intrasurgical and postsurgical complications, with a fast dismissal. They are, currently, in long-term follow-up, with a 100% of survival after 3 years and with none morbility and morbidity.In order to fast restore and preserve women's integrity, total laparoscopic approach of early SCST in adult age, without intensive radical staging, could be an appropriate clinical choice, since these tumors at slow growth, recurring locally and only a long time after initial treatment. This minimally invasive management could be suggested in association with a long-term follow-up, as possible "wait and see" postoperative option.

Objective To show the prevention of adhesion formation by placing an absorbable adhesion barrier after intracapsular myomectomy. Design Prospective blinded observational study. Setting University-affiliated Hospitals. Patient(s) Patients ≥18 years old with single or multiple uterine fibroids removed by laparoscopic or abdominal intracapsular myomectomy. Intervention(s) A total of 694 women undergoing laparoscopic or abdominal myomectomy were randomized for placement of oxidized regenerated cellulose absorbable adhesion barrier to the uterine incision or for control subjects without barriers. The presence of adhesions was assessed in 546 patients who underwent subsequent surgery. Main Outcome Measure(s) The primary and secondary outcomes of the analysis were the presence and severity of adhesions for four groups: laparotomy with barrier, laparotomy without barrier, laparoscopy with barrier, and laparoscopy without barrier. Result(s) There was a higher rate of adhesions in laparotomy without barrier (28.1%) compared with laparoscopy with no barrier (22.6%), followed by laparotomy with barrier (22%) and laparoscopy with barrier (15.9%). Additionally, the type of adhesions were different, filmy and organized were predominant with an adhesion barrier, and cohesive adhesions were more common without an adhesion barrier. Conclusion(s) Oxidized regenerated cellulose reduces postsurgical adhesions. Cohesive adhesions reduction was noted in laparoscopy.

Objective. To compare cesarean section (CS) using open or closed visceral peritoneum of the bladder flap (BF) in relation to fluid collection in vesico-uterine space (VUS) by ultrasound (US) and clinical outcome. Material and methods. A prospective cohort of repeat CS in 474 in advanced first and second stage of labor was studied. All women underwent a Misgav Ladach CS, in local combined anesthesia. These were divided into two groups by surgical management of the BF at the time of CS: Group I (n = 262), with visceral peritoneum left open and Group II (n = 212), with visceral peritoneum closed. An US check for the fluid collections in the VUS was done in the third post-operative day. The two groups were also clinically compared for: intra-operative estimated blood loss, the need for post-CS pain killers, febrile morbidity and duration of hospital stay. Results. Visceral peritoneum (VP) closure resulted in a significant increase blood collections in the VUS (p < 0.05). VP closure resulted in a significantly higher morbidity in all the following parameters. Rate of BFHs, post-operative fever, need for post-operative analgesia, require antibiotic administration and prolonged hospitalisation (p < 0.05). Conclusions. VP suturing of women requiring CS for dystocia is associated to increased rate of blood collection in the VUS, which could possibly explain the higher rate of puerperal complications in these patients. These data clearly indicate that suturing the VP of the BF in women undergoing CS for dystocia is contraindicated. This data could be probably extrapolated to all cesarean deliveries.

The authors studied the presence of substance P (SP) and vasoactive intestinal polypeptide (VIP) and their related fibers in the lower uterine segment (LUS) in 133 women undergoing cesarean sections (CS) during active labor. These were divided into 2 groups: women undergoing repeat or first CSs. Specimens were collected from the LUS and were evaluated by light microscopy and by immunohistochemistry, for the morphometrical quantification of the SP and VIP fibers in the LUS. The SP amount was higher in the post-CS scar, while the VIP amount decreased: nerve fibers contained an SP amount of up to 13 ± 2.6 C.U., while nerve fibers contained a VIP amount of up to 7 ± 1.9 C.U. The SP amount counts 10 ± 1.5% of the total Bodian fibers, and the ratio of the VIP is 10 ± 1.8% of their total amount. In normal conditions only 6.61 C.U. of the Bodian surface is occupied by SP related nerve fibers in contrast to 6.63 C.U. of the total surface by VIP; the amount of SP increased up to 13 ± 2.6 C.U., while it decreased in the LUS previous scars. The SP levels are higher in repeat CS, while the VIP levels are reduced in the LUS. The increase of SP is probably linked to the attempt to achieve cervical ripening in a post-CS LUS, with the possible consequences of dystocia during vaginal birth after CS. Nevertheless, the decrease of VIP probably affects the relaxation of the internal uterine orifice, compromising the LUS formation and cervical ripening.

Objective To allow a morphological evaluation of pseudocapsule vasculature of uterine leiomyomas (ULs). Design Preliminary prospective study. Setting University-affiliated hospitals. Patients Ten women with symptomatic myomas warranting laparotomic hysterectomies. Methods Pseudocapsules of ULs were isolated from the surrounding myometrium, for a digital reconstruction of pseudocapsule vessels and analysis by three-dimensional structure applying the Allen-Cahn mathematical model. The images were converted in a matrix and an appropriate created software elaborated the images. The “nonlocal” Allen-Cahn mathematical model was applied to reduce the image noise and to regulate vessel outlines obtaining a “clean” image. Main outcome measures The geometrical characteristics and morphology of vessel pseudocapsule network of ULs. Results The disarray in vascular architecture was evident from the absence of vessel parallelism and variable intervascular distances. An abnormal vascular branching of pseudocapsule was indicated by the different density of vessels per space and some vascular walls without interruption indicated vessel tortuosity. There were vascular spaces, which did not communicate with other vessels (“cul-de-sac” vessels). Conclusions Pseudocapsule vasculature showed increase of tortuosity, disarray, abnormal branching and the presence of “cul-de-sac” vessels. Three-dimensional reconstruction of leiomyoma pseudocapsule vasculature network, despite the benign nature of ULs, showed geometrical characteristics of malignant neoplasm vessels.

To evaluate the effect of bladder flap formation (BFF) during caesarean section (CS) on the uterine scar, assessed during repeat CS.One hundred and fifteen women undergoing their first CS were divided into two groups: 58 women had a CS with BFF (Group 1) and 57 women had a CS without BFF (Group 2). During the repeat CS, four specimens from the uterine scar from the first CS were collected from each woman, and evaluated by light microscopy and transmission electron microscopy (TEM).Adhesions were found in 28 (48.3) women in Group 1 and 14 (24.1%) women in Group 2 (p0.01). Of the women with adhesions in Group 1, 20 (71.4%) had mild adhesions and eight (28.6%) had severe adhesions. Of the women with adhesions in Group 2, eight (57.1%) had mild adhesions and six (42.9%) had severe adhesions. Light microscopy revealed significant differences in submesothelial fibrosis (39.6% vs 12.2%; p0.01) and neo-angiogenesis of the mesothelial stroma (46.5% vs 21%; p0.01) in Groups 1 and 2, respectively. TEM revealed more specimens with inflammatory cells in Group 1 compared with Group 2 {mean 29.7 [standard deviation (SD) 1.3] vs 18.2 (SD 1.9) patients; p0.01}.BFF during CS leads to an inflammatory and fibrotic reaction, resulting in inflammation reactive and regenerative processes, mesothelial hyperplasia and submesothelial fibrosis. CS without BFF reduces the inflammatory processes and the subsequent intraperitoneal adhesions and adhesions between the bladder and uterus.

The aim of this study was to compare single versus multiple laparoscopic myomectomy with an intracapsular method.A total of 335 laparoscopic intracapsular myomectomies were compared. They were subdivided into two groups. Group I included 195 patients with myoma; group II, 140 patients with multiple myomas, 4-9 cm in diameter. Laparoscopic procedures were compared with respect to intraoperative complications, postoperative compliance, and general surgical feedback. Results were analyzed using SAS software (version 8), considering a P-value of0.05 as significant.No differences (P0.05) between groups were observed with respect to the following: intraoperative blood loss (98 ± 4.7 mL of group I versus 106 ± 6.8 mL of group II), catheter inside pelvis for postsurgical drainage (40% versus 36.4% women), analgesic administration for the first 24 hours (41.5% versus 40% patients), postoperative fever after 24 hours (11.2% versus 9.2% women), postoperative therapeutic antibiotics administration (8.2% versus 6.4% patients), and hospitalization and postoperative ultrasound (US) intramyometrial hematoma detection (6.6% versus 5.7% of group II). The only surgical statistical difference (P0.05) was in the mean total laparoscopic time (60 ± 7.2 minutes for group I versus 97 ± 8.9 minutes for group II).Intracapsular laparoscopic myomectomies, performed in the same session on a single or on multiple fibroids, seem to preserve myometrial integrity and allow the restoration of uterine scar, with few early and late surgical complications.

Antioxidant phytochemicals, including the polyphenols from olive oil oleuropein (OE) and hydroxytyrosol (HT), and red wine antioxidant resveratrol (RSV) and quercetin (Q), are associated with low prevalence of cardiovascular diseases and cancer. Angiogenesis is a key process both in cancer and atherosclerosis, and is tightly regulated by molecular mediators including reactive oxygen species (ROS), cyclooxygenase (COX)-2 and matrix metalloproteinases (MMPs). We studied the effects of olive oil and red wine antioxidants on the angiogenic potential in an in vitro model of angiogenesis, and explored underlying mechanisms.

The isotretinoin, a 13-cis-retinoic acid, has revolutionized the management of severe treatment-resistant acne and it has been widely used for a range of dermatological conditions, in 90% of the time in young women between 13 and 45 years of age. This agent has severe teratogenic effects, as serious craniofacial, cardiovascular, thymic and central nervous system malformations. The baseline population risk of malformations is 3-5%, but it increases to almost 30% in women exposed to isotretinoin during the first trimester of pregnancy. Generally, patients in treatment with isotretinoin avoid eventual pregnancy during assumption and, after its stopping, fertility and foetal development are normal once circulating isotretinoin levels return to normal. There are no known deleterious effects on male fertility and on long-term teratogenic effect of isotretinoin. In this report, we suppose the possibility to develop a foetal malformations after a long-term wash out from isotretinoin therapy. A 32 year-old healthy nullipara pregnant woman, with an uneventful past gynaecological history, was admitted in Hospital, with a severe depressive syndrome in a 18 weeks malformed pregnancy for thoraco-omphalopagus conjoined twins. She only assumed isotretinoin, at dose of 1 mg/kg a day, for a severe and scarring acne for 7 months. After 3 months of pharmacological wash out, patient become pregnant and manifested this severe malformation. Woman interrupted gestation, by labour induction.

Objective Cornual pregnancy refers to the implantation and development of a gestation in one of the upper and lateral portions of the uterus; authors report their experience in laparoscopic therapeutic procedures on three singleton cornual pregnancies. Study design Three healthy women were admitted in General Hospitals with suspect of cornual pregnancies by clinical examination, increasing of β-hCG value and transvaginal ultrasonography. One of them had a haemoperitoneum. Surgeons performed all operative laparoscopies, by incision and enucleating of ectopic cornual mass, coagulating of its surrounding vessels and suturing of the uterine incision site. Results Patients were successfully treated only by laparoscopy, post-operative recovery period was normal in all women, with no further therapeutically intervention in the follow-up course. The aftermath was uneventful at the follow-up of 2 years. Conclusion In cornual pregnancies, the minimally invasive surgical treatment by salpingotomy or resection of the cornual region of the uterus and the suturing of the incision site, should be the option in women interested in future fertility.

Primary peritoneal serous borderline tumor (PPSBT) is an uncommon lesion, histologically indistinguishable from non-invasive peritoneal implants found in association with ovarian tumours of borderline malignancy.A 37-year-old white woman was admitted for acute pelvic pain due to two 5 cm retrouterine bilateral ovarian cysts with an endometrioid aspect. Clinical examination, CA 125, transvaginal ultrasonography and magnetic resonance were used preoperatively to confirm the suspected diagnosis of pelvic endometriosis; conservative laparoscopy with an extensive pelvic toilette of pelvic scarring was performed to preserve her fertility. Surgeons performed cyst removal, detached bowel adhesions, removed all soft vesicular cysts and a soft blue nodule from the bowel, and coagulating all similar endometriotic islands in the pelvis. Surprisingly, the anatomopathological examination of samples revealed a rare PPSBT with diffuse implants on the bowel, bladder, and visceral and parietal peritoneum of the Douglas pouch.Although PPSBT is a rare entity, it is nonetheless important because of its macroscopic similarity to endometriosis and microscopic similarity to other peritoneal and mullerian proliferations of both benign and malignant biologic potential. It should be considered in the differential diagnosis of endometrioid lesions on the peritoneal surfaces of visceral and parietal peritoneum in patients submitted for gynaecological problems.

Background To compare the complications after total laparoscopic hysterectomy (LPS) and abdominal hysterectomy with lymphadenectomy (LPT) for early stage endometrial cancer in a series of 226 women and to assess the disease-free survival and the recurrence rate. Patients and methods Two hundred and twenty six patients with clinical stage I endometrial cancer were enrolled in a multicenter study and underwent surgical staging consisting of inspecting the intraperitoneal cavity, peritoneal washing, total hysterectomy, bilateral salpingo-oophorectomy, and in all cases we performed systematic bilateral pelvic lymphadenectomy by LPS or LPT approach. Results One patient of the LPS group had an uretero-vaginal fistula and another patient had an ureteral stricture temporarily treated with a stent. One patient of the LPS group had a bowel perforation due to dense adhesions with the peritoneum under the umbilicus, resolved with a bowel resection and an end-to-end anastomosis. In three patients of the LPS group we observed a vaginal cuff dehiscence and in one case a pelvic lymphocyst was reported. Conclusions The low intraoperative and postoperative complications rate, observed in the LPS group, highlights the feasibility, safety and efficacy of this surgical approach. The operating time was longer in the LPS group but the recurrence rate and the complication rate appear similar and not more than what is traditionally expected with the LPT approach, although further studies and cost-benefit analyses are required to determine whether the use of LPS improves the outcome over standard LPT and whether the advantages of this technique could be extended to a larger proportion of patients.

Objective: Genital prolapse is frequent in postmenopausal women; it describes the loss of support to the pelvic organs, resulting in a herniation of these into the vaginal channel. This problem affects 50% of parous women, and at least 50% of all women develop a mild form of genital prolapse after pregnancy. Methods: An extensive literature review from 1990 to 2008 was performed on prolapse etiology and its risk factors; analyzing the data, we reviewed the genetic and biological aspects, age-related prolapse, biological tissue modifications, surgical problems, pelvic musculature modifications, and neuropathy. Results: Data suggested that aging, pelvic trauma, and surgery evoke tissue denervation and devascularization, anatomic alterations, and increased degradation of collagen; all of these may lead to a decrease in mechanical strength and predispose an individual to prolapse. It has been demonstrated that there is a reduction in protein content and estrogens in uterosacral ligaments, in the vagina, and in the parametrium of women with prolapse. This is a possible explanation for why many surgical procedures to correct prolapse fail and recurrences after surgical correction are frequent. Conclusions: Even if the etiology of pelvic prolapse is poorly defined and multifactorial, aging risk factors, such as biomechanical abnormalities in connective tissue composition, hormonal deficiency, and irregular tissue metabolism, are nonmodifiable and therefore largely stated in clinical practice. Regardless of future developments, based on the reported findings, prolapse therapy will be more influenced by genetics, biological pelvic changes, changes in tissue homeostasis, and topical hormones, rather than general pelvic corrective surgical anatomy.

Vinorelbine (i.v.) plus capecitabine (oral) combination therapy is active in anthracycline/taxane pretreated patients with metastatic breast cancer. Availability of oral vinorelbine provides this combination in an all-oral formulation. Two consecutive phase II trials differing only in vinorelbine administration routes evaluated their respective activities and tolerabilities in this population. In the i.v. group (n = 38) disease control was 61% (37% PR, 24% SD), median TTP 6.8 months and median survival 11.3 months. In the oral group (n = 38) disease control was 77% (5.4% CR, 34% PR, 38% SD), median TTP 7 months and median survival 10 months. G3-G4 neutropenia was more common in the oral group (p < 0.05); G2-G3 anaemia [5] and G3 thrombocytopenia [1] were observed only in the oral group. Although the comparison between the two regimens was not randomized, the results observed in these two consecutive phase II studies may suggest that oral and iv vinorelbine, in combination with capecitabine, can achieve similar responses in patients with metastatic breast cancer refractory to anthra-taxane combinations.

More than 50% of major laparoscopic complications occur during the initial entry into the abdomen. We investigated the efficacy and the safety of two laparoscopic access techniques: the direct optical access (DOA) versus the classical open entry, as described by Hasson.Two hundred and two premenopausal women, homogeneous in age, parity, and body mass index undergoing laparoscopic surgery for simple ovarian cysts, were prospectively, randomly assigned to either open or DOA abdominal entry for laparoscopic surgery. The following parameters were compared: duration of access for entry into the abdomen, occurrence of vascular and/or bowel injury, and blood loss. The results were analyzed by using SAS software (SAS Institute, Inc., Cary, NC), considering a P-value of0.05 as significant.No statistically significant differences were observed in the occurrence of major vascular and/or bowel injury between the two techniques. However, time for establishment of abdominal entry was significantly reduced in the DOA group, as was the blood loss (P0.05).The results of this preliminary comparison on the DOA and the Hasson methods, commonly used by general surgeons and less frequently by gynecologists, suggest that the visual entry system confers a little statistical advantage over the traditional Hasson entry, in terms of safety, minimal time saving, and in reducing blood loss, allowing a safe, fast, visually guided entry.

Objective To describe a rare case of a singleton 9-week cervical–isthmic pregnancy (CIP), treated by laparoscopic removal of the ectopic pregnancy and suturing of the uterine site of the ectopic pregnancy with single stitches. Design Case report. Setting Main general hospital. Patient(s) A 37-year-old woman was admitted for suspected singleton CIP at week 9, following two Cesarean sections. Clinical examination, β-hCG increase, and transvaginal ultrasonography were used to monitor the suspected diagnosis of an ectopic pregnancy. Following failure of methotrexate administration, surgeons performed a laparoscopy. Intervention(s) The CIP removal was performed by laparoscopic incision, enucleating the isthmic mass and suturing the uterine site of the ectopic pregnancy with single stitches. Main Outcome Measure(s) Intraprocedural or postprocedural complications and uterine integrity preservation. Result(s) Postoperative recovery period was normal, without intraprocedural or postprocedural complications. Uterine integrity was preserved. No further therapeutic interventions were needed in follow-up. Conclusion(s) In the case of CIP in women interested in minimally invasive treatment, resection of an ectopic pregnancy and suturing of the removal site may be an option to preserve uterine integrity. By improving endosurgical skills, these treatments may be safely proposed avoiding further invasive therapies.

Tumors of the epithelial surface account for about 80% of all ovarian neoplasms and exhibit a heterogeneous histological classification affecting survival. Tumors of low malignant potential, defined as borderline ovarian tumors(BOTs), have a markedly better survival and low recurrence, even if surgery still represents the common management for this type of cancer. It is still debated in the literature if BOTs can be considered as intermediate precursors in the progression to high grade ovarian tumors. Evidences now propose that high-grade serous carcinomas are not associated with a defined precursor lesion. Together with histopathological studies, mutations of KRAS, BRAF and p53 genes, microsatellite instability (MSI)and under- or over-expression of many genes and proteins have been used to address this question. Despite the large body of data summarized, a limited number of molecules proved to be useful in elucidating BOTs pathogenesis and only a few of these showed possible application in the therapy. We believe that high-throughput technologies would help to overcome these limitations offering the promise of a better understanding of BOTs classification. The aim is to guide the diagnosis and prognosis of BOTs to develop new possible therapeutic molecular targets avoiding surgery.

Docetaxel is a chemotherapeutic drug which has recently demonstrated high efficacy in the treatment of a wide variety of tumors. Numerous novel targeted drugs are being introduced in preclinical and clinical practice, aiming to directly inhibit pathways responsible for the maintenance of transformed and immortalized phenotypes of cancer cells. Herein we reported the efficacy and safety results of the most significant clinical trials evaluating different combinations and schedules of docetaxel plus biological therapeutics.

Objective To outline the most recent information regarding conservative laparoscopic surgery for young women with borderline ovarian tumors. Design Review article. Setting Advanced Gynecological Endoscopy Center, Malzoni Medical Center, Avellino, Italy. Patient(s) Young women with low-stage borderline ovarian tumors who wish to preserve their fertility. Intervention(s) Conservative laparoscopic surgery with unilateral salpingo-oophorectomy or cystectomy. Main Outcome Measure(s) Recurrence rate and outcomes. Result(s) Laparoscopic cystectomy may have more chance of preserving a woman's fertility compared with adnexectomy because of the removal of less ovarian tissue. Its greatest danger is the risk of inadvertently leaving behind some malignant cells. Therefore, this procedure should be reserved for patients with previous unilateral salpingo-oophorectomy or when bilateral lesions are present to preserve at least some ovarian tissue. Conclusion(s) When borderline ovarian tumors are identified at surgery by intraoperative histology, the recommended conservative treatment should be laparoscopic salpingo-oophorectomy. Recurrence can be noted after this type of treatment, but the cases of recurrent disease can be detected with close follow-up and treated accordingly. For these reasons, careful selection of candidates for this kind of treatment is, of course, necessary and close follow-up is required. If these restrictions are rigorously applied, then fertility-sparing surgery may be considered a safe option for this pathology, but all laparoscopic procedures should be reserved for oncologic surgeons trained in extensive laparoscopic procedures.

Objective : Complications associated with initial abdominal entry are a prime concern for laparoscopic surgeons. In order to minimize first access-related complications in laparoscopy, several techniques and technologies have been introduced in the past years. This investigation compares two laparoscopic access techniques. Study design : 194 women underwent laparoscopic surgery for simple ovarian cysts: 93 were assigned to direct optical access (DOA) abdominal entry (group I), and 101 women to classical closed method by Verres needle, pneumoperitoneum and trocar entry (group II). The following parameters were compared: time required for entry into abdomen, occurrence of vascular and/or bowel injury, blood loss. The results were analyzed using SAS software. p -value Results : No statistically significant differences were observed in the occurrence of blood loss and minor vascular injury between the two techniques, as well as minor bowel injuries; time for of abdominal entry, instead, were significantly reduced in the DOA group. Conclusions : The results of the preliminary comparison between the DOA and the Verres methods, commonly used by gynecologists, suggests that the visual entry system confers a statistical advantage over closed entry technique with Verres needle, in terms of time saving and due to the minor vascular and bowel injuries, thus enabling a safe and expeditious, visually-guided, entry for surgeons.

article i nfo Objective: To determine the effect of closure or non-closure of the visceral peritoneum at cesarean delivery on uterine scar formation assessed at repeat cesarean delivery. Methods: Women undergoing initial cesarean delivery were allocated into 2 groups: group 1 underwent visceral peritoneal closure, while in group 2 the visceral peritoneum was not closed. At repeat cesarean delivery 4 specimens from the initial uterine scar were collected and assessed by light microscopy and scanning electron microscopy. Results: In group 1, 57% of women had adhesions compared with 20.6% in group 2 (Pb0.05). Light microscopy revealed reactive mesothelial hyperplasia (51.8% vs 13.7%), submesothelial fibrosis (48.1% vs 6.8%), and neoangiogenesis of mesothelial stroma (44.4% vs 12%) in group 1 and group 2 patients, respectively (Pb0.05). Scanning electron microscopy showed more patients with pericytes on the surface of microvessels in group 1 compared with group 2 (26.3±1.4 vs 11.5±1.1 patients; Pb0.05). Conclusion: Closure of the visceral peritoneum at cesarean delivery may produce an inflammatory reaction and adhesions, evidenced by reactive and regenerative mesothelial hyperplasia and submesothelial fibrosis. © 2009InternationalFederationofGynecologyandObstetrics. Publishedby Elsevier Ireland Ltd. All rightsreserved.

Background: Endometriosis is an estrogen-dependent disease, associated with pelvic pain and infertility, with still limited knowledge of the pathogenesis, pathophysiology of related infertility and evolution. Objective: To investigate proteogenomic approaches and new trends of endometriosis treatment. Methods: A literature search was carried out for all articles on endometriosis related to immune system, and to nonhormonal, antiangiogenic and experimental therapies. Results/Conclusions: Classic endometriosis pharmacotherapy is represented by GnRH agonists, oral contraceptives and Type II progesterone receptor ligands. New proteomic and genomic technologies could help to clarify the aetiology of endometriosis and promise the rapid identification of a new generation of drugs with a specific molecular target, with the aim to ameliorate the patients quality of life.

The cesarean section (CS) is one of the most frequently performed surgical procedures worldwide, performed by suturing or not suturing the visceral peritoneum. In the case of not suturing the visceral peritoneum, pathological fluid collections can arise in this space and spill into the large peritoneal cavity, creating a hemoperitoneum.In this retrospective study we evaluated 3890 repeat and first CS, performed under spinal or combined spinal-epidural anesthesia, over the last 10 years. In all the CS evaluated, we excluded those performed with open parietal peritoneum and the classical CS by closure of the visceral and parietal peritoneum.Three important early puerperal post-CS complications with hypovolemic shock signs were detected, urgently treated by two relaparotomies and a laparoscopy.The scientific literature reports the early benefit of not suturing the visceral peritoneum during CS, but in rare cases, early and dangerous complications occur. The post-CS hemoperitoneum must be detected immediately by transvaginal or transabdominal ultrasonography, and must be treated by needle aspiration in slight cases and by laparoscopy or laparotomy in heavy cases, with drainage and accurate hemostasis.

Cervical pregnancy (CP) is a rare and life-threatening ectopic pregnancy characterized by implantation of the fertilized ovum into the cervix, whereas exocervical pregnancy is an extremely rare CP with implantation of the fertilized ovum on the exocervix. Possible causative factors of CP such as tubal dysfunction, impaired sperm motility, previous uterine surgery, or the use of intrauterine device were not clearly associated with the development of CP until now. Diagnosis of CP is usually established by ultrasonography and by beta-human chorionic gonadotropin serum tests, but definitive diagnosis is by histologic examination. Current treatment strategies of CP, which were described in some reports, involve: medical treatment with methotrexate, surgical removal of ectopic trophoblastic tissues, cervical cerclage and vaginal packing, ligation of descending branches of uterine arteries or hypogastric arteries, and unilateral internal iliac artery embolization. We report a case of exocervical pregnancy contemporary to intrauterine device normally inserted, diagnosed by colposcopy, beta-human chorionic gonadotropin, and histology, and treated by a local excision without using methotrexate chemotherapy.

The purpose of this study is to describe the technique of total laparoscopic radical hysterectomy (type III procedure) with lymphadenectomy as performed at the Advanced Gynecological Endoscopy Center of the Malzoni Medical Center, Avellino, Italy. Seventy-seven patients underwent total laparoscopic radical hysterectomy (type II, III) with lymphadenectomy between January 2000 and March 2008. FIGO stage included five patients Ia1 with LVSI (lymph-vascular involvement), 24 patients Ia2, and 48 patients Ib1. 60 patients underwent a class III procedure and 17 patients a class II procedure according to the Piver classification. Histological types included squamous cell carcinoma in 65 patients, adenocarcinomas in 10 patients, and adenosquamous carcinoma in two. Para-aortic lymphadenectomy was performed up to the level of the inferior mesenteric artery in eight cases with positive pelvic lymph nodes at frozen section evaluation. Total laparoscopic radical hysterectomy can be considered a safe and effective therapeutic procedure for the management of early stage cervical cancer with a low morbidity; moreover, the laparoscopic route may offer an alternative option for patients undergoing radical hysterectomy, although multicenter studies and long-term follow-up are required to evaluate the oncologic outcomes of this procedure.

Introduction: Tuberculosis (TB) is a rare curable infective disease, caused mainly by Mycobacterium tuberculosis, which in abdominopelvic (AP) localisation, can mimic a disseminated carcinomatosis. Symptoms of AP-TB are non-specific, so diagnosis is difficult and elusive as the affected patients have normal chest X-ray and elevated levels of CA125. Female ultrasonographic features of AP-TB mimic peritoneal carcinomatosis, and the computed tomography has also been suggested to be helpful, but the final diagnosis was reached by histology and serology. Aim of the study: To propose the validity of the combination of laparoscopy (LPS), histopathology and enzyme-linked immuno-spot (ELIspot) in the diagnosis of AP-TB. Methods: In the last two years, we had six women with suspect of AP-TB, who, after the routine exams, were referred for a diagnostic LPS that revealed turbid-free fluid in pelvis or ascites (collected for serology), multiple peritoneal and/or bowel tubercles (randomly sampled), fibrous bands, adhesions, hyperaemic and oedematous bowel loops. Results: LPS diagnosis was confirmed by intra-LPS biopsy of nodules and histological examination of specimens: epithelioid granulomas with central caseous necrosis in five patients (83.3%) and a non-caseating granulomatous inflammation in the last one. An outer layer of epithelioid histiocytes and Langhans cells was present in all patients. Using the ELIspot technique performed on free fluids, the final diagnosis of TB was made in all patients. Conclusions: Even if gynaecological LPS appearance of the peritoneum can mimic other conditions, ELIspot and histopathological exam can confirm the suspect of AP-TB.

Objective To determine the diagnostic accuracy of transvaginal ultrasonography (TVS) and hysteroscopy for the diagnosis of endometrial pathology in postmenopausal women with abnormal uterine bleeding (AUB). Design This prospective nonrandomized study was conducted on 752 postmenopausal women with AUB who underwent TVS and outpatient hysteroscopy with eye-directed biopsy. Histologic diagnoses were compared with the ultrasonographic and hysteroscopic findings, and the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were determined. Results In three cases of atrophic endometrium on hysteroscopy, histologic examination revealed endometrial carcinoma. TVS using an endometrial thickness of less than 4 mm as the cutoff showed sensitivity of 89%, specificity of 86%, a positive predictive value of 82%, a negative predictive value of 92%, and diagnostic accuracy of 87%. Hysteroscopy was technically successful in all women and revealed sensitivity of 98%, specificity of 91%, a positive predictive value of 88%, a negative predictive value of 98%, and diagnostic accuracy of 94%. Conclusions Hysteroscopy is a significantly more accurate diagnostic method for the detection of endometrial pathology than TVS, has better specificity, and should be considered for all patients with AUB with an endometrial thickness of more than 4 mm. Hysteroscopy shows great efficiency in the diagnosis of focal abnormalities of the endometrium, which are unlikely recognized by ultrasonography and should be indicated in cases of AUB with an endometrial thickness less than 4 mm on ultrasonography because of the possibility of missing infrequent (0.8%) but relevant endometrial pathologies. Among such women showing abnormal or suspicious lesions, it is necessary to perform hysteroscopy with eye-directed biopsy because some cases of endometrial carcinoma could be missed.

Endometrial cancer is one of the most common invasive gynecologic malignancies in developed countries and the eighth leading cause of cancer death in women; it typically arises in the sixth or seventh decade of life. The aim of this review was to evaluate possible roles of genetic and socio-biological factors in type I endometrial cancer, largely confined to pre- and perimenopausal women, with a history of estrogen exposure and/or endometrial hyperplasia.An extensive literature review, from 1990 to 2007 was performed on modifiable risk factors for type I endometrial cancer. Additionally, carcinogenesis mechanisms, biomarker and hormonal and biomolecular approaches to cancer detection, progression and monitoring and socio-biological factors were reviewed.Several socio-biological and lifestyle characteristics, such as hormone replacement therapy, glycemic index, obesity, alcohol use, antipsychotic medication, melatonin, physical activity and variants in hormone metabolism genes have been identified as risk factors for developing endometrial cancer of type I, the majority of which are associated with excess estrogens causing continued stimulation of the endometrium. There is a genetic link to non-polyposis colorectal cancer syndrome, but association of endometrial cancer risk to other genetic polymorphisms has yielded conflicting results.Many factors linked to hormonal imbalance, such as obesity, weight change, body size, alcohol, hyper-androgenic states, glycemic index and antidepressant agents, influence the endometrial cancer risk, central to which are endogenous and exogenous estrogen hyperstimulation of the endometrium. Conversely, smoking cigarettes, diet, physical activity and melatonin production seem to reduce the risk of cancer development. Other external factors fit well with the unopposed estrogen theory, but more studies are needed to investigate modifiable and added risk factors for endometrial cancer.

Our study was aimed at evaluating the efficacy of therapy with promestriene, a synthetic diethyl-ether of estradiol with no distal hormonal effects, in patients undergoing surgical correction for stress urinary incontinence (SUI).Ninety-eight healthy, postmenopausal women, non-users of hormone replacement therapy, with a diagnosis of SUI and vulvovaginal dystrophy, were recruited and openly randomized into two main groups. Group I (48 patients) received promestriene 10 mg daily, by vaginal capsule, for 21 days before the operation. Group II (50 patients) underwent the surgical procedure with TVT (Tension-free Vaginal Tape) directly, without pharmacological preparation. The results were collected and analyzed using SAS software (version 8).The two groups were homogeneous in terms of age, parity and body mass index. There were no significant differences between the two groups with respect to the time required to accomplish the TVT, blood loss, length of hospital stay, blood component measurements and postoperative subjective symptoms. There were slight differences postoperatively in problems during intercourse and the appearance of new genital symptoms, but again they were not shown to be statistically significant.Our results, although preliminary and subjective, confirm the efficacy of remedial surgical treatment of SUI with TVT. Preoperative administration of promestriene seems to favor trophism and vascularization of the whole muscular and fascial support of the pelvic floor and facilitates performance of the operation, but is not supported statistically.

The bladder-flap hematoma (BFH) is an unusual complication of the cesarean section (CS) performed by Misgaw Ladach method or Stark CS (performed without peritoneal closure) and it is an usual event after the visceral peritoneal closure performed during the traditional method. A BFH is generally thought of as a blood collection located in a space placed between the bladder and lower uterine segment (LUS), called vescico-uterine space. If, during a Stark CS, pathological fluid collections arise in this space by uterine suture bleeding, these decant into the large peritoneal cavity causing a hemoperitoneum. This last complication can be easily and accurately detectable by ultrasonography, which can be utilised by non-invasive monitoring as a guide for the clinical follow-up. In the authors' experience, the CS by Stark method is associated with a lower febrile and infective morbidity and it is possible also to perform a successful conservative laparoscopy for the BFH management. Laparoscopical treatment of BFH offers to patients the potential clinical benefits of the minimally invasive endoscopical treatments, but it should be reserved for surgeons trained in extensive laparoscopic procedures.

Aim: To compare early hemorrhagic complications and the surgical and clinical outcome in the closure and non-closure of the parietal peritoneum in cesarean section (CS) patients. Material and Methods: We retrospectively evaluated 2,576 post-CS women subdivided and compared in two groups by open and closed parietal peritoneum (group I, n = 1,580, group II, n = 996). Results: The ultrasonographical detection of 23 blood collections (0.89%) was 14 in group I and 9 in group II, and of these we surgically treated 11 patients in group I and 8 patients in group II, with no statistical difference (p > 0.05); all group I patients showed hemoglobin point decreases and needed blood transfusions, with statistical significance (p < 0.05) linked to more severe early complications that make the post-CS outcome worse; no difference was confirmed in terms of antibiotic administration (p > 0.05). Conclusions: There was a significant increase of blood loss and transfusions in the first group. As the posterior surface of the Retzius space is open and if post-CS pathological bleeding occurs, blood can invade the peritoneal cavity causing a hemoperitoneum, with the possibility of hemorrhagic shock and a worse clinical outcome.

HPV (human papillomavirus) is a virus responsible for many female and male genital tract diseases. It is a small nonenveloped virus with icosahedral symmetry that contains a double-stranded DNA genomes of approximately 7,900 bp. Approximately 200 different HPVs have been characterized, classified in mucosal and cutaneous viruses, responsible for a wide spectrum of clinical conditions, from simple feet and hands warts to genital cancer. Their genome is functionally distinct in three regions. The condition of the host immune system is one of the factors that can strongly influence the natural history of HPV infection. The primary response to viral infection is cell-mediated, so conditions that compromise the immune system increase the viral infection risk. The molecular mechanisms involved in the onset of the cervical carcinoma are well defined, and they are mainly associated to the ability of the proteins E6 and E7 to neutralize the activity of p53 and retinoblastoma protein, respectively. The infection of HPV is mainly diagnosed through molecular methods. Several assays have been developed for the simultaneous identification of HPV types, the majority of which are polymerase chain reaction-based assays. Side by side with these assays, the emerging technology of the DNA chip may offer a reliable diagnostic tool for discriminating easily between many HPV genotypes.

The ovarian failure and the termination of reproductive female functions could influence the mental neurotransmission and the cognitive activity of menopausal women; female menopausal brain, one of the favorite estrogens target, could suffer of a negative homeostasis modification, affecting the daily behavior. So, neurotransmissive degeneration could expose aged women to some psychological disturbances, some of these frequently associated to hypoestrogenic hot flushes rise. Many studies showed the estrogen influence on female brain, and tried to explain how the hormonal replacement therapy (HRT), act on mood, life energy and cognitive activities. Although brain estrogenic activity seems to establish a useful role on neuromodulation and on the prevention of some psychopathologies, the conventional administration of HRT, improves the mood and menopausal female well-being, but it does not act on clinically depressed women.

Dysfunctional uterine bleedings are uterine hemorrhage, frequent in the climacteric period and are a usual gynecologic pathology in ambulatorial controls (10%).60 premenopausal women, have been enrolled, all affected by hyper-polymenorrhea or dysfunctional uterine bleeding; than they were subdivided them into 2 groups; Group I: 30 patients with GnRH analogues treatment (Decapeptyl da 3.75 mg/month, 6 months of therapy); Group II: 30 patients with Danazol treatment (danatrol, 200 mg/daily, 6 months of therapy). Clinical controls were performed by visit, a questionnaire compilation (Kuppermann index) and biochemical examinations, with this frequency: 0, 3, 6 and 9 months. Statistical evaluation was performed by Student "t" test.In both groups, either amenorrohea and symptomatic improvement after 3 months of therapy were observed, without statistical differences; a statistical difference (p0.01) was assessed in patients compliance, since were observed, without statistical differences a major frequency in collateral effects in II Group, with danazol therapy was observed. The results of this study show that, the limited occurrence of side effects in perimenopausal patients affected by dysfunctional uterine bleeding, treated with GnRH analogues, could affect the choice of pharmacological therapy in favor of these one.

To translate the concept of full-conditioning (FC) from animal experiments to the human, and to evaluate the efficacy for adhesion prevention. FC consisted of decreasing acute inflammation by 86% CO2+ 10% N2O + 4% O2 for the pneumoperitoneum, cooling of the peritoneal cavity, humidification, heparinized rinsing solution and 5 mg of dexamethasone as demonstrated in animal models.A randomized controlled trial (RCT: NCT01344486) comparing standard laparoscopy with full conditioning together with a barrier in a 2/3 ratio in 44 women undergoing deep endometriosis surgery at KULeuven. The primary aim was reduction of adhesions. Secondary aims were CO2 resorption, postoperative pain and recovery. Randomization was performed after signing informed consent. Adhesion scoring during second look laparoscopy and pain scoring were done blindly.In the FC group (n = 16) adhesions were completely prevented in 12/16 women whereas in the control group (n = 11) all women had severe adhesions (P 0.0005). Also the area, density and severity of adhesions were less. (P0.001). In the control group, severity, density and area of adhesions were strongly interrelated (P = 0.0001 for all areas) suggesting a common enhancing factor. In the FC group CO2 resorption (P 0.001), postoperative pain (P 0.001), and CRP concentrations (P 0.01) were lower while clinical recovery was faster (P 0.0001) and time to first flatus (P 0.002) shorter.This translational research confirms in the human the efficacy of FC in reducing CO2 resorption and adhesions with in addition less postoperative pain, lower postoperative CRP concentrations and an accelerated recovery.

Background: Optimal debulking surgery is postulated to be useful in survival of ovarian cancer patients. Some studies highlighted the possible role of bowel surgery in this topic. We wanted to evaluate the role of bowel involvement in patients with advanced epithelial ovarian cancer who underwent optimal cytoreduction. Methods: Between 1997 and 2004, 301 patients with advanced epithelial cancer underwent surgery at Department of Gynecological Oncology of Centro di Riferimento Oncologico (CRO) National Cancer Institute Aviano (PN) Italy. All underwent maximal surgical effort, including bowel and upper abdominal procedure, in order to achieve optimal debulking (R < 0.5 cm). PFS and OS were compared with residual disease, grading and surgical procedures. Results: Optimal cytoreduction was achieved in 244 patients (81.0%); R0 in 209 women (69.4.%) and R < 0.5 in 35 (11.6%). Bowel resection was performed in 116 patients (38.5%): recto-sigmoidectomy alone (69.8%), upper bowel resection only (14.7%) and both recto-sigmoidectomy and other bowel resection (15.5%). Pelvic peritonectomy and upper abdomen procedures were carried out in 202 (67.1%) and 82 (27.2%) patients respectively. Among the 284 patients available for follow-up, PFS and OS were significantly better in patients with R < 0.5. Among the 229 patients with optimal debulking (R < 0.5), 137 patients (59.8%) developed recurrent disease or progression. In the 229 R < 0.5 group, bowel involvement was associated with decreased PFS and OS in G1-2 patients whereas in G3 patients OS, but not PFS, was adversely affected. In the 199 patients with R0, PFS and OS were significantly better (p < 0.01) for G1-2 patients without bowel involvement whereas only significant OS (p < 0.05) was observed in G3 patients without bowel involvement versus G3 patients with bowel involvement. Conclusions: Optimal cytoreduction (R < 0.5 cm and R0) is the most important prognostic factor for advanced epithelial ovarian cancer. In the optimally cytoreduced (R < 0.5 and R0) patients, bowel involvement is associated with dismal prognosis for OS both in patients with G1-2 grading and in patients with G3 grading. Bowel involvement in G3 patients, carries instead the same risk of recurrence for PFS.

The clinical evaluation of the correct position of the fetal head during labor is often limited and wrong when the uterine cervix is not still well dilated, for the occurrence of ‘caput succedaneum...

Surgical repair of pelvic organ prolapse and follow-up: An institutional multi-center experience