Search

Introduction and Aim: Ovarian carcinoma (OC) is a common cancer in the Western Countries, and an important cause of death in patients suffering with gynaecologic malignancies. The majority of patients present with advanced disease at the time of diagnosis. Treatment with debulking surgery followed by chemotherapy is the standard approach while chemotherapy is contemplated when surgery is not possible. A correct pre-operative staging is important to ensure a most appropriate management. Laparoscopy (LPS) is the standard diagnostic tool for the assessment of intraperitoneal infiltration but is invasive and requires general anaesthesia. FDG-PET/CT is increasingly used for staging different types of cancer, and the aim of this study is to assess the value of FDG-PET/CT in staging advanced OC and its sensitivity to detect lesions in different quadrants of the abdominal-pelvic area compared to laparoscopy., Materials and Methods: From September 2004 till April 2008, 40 patients with high suspicion of OC were referred to our hospital for diagnostic LPS to explore the possibility of optimal debulking surgery. Those who were not suitable for surgery were referred for chemotherapy. Before chemotherapy, the patients underwent an FDG-PET/CT scan. The findings in 9 quadrants of abdominal-pelvic area (total 360 quadrants) for PET/CT and LPS were recorded and compared., Results: In 14/360 areas (3.8%), surgical evaluation was not possible because of presence of adhesions, thus the number of areas explored by laparoscopy was 346. Tumour was found in 308 quadrants (38 quadrants free of disease). PET/CT was positive in all 40 patients with true negative results in 26/346 quadrants (7.5%), and true positives results in 243/346 quadrants (70.2%). False positive and negative PET/CT results were found in 12/346 and 65/346 quadrants, respectively. False positive PET/CT findings were evenly present in all quadrants. False negative PET/CT findings were present in 31/109 (28.4%) upper abdominal quadrants (epigastrium and diaphragmatic areas). Final analysis showed a sensitivity and specificity for PET/TC of 78.9 and 68.4% respectively with a positive predictive value of 95.3%. A significant difference was noted between mean SUVmax associated with lesions smaller or larger than 0.5 cm (p=0.006)., Conclusion: Our results suggest that PET/CT may prove a useful tool for pre-surgical staging of ovarian cancer with a sensitivity and specificity of 78 and 68%, respectively. However, it may be used in combination with laparoscopy for better results. PET/CT showed an adequate correlation between SUVmax values and laparoscopy findings of lesions>5mm, but a high rate of false negative results in lesions<5mm such as in carcinomatosis. PET/CT should be used carefully in early stage disease, with low risk of peritoneal infiltration, because of high rate of false positive results, to avoid unnecessary therapy procedures., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

The long-term effects and tolerability of flutamide (Flu) in women with acne and seborrhea were evaluated. Over the 15-year period, which spans from January 1991 to January 2006, a total of 230 Caucasian women with acne, 211 of which also with seborrhea, received yearly reducing doses (250, 125, and 62.5 mg/day) of Flu alone or combined with oral contraceptive for a period varying from 3 to 6 years and more. Clinical and endocrine evaluations were performed half-yearly and yearly, respectively, in the first 3 years of the study, and yearly in the following years. Liver function evaluations were performed quarterly. Both the groups of patients under Flu therapy showed a similar, marked decrease in acne and seborrhea scores after 6 months of treatment compared with basal values. The maximum drug effect was observed after 1 year, and it was maintained during the following years of treatment. Androgens were strongly suppressed during treatment. During the first year of treatment with 250 mg/day, 4.8% of patients interrupted the study due to hepatic disorders. During the following years on the 125 and 62.5 mg/day doses, no transaminase elevation was observed. The study supports very low-dose Flu as a first-line therapy for women with acne and seborrhea.

Aim: The aim of this study was to investigate the feasibility and safety of laparoscopic staging of overweight women with endometrial cancer and to compare the surgical outcomes among these patients with those managed by laparotomy., Methods: This was a retrospective analysis (Canadian Task-force Classification II-3). We reviewed operative and hospital records of 70 patients with a body mass index >25 kg/m2 who underwent surgical treatment for endometrial cancer between 2001 and 2008. Thirty-five patients treated laparoscopically were compared to an equivalent group of patients treated by laparotomy. Operative and postoperative variables were afterwards assessed., Results: Women in laparoscopic group had a significantly lower blood loss (median, 25th-75th percentiles: 1.2, 0.8-2.0 in laparoscopic versus 1.8, 1.0-2.8 in laparotomic group, P<0.05). No differences between both group in terms of operative time (median, 25th-75th percentiles: 165 min, 130-183 in laparoscopic versus 135 min, 110-170 in laparotomic; P>0.05) and mean number of pelvic and para-aortic lymph nodes removed (22 ± 8.4 versus 24 ± 6.2 and 9.2 ± 2.5 versus 9.3 ± 5 respectively; P>0.05). Length of urethral catheter and hospital stay were statistically higher in laparotomic group (two days versus three days; four days versus seven days respectively; P<0.05)., Conclusion: Laparoscopic surgery in overweight women with endometrial cancer had equivalent surgical staging than women operated by laparotomy. With regard to postsurgical variables, overweight women who underwent laparoscopic surgery had better results than those treated by laparotomy.

Objective: To estimate whether, by using a new ultrasonographic technique (extended view; XTD view), young lean women with polycystic ovary syndrome (PCOS) have a more android fat distribution in comparison with normally menstruating women with ultrasonographic evidence of polycystic ovaries (PCO) and healthy control subjects, matched for both age and body mass index., Design: Prospective observational study., Setting: University Hospital., Sample: Forty-nine lean women with PCOS, 42 eumenorrheic women with bilateral PCO and 40 healthy volunteers with regular ovulatory cycles., Methods: Fasting blood sampling, ultrasonographic and Doppler analyses and blood pressure monitoring., Main Outcome Measures: Medical examination, biochemical and hormonal parameters, ultrasonographic abdominal fat measurements, ultrasonographic evaluation of carotid intima-media thickness and Doppler analysis of ophthalmic artery. An oral glucose tolerance test was performed to analyze glucose, insulin and C-peptide levels., Results: The XTD ultrasonographic preperitoneal area was significantly larger in women with PCOS than in control subjects (p=0.011). The preperitoneal/subcutaneous ratio was significantly higher in women with PCOS (1.1±0.26) compared with women with PCO (0.84±0.13; p=0.05) and control women (0.67±0.13; p<0.001). The mean pulsatility index of ophthalmic arteries was higher in the PCOS women (1.93±0.57) than in control subjects (1.84±0.38; p=0.041). Total cholesterol, triglycerides and LDL cholesterol were significantly higher in women with PCOS than in those with PCO and in control subjects., Conclusions: Women with PCOS have an android fat pattern correlated with an age-dependent increased risk of cardiovascular diseases., (© 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2011 Nordic Federation of Societies of Obstetrics and Gynecology.)

Background: Flutamide has been rarely used for the treatment of female pattern hair loss (FPHL). Flutamide treatment for FPHL has not been evaluated in long-term studies with sufficiently large numbers of women., Objective: To evaluate long-term effects, safety, and tolerability of flutamide in women with FPHL., Methods: A prospective cohort study was conducted in our tertiary care university hospital. The cohort included 101 women diagnosed with FPHL from January 1991 to January 2006. These women received yearly reducing doses (250, 125, and 62.5 mg/day) of flutamide for 4 years. The cohort included 33 patients treated with flutamide alone and 68 treated with flutamide combined with an oral contraceptive. Clinical and endocrine evaluations were assessed semiannually and annually, respectively, in the first 3 years of the study, and once in the following year. Liver function was evaluated quarterly., Results: Both groups showed a marked decrease in alopecia scores after 12 months of flutamide therapy, compared with baseline values. The maximum drug effect occurred after 2 years and was maintained during the following 2 years of treatment. Androgens were strongly suppressed. During the first year of treatment, 4% of patients abandoned the study due to hepatic disorders related to the drug. During the following years, with the lower treatment regimen, no patient abandoned the study because of hepatic alterations., Conclusions: Flutamide is a satisfactory therapeutic regimen for treatment of FPHL in the long run. Moreover, the use of very low doses (62.5 mg/day) of flutamide is associated with complete hepatic tolerability and high adherence.

Introduction: In males, an isolated gross postcoital hematuria is a very rare clinical phenomenon. No cases of postcoital macroscopic hematuria have been previously reported in females., Aim: To report a case of female urethral fibroepithelial polyp (FEP) associated with recurrent postcoital hematuria., Methods: A young (31 years old), eumenorrheic woman complained of three episodes of postcoital macrohematuria. The patient was assessed with a detailed history, with a bimanual pelvic examination and with bidimensional and tridimensional ultrasonographic and color Doppler analyses of the internal genitalia and of the urethrovaginal space., Main Outcomes Measures: Transvaginal two-dimensional (2-D) ultrasonographic evaluation of internal genitalia, bladder and urethra and three-dimensional (3-D) analysis of the urethra and paraurethral structures., Results: The 2-D transvaginal evaluation and the 3-D reconstruction showed a polypoid hypervascularized structure arising from the anterior urethral wall. A cystourethroscopy confirmed the presence of a FEP arising from the anterior wall of the urethra and allowed its removal., Conclusions: A gross postcoital hematuria may be associated with a urethral polyp. The ultrasonographic evaluation of the urethrovaginal space can facilitate the diagnosis., (© 2010 International Society for Sexual Medicine.)

Background/aims: Endometriosis is an invasive disease. Its diagnosis depends on laparoscopy, which is traumatic and associated with potential complications. The aim of this study was to develop a rapid, reliable, and less invasive diagnostic test for endometriosis. We hypothesized that genes related to cell invasion would be transcriptionally upregulated in endometriosis, and tested whether blood levels of their transcripts might be used as biomarkers of endometriosis., Methods: We used quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) to quantify the mRNA levels of vascular endothelial growth factor A (VEGFA), matrix metalloproteinase-3 (MMP-3), and MMP-9 in peripheral blood from 20 patients with mild/intermediate endometriosis, 20 patients with severe endometriosis and 20 endometriosis-free subjects., Results: Our results indicate that circulating mRNA for MMP-3 is significantly higher in patients with endometriosis than in control patients, regardless of the degree of severity. Conversely, the level of circulating mRNA for VEGFA and MMP-9 did not distinguish patients from controls., Conclusion: MMP-3 mRNA is a promising peripheral blood marker that discriminates between patients with endometriosis and healthy subjects. Our results support the possibility of finding genes suitable for diagnostic qRT-PCR for endometriosis in peripheral blood and should be explored further., (Copyright © 2010 S. Karger AG, Basel.)

Chemotherapy and/or radiotherapy protocols have improved the long-term survival of cancer patients. Frequent consequences of antiblastic treatments, used to eradicate malignancies, are the partial loss of ovarian function, which in children and young women can result in permanent sterility. Ovarian tissue cryopreservation implemented before the beginning of treatment may potentially restore fertility. However, the physical effects of cryopreservation can damage oocyte survival and decrease follicular cell integrity and stromal preservation. The aim of this study was to examine the effects of different concentrations of 1,2-propanediol (PROH) and sucrose as cryoprotectants and human serum as protein support. Particular concentrations tested were 1.26, 1.5 and 1.08 mol/l PROH, 0.175, 0.2, 0.224 and 0.3 mol/l of sucrose and 20%, 30% and 40% human serum in the freezing solutions and normal or raised sucrose concentrations in the dilution solutions. Ovarian cortical slices from 13 patients, aged 5-38 years, were cryopreserved using slow freezing-rapid thawing. Tests were conducted using light and transmission electron microscopy. Cryo-damage occurred predominantly in the stromal and follicular cells. The best preservation of morphological characteristics was obtained using the freeze-thaw protocol in which concentrations of cryoprotectants were among the lowest (1.26 mol/l PROH+0.175 mol/l sucrose) with 30% human serum., (Copyright © 2010 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: To verify the effects of a pill containing drospirenone on the surrogate markers of arterial function and to evaluate the possible improvements induced by the addition of L-arginine., Design: A prospective, placebo controlled, randomised, pilot study., Setting: University of Bologna., Population: Twenty-eight young women with PCOS., Methods: Random submission to: drospirenone + ethinylestradiol+ a placebo (Group I; n = 15) or drospirenone + ethinylestradiol + oral L-arginine (4 g × 2/daily) (Group II, n = 13)., Main Outcome Measures: Medical examination; blood measurement of nitrites/nitrates, biochemical and hormonal parameters; ultrasonographic analysis and colour Doppler evaluation of uterine, stromal ovarian and ophthalmic arteries; analysis of brachial artery flow-mediated vasodilatation; and 24-h ambulatory blood pressure monitoring. The above parameters were evaluated before and after 6 months., Results: The low dose oral contraceptive containing drospirenone favoured a pre-hypertensive state. The L-arginine supplementation increased the circulating levels of nitrites/nitrates and improved the endothelium-dependent vasodilatation counteracting the negative effect of the contraceptive pill., Conclusions: Although, the present pilot study was conducted in a limited number of patients, it seems that the L-arginine co-treatment may improve the long-term side effects of the pill reducing the risk of cardiovascular diseases.

Objective: To compare the effects of a pill containing drospirenone with those of a combined contraceptive vaginal ring on the lipid and carbohydrate metabolism and on the surrogate markers of arterial function., Setting: Bologna University School of Medicine., Patient(s): Thirty-seven women with polycystic ovary syndrome (PCOS) were randomly submitted to drospirenone+ethinylestradiol (group I; n=19) or combined contraceptive vaginal ring (group II; n=18) therapy. The duration of the study was 6 months., Intervention(s): The effect of treatments was assessed after 6 months of therapy., Main Outcome Measure(s): Utero-ovarian ultrasound analysis and color Doppler evaluation of uterine and stromal ovarian arteries. In addition, analysis of brachial artery flow-mediated vasodilatation and 24-hour ambulatory blood pressure monitoring were performed. Fasting blood samples were drawn for testing biochemical and hormonal parameters and nitrites/nitrates., Result(s): Both treatments improved hirsutism, hyperandrogenemia, and ultrasound and color Doppler ovarian parameters. Both drospirenone+ethinylestradiol or contraceptive vaginal ring induced a slight but significant increase of diurnal and 24-hour blood pressure. Although both therapies worsened the lipid profile, the oral pill administration was associated with a more evident increase of circulating triglycerides. The 6-month treatment with the vaginal ring significantly improved the area under the curve for glucose, insulin, and C-peptide, whereas the drospirenone+ethinylestradiol pill induced an increase in the insulinogenic index and homeostatic model assessment estimate for insulin resistance values., Conclusion(s): Vaginal hormonal contraception appears to be preferable to oral ethinylestradiol + drospirenone administration in hyperinsulinemic patients with PCOS., (Copyright (c) 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: The vaginal orgasm seems to be evocated by the stimulation of the G-spot: a highly sensitive area on the anterior wall of the human vagina. However, the existence of such a spot is controversial., Aim: To evaluate, by the use of three-dimensional (3-D) ultrasonography, the anatomic structures of the urethrovaginal space both in polycystic ovarian syndrome (PCOS) patients and eumenorrheic non-hirsute controls., Methods: Twenty-three (Group I) PCOS patients and 25 eumenorrheic young women (Group II) were submitted to two-dimensional (2-D) and 3-D ultrasonography and color Doppler analysis of the urethrovaginal space and of the clitoris., Main Outcome Measures: 2-D ultrasonographic evaluation of the ovaries and of the urethrovaginal space; color Doppler evaluation of the ovarian stromal arteries, urethrovaginal main feeding artery, and dorsal clitoral arteries; 3-D volume calculation of the urethrovaginal space, and 3-D power Doppler analysis of the vascularization index; flow index; and vascularization flow index; hormonal evaluation., Results: The vaginal orgasm was present in 13/23 (56%) patients in PCOS Group and in 13/25 (52%) in the controls. The 3-D reconstruction of the urethrovaginal space demonstrated a gland-like aspect with small feeding vessels: "female prostate." The 3-D mean volume of the "female prostate" was significantly higher in Group I (0.48 ± 0.21 mL) than in Group II (0.39 ± 0.19 mL; P = 0.044). The Virtual Organ Computer-aided AnaLys (VOCAL) built mean volume of the "female prostate" was positively correlated with the time since intercourse (r = 0.486; P = 0.032), with the total length of the urethrovaginal space (r = 0.616; P = 0.025) and with the testosterone (r = 0.424; P = 0.048) circulating values., Conclusions: The presence of the G-spot and its role in vaginal orgasm remains controversial. In Italians, and normal weight PCOS patients the hyperandrogenism seems to result in ovarian stromal and "female prostate" hyperplasia., (© 2010 International Society for Sexual Medicine.)

Introduction: In the adult female, a cyst of the Skene's duct is a rare event that may be either the late consequence of a congenital abnormality or the result of a chronic acquired inflammation., Aim: To report a case of bilateral paraurethral Skene's duct cysts., Methods: A young (32 years old), eumenorrheic (menstrual cycle of >25 and <35 days) woman complained of a 6-month intermittent scarce lubrication during intercourse and a sensation of a small intravaginal "extraneous" body. The patient was repeatedly assessed with a detailed history, with a bimanual pelvic examination and with bi- and tridimensional ultrasonographic and color Doppler analyses of the urethrovaginal space., Main Outcomes Measures: Transvaginal two-dimensional ultrasonographic evaluation of internal genitalia, bladder, and urethra and three-dimensional analysis of the paraurethral structures., Results: The evaluation of the structures comprised in the urethrovaginal space evidenced two small (1.7 and 1.1 cm in the maximum diameter) anechoic cysts with some debris in the most declivous part, laterally displaced to the middle/distal urethra. The cysts disappeared after a medical therapy., Conclusions: A sudden reduction of the vaginal lubrication requires a prompt gynecological and ultrasonographic evaluation of the urethrovaginal space., (© 2009 International Society for Sexual Medicine.)

Objective: The aim of the study was to evaluate the long-term effects and tolerability of flutamide (Flu) in hirsute women. To the best of our knowledge, this study represents the largest report, concerning the population studied and the duration of treatment, to evaluate Flu use in hirsutism treatment., Design, Patients and Methods: Over a 15-year period spanning from January 1991 to January 2006, a total of 414 premenopausal women with hirsutism of different aetiopathogeneses received yearly reducing doses (250, 125 and 62.5 mg/day) of Flu alone or in combination with oral contraceptives for a period varying from at least 3 to 8 years and more. Clinical and endocrine evaluations were assessed half-yearly and yearly respectively in the first 3 years of the study, and yearly in the following years. Liver function evaluations were assessed quarterly., Results: Both the groups of patients under Flu therapy showed a marked decrease in hirsutism scores after 12 months compared with basal values. The maximum drug effect was observed after 2 years, and it was maintained during the following years of treatment. Androgens were strongly suppressed during treatment. During the first year of treatment, 6.0% of patients abandoned the study due to hepatic disorders related to the drug. During the following years with the lowest treatment regimen, none of the patients abandoned the study due to hepatic discomfort., Conclusions: Flu is a satisfactory therapeutic regimen for any form of hirsutism in the long run. Moreover, the use of very low doses of Flu is associated with minimal side-effects and high compliance.

Objective: To evaluate postoperative long-term cyclic and continuous administration of combined oral contraceptive (OC) pills in preventing endometriosis-related pain recurrence., Design: Prospective, randomized, controlled trial., Setting: Tertiary care university hospital., Patient(s): Three hundred eleven women who underwent laparoscopic excision for symptomatic ovarian endometrioma., Intervention(s): Patients were randomly divided into three groups: nonuser group receiving no therapy, and cyclic user group and continuous user group receiving low-dose, monophasic OC pills for 24 months in either cyclic or continuous administration., Main Outcome Measure(s): Presence and intensity of dysmenorrhea, dyspareunia, and chronic pelvic pain were assessed by a 10-point visual analogue scale (VAS) at 6, 12, 18, and 24 months postoperatively., Result(s): A significant reduction in recurrence rate and VAS scores for dysmenorrhea was evident in the continuous users versus the other groups at 6 months, and in cyclic users versus nonusers at 18 months postoperatively. No significant differences in recurrence rate and VAS scores for dyspareunia and chronic pelvic pain were demonstrated among the groups. The increase of VAS scores from 6-24 months during the study period for dysmenorrhea, dyspareunia, and chronic pelvic pain was significantly higher in nonusers than in the other groups., Conclusion(s): Long-term postoperative use of OC pills can reduce the frequency and the severity of recurrent endometriosis-related dysmenorrhea., (Copyright 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

In the last years, advances in diagnosis and new treatments of cancer patient have increased the life expectancy of children, adolescent and women with cancer. Unfortunately, the ovaries are very sensitive to chemio-radiotherapy that may induce the loss of ovarian function and fertility with consequent premature ovarian failure. The different cryopreservation options available for fertility preservation in cancer patients are embryo cryopreservation, oocyte cryopreservation and ovarian tissue cryopreservation. The choice depends on different parameters: the type and timing of cancer treatment, the type of disease, the patient's age. The advances in reproductive technology have made fertility preservation a real possibility for patients whether they are girls or young women whose gonadal function is threatened by natural premature menopause, or by cancer therapy or surgical sterilisation.

Introduction: The existence of the G-spot is controversial., Aim: To evaluate, by the use of three-dimensional (3-D) ultrasonography, the anatomic structures of the urethrovaginal space., Methods: Nineteen (Group I) eumenorrheic young women who experienced, and 20 (Group II) who did not experience a vaginal orgasm underwent two-dimensional (2-D) and 3-D ultrasonography and color Doppler analysis of the urethrovaginal space and of the clitoris during the early follicular phase of the menstrual cycle., Main Outcome Measures: 2-D ultrasonographic evaluation of the urethrovaginal space, and color Doppler evaluation of the urethrovaginal main feeding artery and dorsal clitoral arteries; 3-D volume calculation of the urethrovaginal space, and 3-D power Doppler analysis of vascular indices of the urethrovaginal space and clitoral body (vascularization index, flow index, vascularization flow index); hormonal evaluation., Results: The 3-D reconstruction of the urethrovaginal space demonstrated a gland-like aspect with small feeding vessels. The total length (19.1 + or - 2.7 mm vs. 17.5 + or - 2.1 mm; P = 0.047), measured with 2-D ultrasound, and the 3-D mean volume (0.59 + or - 0.13 mL vs. 0.26 + or - 0.07 mL; P < 0.001) of the structures contained in the urethrovaginal space were significantly higher in Group I than in Group II. The mean time since the last intercourse was 31 + or - 9 hours in Group I and 18 + or - 3 hours (P = 0.033) in Group II. The urethrovaginal space vascularization, the clitoral volume and vascularization, and the circulating hormonal values did not significantly differ among the two groups. The mean volume of the structures contained in the urethrovaginal space was correlated with time since intercourse (r = 0.685; P = 0.021) and with serum testosterone (r = 0.637; P = 0.032) and androstenedione (r = 0.744; P = 0.011)., Conclusions: The structures we observed in the urethrovaginal space have a gland-like aspect and their volume is correlated with both serum androgen concentrations and time since intercourse.

Objective: To present a case of complicated deep infiltrating endometriosis managed by a multidisciplinary minimally invasive approach., Design: Case report., Setting: Tertiary care university hospital., Patient: A 32-year-old woman with deep infiltrating endometriosis involving the rectovaginal septum, the rectum, and the left ureter, complicated by silent left renal function loss., Intervention(s): Laparoscopic left nephrectomy, ureterectomy, excision of a left ovarian endometrioma, removal of a large rectovaginal nodule, and segmental bowel resection with minilaparotomic end-to-end anastomosis., Main Outcome Measure(s): Multidisciplinary diagnosis and minimally invasive surgical approach to deep infiltrating endometriosis involving the rectum and the urinary tract., Result(s): Collaboration between gynecologists, urologists, and colorectal surgeons enabled a successful management of the case in one surgical intervention providing minor risk of complications, shorter hospital stay, and faster functional recovery., Conclusion(s): Deep infiltrating endometriosis is a global pathology that may involve different structures. A multidisciplinary, minimally invasive approach should be recommended to achieve appropriate disease management., (Copyright 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Endometrial cancer is the most common gynaecological malignancy and its incidence is increasing. In 1998, international federation of gynaecologists and obstetricians (FIGO) required a change from clinical to surgical staging in endometrial cancer, introducing pelvic and paraaortic lymphadenectomy. This staging requirement raised controversies around the importance of determining nodal status and impact of lymphadenectomy on outcomes. There is agreement about the prognostic value of lymphadenectomy, but its extent, therapeutic value, and benefits in terms of survival are still matter of debate, especially in early stages. Accurate preoperative risk stratification can guide to the appropriate type of surgery by selecting patients who benefit of lymphadenectomy. However, available preoperative and intraoperative investigations are not highly accurate methods to detect lymph nodes and a complete surgical staging remains the most precise method to evaluate extrauterine spread of the disease. Laparotomy has always been considered the standard approach for endometrial cancer surgical staging. Traditional and robotic-assisted laparoscopic techniques seem to provide equivalent results in terms of disease-free survival and overall survival compared to laparotomy. These minimally invasive approaches demonstrated additional benefits as shorter hospital stay, less use of pain killers, lower rate of complications and improved quality of life.

Objective: To evaluate long-term cyclic and continuous administration of oral contraceptive pills (OCP) in preventing ovarian endometrioma recurrence after laparoscopic cystectomy., Design: Prospective, randomized, controlled trial., Setting: Tertiary care University Hospital., Patient(s): Two hundred thirty-nine women who underwent laparoscopic excision of ovarian endometriomas., Intervention(s): Patients were divided randomly into three groups: nonusers receiving no therapy and cyclic and continuous users receiving low-dose, monophasic OCP for 24 months in cyclic or continuous administration, respectively., Main Outcome Measure(s): Endometrioma recurrence, size of recurrent endometrioma, and growth rate during at least 2 years follow-up evaluated by transvaginal ultrasonography., Result(s): The crude recurrence rate within 24 months was significantly lower in cyclic (14.7%) and continuous users (8.2%) compared with nonusers (29%). The recurrence-free survival was significantly lower in nonusers compared with cyclic and continuous users. The mean recurrent endometrioma diameter at first observation was significantly lower in cyclic (2.17 +/- 0.45 cm) and continuous users (1.71 +/- 0.19 cm) compared with nonusers (2.73 +/- 0.56 cm). The mean diameter increase every 6 months of follow-up was significantly reduced in cyclic users (0.31 +/- 0.18 cm) and continuous users (0.25 +/- 0.09 cm) versus nonusers (0.48 +/- 0.3 cm). No significant differences between cyclic users and continuous users in terms of endometrioma recurrence were demonstrated., Conclusion(s): Long-term cyclic and continuous postoperative use of OCP can effectively reduce and delay endometrioma recurrence., (Copyright 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate the accuracy and the potential limitations of transvaginal sonography (TVS) in the preoperative evaluation of women with clinically suspected bladder endometriosis and to describe the sonographic features of the pathological condition in cases in which it was confirmed., Methods: In the period between 2001 and 2006, we operated on 490 patients with clinically/sonographically suspected endometriosis. In 41 cases, bladder endometriosis was diagnosed at surgery and confirmed at histopathological examination. All patients underwent TVS in a standardized manner not more than 1 month before surgery. Findings at preoperative TVS were described and compared with those at laparoscopy in order to evaluate the sensitivity, specificity, and positive and negative predictive values of TVS., Results: Bladder endometriosis was correctly identified at TVS in 18/41 cases (43.9%) while 23/41 (56.1%) patients had a negative preoperative sonogram. The sensitivity, specificity and positive and negative predictive values of TVS for bladder endometriosis were 44% (18/41), 100% (449/449), 100% (18/18) and 95% (449/472), respectively, and the total accuracy was 95% (467/490). The detection rate was strongly related to mean lesion diameter as measured by the pathologist (mean +/- SD, 42.5 +/- 22.1 mm in the nodules detected vs. 28.9 +/- 14.8 mm in the nodules missed; P = 0.029) and to a history of previous surgery for endometriosis (70.6% vs. 25.0%; P = 0.005). At TVS, the nodule was hypoechogenic, its morphology was either elongated ('comma-shaped': 12/18, 66.7%) or spherical (6/18, 33.3%), and the site involved was the dome (11/18, 61.1%) or the base (7/18, 38.9%) of the bladder. Small anechogenic cystic areas within the nodule were seen in five of the 18 patients (27.8%) and a bright hyperechogenic rim was seen in 10 (55.6%)., Conclusions: The detection rate of bladder endometriosis by TVS depends on the size of the endometriotic nodules, with detected nodules being larger than those that were missed. A history of previous surgery for endometriosis increases the likelihood of bladder endometriosis being detected on ultrasound examination., (Copyright (c) 2009 ISUOG. Published by John Wiley & Sons, Ltd.)

Introduction: Vaginal dryness, low sexual desire, and low sexual arousability are critical issues for many postmenopausal women. Hormone therapy seems to improve vaginal lubrication and dyspareunia., Aim: To evaluate, in postmenopausal women who refused hormonal therapy, the role of genistein in the treatment of vasomotor symptoms and its capacity to induce clitoral volumetric and vascular modifications independently from sexual stimulation., Methods: Twenty-nine postmenopausal women who refused hormonal therapy were submitted to oral daily treatment with genistein 45 mg (Group I; N = 15); or no treatment (Group II; N = 14). The Group II patients served as controls. The patients were not randomly assigned to the two groups. The patients were studied before and after 3 months., Main Outcomes Measures: Endometrial and clitoral ultrasonographic analysis; color Doppler evaluation of the dorsal clitoral artery; evaluation of hormonal plasma concentrations; administration of the two-factor Italian McCoy Female Sexuality Questionnaire; compilation of a monthly diary reporting the number of hot flashes. The ultrasound, color Doppler and psychometric tests were performed by examiners blinded to the participant's group assignment., Results: In the genistein-treated patients the vasomotor symptoms ameliorated at the end of the study. The use of genistein did not influence any other parameter., Conclusions: Postmenopausal women submitted to a 3-months treatment with genistein showed an improvement of vasomotor symptoms. However, isoflavones seem to not induce any modification in the clitoral structures.

Background: Endometriosis recurrence after conservative surgery is not infrequent. Variable regimens of hormonal therapy have been proposed as adjuvant post-operative measures for prophylaxis against recurrence. Among these, the combined oral contraceptive pills (OCP), represents a valuable option in terms of safety and tolerability for long-term use. The objective of this review is to evaluate the effect of post-operative use of OCP in preventing symptom recurrence, and/or anatomical relapse of endometriosis., Methods: A systematic search of Medline identified seven studies evaluating post-operative OCP treatment on prevention of endometriosis recurrence., Results: A reduction in anatomical relapse rate was observed when oral contraceptive therapy was administered for more than 1 year after conservative surgery. Post-operative use of OCP was associated with a reduction in frequency and intensity of dysmenorrhoea recurrence. No association was found between OCP therapy and dyspareunia prevention, although the effect of OCP on chronic pelvic pain was conflicting., Conclusion: Long-term OCP therapy can be a reliable adjuvant post-operative measure to prevent or reduce frequency/severity of recurrent dysmenorrhoea and anatomical relapse of endometriosis. Since both continuous and cyclic OCP administration regimens seem to have comparable effects, the choice of regimen can be modulated according to patient preferences. The protective effect seems to be related to the duration of treatment.

Introduction: Clitoral functional modifications occur during the menstrual cycle., Aim: To prospectively evaluate, by the three-dimensional (3-D) Doppler flow analysis, the hemodynamic clitoral blood flow variations during the menstrual cycle. METHODS. Fourteen young (18-35 years), eumenorrheic (menstrual cycle of >25 and <35 days) women in a stable heterosexual relationship (>1 year) and without any sexual dysfunction (as resulted from the two-factor Italian McCoy female sexuality questionnaire > or =35) were submitted, in the early follicular (day 3-5) and in the periovulatory (day 12-14) phases of the menstrual cycle, to bi- and tridimensional ultrasonographic and color Doppler analyses of the clitoral structures. On the same days, the circulating estradiol values were assayed. MAIN OUTCOMES MEASURES. Two-dimensional ultrasonographic evaluation of follicular diameter and color Doppler evaluation of the dorsal clitoral arteries; 3-D power Doppler analysis of the clitoral body volume and of the indices of clitoral vascularization and blood flow; estradiol assay., Results: The mean virtual organ computer-aided analysis (VOCAL) volume of the clitoral body was lower in the follicular (0.79 +/- 0.19 mL) phase with respect to the periovulatory phase (0.98 +/- 0.22 mL; P < 0.001); the clitoral arteries demonstrated a significant decrease of the pulsatility index (PI) from the follicular (1.75 +/- 0.18) to the periovulatory phase (1.26 +/- 0.21; P = 0.002); the 3-D power Doppler histogram analysis showed significant changes of the indices of vascularization and blood flow (vascularization index [VI] = 2.239 +/- 1.201 vs. 3.302 +/- 1.305, P = 0.001; flow index = 27.290 +/- 2.454 vs. 33.620 +/- 1.712, P < 0.001; vascularization flow index = 0.578 +/- 0.573 vs. 1.091 +/- 0.461; P = 0.001) between the follicular and the periovulatory phase of the menstrual cycle. The relationship between the different parameters evidenced that estradiol is positively correlated with the VOCAL clitoral body volume (r = 0.512; P = 0.033) and inversely correlated with the dorsal clitoral artery PI (r = -497; P = 0.048) and with VI (r = 0.622; P = 0.011)., Conclusions: During the normal menstrual cycle, the estrogens may, probably, influence the clitoral anatomic and vascular structures and the 3-D ultrasonography may easily and precisely demonstrate these modifications.

Introduction: Persistent genital arousal disorder (PGAD) is an unwanted genital arousal which occurs in absence of sexual interest and desire., Aim: To report a case of PGAD presumably due to the use of trazodone in a young eumenorrheic woman., Methods: A young (29 years old), eumenorrheic (menstrual cycle of >25 and <35 days) woman suffered of unwanted genital arousal and uncontrollable orgasms. In the past, the patient undertook trazodone treatment. The patient was submitted, in the periovulatory (day 12) phase of the menstrual cycle, to bi- and tri-dimensional ultrasonographic and color Doppler analyses of the clitoral structures prior and after an unwanted orgasm., Main Outcomes Measures: 2D ultrasonographic evaluation of the clitoral body volume and color Doppler evaluation of the dorsal clitoral arteries; 3D power Doppler reconstruction of the clitoral vascularization., Results: The clitoral volume was 1.33 mL before the orgasm and resulted 1.36 mL and 1.33 mL, respectively after 1 minute and 15 minutes from the orgasm. The Pulsatility Index (PI) of the dorsal clitoral artery was 1.05 before the orgasm. It resulted lower after 1 minute (PI = 0.82) and 15 minutes (PI = 0.85) from the orgasm., Conclusions: A subtle and intermittent clitoral priapism may favor the feeling of arousal persistence and elicit unbidden and unwelcomed orgasms.

Introduction: A decline in sexual activity has been reported as women age., Aim: To compare, in young adult and middle-aged women, the clitoral volumetric and vascular modifications during the periovulatory phase of the menstrual cycle, and to analyze their relationship with circulating hormones, nitric oxide levels, and with questionnaires on sexuality, relationship, and depression., Methods: Fifteen young (18-25 years; Group I), and 16 middle-aged (35-45 years; Group II) eumenorrheic women were submitted, on day 14 of their menstrual cycle, to utero-ovarian and clitoral ultrasonographic analysis, and to color Doppler evaluation of the uterine and dorsal clitoral arteries. On the same day, hormonal parameters and plasma concentrations of nitrites/nitrates were assayed, and the two-factor Italian McCoy female questionnaire and the Beck's Depression Inventory questionnaire were administered., Main Outcomes Measures: Utero-ovarian and clitoral ultrasonographic analysis, color Doppler evaluation of the uterine and dorsal clitoral arteries; evaluation of hormonal and nitrites/nitrates plasma concentrations; administration of the two-factor Italian McCoy Female Sexuality Questionnaire and the Beck's Depression Inventory questionnaire. RESULTS. The plasma levels of estradiol, testosterone, sex hormone binding globulin, and nitrites/nitrates were similar in both groups. Neither the ultrasonographic assessment of the clitoral body volume (0.82 +/- 0.24 mL vs. 0.73 +/- 0.26 mL) nor the Doppler analysis of the dorsal clitoral artery [pulsatility index (PI) = 1.35 +/- 0.31 vs. PI = 1.36 +/- 0.19] evidenced any significant differences in either Group I or Group II. The two-factor Italian McCoy Female Sexuality Questionnaire and the Beck Depression Inventory questionnaire gave the same results in Group I and Group II. The relationship between the different parameters evidenced that the NO(2-)/NO(3-) circulating levels are inversely correlated with uterine artery (r = -0.4611; P = 0.008) and dorsal clitoral artery (r = -0.331; P = 0.041) PIs. Furthermore, estradiol resulted inversely correlated with depression (r = -0.332; P = 0.045). The two sections (sexuality and partnership) of Italian McCoy Female Sexuality Questionnaire were positively correlated (r = 0.849; P < 0.0001) between each other., Conclusions: In eumenorrheic young adult and middle-aged women, the periovulatory clitoral anatomic and vascular modifications similarly occur.

Background: Human papillomavirus (HPV) infection is a necessary event in the development of cervical carcinoma. High risk (HR) HPV genotypes, however, may progress differentially from low grade lesions to malignancy., Objectives: The necessity to genotype and quantify HPV-DNA in cervical screening programs, in the follow up post-surgical treatments and in monitoring the effectiveness of HPV vaccination programs, requires access to economical, high-throughput and flexible molecular technologies., Study Design: A high-throughput two-step LNA real time PCR assay was developed consisting of real time PCR reactions with fluorescent Locked Nucleic Acid (LNA) probes. The first step permits classification into three prognostic-risk groups of nine HR HPV genotypes (16, 18, 31, 33, 35, 45, 52, 56 and 58) most frequently found associated with cervical lesions in Europe. The second step allows us to genotype/quantify the HPV-DNA only when clinical, epidemiological or prophylactic aims exist., Results: The specificity, repeatability, detection and quantitation limit, and linearity of the assay were evaluated and appear to be in agreement with guidelines for the validation of analytical procedures. The overall genotype concordance on cervical samples between our assay and INNOLiPA test was 94% (k 0.83) indicating good agreement., Conclusions: The two-step PCR assay can give much information relative to the predictive value of different HR HPV types and can quantify the genotype-specific viral load. In particular, its ability to detect and quantify nine HR HPV genotypes can help provide more efficient and successful patient care and may be useful for the monitoring of the efficacy of HPV vaccines.

Background: Objective evaluation of pelvic pain symptoms using a standard pain questionnaire is essential to assessing the treatment of endometriosis and related pain., Aim: To evaluate the McGill Pain Questionnaire (MPQ) as a multi-dimensional verbal scale in providing information about chronic pelvic pain associated with endometriosis, before and after laparoscopic surgery., Methods: Fifty-five women undergoing laparoscopy for severe endometriosis were asked to complete the MPQ before surgery and at the 6-month follow up. All patients presented with preoperative pain symptoms of variable severity. We obtained the pain indexes and studied their relation with: patients' characteristics (age, body mass index, parity, qualification, occupation); operative findings (number, site and size of endometriotic lesions and presence of pelvic adhesions); and postoperative evolution of variable MPQ pain indexes at the 6-month follow up., Results: Median present pain index (PPI) (index of pain intensity), before surgical treatment was 3 (2-4): preoperative PPI was <2 in 25% of patients while 25% of patients had PPI > 4. Overall median PPI after surgical treatment was 1 (0-2): postoperative index of pain intensity was <1 in 50% of patients, >2 in 25% of patients while 25% of patients did not experience postoperative pain. Overall pain intensity significantly decreased after laparoscopic treatment of endometriosis (Wilcoxon test P < 0.0005). None of the patients' characteristics were found to be significantly correlated with the severity or improvement of preoperative pain at postoperative follow up (P > 0.05), and the intensity of preoperative pain was not correlated to any of the operative variables. There was a significant reduction in all individual MPQ pain indexes; however 18.2% of women did not show improvement of pain symptoms after laparoscopic surgery. An increasing endometrioma diameter was associated with a significant decrease in the difference in evaluative rank score of pain rating index between pain indexes at the 6-month follow up and preoperatively (P = 0.04, Spearman's rank correlation Rho = -0.277)., Conclusions: MPQ appears to be useful as a multi-dimensional scale in describing patients' pain semiology and evaluating pain evolution after surgical treatment. However, due to the extreme variability of pain experience, MPQ results don't clarify the relationship between pain intensity and the severity of endometriosis.

The presence of HPV 16 E6*I/E6*II spliced transcripts, in cervical lesions of different grade, was analyzed to characterize the transcription pattern. The presence and amount of spliced transcripts were correlated with DNA viral markers such as E2/E6 ratio and physical state. The detection of HPV 16 E6*I/E6*II mRNAs was set up by an SYBR Green real-time reverse transcriptase PCR assay with an optimal dynamic range and sensitivity. The assay was applied to the analysis of 71 specimens, positive to HPV 16 as a sole infection, from women with abnormal cervical smears, precisely 31 low-grade squamous intraepithelial lesions and 40 high-grade lesions. Samples negative to both transcripts were found only in low-grade cervical lesions. Three different transcription profiles were found in the low- and high-grade lesions analyzed: in low-grade lesions samples positive only to E6*II and in high-grade lesions samples positive only to E6*I were detected. In low- and high-grade lesions, samples positive to both E6*I and E6*II were found. In the samples positive for both transcripts, the E6*I/E6*II ratio was higher than that in the majority of high-grade lesions and lower than that in all the low-grade lesions. Analyzing the transcription pattern in relation to E2/E6 ratio and to the DNA physical state, the presence of high values of E6*I was associated mainly with low values of E2/E6 ratio and of mixed DNA forms. The detection of HPV 16 E6*I/E6*II mRNAs may serve to identify transcription patterns indicative of cervical disease progression and help physicians to decide clinical management., (Copyright 2009 Wiley-Liss, Inc.)

Classification of cervical intraepithelial neoplasia (CIN) lesions in low-grade (CIN1) or high-grade (CIN2-3) ones is crucial for optimal patient management, but current histological diagnosis on bioptic samples is often hampered by inter-observer variability. To allow objective classification, we have exploited the peculiar characteristics of chemiluminescence detection, such as high sensitivity and easy quantification of the luminescence signal, to perform sequentially in the same tissue section both an immunohistochemical quantitative detection of p16(INK4A) (a protein marker of high-grade CIN lesions) and an in situ hybridization for human papillomavirus (generally accepted as a necessary but insufficient cause of cervical carcinoma). Different label enzymes (alkaline phosphatase and horseradish peroxidase) were employed in order to avoid any interference between the two assays, and quantitative chemiluminescence image analysis was used to obtain objective evaluation of sample positivity. The multiplexed method allowed detection of two complementary biomarkers and provided discrimination between different lesions (non-neoplastic, low-grade and high-grade CIN). This assay might thus represent an accurate and objective diagnostic test providing important information for counseling, selection of therapy and follow up after surgical treatment.

The presence of HPV 16 E1 and E2 genes was detected in cervical cytological samples using polymerase chain reaction assays. A total of 48 samples were analyzed from patients with HPV 16 infections associated with 13 low-grade cervical intraepithelial neoplasia and 35 high-grade cervical intraepithelial neoplasia. Disruption/deletion sites, within E1 and E2 genes, were detected using 6 primer pairs spanning the entire gene sequences. This technique is not able to recognize mixed DNA forms (integrated plus episomal DNA); therefore, it detects only the presence of pure integrated DNA. Both E1 and E2 genes were detected in 84.6% and in 62.9% of low and high-grade lesions, respectively. The rate of samples with disrupted/deleted genes was significantly higher in high-grade cervical intraepithelial neoplasia than in low-grade cervical intraepithelial neoplasia (P<0.05). In high-grade cervical intraepithelial neoplasia the disruption/deletion pattern involved both E1 and E2 genes and E2 gene was always involved, while in the low grade cervical intraepithelial neoplasia only E1 gene was involved. In conclusion, in high-grade cervical lesions E2 gene seems a suitable target to identify HPV 16 DNA integration into cellular genome.

A number of studies indicated a clear decline in semen quality in the past 30-50 years and there is accumulating evidence that this decline might result from exposure to high levels of air pollution. To examine the impact of environment on male reproductive ability, we undertook for the first time a pilot study on semen quality of infertile men exposed to purification of indoor air. Ten subjects with a history of unexplained male infertility and poor semen quality were exposed for at least 1 year to a cleaning indoor air system (Koala technology). The key feature of this air purifier is the unique innovative multiple filtering system. The treatment of total purification of indoor air showed neither improvements in semen parameters nor variation in reproductive hormones (P = N.S.), but induced an evident increase (P < 0.03 and more) in seminal leucocytic concentrations. Within the limits due to the small sample of subjects recruited, the sole purification of indoor air does not seem enough to improve semen quality, although the increase in leucocytic concentrations could indicate an activation of the role of immunosurveillance in a purified indoor air environment.

Objective: To investigate spindle behavior during and after slow freezing at room temperature (RT) and vitrification at different temperatures., Design: Randomized, comparative study., Setting: University hospital., Patient(s): Patients undergoing IVF treatment volunteered for the study and donated part of their supernumerary oocytes., Intervention(s): Metaphase II oocytes were divided into group A: slow freezing RT /thawing RT; group B: vitrification RT/warming RT; group C: vitrification RT/warming 37 degrees C; and group D: vitrification 37 degrees C/warming 37 degrees C. Spindle presence was evaluated at each step of the four procedures and in culture., Main Outcome Measure(s): Cumulative spindle recovery rate comparing warming phase of the three vitrification groups and culture phase among the four groups., Result(s): During warming, the three vitrification groups showed a significantly fast spindle recovery rate compared to the thawing of the slow freezing group. A progressively significant fast cumulative recovery rate was observed in the three vitrification groups by increasing the number of phases at physiological temperature (hazard rate = 2.68; 95% confidence interval 1.71-4.02)., Conclusion(s): The present study demonstrates that spindle recovery is faster in vitrification than in slow freezing. These data support a possible protective effect of vitrification/warming at 37 degrees C on the meiotic spindle structure and, therefore, on the subsequent clinical outcome of the procedure, although comparative clinical studies are needed.

This paper reviews the most relevant literature from the past 10 years on different techniques for the culture of fresh and cryopreserved ovarian tissue from animals and humans. Information on strategies for culturing whole ovarian tissue and isolated follicles are provided as well as an updated and comprehensive view of the role that growth factors have in mediating and regulating in vitro folliculogenesis.

Purpose of Review: To evaluate the present state of research and clinical application of human oocyte cryopreservation in infertility and oncology., Recent Findings: Recent literature documents have an increasing interest in cryopreserving human eggs. A number of studies report on different freezing protocols and various types of clinical application. Increasing attention is paid to vitrification as an alternative to slow cooling for oocyte cryopreservation. Several studies cover the modification of meiotic spindle during cryopreservation in order to assess the less damaging cryopreservation system. The first births with cryopreserved oocytes in cancer patients are reported., Summary: Egg freezing may circumvent the ethical and legal concerns regarding embryo cryopreservation, increase assisted reproduction flexibility and be a concrete option to save fertility in women with cancer. Recently, egg survival and pregnancy rates improved, with the birth of more than 500 children. The birth rate per thawed oocyte is around 5-6%. As regards safety, data on birth defects seems to be reassuring so far but must be monitored by an international registry. Comparative studies between slow freezing and vitrification in the same patient population are needed to elucidate pros and cons of each technique.

Study Objective: To evaluate the relationship between anatomic locations and diameter of endometriotic lesions with severity of perimenstrual dyschezia (pain with defecation) as a possible location-indicating pain symptom for posterior deep infiltrating endometriosis (DIE)., Design: Retrospective analysis (Canadian Task Force classification II-3)., Setting: Tertiary care university hospital., Patients: We reviewed hospital records of patients who underwent laparoscopic treatment for pelvic endometriosis in our center between 2001 and 2006. In all, 360 patients with posterior DIE (endometrial glands and stroma infiltrated excised tissues of the specified organs) were included for whom preoperative scoring of perimenstrual dyschezia was performed using a 10-point visual analog scale (VAS). Data about anatomic location and diameter of excised nodules were retrieved from operative and pathological records., Interventions: Laparoscopic excision of suspected endometriotic lesions., Measurements and Main Results: Mean VAS score of dyschezia for patients with overall posterior DIE was 3.9 +/- 3.8, whereas in unaffected patients it was 1.9 +/- 3.3 (Mann-Whitney test p <.0005). Rectovaginal involvement (posterior vaginal wall, rectovaginal septum, and anterior rectal wall) was found in 240 of 360 women. Mean VAS score for dyschezia was 4.1 +/- 4 and 2.1 +/- 3.3 in affected and nonaffected patients, respectively (p <.0005). Mean lesion diameter in affected patients was significantly correlated with mean VAS score (Spearman rho = 0.21). Patients with anterior rectal wall endometriosis (71/240) had a mean VAS score of 4.2 +/- 4 and in nonaffected patients it was 2.7 +/- 3.6 (p <.05). Mean lesion diameter in affected patients was not significantly correlated with mean VAS score of dyschezia (Spearman rho = 0.16)., Conclusion: Severity of dyschezia was significantly correlated with posterior DIE. A positive correlation occurred between severity of dyschezia and lesion diameter with rectovaginal endometriosis but not with anterior rectal wall involvement.

A quantitative evaluation of p16 INK4A overexpression together with its topographical localization in the epithelium of cervical biopsies from non-neoplastic lesions and cervical intraepithelial neoplasias (CIN 1, 2, and 3) was obtained by the development of an objective and sensitive immunohistochemical assay with chemiluminescent detection (CL IHC assay). The cervical biopsy samples were also checked for the presence of human papillomavirus nucleic acids. The quantitative evaluation of p16 INK4A expression was performed by combining 2 parameters: (1) intensity of the chemiluminescent-positive signal in the epithelium and (2) percentage of epithelium interested by the overexpression of p16 INK4A, to obtain a p16 INK4A expression score. A cut-off value was determined by using the receiver-operator characteristic analysis to distinguish between low-grade and high-grade CIN. Quantitative data showed that both p16 INK4A expression parameters increased with worsening grades of CIN and, when combined to obtain the p16 INK4A expression score, they showed a sharp discrimination among different lesions. The differences between the average p16 score of CIN1 versus CIN2 (0.57 versus 1.05), of CIN1 versus CIN3 (0.57 versus 1.31) and of CIN1 versus CIN2/3 (0.57 versus 1.20) were statistically significant. The quantitative evaluation of p16 INK4A expression by CL IHC assay could be therefore an interesting adjuvant method to distinguish different CIN grades and to predict the risk of progression of early CIN lesions.

Anti-neoplastic treatments have significantly increased the survival of cancer patients, but female patients risk premature menopause. Oocyte cryopreservation has been proposed as a fertility-saving option. This report describes the first live birth achieved with autologous cryopreserved oocytes in an ovariectomized borderline cancer patient. A patient with a borderline ovarian tumour asked for oocyte cryopreservation after a right adnexectomy. Ovulation induction resulted in the retrieval and cryopreservation of seven mature oocytes. Thirty-nine months after a left ovariectomy, the patient asked for oocyte thawing and embryo transfer. Endometrial growth was induced using hormone replacement treatment. Three of the seven cryopreserved oocytes were thawed; they survived and, after insemination, normal fertilization took place. Three embryos were transferred into the patient's uterus. A twin pregnancy was achieved with the birth of two healthy females. Oocyte cryopreservation may be a reliable option for preserving fertility in young cancer patients who risk premature menopause due to surgery, chemotherapy or radiotherapy.

Purpose of Review: By the current review we aim to describe different options for laparoscopic hysterectomy in patients with endometrial cancer and discuss the reported risk factors and limitations of laparoscopic hysterectomy in surgical staging of endometrial cancer., Recent Findings: Laparoscopic techniques and equipment have matured over the last 15 years and are now widely used to treat patients with endometrial cancer, thereby potentially reducing perioperative morbidity and postoperative pain, and providing shorter hospital stay, faster recovery and improved quality of life compared with the corresponding open procedures. However, some risk factors are postulated to limit the use of laparoscopic hysterectomy in staging of endometrial cancer., Summary: Surgical staging of endometrial cancer by laparoscopic hysterectomy is feasible and well tolerated. This surgical approach does not seem to affect recurrence and overall survival rates. Limitations of laparoscopic hysterectomy in management of endometrial cancer need to be evaluated.

The evidence on genotype-specific risk in women infected with human papillomavirus (HPV) with normal cytology and the importance of the distinction of high-risk (HR)-HPV genotypes in the management of low-grade lesions suggest that the distinction of HR-HPV genotypes has the potential to improve the follow-up of patients treated for high-grade cervical lesions. The aims of this study were to define the persistence of the different HR-HPV in the follow-up of surgical treated women, to detect the changes of genotypes from the pre- to the post-operative status, and to evaluate whether genotype-specific persistence can predict the development of residual or recurrent disease during the follow-up. HR-HPV detection and genotyping was carried out by the Linear Array HPV Genotyping Test on cervical cytological samples from 72 women treated by surgery. The 6-month post-operative HPV status was correlated with the pre-operative HPV genotype and with the residual or recurrent disease within 24 months. It was observed that the residual or recurrent disease in women with persistence of HPV 16 and/or HPV 18 was higher (82.4%) than in women with persistence of at least one HR-HPV type of group 2 (HPV 31, 33, 35, 45, 52, and 58) (66.7%) and at least one type of group 3 (HPV 39, 51, 56, 59, 68, 26, 53, 66, 73, and 82) (14.3%). These data defined HR-HPV groups for the risk of progression of disease and suggested that the identification of persistent infection with different HR-HPV genotypes has the potential to improve the management of these patients.

Study Objective: To discuss our clinical and surgical experience with 30 cases of ureteral endometriosis., Design: Retrospective analysis (Canadian Task Force classification II-3)., Setting: Tertiary care university hospital., Patients: Records were assessed for all patients who underwent laparoscopic surgery for deep infiltrating endometriosis (DIE) from June 2002 through June 2006. Thirty patients were laparoscopically given a diagnosis that was histologically confirmed of ureteral involvement by endometriosis., Interventions: Laparoscopic retroperitoneal examination and management of ureteral endometriosis., Measurements and Main Results: Variables assessed were: preoperative findings (patient characteristics, clinical symptoms, preoperative workup), operative details (type and site of ureteral involvement, associated endometriotic lesions, type of intervention, intraoperative complications), and postoperative follow-up (short- and long-term outcomes). We recorded details of 30 patients with a median age of 33.33 years and a median body mass index of 21.96. Symptoms reported were: none in 20 (66.7%) of 30 patients, specific in 10 (33.3%) of 30, dysuria (30%), renal angle pain (10%), hematuria (3.3%), and hydroureteronephrosis (33.3%). Ureteral endometriosis was presumptively diagnosed before surgery in 40% of patients. Ureteric involvement was on the left side in 46.7%, on the right side in 26.7%, and bilaterally in 26.7%. It was extrinsic in 86.7% and intrinsic in 13.3%. It was associated with endometriosis of homolateral uterosacral ligament in all (100%) of 30, the bladder in 50%, rectovaginal septum in 80%, ovaries in 53.3%, and bowel in 36.7%. Laparoscopic intervention was: only ureterolysis in 73.3%, segmental ureteral resection and terminoterminal anastomosis in 16.7%, and segmental ureterectomy and ureterocystoneostomy in 10%. Early postoperative complications were: fever greater than 38 degrees C requiring medical therapy for 7 days in 7 patients and 1 patient had transient urinary retention requiring catheterization that resolved without further treatment. During a mean follow-up period of 14.6 months, endometriosis recurred in 3 patients with no evidence of ureteral reinvolvement., Conclusion: Ureteral involvement is a silent, serious complication that must be suspected in all cases of DIE. Retroperitoneal laparoscopic isolation and inspection of both ureters helps to diagnose silent ureteral involvement. Conservative laparoscopic surgery provides a safe, feasible modality for management of ureteral endometriosis.

A case of intrapartum, complete, low-posterior wall, transverse uterine rupture, complicated by uterine atony and treated by emergency hysterectomy in a primigravida with uterine adenomyosis who delivered vaginally at 37 weeks plus 5 days of gestation, 9 months after undergoing laparoscopic resection of rectovaginal septum endometriosis.

The aim of this study was to evaluate the systemic production of nitric oxide (NO) in missed and threatened abortion and in nonpregnant and regular pregnant controls with the purpose of defining its role in the mechanisms regulating the first-trimester pregnancy toward either positive or negative evolution. Patients with missed abortion showed serum NO levels clearly decreased compared with nonpregnant patients and patients with regular pregnancy and threatened abortion, supporting a direct functional role of the NO mediator in early embryonic development and confirming its importance in the uterus and cervix during abortion.

Study Objective: The purpose of this study was to evaluate the relationship between frequency/severity of dysuria with anatomic location and diameter of bladder endometriotic lesions., Design: Retrospective analysis (Canadian Task Force classification II-3)., Setting: Tertiary care university hospital., Patients: Forty-one patients with bladder endometriosis (endometrial glands and stroma microscopically diagnosed to infiltrate the muscularis propria)., Interventions: Laparoscopic partial cystectomy, preoperative scoring of dysuria using 10-point verbal analog scale (VAS)., Measurements and Main Results: Records of all patients with bladder endometriosis were assessed for frequency/severity of preoperative dysuria, anatomic location (base or dome), and diameter of bladder endometriotic nodule. Basal bladder lesions were observed in 18 (43.9%) of 41 patients versus 23 (56.1%) of 41 in the dome. Of the patients with basal lesions, 14 (77.8%) of 18 had preoperative dysuria versus 8 (34.8%) of 23 with dome lesions. Mean VAS score was 8.5 +/- 2.37 and 5.75 +/- 1.91 for base and dome lesions, respectively. Preoperative dysuria was found in 22 (53.7%) of 41 patients. Mean lesion diameter in patients with dysuria was 25.0 +/- 12.6 mm versus 16.3 +/- 6.8 mm in patients without dysuria., Conclusion: Frequency and severity of preoperative dysuria were significantly higher in patients with basal endometriotic nodules. There was a positive correlation between severity of dysuria and lesion diameter.

Objectives: Cervical intraepithelial neoplasias (CIN) associated with high-risk (HR) human papillomavirus infection, in addition to HR-HPV typing need other viral marker testing to distinguish a subset of lesions with clinical relevant infections. This study has evaluated the significance of viral markers, such as viral load, physical status and E2/E6 ratio, to stratify HPV16 infected women at a single point in time for grade of cervical lesions., Methods: One hundred sixty-six cytological specimens were selected from women with low (n=72) and high (n=94) grade squamous intraepithelial lesions (SIL), and positive to HPV16. All the 72 LSIL were CINI, 83 of the 94 HSIL were CINII/III and 11 SCC (Squamous Cervical Carcinoma). Cytological specimens were analysed by two different SYBR Green Real-time PCR assays (RT-PCR). Specific primers for both E2 and E6 viral genes and GAPDH cellular gene were designed to determine viral load, physical status and E2/E6 ratio., Results: The viral load was significantly higher in HSIL than in LSIL. In CINI episomal DNA was prevalent (72.2%), mixed forms (episomal and integrated) were 27.8%, suggestive of an early integration of viral DNA into cellular genome, no pure integrated forms were detected. However in CINII/III mixed DNA forms were prevalent (73.5%). In SCC pure integrated DNA was prevalent (81.8%) in absence of episomal forms. E2/E6 ratio decreased significantly from CINI to CINII/III and SCC with a linear trend. The logistic regression analysis showed that viral load higher than 1.38x10(6) genome copies per 300 ng of total DNA associated with E2/E6 ratio lower than 0.90 was highly significant in differentiating CINII/III versus CINI, while the only E2/E6 value lower than 0.17 was significant in differentiating SCC from CINI., Conclusions: Viral load higher than 1.38x10(6) genome copies per 300 ng of total DNA and E2/E6 ratio values allow HPV16 infected women with high grade cervical intraepithelial lesions to be recognized.

Objective: The present study assessed (i) the clinical outcome of patients with conservatively treated cervical adenocarcinoma in situ (AIS), (ii) the accuracy of diagnosing AIS by cytology, colposcopy and histology, as well as (iii) the performance of cervical cytology and HPV testing in detection of residual or recurrent disease after conservatively treated AIS., Methods: A series of 42 consecutive women (mean age 40.5 years; range 27-63 years) underwent conservative (cone) treatment of AIS and were prospectively followed up for a mean of 40 months (median 42 months), using colposcopy, PAP smear, biopsy and HPV testing (with hybrid capture II) repeated at 6-month intervals., Results: In their referral PAP test, only 42.9% of patients had atypical glandular cells (AGC) smear. Colposcopy was unsatisfactory in 54.8% cases and negative in 16.7%. Twenty four patients (57.1%) had AIS as a pure lesions and 18 combined with squamous cell lesion (four had invasive SCC). Persistent or recurrent disease was observed in 17 (40.4%) cases, 19% in patients with free margins, and 65% among those with involved margins on the first conization. In four patients, an adenocarcinoma (AdCa) stage IA1 was diagnosed during the follow-up. HPV testing significantly predicted disease persistence/clearance with OR 12.6 (95% CI 1.18-133.89), while the predictive power of PAP smear did not reach statistical significance at any of the follow-up visits. The combination of PAP smear and HPV testing gives SE of 90.0%, SP 50.0%, PPV 52.9% and NPV 88.9% at first follow-up, and 100% SE and 100% NPV at the second follow-up visit., Conclusions: These results suggest that HR-HPV test in conjunction with cytology offers clear advantages over single cytology in monitoring the women conservatively treated for cervical AIS.

The objective of this study was to report morphological and functional evidence of a well-preserved preantral follicle recovered from human frozen-thawed ovarian tissue in a long-term culture. The tissue was originally obtained from a 26-year-old woman with breast cancer. The ovarian cortex was collected by laparoscopy and frozen/thawed and cultured for 32 weeks in minimum essential medium alpha-MEM, supplemented with insulin transferrine selenite (ITS), human serum (HS), antibiotics, follicle-stimulating hormone (FSH). and N-acetyl cysteine (NAC). Thawed tissue samples were examined by light microscopy (LM), transmission electron microscopy (TEM), and real-time RT-PCR. LM examination of cortical pieces after 32 weeks of culture showed a healthy early preantral follicle; TEM and real-time PCR confirmed its good state of preservation. The synergy in action of NAC and FSH plays an important role in follicle growth of ovarian tissue cultures. For the first time a well-preserved preantral follicle was found in a culture of frozen-thawed human ovarian tissue.