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The evaluation of endometriosis in an adolescent girl is a challenging topic. The initial stage of the disease and the limited diagnostic instrument appropriate for the youth age and for its typical features can reduce the ability of the gynecologist. At the same time, missing a prompt diagnosis can delay the beginning of specific and punctual management of endometriosis, which could avoid a postponed diagnosis from 6 to 12 years, typical of adolescent girls complaining of dysmenorrhea. This article aimed to answer all the potential questions around the diagnosis and management of endometriosis in adolescents starting from a clinical case looking at the possible solution that is easily reproducible in the clinical practice., (Copyright © 2023. Published by Elsevier Inc.)

Background and Aims: Performing colonoscopy can be technically challenging in female patients. Female patients may prefer having a female endoscopist. This preference, coupled with the fact that there are fewer female endoscopists, may result in gender differences in colonoscopy practice. We hypothesized that the duration of female colonoscopy is longer and that female endoscopists perform a higher proportion of female colonoscopy than male colleagues. We explored the potential revenue implications of gender differences in screening colonoscopy., Methods: We analyzed procedure time and gender differences in 16,573 screening colonoscopies performed by 27 male and 7 female endoscopists over a three-year period in one large academic practice. We modeled the potential revenue impacts of differences in procedure duration, proportion of female colonoscopy and the frequency of detected adenomas., Results: We found that screening colonoscopy takes 8.8% more time to complete in female patients compared to male patients for all endoscopists (p < 0.001), and that female endoscopists perform an average of 71.2% female exams compared to male endoscopists, who perform an average of 50.8% female exams (p < 0.001). Female patients had a lower detection adenoma rate (ADR), reducing the frequency of polypectomy and reimbursement in an RVU model. The observed gender differences could account for an estimated 9.6% revenue loss per 8-h session for a female gastroenterologist performing screening colonoscopy compared to a male counterpart., Conclusion: Longer colonoscopy duration in females, increased proportion of female colonoscopies for female endoscopists and lower ADR in females may contribute to the gender gap in physician pay in gastroenterology., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Infertility is a highly relevant global issue affecting the reproductive health of at least 15% of reproductive-aged couples worldwide. The scope and severity of the infertility problem is even more prevalent in developing countries, mostly due to untreated reproductive tract infections (RTIs). Infertility, however, goes beyond the mere inability to procreate, but brings about profound psychological, social, and ethical implications of enormous magnitude. In vitro fertilization (IVF) and other assisted reproduction technologies (ARTs) have gradually become widespread therapeutic options. After all, the implementation of medically assisted reproductive procedures in order to overcome infertility is in keeping with the tenets of the reproductive rights agenda laid out at the International Conference on Population and Development (ICPD) in Cairo in 1994. Nonetheless, concerns still linger about how to implement and regulate such interventions in an ethically tenable fashion. The unremitting pace at which such techniques develop have upset the very notion of sexuality relating to reproduction as well as the concept of family itself. That rift risks causing a crisis in terms of bioethics sustainability and enforcement, which is bound to happen when science and innovation outpace the bioethical precepts on which we rely for essential guidance in medical practice. The authors argue in favor of an approach to regulation and policy-making that puts on the forefront a thorough assessment as to potential risks that such interventions might entail for foundational bioethics principles and inalienable human rights.

Background: Coronavirus disease 2019 (COVID-19) is associated with elevated liver biochemistries in approximately half of hospitalized patients, with many possible etiologies., Aim: To assess agreement on the etiology of abnormal liver biochemistries and diagnostic recommendations in COVID-19., Methods: Twenty hepatology consultations were reviewed by three senior hepatologists who provided a differential diagnosis and diagnostic recommendations. Kappa agreement on the primary etiology was calculated., Results: Kappa agreement between hepatologists on the primary etiology of elevated liver biochemistries was 0.10 (p = 0.03). Agreement was greater around drug-induced liver injury 0.51 (p < 0.0001) and SARS-CoV-2-related liver injury 0.17 (p = 0.03). Serial liver biochemistries were recommended in all consultations over other evaluations., Conclusion: In COVID-19, elevated liver biochemistries present a diagnostic challenge and can often be monitored conservatively.

Background: In cervical cancer screening programs, women with abnormal cytology and confirmation by biopsy are referred for colposcopy for histological evaluation., Methods: We characterized the presence and the genotype of HPV by Linear Array HPV genotyping assay in cytological samples collected from about 400 women undergoing conization, with reported high CIN grade after biopsy., Results: The most prevalent genotype was HPV 16, with an increasing presence depending on the severity of the CIN and with the highest incidence in the 26-35 age range. In the group of younger women (<25) we found the highest percentage of CIN3 (39.3%) and the lowest of CIN1 (17.9%). An increase of CIN1 with increasing age was observed. A different distribution of HPV presence was observed depending on CIN grade (P<0.001): CIN1 HPV negative samples were 46.3%, CIN2: 5.8% and CIN3: 1.4%. Interesting, in the analyzed cohort, we observed the presence of 30% of CIN1. Moreover, within CIN1, 85% of them were associated to negative HPV detection, this observation suggested that the detection of HPV presence may be useful to identify low CIN grade that should be reconsidered for surgical treatment., Conclusions: These findings suggest implementing the protocol for the management of women with high risk precancer lesions, with a further HPV test before surgical treatment. The evaluation of HPV presence and genotype before conization might represent a useful tool in reducing or postpone the conization treatment.

Background: Hepatitis B virus (HBV) screening during pregnancy is standard of care to prevent vertical transmission to infants, yet the mothers themselves may not receive appropriate follow-up., Goals: Using a national database, we sought to determine rates of maternal peripartum follow-up with a HBV specialist and identify factors associated with a lack of follow-up., Materials and Methods: We identified women who delivered in 2000 to 2012 and were diagnosed with HBV according to International Classification of Diseases-9 codes using a national database (Optum) derived from commercial insurance claims with ∼46 million members ages 0 to 64 in all 50 states. Our primary outcome was follow-up during or after pregnancy with a HBV specialist (gastroenterology/infectious diseases)., Results: The prevalence of HBV was 0.27% (2558/959,747 pregnancies), and median follow-up was 45 months. Only 21% of women had peripartum HBV specialist follow-up. On multivariable regression, predictors of peripartum follow-up at 1-year included younger age [odds ratio (OR), 0.97/y; 95% confidence interval (CI), 0.94, 0.99], Asian race/ethnicity (OR, 1.56 vs. white; 95% CI, 1.13, 2.17), and residing in the Northeast (OR, 1.70; 95% CI, 1.09, 2.66) and Midwest (OR, 1.73; 95% CI, 1.07, 2.81) versus West. Predictors of testing for HBV DNA and alanine aminotransferase at 1 year included Asian race (OR, 1.72; 95% CI, 1.23, 2.41), a primary care physician visit within 2 years of delivery (OR, 1.63; 95% CI, 1.19, 2.22), and peripartum HBV specialist follow-up within 1 year (OR, 15.68; 95% CI, 11.38, 21.60)., Conclusions: Maternal HBV specialist follow-up rates were extremely low in this large, diverse cohort representing all United States regions. Referral to a HBV specialist was the strongest predictor of appropriate postpartum HBV laboratory testing. Follow-up rates may be even lower in uninsured populations.

Study Question: Is there molecular evidence for a link between endometriosis and endometriosis-associated ovarian cancers (EAOC)?, Study Answer: We identified aberrant gene expression signatures associated with malignant transformation in a small subgroup of women with ovarian endometriosis., What Is Known Already: Epidemiological studies have shown an increased risk of EAOC in women with ovarian endometriosis. However, the cellular and molecular changes leading to EAOC are largely unexplored., Study Design, Size, Duration: CD73+CD90+CD105+ multipotent stem cells/progenitors (SC cohort) were isolated from endometrium (n = 18) and endometrioma (n = 11) of endometriosis patients as well as from the endometrium of healthy women (n = 14). Extensive phenotypic and functional analyses were performed in vitro on expanded multipotent stem cells/progenitors to confirm their altered characteristics. Aberrant gene signatures were also validated in paired-endometrium and -endometrioma tissue samples from another cohort (Tissue cohort, n = 19) of endometriosis patients., Participants/materials, Settings, Methods: Paired-endometrial and -endometriotic biopsies were obtained from women with endometriosis (ASRM stage III-IV) undergoing laparoscopic surgery. Control endometria were obtained from healthy volunteers. Isolated CD73+CD90+CD105+ SC were evaluated for the presence of known endometrial surface markers, colony forming efficiency, multi-lineage differentiation, cell cycle distribution and 3D-spheroid formation capacity. Targeted RT-PCR arrays, along with hierarchical and multivariate clustering tools, were used to determine both intergroup and intragroup gene expression variability for stem cell and cancer-associated markers, in both SC+ and tissue cohorts., Main Results and the Role of Chance: Isolated and expanded SC+ from both control and patient groups showed significantly higher surface expression of W5C5+, clonal expansion and 3D-spheroid formation capacity (P < 0.05) compared with SC-. The SC+ cells also undergo mesenchymal lineage differentiation, unlike SC-. Gene expression from paired-endometriosis samples showed significant downregulation of PTEN, ARID1A and TNFα (P < 0.05) in endometrioma compared with paired-endometrium SC+ samples. Hierarchical and multivariate clustering from both SC+ and tissue cohorts together identified 4 out of 30 endometrioma samples with aberrant expression of stem cell and cancer-associated genes, such as KIT, HIF2α and E-cadherin, altered expression ratio of ER-β/ER-α and downregulation of tumour suppressor genes (PTEN and ARID1A). Thus, we speculate that above changes may be potentially relevant to the development of EAOC., Large-Scale Data: N/A., Limitations, Reason for Caution: As the reported frequency of EAOC is very low, we did not have access to those samples in our study. Moreover, by adopting a targeted gene array approach, we might have missed several other potentially-relevant genes associated with EAOC pathogenesis. The above panel of markers should be further validated in archived tissue samples from women with endometriosis who later in life developed EAOC., Wider Implications of the Findings: Knowledge gained from this study, with further confirmation on EAOC cases, may help in developing screening methods to identify women with increased risk of EAOC., Study Funding/competing Interest(s): The study is funded by the Swedish Research Council (2012-2844), a joint grant from Stockholm County and Karolinska Institutet (ALF), RGD network at Karolinska Institutet, Karolinska Institutet for doctoral education (KID), Estonian Ministry of Education and Research (IUT34-16), Enterprise Estonia (EU48695), Horizon 2020 innovation program (WIDENLIFE, 692065), European Union's FP7 Marie Curie Industry-Academia Partnerships and Pathways funding (IAPP, SARM, EU324509) and MSCA-RISE-2015 project MOMENDO (691058). All authors have no competing interest.

Objectives Hepatitis B (HBV) remains a significant public health burden, despite effective therapy. Routine HBV screening is recommended during pregnancy to reduce the risk of vertical transmission, but the rates of follow-up care peri-partum are low. The aim of this study was to evaluate physician practices and knowledge regarding HBV in women diagnosed perinatally. Methods A survey was distributed to obstetricians and midwives within the Partners HealthCare system at Brigham and Women's Hospital and Massachusetts General Hospital. Results Of 118 survey respondents (response rate 56%), 97% reported that they always tested for hepatitis B, and 77% referred new diagnoses of HBV during pregnancy to a HBV specialist for further care. Only 10% of respondents reported that there was formal referral mechanism in place to facilitate follow-up care for mothers diagnosed with hepatitis B infection. 91% of survey respondents selected hepatitis B surface antigen as the correct screening test, and 76% selected hepatitis B immune globulin with vaccination for the newborn as the correct prophylaxis regimen. Only 40 and 51% of respondents accurately identified serologies that were consistent with acute and chronic infection, respectively. Conclusions for Practice Routine screening for HBV in this population presents an important opportunity to identify cases and to reduce the public health burden of this disease. Providers were somewhat knowledgeable about HBV, but the lack of formal referral mechanism may explain why HBV follow-up is suboptimal in this healthcare system. Supplemental provider education and formal linkage to care programs may increase rates of follow-up HBV care.

Objectives: Hepatocellular carcinoma (HCC) surveillance with biannual ultrasound is currently recommended for all patients with cirrhosis. However, clinical implementation of this "one-size-fits-all" approach is challenging as evidenced by its low application rate. We aimed to evaluate the cost-effectiveness of risk-stratified HCC surveillance strategies in patients with cirrhosis., Methods: A Markov decision-analytic modeling was performed to simulate a cohort of 50-year-old subjects with compensated cirrhosis. Risk-stratified HCC surveillance strategies was implemented, in which patients were stratified into high-, intermediate-, or low-risk groups by HCC risk biomarker-based scores and assigned to surveillance modalities tailored to HCC risk (2 non-risk-stratified and 14 risk-stratified strategies) and compared with non-stratified biannual ultrasound., Results: Quality-adjusted life expectancy gains for biannual ultrasound in all patients and risk-stratified strategies compared with no surveillance were 1.3 and 0.9-2.1 years, respectively. Compared with the current standard of biannual ultrasound in all cirrhosis patients, risk-stratified strategies applying magnetic resonance imaging (MRI) and/or ultrasound only in high- and intermediate-risk patients, without screening in low-risk patients, were cost-effective. Abbreviated MRI (AMRI) for high- and intermediate-risk patients had the lowest incremental cost-effectiveness ratio (ICER) of $2,100 per quality-adjusted life year gained. AMRI in intermediate- and high-risk patients had ICERs <$3,000 across a wide range of HCC incidences., Conclusions: Risk-stratified HCC surveillance strategies targeting high- and intermediate-risk patients with cirrhosis are cost-effective and outperform the currently recommended non-stratified biannual ultrasound in all patients with cirrhosis.

Goals: To determine postpartum hepatitis B virus (HBV) laboratory testing rates and identify factors associated with a lack of follow-up testing in Massachusetts., Background: Screening for HBV infection in pregnant women is standard of care. Guidelines recommend that patients with chronic HBV have ongoing care and laboratory testing, but little is known about postpartum maternal HBV care outcomes., Study: We conducted a retrospective cohort study using Massachusetts Virtual Epidemiologic Network, an electronic public health surveillance system maintained by the Massachusetts Department of Public Health. We identified women who tested hepatitis B surface antigen positive during their first reported (index) pregnancy in Massachusetts from 2007 to 2012 and measured HBV-related laboratory tests reported to Massachusetts Department of Public Health during and after pregnancy., Results: We identified 983 hepatitis B surface antigen positive pregnant women. Half (492/983) did not have evidence of additional postpartum HBV laboratory testing following their index pregnancy. Women who had postpartum laboratory tests reported were younger [mean age (SD): 29 (5.3) vs. 31 (5.5) y, P=0.0001] and more likely to have >1 pregnancy during the study period (41% vs. 1%, P<0.0001). There were no differences in race, ethnicity, and US born status. On multivariable logistic regression, older age predicted a lower likelihood of having postpartum laboratory testing (odds ratio, 0.77; 95% confidence interval, 0.70-0.90)., Conclusions: Postpartum maternal HBV follow-up laboratory testing occurred in only half of Massachusetts women and did not vary by race, ethnicity, or US born status. Our results were limited to a single state surveillance database, which likely underestimates the number of tests ordered.

Few studies analyzed the risk for high-grade squamous intraepithelial lesions or worse (HSIL+) among immigrants and natives attending organized cervical cancer (CC) screening programs (SP). We evaluated participation and diagnosis of HSIL+ by country of birth with logistic models. Overall 540,779 invitation letters were delivered to target women of Florence SP in three screening rounds (years 2000-2002, 2003-2005, 2006-2008). The probability of attending screening was lower for immigrants than natives, but the difference decreased from 35% (1st round) to 20% (2nd-3rd round) for women born in high migration pressure (HMP) countries. The risk of HSIL+ was double than natives for HMP-born women from countries with high prevalence of human papillomavirus, even adjusting for age and previous history of Pap test. This is an important public health problem due to an increasing proportion over time of immigrant women with a lower attendance and greater risk for CC.

Compared to spontaneous screening, an organized screening programme is characterized by the presence of protocols and recommendations for all stages including follow-up. Despite the availability of well-functioning screening programmes throughout the country, the follow-up protocol after an abnormal Pap test and negative colposcopy is not clearly defined in Italy, and there is no uniformity of indications. HPV testing for oncogenic human papillomavirus (hr-HPV) has a high negative predictive value (NPV) and high positive predictive value (PPV) for CIN2+ and its employment can reduce follow-up assessments. In order to provide indications about the management of women with ASC-US+ and the follow-up of women with cytological abnormalities and negative colposcopy, a literature analysis was carried out, taking into consideration European and American guidelines and good practice recommendations from the most important scientific associations and regulatory agencies. GISCi (Italian Group for Cervical Screening) drafted recommendations for the management of women with ASC-US, L-SIL, ASC-H, AGC, and H-SIL until their return to the routine screening interval. This protocol can be applied not only in the management of abnormal Pap smears in cytology-based programmes, but also in the management of abnormal Pap test triage after HPV positive test when HPV is the primary screening test. The protocols approved within the screening programmes must have an extensive consensus among all involved professionals, including any that women might meet outside the programme.

With the introduction of Human papillomavirus (HPV) vaccination in young girls in 2007, it is important to monitor HPV infections and epidemiological changes in this target population. The present study has evaluated the detection of human papillomavirus DNA in paired cervical and urine samples to understand if HPV testing in urine could be used as non-invasive method to monitor HPV status in young women. The study enrolled 216 twenty five-year-old women, resident in Florence and invited for the first time to the cervical cancer Screening Program within a project evaluating the impact of HPV vaccination. HPV genotyping was performed on 216 paired urine and cervical samples. The overall concordance between cervix and urine samples, investigated by HPV genotyping (INNO-LiPA HPV Genotyping Extra), was: 85.6% (184/215), 84.6% (182/215), 80% (172/215) when the same HPV, at least the same HR HPV and all HR HPV, respectively, were detected. HPV type specific concordance in paired urine and cervical samples was observed in 85.8% (175/204) of women with normal cytology and in seven out of nine women with abnormal cytology. Urine seems to be a suitable and reliable biological material for HPV DNA detection as evidenced by the high concordance with HPV detected in cervical samples. These results suggest that urine could be a good noninvasive tool to monitor HPV infection in vaccinated women., (© 2014 Wiley Periodicals, Inc.)

Objective: We sought to determine rates of maternal postpartum hepatitis B virus (HBV) follow-up with a HBV specialist and identify factors associated with poor follow-up, as prior research has focused on infant outcomes and not maternal care., Study Design: We conducted a retrospective review of data from Partners HealthCare system, the largest health care system in Massachusetts, and identified women with chronic HBV who delivered from 2002 through 2012., Results: We identified 291 women (mean age 31.5 years, 51% Asian) with incident HBV during pregnancy. In all, 47% had postpartum follow-up with a HBV specialist, but only 19% also had appropriate laboratory tests (hepatitis B e antigen [HBeAg], hepatitis B e antibody, HBV DNA, and ALT) within 1 year of their HBV diagnosis. Mothers with HBV follow-up were more likely to have a primary care physician (PCP) within the Partners HealthCare system (66% vs 38%, P < .0001), a positive HBeAg (20% vs 8%, P = .004), and elevated AST values (17% vs 8%, P = .02). On multivariable logistic regression analysis, a mother who had a PCP (odds ratio, 2.50; 95% confidence interval, 1.37-4.59) or positive HBeAg (odds ratio, 4.45; 95% confidence interval, 1.64-12.06) had a greater likelihood of having HBV follow-up., Conclusion: Only 19% of HBV-infected mothers met care guidelines 1 year after being diagnosed with HBV. Inadequate postpartum HBV care affects women of all races/ethnicities. Women who had a PCP as well as those who were HBeAg positive were more likely to be referred for postpartum follow-up with a HBV specialist, suggesting that providers might be referring patients when they perceive HBV to be more serious or complex., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Study Question: Does the methylation status of the promoter region of the HOXA10 gene differ in eutopic and ectopic endometrium?, Summary Answer: The eutopic endometrium in women with endometriosis is significantly more methylated when compared with controls., What Is Known Already: Expression of the HOXA10 gene, which is important for successful implantation, is reduced in women affected by endometriosis., Study Design, Size and Duration: A pilot study was carried out including 18 women admitted for surgery for endometriosis-related pain (cases) and 12 women admitted for surgery because of non-endometriotic disease (control). Sample collection and analysis were performed between November 2010 and July 2013., Participants/materials, Setting, Methods: Endometrial tissue (eutopic and ectopic) underwent sodium bisulfite DNA modification, PCR amplification of two regions of the HOXA10 promoter and pyrosequencing analysis., Main Results and the Role of Chance: The eutopic endometrium of women with endometriosis was significantly more methylated compared with endometrium from the control group (sequence 1: 8.68% in cases and 6.25% in the control group: P = 0.037, sequence 2: 11.89% in cases and 9.25% in the control group: P = 0.032). The eutopic endometrium was significantly more methylated than the ectopic tissue in patients with endometriosis (mean difference -3.6 sequence 1: P = 0.001 and -6.0 sequence 2: P = 0.0001)., Limitations, Reasons for Caution: The study had a limited sample size and the fertility status of the majority of patients in our study was unknown., Wider Implications of the Findings: Our data regarding methylation state of the ectopic tissues contribute to a better etiopathologic understanding of endometriosis., Study Funding/competing Interests: No external funding was either sought or obtained for this study. The authors have no conflicts of interests to declare., (© The Author 2014. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

A decrease in HOXA10 gene expression in eutopic mid-secretory endometrium has been found in women with endometriosis-associated infertility. Promoter hypermethylation of HOXA10 is thought to be the leading mechanism for epigenetic gene regulation in patients with endometriosis. In our series we documented significantly higher HOXA10 promoter methylation levels in women with ovarian endometriomas than in healthy controls during the mid-luteal phase. Development of epigenetic-based strategies for non-surgical treatment of infertility related to ovarian endometriomas could be an attractive field of research in the coming years., (© 2013 Nordic Federation of Societies of Obstetrics and Gynecology.)

Rates of transmission of hepatitis B virus (HBV) infection from organ donors with HBV markers to recipients along with reactivation of HBV during immunosuppression following transplantation have fallen significantly with the advent of hepatitis B immune globulin (HBIg) and effective antiviral therapy. Although the availability of potent antiviral agents and HBIg has highly impacted the survival rate of HBV-infected patients after transplantation, the high cost associated with this practice represents a major financial burden. The availability of potent antivirals with high genetic barrier to resistance and minimal side effects have made it possible to recommend an HBIg-free prophylactic regimen in selected patients with low viral burden prior to transplant. Significant developments over the last two decades in the understanding and treatment of HBV infection necessitate a re-appraisal of the guidelines for prophylaxis of HBV infection in solid organ transplant recipients.

Background & Aims: Cirrhosis affects 1% to 2% of the world population and is the major risk factor for hepatocellular carcinoma (HCC). Hepatitis C cirrhosis-related HCC is the most rapidly increasing cause of cancer death in the United States. Noninvasive methods have been developed to identify patients with asymptomatic early-stage cirrhosis, increasing the burden of HCC surveillance, but biomarkers are needed to identify patients with cirrhosis who are most in need of surveillance. We investigated whether a liver-derived 186-gene signature previously associated with outcomes of patients with HCC is prognostic for patients with newly diagnosed cirrhosis but without HCC., Methods: We performed gene expression profile analysis of formalin-fixed needle biopsy specimens from the livers of 216 patients with hepatitis C-related early-stage (Child-Pugh class A) cirrhosis who were prospectively followed up for a median of 10 years at an Italian center. We evaluated whether the 186-gene signature was associated with death, progression of cirrhosis, and development of HCC., Results: Fifty-five (25%), 101 (47%), and 60 (28%) patients were classified as having poor-, intermediate-, and good-prognosis signatures, respectively. In multivariable Cox regression modeling, the poor-prognosis signature was significantly associated with death (P = .004), progression to advanced cirrhosis (P < .001), and development of HCC (P = .009). The 10-year rates of survival were 63%, 74%, and 85% and the annual incidence of HCC was 5.8%, 2.2%, and 1.5% for patients with poor-, intermediate-, and good-prognosis signatures, respectively., Conclusions: A 186-gene signature used to predict outcomes of patients with HCC is also associated with outcomes of patients with hepatitis C-related early-stage cirrhosis. This signature might be used to identify patients with cirrhosis in most need of surveillance and strategies to prevent the development of HCC., (Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: There are no clinically available biomarkers for nonalcoholic steatohepatitis (NASH); differentiating between steatosis and NASH requires histologic evaluation. Noninvasive methods are needed to replace liver biopsy and its associated risks. Production of very low density lipoprotein (VLDL) contributes to the development of NASH and might be used to distinguish steatosis from NASH. However, it is not possible to measure levels of VLDL directly in the clinic. Non-high-density lipoprotein-cholesterol (non-HDL-C) encompasses all apolipoprotein-B-containing lipoproteins, including VLDL, and can be calculated from standard lipid panels without additional cost., Methods: We evaluated the ability of non-HDL-C to differentiate steatosis from NASH in a prospective study of 218 patients with suspected NASH (steatosis, n = 100 and NASH, n = 118)., Results: Patients with NASH had a trend toward increased levels of non-HDL-C, compared with those with steatosis (P = .08). However, among subjects not on lipid-lowering medications, those with NASH had significantly higher levels of non-HDL-C (144.6 mg/dL) than those with steatosis (129.3 mg/dL; P = .025). This difference remained significant when adjusted for levels of cholesterol and triglycerides, indicating that the difference results from increased levels of apolipoprotein B including VLDL. These findings were validated in a cohort of 40 patients with steatosis or NASH who were not taking lipid-lowering agents. The NASH group had significantly higher levels of non-HDL-C than the steatosis group (162.8 vs 145.9 mg/dL; P = .04)., Conclusions: NASH is associated with significantly higher levels of non-HDL-C than steatosis in patients who do not take lipid-lowering agents. This low-cost biomarker could be used in noninvasive differentiation between steatosis and NASH., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Aim: To compare minilaparotomic and vaginal surgery in selected obese patients with early-stage endometrial cancer at high surgical risk., Patients and Methods: Data of 37 consecutive class II-III obese patients submitted to minilaparotomic surgery were retrospectively reviewed. Thirty-seven women matched for demographic characteristics, BMI and stage of disease submitted to vaginal surgery in the same period comprised the control group., Results: No difference was observed concerning intra- and postoperative data among the two groups. The patients who were submitted to general anesthesia exhibited a larger use of supplemental drugs for pain control (p>0.01), a higher incidence of thromboembolic events (p>0.005) and a longer hospitalization (p>0.02). No statistical difference was observed in terms of pattern of recurrence, disease-free survival and overall survival between the two groups of patients., Conclusion: Obese patients with endometrial cancer unfit for vaginal surgery can be safely managed through mini-laparotomy with the same surgical and oncological outcomes.

We present two cases of acute liver injury resulting from consumption of wild mushrooms. The first case was a male who developed acute hepatitis after ingestion of diverse mushrooms including Amanita species. His clinical course was favorable with complete recovery of liver function. The second case was a male who developed acute liver failure (ALF) after ingestion of Amanita bisporigera. He required MARS therapy as a bridge to liver transplantation but transplantation was not performed because he succumbed to multiorgan failure. There are few trials demonstrating the efficacy of the different treatments for mushroom poisoning. These cases demonstrate that the consumption of wild mushrooms without proper knowledge of toxic species represents a serious and under recognized health problem.

Long-term users of tamoxifen (TMX) are at increased risk for developing endometrial cancer. Early diagnosis is mainly based on transvaginal scan (TVS) and hysteroscopy with endometrial biopsy. Nevertheless, TVS does not provide a definitive diagnosis in most cases, particularly due to its high false-positive rate. In addition TMX related changes, such as "pseudocistic" pattern, affect endoscopic evaluation of the endometrium and biopsy sampling (in particular blind procedures) frequently yields insufficient tissue for diagnosis. The cause of the high inadequacy rate of endometrial biopsies in women on TMX might be related to the increase in endometrial fibrous component. The present case emphasizes the main difficulties in surveillance and early diagnosis of endometrial pathologies in TMX users. Liquid-based endometrial cytology played a determinant role in the diagnostic pathway of this patient. We believe it could be used solely or in association with TVS leading to many advantages in the surveillance of women receiving TMX.

Extrapelvic endometriosis is an uncommon condition but can involve nearly every organ, resulting in a wide range of clinical manifestations. Herein, we describe the case of a 45-year-old woman not a candidate for hormonal therapy who had cyclic pain in the left thigh associated with progressive impairment of walking ability. Clinical, instrumental, and laboratory data supported the diagnosis of endometriosis involving the adductor muscles compartment associated with ovarian endometriomas. Laparoscopic bilateral salpingo-oophorectomy and local wide excision in collaboration with an experienced orthopedic oncologist were performed, and definitive histologic analysis confirmed the diagnosis of endometriosis. The patient was pain-free at 6-month follow-up and demonstrated substantial improvement in ambulation and quality of life. Large-muscle endometriosis is a rare entity that can compromise musculoskeletal integrity and decrease quality of life. In this case, surgical excision in collaboration with an orthopedic oncologist was the cornerstone of treatment., (Copyright 2010 AAGL. Published by Elsevier Inc. All rights reserved.)

Young women with polycystic ovary syndrome (PCOS) are at increased risk of endometrial adenocarcinoma (EAC) through chronic unopposed estrogen production. We describe the first case, to our knowledge, of grade 1 endometrioid EAC arising in the context of complex atypical endometrial hyperplasia in a 26-year-old woman with thrombophilia and PCOS who wished to retain fertility potential and was treated using a levonorgestrel-releasing intrauterine system alone. At first follow-up biopsy, a single focus of complex hyperplasia without atypia was documented. All specimens sampled during subsequent follow-up demonstrated inactive endometrium with pseudodecidual changes, and no ultrasonographic or magnetic resonance (MR) images exhibiting myometrial invasion or endoabdominal spread were observed. This successful outcome suggests that insertion of a levonorgestrel-releasing intrauterine system is a treatment option in selected young women with early-stage EAC who are not candidates for systemic therapy and who wish to maintain fertility potential. Close histologic follow-up is required, and immediate surgery is mandatory if endometrial cancer persists.

Unlabelled: Recent studies suggest that long-term suppression of viral replication is critical to reducing the complications of chronic hepatitis B virus (HBV) infection. Monitoring for continued virological response during and after treatment is essential because current treatment options have limited success in achieving durable endpoints, and antiviral resistance may emerge during long-term therapy. Methods of monitoring treatment response include tests for serum aminotransferase levels, HBV DNA level, hepatitis B e antigen (HBeAg) and antibody (anti-HBe), hepatitis B surface antigen (HBsAg) or antibody (anti-HBs), and liver histology. Virological suppression and loss of HBeAg or HBsAg with or without seroconversion play a prominent role in decision-making regarding the success and duration of antiviral therapy. Guidelines recommend that testing for serum markers be repeated every 12-24 weeks during antiviral therapy and every 6-12 months afterward. Recent data also suggest that serum HBV DNA levels should be assessed at weeks 12 and 24 of therapy, because early viral response may predict the likelihood of sustained response and antiviral resistance. The use of serum HBV DNA levels for this purpose requires an assay with a wide range of quantification, such as real-time polymerase chain reaction assays, which have a 7-8 log(10) dynamic range. Newer, investigational methods for monitoring treatment response include quantitative measurement of HBsAg, HBeAg, and intrahepatic covalently closed circular DNA., Conclusions: Better methods for defining durable treatment endpoints are needed. Other areas requiring further research include the optimal treatment duration and the establishment of the optimal use of early viral kinetics for decision-making during antiviral therapy.

Chemokines and their receptors seem to act as important regulators of the metastatic cascade. CXCL12 and its receptor CXCR4 were shown to be involved in human cancer progression. There is increasing evidences suggesting that the expression of CXCR4 in human cancers is correlated with poor patient prognosis and that CXCR4 neutralization can prevent metastases in vivo. Here we tested the role of the CXCR4/CXCL12 axis in a neoplasia with a reduced risk of metastatic progression, such as human endometrial cancer. CXCR4 and CXCL12 mRNA expression was measured in 41 endometrial cancers and in corresponding not affected tissues. The expression of CXCR4 was predominant in endometrial cancer (P = 0.035) whereas CXCL12 was overexpressed in normal mucosae (P = 0.002). CXCR4 expression (P = 0.035), but not CXCL12, was significantly related to cancer differentiation. Endometrial cancer cells (HEC1A) were able to generate diffuse metastases in peritoneum, lung and liver of CD-1 nude mice, but the simultaneous treatment with a neutralizing anti-CXCR4 monoclonal antibody dramatically reduced the number and the size of metastases in the animals. In conclusion, our data seem to indicate that the CXCR4-CXCL12 axis can play a role in the progression of endometrial carcinoma and that specific therapies with antagonists of chemokines receptors could be of help in the treatment of metastatic patients.

Purpose of Investigation: To assess the ability of detecting the number of uterine myomas by transvaginal ultrasonography (TVS) performed supporting the clinical examination of general gynecologists' office practice., Methods: A retrospective comparison of the number of myomas revealed by preoperative in-office TVS and documented after laparotomic myomectomy was conducted in 110 consecutive premenopausal patients referred for surgery., Results: The sensitivity of TVS in revealing the exact number of myomas was 59.4% in the whole series. In the subgroup of 88 patients with a preoperative diagnosis of three or fewer myomas TVS missed at least one myoma in 31 (35.2%) cases, achieving a 64.8% sensitivity. Among the 72 women diagnosed with one myoma at preoperative TVS, 19 (26.4%) resulted to have two or more myomas at the end of surgery, reaching a 73.6% sensitivity of TVS in revealing the exact number of myomas., Conclusions: In-office TVS reinforces the clinical diagnosis of uterine myomas but it often fails in the detection of their number, resulting in a poor preoperative characterization of patients. The fact that one myoma may be overlooked in one-third of patients theoretically eligible for laparoscopic conservative surgery may motivate the implementation of US diagnosis when laparoscopic myomectomy is considered.

Objective: To investigate the effect of levonorgestrel and mifepristone on the expression of endometrial receptivity markers in a three-dimensional endometrial construct., Design: In vitro study., Setting: University hospital and research laboratory., Patient(s): Twelve fertile donors., Intervention(s): Timed endometrial biopsy., Main Outcome Measure(s): Examine the effect of levonorgestrel along with another well-studied fertility-regulating drug, mifepristone, on the expression of endometrial receptivity factors in a three-dimensional stromal and epithelial cell coculture model by immunohistochemistry., Result(s): Both epithelial and stromal cells of in vitro endometrial construct showed the presence of estrogen receptor-alpha, estrogen receptor-beta, progesterone receptors-(A+B), vascular endothelial growth factor, leukemia inhibitory factor, interleukin-1 beta, and cyclooxygenase-2, whereas the expression of progesterone receptor-B (AR), integrin alpha(V)beta(3,) and MUC1 were confined to epithelial cells. Mifepristone up-regulated expression of epithelial estrogen receptor-beta and progesterone receptor-B and down-regulated stromal vascular endothelial growth factor and surface molecules MUC1 and integrin alpha(V)beta(3) as observed in vivo. Levonorgestrel had no effect on the expression of endometrial receptivity markers studied., Conclusion(s): This in vitro model expresses progesterone-regulated endometrial receptivity factors seen in the physiologic condition. Treatment with levonorgestrel did not affect the expression of these endometrial receptivity markers in contrast to mifepristone. This in vitro model holds the potential to study endometrial receptivity, the embryo-endometrial interaction, and develop new agents for fertility control.

Background & Aims: The increasing incidence of hepatocellular carcinoma (HCC) in the United States has significant health and economic consequences. Ultrasound (US) surveillance is recommended for patients with cirrhosis because of their high risk of HCC and improving treatment outcomes for small tumors. We assessed the costs, clinical benefits, and cost effectiveness of US surveillance and alternative strategies for HCC in cirrhosis using a computer-based state transition model with parameters derived from available literature., Methods: Our model compared a policy of no surveillance with 6 surveillance strategies in cirrhotic patients ages 50 years and older in the United States: (1) annual US, (2) semiannual US, (3) semiannual US with alpha-fetoprotein, (4) annual computed tomography (CT), (5) semiannual CT, and (6) annual magnetic resonance imaging. The number of screening tests needed to detect one small HCC, cost per treated HCC, lifetime costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios were calculated., Results: Semiannual US surveillance for HCC in cirrhosis increased quality-adjusted life expectancy by 8.6 months on average, but extended it nearly 3.5 years in patients with small treated tumors. Semiannual US surveillance had an incremental cost-effectiveness ratio of $30,700 per quality-adjusted life year (QALY) gained, and was more cost effective than the alternative surveillance strategies using a threshold of $50,000 per QALY gained. The incremental cost-effectiveness ratios for the combined alpha-fetoprotein/US and annual CT strategies exceeded $50,000/QALY unless the sensitivity and specificity of US decreased to less than 65% and 60%, respectively., Conclusions: Semiannual US surveillance for HCC in cirrhotic patients improves clinical outcomes at a reasonable cost.

Aim: To investigate the therapeutic efficacy of cylindrical or cone-shaped excision performed by laser CO2 in the conservative management of persistent-recurrent high-grade cervical intraepithelial neoplasia (HG-CIN) in women of fertile age., Patients and Methods: Ninety-four premenopausal patients with persistent-recurrent HG-CIN had undergone re-conization or cylindrical excision according to the time of reappearance of the disease. The length of the procedures, intra- and postoperative complications, height of the excised specimens, final histological findings and follow-up data were retrospectively evaluated., Results: Fifty-five (58.5%) persistent and 39 (41.5%) recurrent cases had undergone cylindrical excision and standard re-conization respectively. All the treatments were successfully performed in an out-patient setting under local anesthesia with no differences in term of operative time, height of removed specimens, intra- and postoperative complications between the two groups. Definitive histology confirmed HG-CIN in 95.7% of the cases and FIGO Stage Ia1 cervical cancer (negative lymph vascular space involvement, LVSI) in 4.3% of the cases. The endocervical margins were involved in 3.6% of the cylindrical (persistent) and in 17.9% of the cone-shaped (recurrent) specimens (p = 0.03). The overall cure rate after a median follow-up time of 54 months (range 10-196) was 91.5%. A third excisional procedure was performed in 8 cases of persistent-recurrent HG-CIN with a disease-free subsequent follow-up of 38 months (range 6-108)., Conclusion: Cylindrical or conical re-excision performed by CO2 laser according to the time of reappearance of the disease seems to be a promising conservative approach for persistent-recurrent HG-CIN even though further randomised prospective studies are needed to confirm the long-term efficacy and reproductive outcomes.

We present the case of a 52-year-old woman with a history of excised cutaneous malignant melanoma complaining of abnormal uterine bleeding 11 years after initial diagnosis. Hysteroscopic examination showed an endometrial lesion with polypoid shape and endometrial biopsy was suggestive for melanoma. After a complete clinical work-up ruling out other metastatic sites, the patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy. Final histopathological and immunohistochemical analysis confirmed the diagnosis of endometrial melanoma with initial myometrial invasion. After a 6-month follow-up period, the patient was disease free. Even after many years of negative follow up, gynecologists should be aware of the possibility that abnormal uterine bleeding could represent the clinical expression of metastatic melanoma in order to offer a prompt diagnosis and a personalized strategy of treatment.

Study Objective: To evaluate the effectiveness of carbon-dioxide laser vaporization as definitive treatment for Bartholin gland cyst., Design: Retrospective analysis (Canadian Task Force classification II-3)., Setting: University teaching hospital., Patients: A consecutive series of 200 patients with monolateral or bilateral Bartholin gland cyst., Interventions: A standardized technique of cyst vaporization performed by carbon-dioxide laser in outpatient setting and local anesthesia., Measurements and Main Results: Records of all patients were reviewed for anamnestic information, anatomic parameters, intraoperative and postoperative outcomes, and follow-up data. Seven patients having bilateral cyst were treated in a single session; 207 procedures were performed. The cyst mean size was 6.3 +/- 2.3 cm (95% CI 5.93-6.67). All treatments were completed in outpatient regimen and local anesthesia with a median operative time of 17 minutes (range: 7-45). Three (1.5%) cases of intraoperative major bleeding were observed. The cure rate of a single laser treatment was 95.7%. The 9 patients with recurrent disease observed during follow-up underwent carbon-dioxide laser reintervention by the same therapeutic strategy with a 100% cure rate after 2 or 3 treatments., Conclusion: Carbon-dioxide laser vaporization of Bartholin gland cyst represents a safe and effective procedure with complete healing and positive follow-up outcomes. Further randomized trials should be conducted to confirm these findings and to establish the best surgical strategy.

Objective: To compare the PCR detection rates of high risk human papillomavirus DNA in self-collected urine and cervical scrapes during follow-up of patients treated for HG-CIN by laser CO2 conization., Patients and Methods: 52 women who submitted to laser conization for HG-CIN were enrolled into this prospective follow-up study receiving liquid-based cytology and HR-HPV testing by PCR assay on self-collected urine and cervical scrapes before and at 3, 6 and 12 months after treatment. Diagnostic accuracy and predictive values for treatment failure were evaluated for both urinary and cervical HPV testing and follow-up cytology., Results: 3 cases (5.8%) of recurrent HG-CIN occurred during follow-up. Positive margins and HR-HPV persistence resulted to significant risk factors for recurrence (p=0.01). The overall concordance on HR-HPV detection between paired urine and cervical samples was 96.6% and discord trend between agreement rates during follow-up were excluded by overall fixed-effect index (OR 1.03; 95% CI 0.62-1.70). No difference was observed comparing the three- and six-month cumulative sensitivity and NPV for recurrent disease of urinary and cervical HPV detections, with an increase of 5.6% in specificity associated with urinary testing., Conclusions: PCR detection of HR-HPV in paired urine and cervical samples during follow-up revealed an excellent concordance, suggesting a potential equivalent role of the two methods within post-treatment follow-up. In our experience HPV testing on self-collected urine was more sensitive than cytology and more specific than cervical HPV detection to predict treatment failure. Larger studies are needed to definitively establish the role of urine-based HPV testing during follow-up.

The proper management of endometrial polyps still represents a clinical ongoing challenge, especially when they are asymptomatic and occasionally discovered. The aim of this study was to evaluate liquid-based endometrial cytology to manage endometrial polyps in postmenopausal age by its ability to exclude hidden premalignant and malignant changes within polyps. Three hundred fifty-nine consecutive postmenopausal patients who underwent hysteroscopic diagnosis of endometrial polyp over a 3-year period and who were scheduled for surgical removal within the three subsequent months were retrospectively evaluated. Histologic results after resection during operative hysteroscopy or during hysterectomy were compared with liquid-based cytology and endometrial biopsy obtained at the time of diagnostic hysteroscopy. Eight of 359 patients (2.2%) had malignant or premalignant polyps interpreted as benign finding at hysteroscopy. Unsatisfactory samples were higher for endometrial biopsy compared to liquid-based cytology in the whole series and in the subgroup of low-risk asymptomatic patients (P < 0.001). Endometrial biopsy and liquid-based cytology revealed a sensitivity of 62% and 87.5%, respectively and a 100% specificity. Considering the subgroup of low-risk asymptomatic patients, liquid-based cytology disclosed all the five pathologic lesions with a 100% sensitivity and specificity. In conclusion, liquid-based cytology proved to be a useful tool to establish the nature of endometrial polyps in postmenopausal patients. Complete removal of the lesion should be offered to all symptomatic patients and those with established risk factors for endometrial cancer. Conversely, a wait and see attitude should be considered in case of asymptomatic low-risk polyps with typical appearance on hysteroscopy and negative liquid-based cytology.

Background: During the last years, the incidence of obstetric anal sphincter rupture (OASR) has increased markedly in Sweden, and significantly less frequently in Italy. Our objective was to explore if different delivery management may explain the variation in OASR incidences., Methods: In a retrospective study, data from 2,000 primiparous women in a Swedish and an Italian delivery unit were compared with respect to OASR, maternal age, gestational length, birth weight, labour induction, use of epidural analgesia (EDA) and oxytocin, vacuum extraction, episiotomy, and duration of the second stage of labour., Results: Incidences of OASR were 9.2 and 0.4% in the Swedish and Italian centres, respectively. Other significant differences were noticed in maternal age, birth weight, gestational length, use of EDA, oxytocin, vacuum extraction, episiotomy, and frequency of induction. Further analysis of the Swedish population revealed a significant association between OASR and birth weight as well as vacuum extraction. The association with gestational age and duration of the second stage of labour approached significance level. However, no association could be found between OASR and maternal age, EDA, episiotomy or induction of labour., Conclusion: Women delivering in the Swedish setting had a 23 times higher risk of OASR. An association between OASR and birth weight, gestational age, instrumental vaginal deliveries and duration of second stage was found. These factors varied between the settings and could possibly explain the differences in OASR incidence. The importance of alternative management, such as constant midwife support and perineal protection during delivery, may be a subject for further studies.

Purpose of Investigation: To estimate the persistence rate of high-risk HPV DNA (HR-HPV DNA) in a population treated totally by laser CO2 conization for high-grade cervical intraepithelial neoplasia (HG-CIN), and to examine if this persistence might be considered an independent risk factor for relapsing disease., Methods: All women with a histological diagnosis of HG-CIN and planned for laser CO2 conization from January 2003 to December 2004 were prospectively submitted to a HR-HPV test prior to surgery and at three and six months of follow-up. Women providing written informed consent with 24 months of follow-up were enrolled in the study group. A positive HPV test, involvement of resection margins, age at first intercourse, smoking habits, parity and age at conization > 50 years old were considered as risk factors for relapsing HG-CIN during follow-up, and were univariately and multivariately analyzed to discover any independent influencing factors., Results: Of HG-CIN 15.4% resulted not to be HPV related nor relapsing. The HPV clearance rate after treatment was 78.8%. Involvement of resection margins and HR-HPV DNA persistence post-treatment resulted as the only two statistically significant risk factors for HG-CIN recurrence (rate 3.8%). HR-HPV DNA persistence in follow-up resulted to be independent from other risk factors at multivariate analysis., Conclusions: Although able to reach a low recurrence rate of HG-CIN, laser CO2 conization does not remove HPV infection completely from the cervix with a case of persistence in every five treated patients. In our experience this persistence in itself represents an independent risk factor for developing relapsing disease and constitutes the basis to introduce HPV testing even in the follow-up of patients treated for HG-CIN by laser CO2 conization.

Praziquantel is the treatment of choice for schistosomiasis because of its efficacy, ease of administration, limited side effects, and low cost. Praziquantel has been so effective that alternative therapies are increasingly difficult to obtain, and the development of novel medications has been limited. The possibility of praziquantel resistance is a grave concern. Low cure rates for praziquantel have been reported in several countries, but despite widespread use, no significant loss of efficacy has occurred to date. The primary goal of antischistosomal therapy is parasite eradication, which reduces the likelihood of chronic complications, including advanced hepatic fibrosis. Mild to moderate hepatic fibrosis results from the immune response to schistosome eggs deposited in the portal venules and reverses with successful treatment. Most individuals clear schistosomiasis with a single course of therapy. Repeat doses cure the majority of patients in whom eradication does not occur after the initial dose. A secondary goal of therapy for patients with persistent or recurrent infection is egg burden reduction, which also reduces the risk of hepatic fibrosis and lowers community spread. Community eradication programs in highly endemic regions use periodic retreatment to limit chronic schistosomiasis' morbidity. Advanced liver fibrosis and portal hypertension due to chronic schistosomiasis are irreversible. Variceal bleeding is the primary cause of death in hepatic schistosomiasis. The bleeding risk is best reduced through use of beta-blocker prophylaxis or endoscopic banding or sclerotherapy. Surgical management of varices, including splenectomy with esophagogastric devascularization or selective shunts such as the distal splenorenal, is effective in patients with recalcitrant bleeding. Because hepatic synthetic function is normal in patients with schistosomiasis, procedures that reduce portal pressures may lower hepatic perfusion and cause hepatic impairment. The risk of encephalopathy after shunt surgery is higher in patients with schistosomiasis than in those with cirrhosis. For these reasons, nonselective shunt surgery such as the proximal splenorenal or the transjugular intrahepatic portosystemic shunt should not be performed in patients with advanced hepatic schistosomiasis.

Background: To evaluate feasibility and clinical outcomes of myomectomy performed through minilaparotomic access in a large series of consecutive patients., Methods: All patients submitted to laparotomic conservative surgery for uterine myomas through an initial minilaparotomic approach (4-8-cm transverse skin incision) were retrospectively evaluated. Preoperative findings, surgical technique, rate of laparotomic enlargement, operative time, surgical complications and length of recovery were the main analyzed outcomes., Results: One hundred and seventy out of 212 patients experienced minilaparotomic approach for uterine myomatosis. In 97 (57.1%) multiple myomas were present (maximum, 23). The size of the largest myoma ranged from 2 to 19 cm (median 5.6). In 161 (94.7%) patients myomectomy was ended through minilaparotomic access with a mean length of skin incision of 6.2 cm (4-7.8). The correlation between severe obesity and laparotomic enlargement was statistically significant (p<0.05). The mean operative time was 57 min (32-118). One bladder intraoperative injury was successfully managed through minilaparotomic incision. Bowel or vascular complications never occurred. Estimated blood loss was not significant except in three cases (1.9%) requiring transfusion. Febrile complications were observed in nine patients (5.6%). The median postoperative stay in uncomplicated patients was 2.5 days (2-4)., Conclusions: Our report supports the wide application of minilaparotomic myomectomy and suggests that more than 85% of women with fit uterine myomatosis could be successfully managed in this way with a failure rate of 5.3% in eligible patients. The main criteria of minimal invasive surgery seem to be by minilaparotomic myomectomy, which should be considered a valid option for uterine myohas conservative treatment.