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Background The aim of this study is to assess the prevalence of atypical hyperplasia (AH) and endometrial cancer (EC) within endometrial polyps (EPs) removed by hysteroscopy. Methods Hysteroscopic polypectomy interventions were performed over 1436 consecutive patients with Eps to complete a prospective observational trial (Canadian Task Force Classification II-2) including 19 Italian Gynecologic Departments (University-Affiliated or Public Hospitals) for a secondary multicenter analysis. Results At histological analysis, in 1404 patients (97.8%) EPs were classified as benign, whereas in 32 patients (2.2%) EPs were diagnosed as atypical (i.e. with AH or EC). Specifically, AH and EC were found in 17 (1.2%) and 15 (1.0%) cases, respectively. Risk factor analysis showed that menopausal status, BMI and size of EPs were associated with increased risk of atypical EPs (p

In considerazione della tendenza, indotta dai mutamenti sociali, a posporre l'età della prima gravidanza e del fatto che il riscontro dei fibromi aumenta nella quarta decade di vita, è probabile che la prevalenza dei miomi associati ad infertilità sia in aumento e quindi il clinico sia sempre più di frequente obbligato a scegliere condotta ed eventuali terapie in caso di donna gravida con pregressa miomectomia. In concreto, se è disponibile una buona documentazione dell’intervento (eventualmente videoregistrazione), che attesti una sua corretta esecuzione, e/o eventualmente il parere scritto di chi ha eseguito l’intervento, la paziente può essere assimilata a una paziente con pregresso taglio cesareo. Ogni sforzo deve esser fatto per reperire la documentazione. Il management dovrà essere ispirato alle linee guida disponibili in merito. In caso contrario, appare prudente, discussi con la donna i pro e i contro, programmare un taglio cesareo elettivo. Questo atteggiamento non è suffragato da alcuno studio clinico, ma solo dall’analisi dei case reports, che dimostra come il fattore determinante nelle donne con tale complicanza non sia la sede o il numero o le dimensioni del mioma, né l’intervallo fra l’intervento e la gravidanza, ma un difetto della tecnica chirurgica.

ACTA OBSTET GYNECOL SCAND

Myometrial invasion of endometrial carcinoma is an important prognostic factor because the degree of myometrial invasion is correlated with the rate of lymphnode metastases and of recurrences. The aim of the study was a preoperative evaluation of endometrial carcinoma by Magnetic Resonance (MR).The authors present a prospective study performed on 54 cases of endometrial carcinoma collected at the Department of Gynecology and Obstetrics of the University of Trieste (Italy). All the patients were considered as Stage I after hysteroscopy and endocervical curettage. Prior to surgery all the patients underwent MR at the Department of Radiology of the University of Trieste (Italy) in order to evaluate the depth of myometrial invasion. The surgical procedure included total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic and lomboaortic lymphadenectomy in high risk cases. Statistical evaluation was performed by Fischer's exact test.Statistically significant positive correlation was found (p0.001) between MR staging and surgical staging. The sensitivity reported in our series for distinguishing between superficial disease (Stage IA and IB) and deep myometrial invasion (Stage IC) was 92%.Preoperative MR is helpful in selecting patients at high risk of nodal involvement and it is suggested that, although MR is considered an expensive examination, its use should be always considered before surgical treatment of patients with high surgical risk.

Background: Spondylodiscitis can be a rare complication of gynecological surgery, typically of procedures involving the sacrum and the sacrospinous ligament. This report presents a case of spondylodiscitis arising after a laparoscopic sacrocolpopexy with a mesh. We also review the literature finding 52 cases of spondylodiscitis following sacrocolpopexy and (or) rectopexy with or without a mesh.Methods: We performed a comprehensive search from the electronic databases MEDLINE (Pubmed), Scopus, Web of Science, Embase, CINAHL, and Google Scholar from 1990 to February 2021 in order to identify case reports or case series reporting on spondylodiscitis after rectopexy or sacrocolpopexy.Results: We identified 52 total postoperative spondylodiscitis. We examined the mean age of patients, the surgical history, the time from initial surgery to spondylodiscitis, the presenting symptoms, the diagnostic tools, the medical and surgical treatment, the type of mesh used, the surgical access, and the possible causes of spondylodiscitis.Conclusions: Diagnosis of spondylodiscitis may be challenging. From our review emerges that recurrent pelvic pain and lumbosciatalgia may be signals of lumbar spondylodiscitis. Magnetic resonance is the gold standard examination for spondylodiscitis. Surgical practice needs to be improved further in order to establish the best procedure to minimize the incidence of this complication. Awareness of symptoms, timely diagnosis, and treatment are fundamental to prevent irreversible complications.

Interstitial pregnancy is defined as the presence of a gestational sac in the most proximal section of the fallopian tube. Management of interstitial pregnancy remains a debated topic. Depending on hemodynamic stability, size of pregnancy, depth of surrounding myometrium, and desires for future fertility, interstitial pregnancy can be managed medically or surgically. We reviewed the literature in December 2020 using keywords “interstitial pregnancy”, “medical treatment”, “methotrexate”, and “mifepristone”. Articles published from January 1991 until 2020 were obtained from databases EMBASE, SCOPUS, and PUBMED. We describe the case of a patient with an interstitial pregnancy that was managed with a total medical approach in August 2020 at Burlo Garofolo Hospital. The patient was asymptomatic and hemodynamically stable, with a high level of serum β-hCG (22,272 mUi/mL). We used the combination of methotrexate (MTX) and mifepristone. Medical therapy was effective leading to interstitial pregnancy resolution in 51 days without collateral effects for the patient. We found seven previous cases reported in the literature. Our purpose is to underline the efficacy of medical therapy with systemic multidose MTX associated with a single oral dose of mifepristone and also folinic acid when is present a viable fetus and a high serum β-hCG level.

Objective: to evaluate risk factors, causes, management and surgical therapy of postcoital vaginal perforation and evisceration in women with no prior pelvic surgery. Data sources: We used MEDLINE (PubMed), Scopus, Embase and Web of Science for our research. Our review includes all reports from 1980 to November 2020. The research strategy adopted included different combinations of the following terms: (intercourse) AND (coitus) AND (vaginal perforation). Methods of study selection: we report a case of vaginal evisceration after consensual intercourse in a young and healthy woman. In addition, we performed a systematic review of vaginal perforations with or without evisceration in women without prior surgery or any other predisposing disease. All studies identified were listed by citation, title, authors and abstract. Duplicates were identified by an independent manual screening, performed by one researcher and then removed. For the eligibility process, two authors independently screened the title and abstracts of all non-duplicated papers and excluded those not pertinent to the topic. Tabulation, integration and results: We have followed the PRISMA guidelines. Five manuscripts were detected through the references of the works that had been identified with the research on MEDLINE (PubMed), Scopus, Embase and Web of Science. We found 16 cases between 1980 and 2020. The young age and the virginal status represent the principal risk factors and all the lacerations occurred in the posterior vaginal fornix. The most common surgical technique was the laparotomic approach and, in the remaining cases, the laparoscopic and vaginal route was performed. Conclusions: Post-coital vaginal perforation and evisceration in women with no prior pelvic surgery is a rare condition in the clinical practice and, when it is associated with evisceration it is a surgical emergency. Usually, these injuries are not life-threatening conditions but, a delay in diagnosis, can lead to severe complications. In consideration of the high heterogeneity of the data in the literature, it is essential to define a diagnostic–therapeutic management for the patients with vaginal perforation. With our review, we try to identify the associated risk factors, the best and fastest diagnosis, and the best surgical approach. We believe that a combined vaginal and laparoscopic approach can be the best surgical treatment, useful to diagnose injuries of the abdominal organs and to improve postoperative outcome.

Objective Many therapies have been proposed for cervical pregnancy (CP) treatment; however, there is no consensus on the best practice to adopt, mainly owing to the rarity of this condition and the lack of randomized controlled trials. Therefore, there are no clinical practice guidelines for the management of this patient set. We presented an English literature review about the hysteroscopic management of CP. Data Sources The literature review was performed according to the Preferred Reporting Items for Scoping Reviews. The search strategy aimed at identifying cases from the first patients tracked down to those diagnosed in May of 2021. We searched in PubMed, Scopus, Google Scholar, and MEDLINE databases. Mesh terms used included “Cervical Pregnancy,” “Hysteroscopy,” “Ectopic pregnancy,” and “Resectoscopy.” Method of Study Selection Case reports of randomized controlled trials, prospective controlled studies, prospective cohort studies, retrospective studies, case series, and case reports were considered eligible. Review, Letters to the Editor, and abstracts accepted at conferences were ruled out. Tabulation, Integration, and Results We found a total of 3572 articles in all analyzed databases. A total of 2480 articles viewed were duplicated and therefore ruled out. After screening and excluding nonpertinent articles, 109 were assessed for eligibility, and 19 were included in the analysis. All articles were single case reports, small case series with no criteria selection, randomization, or study planning. We classified them as follows: cases treated with 10 mm resectoscope, with or without pretreatments of previous CP hysteroscopic approach, and cases resolved with 5 mm hysteroscopy, with or without pretreatments of previous CP hysteroscopic approach. Conclusion The hysteroscopic method represents a feasible and safe approach to the CP treatment, although there are still some aspects to be clarified, such as the pretreatment need and the instruments’ type and sizes based on the beta-subunit of human chorionic gonadotropin, pregnancy age, and dimension.

Uterine leiomyomas are a common finding in medical practice, but their frequency changes drastically when contextualized in a syndrome, as in the following case. A 50-year-old woman with a known Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome presented at our clinic with abdominal pain located in the lower quadrants and scarcely responsive to analgesic therapy. A twisted gynecological pelvic mass was diagnosed, and management for prompt resolution was adopted. Histologically the mass was described as a leiomyoma. The aim of the present study is to share our experience and to review the literature to compare different manifestation of the disease and different approach used in the various centers. The additional novelty of the paper is the immunohistochemical study we carried out on the leiomyoma that is contrasted with the current etiopathogenetic theories.

Background and objectives: Cervical pregnancy (CP) is a rare form of ectopic pregnancy (EP) in which the embryo implants and grows inside the endocervical canal. Early diagnosis is essential in order to allow conservative medical and surgical treatments. Although many treatment approaches are disponible, the most effective is still unclear. The aim of this study is to evaluate the efficacy of hysteroscopic management in early CP in order to preserve future fertility. Materials and Methods: This is a retrospective observational case series. Five patients with a diagnosis of CP, hemodynamically stables and managed conservatively between 2014 and 2019 at the Institute of Child and Maternal Health Burlo Garofolo in Trieste, Italy, were included. Four patients, with &beta, hCG levels &gt, 5000 mUi/mL were managed by hysteroscopy, with or without a previous systemic Methotrexate (MTX). One case with &beta, hCG levels &lt, 5000 mUi/mL was treated using MTX combined to Mifepristone and Misoprostol. Results: In one patient treated by hysteroscopy alone it occurred a profuse vaginal bleeding with necessity for blood transfusion. Haemorrhage was controlled by a second hysteroscopic procedure. No complications, such as vaginal bleeding, were recorded in the other cases. Serum &beta, hCG levels become undetectable in a range of 15&ndash, 40 days after hysteroscopic management, after medical treatment it become undetectable after 35 days. Serum &beta, hCG levels had a faster drop the day after hysteroscopy than post medical management. The onset of a spontaneous pregnancy at the normal implantation site occurred after five months in one case treated by hysteroscopy. Conclusions: Many therapeutic approaches are effective for CP treatment. Hysteroscopy, alone or in combination with MTX, may provide a greater effect on the descent of &beta, hCG, leading to a reduction of the hospitalization stay, decreasing costs and period for attempt pregnancy. Further prospective studies on larger samples are needed to define therapeutic protocols for CP management

Non-tubal ectopic pregnancies (NT-EPs) are rare but potentially life-threatening conditions. The incidence ranges are between 5&ndash, 8.3% of all ectopic pregnancies. For this retrospective observational study, 16 patients with NT-EP and treated from January 2014 to May 2020 were recruited. Demographic details, symptoms, Beta human chorionic gonadotrophin (&beta, hCG) levels, ultrasound findings, management and treatment outcomes were presented. In hemodynamically stable patients, diagnosis was made using ultrasounds and &beta, hCG levels. Laparoscopy was essential to identify and remove the ectopic pregnancy in clinical unstable patients. A radical laparoscopic approach was chosen in one case of cervical pregnancy diagnosed late in the first trimester. Medical treatment and minimally invasive procedure, alone or combined, resulted in effective strategies in asymptomatic women with an early diagnosis of NT-EP. We report cases of cervical pregnancies successfully treated by hysteroscopy alone or combined with medical treatment, the first case of scar pregnancy treated by mini-reseptoscope and curettage and the fifth case of interstitial pregnancy treated with Methotrexate and Mifepristone. In this manuscript we report a single center experience in the management of NT-EPs with the aim of outlining the importance of the early diagnosis for a minimally invasive treatment in order to reduce maternal morbidity and mortality and preserve future fertility.

Study Objective To evaluate the efficacy of total surgical treatment of ectopic cervical pregnancy [1] with a minimally invasive approach performed by hysteroscopy [2] . Design Step-by-step video demonstration of the surgical technique using 5 mm hysteroscopy followed by 10 mm resectoscopy. Setting A research and university hospital (IRCCS Burlo Garofolo, Trieste, Italy). Patients A 41-year-old woman with an ultrasound diagnosis of ectopic cervical pregnancy at 6 + 6 weeks of gestation with a beta human chorionic gonadotropin serum level of 55.951 mUI/mL. Interventions We performed a 2-step technique using 5- and 10-mm hysteroscopy ( Video 1 ). During the first step, a 5-mm Bettocchi hysteroscope (Karl Storz, Tuttlingen, Germany) with a 5F bipolar electrode Versapoint Twizzle (Gynecare, Menlo Park, CA) was used. In this phase, the gestational sac was identified in order to confirm the diagnosis and its site of implantation. Later, the gestational sac was opened, and the pregnancy was terminated by cord section under an embryoscopic view ( Fig. 1 ). Finally, a partial vessel coagulation was performed. Afterward, the cervix was dilated, and a resectoscopy was performed. During the second step, a 10-mm Gynecare resectoscope with the bipolar Gynecare Versapoint was used and the gestational sac with the embryo was removed; subsequently, a complete chorial villi resection was achieved. At last, a coagulation of bleeding vessels on the implantation site in order to control the hemostasis was performed ( Fig. 2 ). Measurements and Main Results The study was approved by the institutional review board. The patient was discharged 24 hours after the procedure with an uneventful postoperative course, and the beta human chorionic gonadotropin serum level became negative in 20 days. After 40 days, the ultrasound cervical findings were regular, whereas office hysteroscopy showed the implantation site scar. After 5 months, the patient was pregnant with regular intrauterine implantation ( Fig. 3 ). Conclusion The total hysteroscopic approach with a 2-step technique offers an effective, safe, and minimally invasive surgical treatment to ectopic cervical pregnancy. Considering that our method, in contrast with the recent literature 3 , 4 , 5 , is performed without any medical treatment, we reported for the first time an approach, that deserve more clinical data to confirm its effectiveness.

Objective To assess the effects of hormone replacement therapy (HRT) on visual function after menopause. Design This study was conducted on 80 postmenopausal women aged 52 to 70 years. Women were randomly divided into two groups: 40 women were treated by oral HRT (equine conjugated estrogens 0.625 mg/day + dydrogesterone 5 mg/day in a continuous combined regimen), and 40 women were not treated with hormones (control group). Each woman underwent a contrast sensitivity test, a Schirmer test, and an evaluation of intraocular pressure before starting the study and 1 year after the beginning of the study. Statistical analysis was performed by Student's test and Fisher's exact test. Results Contrast sensitivity function was significantly improved in all spatial frequencies (1.5, 3, 6, and 12 cycles per degree) with the exception of 18 cycles per degree in the HRT group 1 year after the beginning of treatment, whereas the control group demonstrated significant impairment at the lowest spatial frequencies (1.5, 3, and 6 cycles per degree). Tear production was significantly improved in the HRT group 1 year after the beginning of treatment, and intraocular pressure was similar in the two groups before and after the beginning of the study. Conclusions HRT improves visual function, promoting a better contrast sensitivity and a higher tear production, but does not modify intraocular pressure.