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Purpose: to summarize and present a single tertiary center’s 25 years of experience managing patients with caesarean scar pregnancies and their long term reproductive and obstetric outcomes. Methods: A 25-year retrospective study included women diagnosed with CSP from 1996 to 2020 in one tertiary center. Data were retrieved from the medical records and through a telephone interview. Diagnosis was made by sonography and color Doppler. Treatments included methotrexate, suction curettage, hysteroscopy, embolization and wedge resection by laparoscopy or laparotomy as a function of the clinical manifestations, the physicians’ decisions, patient counseling, and parental requests. Results: Analysis of the records recovered 60 cases of CSP (two of whom were recurrent). All patients had complete resolution with no indication for hysterectomy. Thirty-five patients had a long-term follow-up, of whom 24 (68.6%) attempted to conceive again and 22 (91.6%) succeeded. There were 17/22 (77.3%) patients with at least one live birth, 3/22 (13.6%) spontaneous miscarriages and 2/22 (9%) recurrent CSP. The obstetric complications included abnormal placentation 5/19 (26.3%), premature rupture of membranes 2/19 (10.5%), preterm delivery 4/19 (21%) and abnormality of the uterine scar 2/19 (10.5%). There was one case of neonatal death due to complications of prematurity 1/19 (5.2%). Conclusion: CSP treatment focusing on reducing morbidity and preserving fertility has favorable long term reproductive and obstetric outcomes. In subsequent pregnancies, we recommend performing an early first trimester vaginal scan to map the location of the new pregnancy, followed by close monitoring given the obstetric complications mentioned above.

Objective To compare oncological outcomes in women with lower uterine segment involvement (LUSI) in endometrial carcinoma (EC) stage ≥ II - staged by a minimally invasive surgery (MIS) versus laparotomy. Study design A retrospective multi-center cohort study. Univariate analysis, Kaplan-Meier survival and Cox proportional hazard analysis were performed to compare between women staged by MIS and those staged by laparotomy. Results Over a median follow-up period of 3 years (interquartile range, 1.5–6 years) 212 women were included, 68 (32.1%) were surgically staged by MIS. Stages of disease did not vary between MIS and laparotomy and were 32.1%, 51.9%, and 16.0%, in stages II, III and IV – respectively. Adjuvant radiation and chemotherapy rate did not differ between groups. Overall recurrence rate was comparable (p = 0.084). Locoregional recurrence rate was higher in the MIS group odds ratio 2.17, 95% confidence interval 1.19–4.20). Overall and progression free survival were similar in both groups (log rank test p = 0.08 and p = 0.912 respectively). In Cox regression model adjusting for age, comorbidities, tumor grade, stage and adjuvant therapy, route of surgery (MIS vs. laparotomy) was not associated with overall survival (p = 0.169). Conclusions In women with advanced EC and LUSI, although MIS is associated with locoregional recurrences, survival is comparable to laparotomy.

SUMMARY Ovarian adrenal rest tumors (OARTs) are very rare. We describe a case of a young woman with uncontrolled classical congenital adrenal hyperplasia (CCAH), presenting with bilateral OARTs, successfully treated with steroid replacement. A 20-year-old woman, known to have 21OH-CCAH, presented with severe abdominal pain, vomiting, diarrhea, and fever. As a result of poor compliance, 6 months before her admission hirsutism worsened and amenorrhea, hyperpigmentation, and weakness developed. ACTH levels were 278 < pmol/L and 17OHP 91.3 nmol/L. She was admitted for parenteral antibiotics and high-dose hydrocortisone treatment. CT revealed bilateral juxta-ovarian masses (6.2 x 3.6 x 7.4 cm left and 5 x 2.2 x 3.2 cm right) that on MRI were iso-intense in T1 and hypointense in T2, with early enhancement and rapid washout. One week of high-dose hydrocortisone resulted in significant clinical and laboratory improvement and the patient was discharged with 2 mg dexamethasone/day. One month later US revealed shrinkage of the masses and dexamethasone dose was decreased. At three months from discharge, she has resumed regular menses, and a repeated MRI revealed the para-ovarian masses have shrunk. One year after the diagnosis, the para-ovarian masses have shrunk more to 2.8 x 1.9 x 4.3 on the left and 2.1 x 0.9 x 1.2 on the right with less contrast enhancement in comparison to previous test possibly due to fibrotic changes of the tissue. OARTs are rare tumors with a poorly known natural history, and surgery has been the first option in the few reported cases. We demonstrate that medical treatment is a good alternative, leading to significant tumor shrinkage over a short period.

ObjectiveEndometrial cancer prognosis is related to stage, histology, myometrial invasion, and lymphovascular space invasion. Several studies have examined the association between pretreatment thrombocytosis and patient outcomes with contrasting results regarding prognosis. Our aim was to evaluate the association of pretreatment platelet count with outcomes in endometrial cancer patients.MethodsThis is an Israeli Gynecologic Oncology Group multicenter retrospective cohort study of consecutive patients with endometrial cancer, who underwent surgery between January 2002 and December 2014. Patients were grouped as low risk (endometrioid G1-G2 and villoglandular) and high risk (endometrioid G3, uterine serous papillary carcinoma, clear cell carcinoma, and carcinosarcoma). Those with stage I disease were compared with stages II–IV. Disease stages were reviewed and updated to reflect International Federation of Gynecology and Obstetrics (FIGO) 2009 staging. All patients underwent pelvic washings for cytology and total abdominal or laparoscopic hysterectomy with bilateral salpingo-oophorectomy. Pelvic lymph node assessment was performed in patients with tumors of moderate–high risk histology or deep myometrial invasion. Para-aortic sampling was performed at the surgeon’s discretion. Patients were categorized by pretreatment platelet count into two groups: ≤400×109/L and >400×109/L (defined as thrombocytosis). Clinical and pathological features were compared using Student t-test, χ2 or Fisher’s exact test. Survival measures were plotted with the Kaplan-Meier method and compared using the log-rank test. A Cox proportional hazards model was used for multivariable comparison of associations.ResultsOf the 1482 patients included, most had stage I disease (961; 74.8%) and most had endometrioid histology (927; 64.1%). A total of 1392 patients (94%) had pretreatment platelet counts ≤400×109/L and 90 (6%) had pretreatment thrombocytosis. Patients with thrombocytosis had a significantly higher rate of high-grade malignancy, advanced stage, lymphovascular space invasion, low uterine segment involvement, and lymph node metastases. They also had shorter 5 year disease-free survival (65% vs 80%, p=0.003), disease-specific survival (63% vs 83%, pConclusionsPretreatment thrombocytosis is an independent prognostic factor for decreased disease-specific survival and overall survival among patients with endometrial cancer, and can serve as a predictor of poor outcome.

Objective: To describe the feasibility of hysteroscopy assisted suction curettage for early pregnancy loss and to investigate whether it reduces the rates of retained products of conception (RPOC) and intrauterine adhesions (IUA). Design: Prospective single-arm cohort study. Setting: University-affiliated department of Obstetrics and Gynecology. Patients: Women admitted for surgical evacuation in cases of early pregnancy loss were offered participation in the study. Intervention: Vaginal misoprostol was administered for cervical ripening preoperatively. Under general anesthesia, a diagnostic hysteroscopy was performed to identify the pregnancy’s implantation wall, followed by ultrasound guided suction and curettage directed to the implantation wall, and diagnostic hysteroscopy to verify complete uterine cavity emptying. Postoperative IUA were evaluated by follow-up office hysteroscopy. Main Outcome Measure: Identification of the pregnancy’s implantation wall on hysteroscopy, and intra- and postoperative complications associated with the procedure. The evaluation of postoperative IUA was limited due to the COVID-19 pandemic and restrictions on elective procedures. Results: 40 patients were included in the study group. Their mean age was 34.0 ± 6.6 years, and their mean gestational age was 8.9 ± 1.6 weeks. In 33 out of 40 cases (82.5%), the implantation wall was clearly visualized on hysteroscopy. The mean operative time was 17.2 ± 8.8 minutes, and no intraoperative complications occurred. In 4 cases, suspected RPOC were diagnosed intraoperatively by hysteroscopy and removed. The histology examination confirmed the presence of RPOC in 3 out of these 4 suspected RPOC cases. Follow-up office hysteroscopy was performed in 9 women, diagnosing mild IUA in one case and a normal cavity in 8 cases. In 15 cases, a new pregnancy was reported at time of follow-up, while 12 women declined to attend the follow up-hysteroscopy and 4 were lost to follow-up. Conclusions: Hysteroscopy assisted suction curettage for early pregnancy loss is a safe, short, and inexpensive procedure, which allows the identification of the pregnancy’s wall in most cases and may reduce the rates of RPOC and IUA.

Objective To compare outcomes of symptomatic and asymptomatic women with endometrial cancer and a preoperative diagnosis of an endometrial polyp. Design An Israel Gynecologic Oncology Group multi-center retrospective cohort study. Methods Of 635 patients with endometrial cancer and a preoperative diagnosis of an endometrial polyp who underwent surgery between 2002 and 2014 in one of 11 centers in Israel were divided into two groups according to the presence of bleeding symptoms. Outcome measures included recurrence-free survival, disease-specific survival and overall survival. Survival data were plotted according to the method of Kaplan and Meier and compared using the log-rank test. Results There were 513 symptomatic and 122 asymptomatic women with endometrial cancer and a preoperative diagnosis of an endometrial polyp. The median follow-up was 52 months (range 12-120 months). There were no differences between patients who experienced bleeding and those who did not in 5-year recurrence-free survival (85.2 % vs. 85.7 %; p=0.83, respectively), disease-specific survival (88.2 % vs. 89.2 %; p=0.71, respectively), or overall survival (80.2% vs. 78.4 %; p=0.97, respectively). Conclusion The diagnosis of endometrial cancer in patients with asymptomatic endometrial polyps is not associated with improved outcomes as compared with patients with bleeding. In the absence of factors indicating a high risk of endometrial cancer, clinical and sonographic follow-up is the advised management strategy for these patients.

Aim Ectopic pregnancy implantation on the tubal stump after salpingectomy is a rare location for extrauterine pregnancy, whose pathogenesis is still unknown. The purpose of this study was to examine whether the time interval elapsed from salpingectomy may predispose the embryo to implantation on the tubal stump in the next pregnancy subsequent to tube removal. Methods Nine women operated for stump pregnancy (study group) between 2008 and 2019 were retrospectively identified. For each case in the study group, 12 consecutive cases that underwent laparoscopic salpingectomy constituted the control group. A sample size of 100 control patients was calculated to achieve statistical power (97.8%) and an α of 0.05. The control groups were triple-matched with the study group for patients' age, indications for salpingectomy (tubal pregnancy or hydrosalpinx prior to in vitro fertilization treatment) and mode of conception of the subsequent pregnancy following salpingectomy. Results Nine women underwent surgery for stump pregnancy during the study period. All women had a surgical history of laparoscopic salpingectomy. The time interval from prior salpingectomy to subsequent pregnancy was significantly shorter in study group than in the control group (4.3 ± 2.1 months vs. 15.6 ± 13.7 months, respectively, p = 0.016). Conclusion A possible association between the short time interval from prior salpingectomy to ectopic implantation on the tubal stump in the subsequent pregnancy was found. The clinical implications of these findings and in particular whether patients should be advised to wait at least 4 months from the salpingectomy to the subsequent pregnancy remain unclear.

Background Second-trimester and early third-trimester uterine rupture in a nonlaboring woman is a very rare and life-threatening condition for both mothers and newborns. We aimed to present clinical characteristics, prenatal findings, and maternal and neonatal outcomes following second-trimester and early third-trimester spontaneous antepartum uterine rupture in our institute. Method The medical records of all women with full-thickness second-trimester and early third-trimester uterine rupture treated in our department from 1988 to 2019 were retrieved from the institutional database and reviewed. Small uterine defects, incomplete ruptures, and silent uterine incision dehiscence were excluded. Results From 1988 to 2019, 213 665 deliveries were recorded in our institute. Of these, 12 patients experienced second-trimester or early third-trimester spontaneous uterine rupture. Obstetric history revealed that 50% of the women in each period had undergone previous classical uterine incisions and 50% had a short interpregnancy (IP) interval. The mean age at diagnosis of uterine rupture was 26.3 ± 5.1 weeks. The ruptures were associated with abnormal placentation in 10 cases (83.3%): placenta previa (n = 7); and placenta previa and percreta (n = 3). No maternal mortality occurred. Seven of the 10 (70%) viable newborns survived. Conclusions The increasing rates of cesarean births (CB) may lead to iatrogenic complications including midgestational prelabor spontaneous uterine rupture, an obstetric emergency, which is hard to diagnose. Maternal and neonatal outcomes can be optimized by a greater awareness of the risk factors, recognition of clinical signs and symptoms, and the availability of ultrasound to assist in establishing a diagnosis to enable prompt surgical intervention.

Background This retrospective study compared perioperative measures, costs, quality of life and survival after open vs. robotic surgery, among obese women diagnosed with low-grade endometrial cancer. Methods Obese women (body mass index (BMI) ≥ 30) who underwent open or robotic surgery for endometrial cancer, in one of two tertiary medical centers in the center of Israel, 2013–2016, postoperative grade 1–2, were included. Costs per patient, including 30-days post-surgery were calculated. Quality of life was evaluated by Physical and Mental Components of the SF-36 and a recovery from surgery questionnaire. Overall survival outcomes were obtained from patients’ files. Surgical outcomes, including operating and anesthesia times, length of hospital stay, and intraoperative and postoperative complications according to the Clavien-Dindo classification scale were reviewed. Results In all, 138 women with BMI ≥30 underwent open (n = 61) or robotic surgery (n = 77) during the study period. The groups had similar BMI, comorbidities, demographics and tumor characteristics. Robotic surgery was associated with shorter hospital stays (mean 1.7 vs. 4.8 days; P > 2, 5.2% vs. 19.7%; P = .0008), but longer operating theater time (3.8 vs. 2.8 h; P P P P P = 0.330). Conclusions Obese women with low-grade endometrial cancer had better quality of life after robotic vs. open surgery. They also had shorter hospital stays and fewer postoperative complications. Centers with high volumes of robotic surgery can achieve similar costs when comparing both methods. These results were achieved without jeopardizing survival. Our results further emphasize the need for the Israeli healthcare system to include specific reimbursement for robotic procedures in the population we studied.

INTRODUCTION Advanced age is considered an adverse factor in endometrial cancers but may be a surrogate for other conditions that impact outcomes. The study objective was to assess the association of age with endometrial cancer features, treatment and prognosis. MATERIAL AND METHODS In this multicenter cohort study, consecutive women with endometrial cancer treated at 10 Israeli institutions between 2000 and 2014 were accrued in an assimilated database. Postmenopausal women were stratified into age groups with a cut-off of 80. Clinical, pathological and treatment data were compared using t test or Mann-Whitney test for continuous variables, and Chi-square Test or Fisher's Exact test for categorical variables. Main outcome measures included disease recurrence and disease-specific and overall survival; these were plotted using the Kaplan-Meier method and compared using the log-rank test. The association between age and recurrence and survival, adjusted for other clinical and pathological factors, was assessed using multivariable Cox regression modeling. RESULTS A total of 1764 postmenopausal women with endometrial cancer were identified. Adverse pathological features were more prevalent in older women, including high-risk histologies (35% vs 27%, P = .025), deep myoinvasion (44% vs 29%, P = .001) and lymphovascular involvement (22% vs 15%, P = .024). Surgical staging was performed less frequently among older women (33% vs 56%; P

Purpose Recurrence of adnexal torsion involving otherwise normal adnexa is not rare. Various oophoropexy (ovarian fixation) procedures have been suggested to prevent recurrence, however, long-term information of their efficacy is lacking. The aim of this study was to investigate the recurrence rate of adnexal torsion following oophoropexy. Methods Retrospective cohort study, including all consecutive patients who underwent an oophoropexy procedure for the prevention of recurrent torsion of “normal adnexa” in our department from 2008 to 2021. Oophoropexy techniques included shortening of the utero-ovarian ligament (between 2008 to 2019) or combined utero-ovarian and round ligament fixation (from 2020). Results Twenty-one patients (age range 7-35 years) with a mean follow-up of 82.7 ± 60.6 months were identified. Fifteen of them (71.4%) were re-operated for recurrent torsion following an oophoropexy procedure, while six (28.6%) did not experience recurrence. Twelve (57.1%) torsion recurrences following an oophoropexy occurred within the first 2 postoperative years. There were no differences in mean age and menarchal status )pre- or post-menarchal) at the time of the first torsion event, age at the time of oophoropexy, oophoropexy side, number of adnexal torsion events before oophoropexy, and follow-up duration between those with and those without post-oophoropexy recurrences. Conclusion Oophoropexy procedures may not prevent recurrent torsion of otherwise normal adnexa. Further studies to determine whether combined fixation (utero-ovarian plication and round ligament) is more efficacious than isolated utero-ovarian plication for the prevention of recurrent torsion are warranted.

Endometrial cancer is the most common gynecologic malignancy in developed countries. The overall risk of recurrence is associated with traditional risk factors.Machine learning was used to predict recurrence among women who were diagnosed and treated for endometrial cancer between 2002 and 2012 at elven university-affiliated centers. The median follow-up time was 5 years. The following data were retrieved from the medical records and fed into the algorithm: age, chronic metabolic diseases, family and personal cancer history, hormone replacement therapy use, endometrial thickness, uterine polyp presence, complete blood count results, albumin, Ca-125 level, surgical staging, histology, depth of myometrial invasion, LVSI, grade, pelvic washing cytology, and adjuvant treatment. We used XGBoost algorithm, which fits the training data using decision trees, and can also rate the factors according to their influence on the prediction.1935 women were identified of whom 325 had recurrent disease. On the randomly picked samples, the specificity was 55% and the sensitivity was 98%. Our model showed an operating characteristic curve with AUC of 0.84.A machine learning algorithm presented promising ability to predict recurrence of endometrial cancer. The algorithm provides an opportunity to identify at-risk patients who may benefit from adjuvant therapy, tighter surveillance, and early intervention.

Study Objective Most cases of adnexal torsion in pregnancy are currently managed by laparoscopy, which may be associated with increased risks for spontaneous abortion and pre-term delivery. We sought to evaluate the obstetrical outcomes of these women with emphasis on their live birth rate and gestational age at delivery. Design Retrospective cohort study and telephone questionnaire. Setting University-affiliated Obstetrics and Gynecology department. Patients All pregnant women who underwent laparoscopy for adnexal torsion between 2007 and 2017. Their obstetrical outcomes were obtained by retrospective review of medical records and a telephone questionnaire. Interventions Laparoscopy for adnexal de-torsion, with or without cyst drainage or cystectomy. Measurements and Main Results The study cohort included 94 women. Most torsion cases (71, 75.5%) were diagnosed in the first trimester of pregnancy, while 21 (22.3%) were diagnosed in the second trimester, and 2 (2.1%) in the third trimester. Conception was achieved by in-vitro fertilization (IVF) or by ovulation induction (OI) in 45 (47.9%) cases. The information on pregnancy outcomes was available for 93 women. Of those, live birth was reported for 86 (92.5%) pregnancies while 6 (6.5%) women had a spontaneous abortion, and one woman experienced an intrauterine fetal death. Five cases of spontaneous abortion were diagnosed in the first trimester, all within 3 weeks of surgery. Pre-term delivery prior to 37 gestational weeks was reported for 18 (19.4%) pregnancies and was significantly associated with twin pregnancy (p=0.002) and with conception following IVF/OI (p=0.03). On logistic regression analysis, preterm delivery was only associated with twin versus singleton gestation (Odds Ratio=6.7, 95% Confidence Interval 1.3-34.8, p=0.02). Conclusion The obstetrical outcomes of pregnant women who underwent laparoscopy for adnexal torsion are generally favorable. However, there is a risk for preterm delivery which is primarily associated with multiple gestation.

Objectives Primary, to explore correlation between the extent of pelvic lymphadenectomy in the surgical staging of endometrial cancer and the number of nodes with metastasis. Secondary, evaluate survival measures in relation to the number of excised nodes. Methods A retrospective multi-center study of prospectively collected information of 2014 women with endometrial cancer, 1032 of whom underwent lymph node staging. Spearman's rank correlation was used to assess the correlation between the number of pelvic nodes excised and the number of metastatic nodes. Women's data were dichotomized by the median number of excised pelvic nodes. Kaplan-Meier and log rank tests were used to examine the effect of the number of pelvic nodes excised on survival. Results There was no significant correlation between the number of pelvic nodes harvested and the number of metastatic lymph nodes (r = 0.301; p = 0.28). The median number of excised pelvic nodes was 9 (range 1–77). There was no difference between women with up to 9 and women with more than 9 lymph nodes excised in the 5-year recurrence-free survival (82.4% vs. 83.9%; p = 0.90), disease-specific survival (83.6% vs. 86.7%; p = 0.37), or overall survival (75.8% vs. 82.8%; p = 0.11). Conclusions The extent of pelvic lymphadenectomy in the surgical staging of endometrial cancer is not associated with a higher yield of metastatic nodes or with longer survival. Current focus should be on sentinel node procedures that offer women the benefit of accurate staging without the complications associated with extensive lymphadenectomy.

Objective To investigate the rates of intrauterine adhesion following hysteroscopy for removal of RPOC associated with surgical termination of pregnancy. Methods We conducted a retrospective cohort study of all cases of removal by hysteroscopy of RPOC associated with surgical termination of pregnancy carried out at the Yitzhak Shamir (Assaf Harofe) Medical Center from January 2013 to December 2018. The rates of postoperative intrauterine adhesion were assessed by follow-up hysteroscopy. Results Our study involved 85 cases of removal by hysteroscopy of RPOC associated with surgical termination of pregnancy. The mean size of the RPOC was 1.9 ± 0.9 cm, and the mean time from termination of pregnancy to hysteroscopy was 1.5 ± 0.9 months. Two patients (2.4%) were readmitted for postoperative complications (fever). Postoperative follow-up information was available for 49 cases (57.6%). A total of 47 of these women had a normal uterine cavity (95.9%) while 2 women (4.1%) were diagnosed with mild intrauterine adhesions. Conclusions Hysteroscopy for removal of RPOC following surgical termination of pregnancy is associated with low rates of postoperative intrauterine adhesions. Additional studies may determine whether this is the procedure of choice in these cases.

Objective To compare survival measures of women with early-stage endometrial cancer who underwent either hysteroscopy or a non-hysteroscopic procedure as a diagnostic procedure. Study design An Israel Gynecologic Oncology Group multicenter study of 1324 patients with stage I endometrial cancer who underwent surgery between 2002 and 2014. Patients were divided into two groups: hysteroscopy and non-hysteroscopy (curettage or office endometrial biopsy). Clinical, pathological, and survival measures were compared between the groups. Results There were 355 patients in the hysteroscopy group and 969 patients in the non-hysteroscopy group. The median follow-up was 52 months (range 12–120 months). There were no differences between the groups in the 5-year recurrence-free survival (90.2% vs. 88.2%; p = 0.53), disease-specific survival (93.4% vs. 91.7%; p = 0.5), and overall survival (86.2% vs. 80.6%; p = 0.22). Conclusion Our findings affirm that hysteroscopy does not compromise the survival of patients with early-stage endometrial cancer.

Objective To assess whether statin use by endometrial cancer patients was associated with a survival advantage. Methods A retrospective chart review study, by the Israeli Gynecologic Oncology Group, of consecutive endometrial cancer patients who underwent surgery in one of 11 medical centers between 2002 and 2014. Clinical and pathological reports, and measures of survival were compared between statin users and nonusers. Kaplan-Meier and Cox proportional hazard models were used to assess the effect of using statins on survival measures. Results Over a mean follow-up period of 6.2 years (range, 1-12 years) for 2017 endometrial cancer patients with complete data, 663 (32.8%) used statins prior to diagnosis and 1354 (67.1%) did not. No statistically significant differences between the groups were observed for most demographic and clinical characteristics. There was no difference between statin users and nonusers in 5-year recurrence-free survival (82% vs 83%; P=0.508), disease-specific survival (86% vs 84%; P=0.549), or overall survival (77% vs 75%; P=0.901). Conclusions In this large cohort of patients with endometrial cancer, no significant associations were found between use of statins and endometrial cancer survival.

Objective: Transvaginal myomectomy is the mainstay of treatment for prolapsed pedunculated submucosal myoma. This research was conducted to evaluate the outcome of transvaginal removal of ...

Study Objective To compare oncological outcomes of women with stage II -IIIc endometrial cancer (EC) who underwent minimally invasive surgery (MIS) versus laparotomy. Design A retrospective cohort study. Setting Academic multi-center. Patients or Participants Consecutive women with EC treated at 11 Israeli institutions between 2002 and 2017 were recorded in an assimilated database with a median follow-up of 52 months (range 12-120 months). Women with stage II -IIIc were stratified into groups by intentional route of surgery; MIS vs. laparotomy. Clinical, pathological and outcome data were compared. Interventions MIS and laparotomy. Measurements and Main Results Three hundred and four women met criteria: 200 underwent laparotomy and 104 MIS. Women in the MIS group were younger, had lower rate of diabetes and lower CA-125 level. Women who underwent laparotomy had higher grade EC and more advanced stage disease; Odds Ratio (OR) and 95% Confidence Interval (CI) 0.34 (0.21-0.56) and 0.56 (0.34-0.92), respectively. Brachytherapy rate was comparable between groups (p=0.715). In a multivariable analysis, including age, comorbidities, disease stage, tumor grade and lymph-vascular space invasion, MIS was not associated with an increased risk for recurrence, progression or decreased overall survival. However, patients operated by MIS had higher risk to recur locally (vaginal cuff or pelvic) (26.9% vs. 16.5%, p=0.032, OR, 1.86, 95% CI 1.05-3.30). MIS was the only independent factor associated with local recurrence, adjusted OR, 2.09, 95% CI 1.12-3.90. Conclusion In women with stage II-IIIc EC, MIS was associated with an increased risk for local recurrence compared to laparotomy.

Women with cervical cancer who undergo radical hysterectomy are often treated postoperatively with chemoradiation. Patient selection that minimizes adjuvant treatment is valuable. We compared two methods for predicting postoperative adjuvant treatment of women with tumor size ≥2 cm and4 cm.This multicenter retrospective study included 272 women with tumor size ≥2 cm and4 cm. A receiver operating characteristic curve (ROC) analysis was used to determine the optimal tumor cutoff size to predict adjuvant treatment. A second analysis compared the rate of adjuvant treatment between women with and without lymph vascular space involvement (LVSI).According to the ROC, the optimal cutoff value of tumor size for predicting adjuvant treatment was 2.95 cm (sensitivity 0.70, specificity 0.67). Tumors were ≥3.0 cm in 166 (61.0%) women. The rate of adjuvant treatment was higher in women with larger tumor diameter (73.8% vs. 47.9%, p 0.0001). Of the 241 women with a LVSI record, LVSI was present in 81 (34%) women. Among women with LVSI, rates were higher of positive lymph nodes (41.0% vs 14.5%, p 0.0001) and postoperative adjuvant treatment (83.3% vs. 53.7%, p 0.001). Among women with tumor size ≥3.0 cm and LVSI, the rate of adjuvant treatment was 90.0%. In the multivariate analysis, both tumor size ≥3.0 cm and the presence of LVSI were independently associated with adjuvant treatment (OR 3.9, 95% CI 2.1-7.1; p 0.0001 and OR 4.9, 95% CI 2.4-10.0; p 0.0001, respectively).In women with cervical cancer who underwent radical hysterectomy, tumors ≥3 cm were associated with a70% rate of adjuvant treatment, and LVSI was associated with a80% rate. These data should be weighed in multidisciplinary consultation with radiation oncologists when deciding treatment strategy.

Adnexal torsion in pregnancy is often associated with functional adnexal cysts, especially in pregnancies conceived by ovulation induction (OI) or in-vitro fertilization (IVF). During laparoscopy for adnexal de-torsion, drainage of the functional cysts can be attempted, although this procedure may cause bleeding.To investigate the characteristics of ovarian torsion in pregnancy associated with functional cysts and to compare the rate of torsion recurrence following de-torsion alone versus cyst drainage.All cases of surgically diagnosed adnexal torsion occurring during pregnancy between January 2007 and April 2019 in our department were retrospectively analyzed. The cases of torsion associated with presumed functional ovarian cysts were selected. The rate of recurrent torsion during the same pregnancy was compared for de-torsion alone versus de-torsion and cyst aspiration.Of the 113 women who experienced adnexal torsion during pregnancy, 71 (67.0%) of torsion cases were caused by presumed functional ovarian cysts. Among women with torsion of functional ovarian cysts, the rate of torsion recurrence was significantly higher in patients who underwent de-torsion alone (n=28) compared to women who underwent aspiration and drainage of the ovarian cysts (n=43) (14.3% vs. 0, P = 0.021). There were no cases of intra- or post-operative bleeding in the study cohort.Functional ovarian cysts are the most common adnexal pathology encountered in pregnant women with torsion. Intra-operative cyst aspiration and drainage may reduce the risk of recurrent torsion. Further multi-center studies are required to validate our data prospectively.

Objective During the 2020 COVID-19 pandemic there was a decrease in emergency room arrivals. There is limited evidence about the effect of this change in behavior on women's health. We aimed to evaluate the impact of the COVID-19 pandemic on the diagnosis, treatment and complications of women presenting with a tubal Ectopic Pregnancy (EP). Study design This is a single centre retrospective cohort study. We compared the clinical presentation, treatment modalities and complications of all women presenting in our institution with a tubal EP during the COVID-19 pandemic between 15 March and 15 June 2020, with women who were treated in our institution with the same diagnosis in the corresponding period for the years 2018–2019. Results The study group included 19 cases of EP (N = 19) that were treated between the 15 March 2020 and 15 June 2020. The control group included 30 cases of EP (N = 30) that were admitted to in the corresponding period during 2018 and 2019. Maternal age, parity, gravity and mode of conception (natural vs. assisted) were similar between the two groups. There was no difference in the mean gestational age (GA) according to the last menstrual period. In the study group more women presented with sonographic evaluation of high fluid volume in the abdomen than in the control group (53 % vs 17 %, P value 0.01). This finding is correlated with a more advanced disease status. In the study group there was a highly statistically significant 3-fold increase in rupture among cases (P

We aimed to assess the association of pre-operatively evaluated ultrasonographic endometrial thickness with outcomes of patients with endometrial cancer.An Israel Gynecologic Oncology Group multicenter retrospective cohort study of consecutive patients with endometrial cancer who underwent surgery between 2002 and 2014 in one of eleven academic centers. Patients were categorized by endometrial thickness into two groups: ≤20 mm and20 mm. Clinical and pathological features were compared using Student T-test for continuous variables and Chi-square or Fisher's exact test for categorical variables. Survival measures were plotted with the Kaplan-Meier method and compared using the log-rank test. A Cox proportional hazards model was used for multivariable comparison of associations.1113 patients in whom endometrial thickness data was recorded were the subject of this study and included 2 groups: ≤20 mm (n = 930),20 mm (n = 183). The median follow-up was 52 months (range 12-120 months). Patients with endometrial thickness20 mm had significantly lower recurrence-free survival (log rank, p .0001), disease-specific survival (log rank, p = .01), and overall survival (log rank, p .0001). On multivariate Cox proportional hazards analysis, endometrial thickness20 mm remained independently associated with an increased hazard of recurrence and death (HR = 1.77, 95% CI 1.07-2.96, p = .03 for recurrence; and HR = 1.68; 95% CI 1.07-2.65; p = .03 for overall survival).In patients with endometrial cancer, endometrial thickness20 mm as measured preoperatively by ultrasound, is independently associated with decreased recurrence-free and overall survival. This finding suggests that thick endometrium may be considered as one of the risk factors for poor prognosis.

Objective Dermoid cysts (benign mature cystic teratoma) are a relatively common cause of adnexal torsion. We aimed to identify the clinical and surgical characteristics associated with adnexal torsion involving dermoid cysts. Study design Retrospective review of all cases of ovarian dermoid cysts (as diagnosed by pathology evaluation) operated in our department between 2008−2019. We collected information on demographic characteristics, clinical presentation, and surgical findings and compared those parameters among women with and without adnexal torsion. Results The study cohort included 231 patients who were operated for ovarian dermoid cysts. Of these, the surgery was performed urgently for suspected adnexal torsion in 77 (33.3%) cases, while adnexal torsion was surgically diagnosed in 51 (22.1%) cases. Diagnosis of torsion was significantly associated with younger mean age (28.8 ± 14.4 years in torsion cases versus 34.5 ± 14.8 years in non-torsion cases, p = 0.01), but not with the mean cyst diameter (81.9 ± 26.3 mm in the torsion group versus 74.7 ± 35.9 mm in the non-torsion group, p = 0.1). Regarding cyst size, torsion was found in women with cyst diameter ≤ 55 mm (9 cases, 17.7% of torsion cases), 60−90 mm (30 cases, 58.8%), and ≥ 100 mm (12 cases, 23.5%) (p = 0.1 for comparison between all groups and p = 0.05 for comparison between the small diameter group versus the intermediate/large diameter groups). Although abdominal pain was reported in most women with and without torsion, patients with adnexal torsion were significantly more likely to present with nausea and/or vomiting (24 cases [47.1%], versus 14 cases [7.8%], respectively, p Conclusion Torsion of dermoid cysts is associated with younger age, but not with the mean cyst’s diameter. Surgical removal of dermoid cysts should be considered in pre-menarchal girls, adolescents and young women to prevent adnexal torsion.

Objectives Data on the outcome of stage IIA1 cervical cancer is limited, as these tumors comprise a small percentage of early tumors. NCCN guidelines suggest consideration of surgical management for small tumors with vaginal involvement. Our objective was to evaluate the risk of adjuvant radiotherapy in stage IIA1 cervical cancer and its associated features, in order to improve selection of patients for surgical management. Methods A retrospective cohort study comparing surgically treated cervical cancer patients with stage IB1 and stage IIA1 disease. Women treated between 2000 and 2015 in ten Israeli medical centers were included. Patient and disease features were compared between stages. The relative risk (Fisher's exact test) of receiving post-operative radiation was calculated and compared for each risk factor. A general linear model (GLM) was used for multivariable analysis. Results 199 patients were included, of whom 21 had stage IIA1 disease. Most features were comparable for stage IB1 and stage IIA1 disease, although patients with vaginal involvement were more likely to have close surgical margins (23.8% vs 8.5%, p = 0.03). Patients with stage IIA1 disease were more likely to receive radiation after surgery (76% vs. 46%, RR = 1.65 (1.24–2.2), p = 0.011). Vaginal involvement as well as depth of stromal invasion, LVSI and lymph node metastases were independent predictors of radiation on multivariable general linear modeling. Conclusions Cervical cancer patients with vaginal involvement are highly more likely to require postoperative radiation. We recommend careful evaluation of these patients before surgical management is offered.

Study Objective To compare oncological outcomes of women with high-grade endometrial carcinoma (HGEC) who underwent surgery by minimally invasive surgery (MIS) versus laparotomy. Design A retrospective cohort study. Setting Academic multi-center. Patients or Participants Consecutive women with HGEC cancer treated at 11 Israeli institutions between 2002 and 2017 were accrued in an assimilated database with a median follow-up of 52 months (range 12-120 months). Women with HGEC were stratified into two groups by route of surgery; MIS vs. laparotomy by an intention to treat. Clinical, pathological and outcome data were compared. Interventions MIS and laparotomy. Measurements and Main Results Six hundred and seventy-eight women met the inclusion criteria: 160 underwent MIS and 518 laparotomy. The two groups were comparable in demographic and clinical characteristics. Local recurrence was more common in the MIS group, Odds Ratio (OR) 95% Confidence Interval (CI) 2.80 (1.80-4.36). Disease progression rates were comparable (p=0.537). In a multivariable analysis, including age, comorbidities, disease stage, CA-125 and lymph-vascular space invasion, MIS was not associated with an increased risk for either overall recurrence rate, disease progression, or overall survival. Independent risk factors for local recurrence were diabetes, stage III-IV, LVSI and MIS, adjusted OR 95% CI 3.30 (1.69-6.48). Conclusion In women with HGEC, MIS is associated with higher rates of local recurrence as compared to laparotomy.

The aim of this study was to investigate the association of clinical, laboratory and ultrasound findings with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion. The study included 199 reproductive age women > 16-year-old who underwent urgent laparoscopy for suspected adnexal torsion between January 2008 and December 2014. The association of various parameters with adnexal torsion was analyzed with a multivariate logistic regression analysis and described as odds ratios (OR) ± 95% confidence intervals (CI). Adnexal torsion was surgically diagnosed in 111/199 (55.8%) cases. On the multivariate logistic regression analysis, complaints of nausea/vomiting (OR 4.5, 95% CI 1.8–11.1), peritoneal irritation signs (OR 100.9, 95% CI 4.2–2421.9), elevated white blood cell count > 11,000 cells/mL (OR 3.7, 95% CI 1.3–10.8), presence of free pelvic fluid on ultrasound (OR 34.4, 95% CI 6.7–177.9), ultrasound findings suggestive of ovarian edema (OR 4.2, 95% CI 1.5–11.6), ultrasound findings suggestive of benign cystic teratoma (OR 7.8. 95% CI 1.2–49.4) and location of the ultrasound pathology on the right side (OR 4.7. 95% CI 1.9–11.9) were positively associated with adnexal torsion, while ultrasound findings suggestive of hemorrhagic corpus luteum cyst (OR 0.04, 95% CI 0.008–0.2) were negatively associated with adnexal torsion. By combining these eight parameters, the ROC curve was calculated, yielding an area under the curve of 0.93, 95% CI 0.90–0.97 (p

Objectives To compare survival measures of women with early-stage endometrial cancer who underwent either hysteroscopy or a non-hysteroscopic procedure as a diagnostic procedure. Methods An Israel Gynecologic Oncology Group multicenter study of 1324 patients with stage I endometrial cancer who underwent surgery between 2002 and 2014. Patients were divided into two groups: hysteroscopy and non-hysteroscopy (curettage or office endometrial biopsy). Clinical, pathological, and survival measures were compared between the groups. Results There were 355 patients in the hysteroscopy group and 969 patients in the non-hysteroscopy group. The median follow-up was 52 months (range 12–120 months). There were no differences between the groups in the 5-year recurrence-free survival (90.2% vs. 88.2%; p=0.53), disease-specific survival (93.4% vs. 91.7%; p=0.5), and overall survival (86.2% vs. 80.6%; p=0.22). Conclusions Our findings affirm that hysteroscopy does not compromise the survival of patients with early-stage endometrial cancer.

Retained products of conception (RPOC) may occur as the result of a morbidly adherent placenta. In these cases, the hysteroscopic removal of RPOC may be technically challenging, and may require more than one hysteroscopic procedure. We sought to compare the clinical, surgical, and postoperative characteristics of cases managed by either a one-step hysteroscopy procedure or a two-step hysteroscopy approach. A retrospective review of all RPOC cases managed by hysteroscopy from 1/2013 to 3/2018. We included cases of RPOC occurring following delivery and medical or surgical pregnancy terminations. The rates of postoperative intrauterine adhesions were assessed by office hysteroscopy. A two-step procedure was required in 11 (3.9%) of the 358 women who underwent hysteroscopy for removal of RPOC during the study period. Comparison between the two-step and the one-step procedure groups revealed that the women in the two-step group were significantly older and the mean RPOC size was significantly larger (35.5 ± 4.1 years versus 30.7 ± 5.9 years, respectively, p = 0.01, and 38.6 ± 9.8 mm versus 22.3 ± 7.5 mm, p

Study Objective: To investigate the use of operative hysteroscopy instead of traditional curettage in women with retained products of conception (RPOC) following first trimester medical abortion, with the aim of reducing post-operative intrauterine adhesions. Design: Retrospective study. Setting: Gynecology department in a University affiliated hospital. Patients: All women treated by hysteroscopy for RPOC following first trimester medical abortion using the mifepristone-misoprostol protocol for pregnancy termination or the misoprostol protocol for early missed abortion from January 2013 to August 2016. Intervention: Operative hysteroscopy for removal of RPOC. Post-operative intrauterine adhesions were assessed by diagnostic office hysteroscopy after 6â8 weeks. Measurements and Main Results: 50 cases were identified. The mean time from medication administration to the operative hysteroscopy was 1.7 ± 0.7 months. Operative hysteroscopy with blunt use of the resectoscopic loop was used to remove all specimens, and all procedures were completed without intra-operative complications. Two patients (4.0%) were readmitted for fever. Pathology confirmed the presence of RPOC in 45 (90.0%) cases. On follow-up office hysteroscopy, a normal uterine cavity without evidence of intrauterine adhesions was seen in 29/29 (100%) women. Conclusion: Hysteroscopy for removal of RPOC following medical abortion is associated with low rates of complications and post-operative intrauterine adhesions. Keywords: abortion, hysteroscopy, intrauterine adhesions, retained products of conception

To investigate whether hysteroscopic features can contribute to the diagnosis of malignancy in endometrial polyps.Retrospective review.Obstetrics and gynecology department.All women who underwent operative hysteroscopy for the removal of endometrial polyps between January 2012 and September 2017. Their medical records were reviewed, and information on medical, surgical, and obstetric history and hysteroscopic findings (including the number, size, and vascular appearance of the polyps) were abstracted.Operative hysteroscopy with resection or biopsy of endometrial polyps.Five hundred fifty-six women were included in the study. Their mean age was 55.4 ± 12.4 years, and 322 (57.9%) were menopausal. Endometrial carcinoma was found in 26 (4.7%) cases, whereas endometrial hyperplasia was found in 5 (0.9%) cases. Endometrial carcinoma or hyperplasia was significantly associated with patients' age, menopausal status, increased polyp vascularity on hysteroscopy, and the presence of 3 or more polyps on hysteroscopy (p.01 for all comparisons). However, the size of the largest polyp was not associated with endometrial carcinoma or hyperplasia. On logistic regression analysis, only increased polyp vascularity was associated with endometrial carcinoma or hyperplasia (odds ratio =13.5; 95% confidence interval, 5.6-32.3; p.001). The sensitivity, specificity, positive predictive value, and negative predictive value of polyp vascularity for the diagnosis of polyps of nonbenign pathology were 51.6%, 94.3%, 34.8%, and 97.1%, respectively.Hysteroscopic findings of increased vascularity of endometrial polyps and numerous endometrial polyps may suggest the diagnosis of malignant polyps, in addition to demographic parameters such as age and menopausal status.

To assess fetal abnormalities leading to termination of pregnancy (TOP) performed in twin pregnancies.The current study consisted of all women with dichorionic twin pregnancies (study group) who underwent TOP due to fetal abnormalities in our institute from 1999 to 2015. The data were compared to our registry of all parturient women with a singleton pregnancy (control group) that underwent TOP due to fetal anomalies at the same period.There were 2495 cases of TOP because of fetal indications during the study period. Of them, 86 (3.4%) and 2409 (96.6%) were from the study and control group, respectively. Structural anomalies were the leading indication for TOP in twins compared with singleton pregnancies (81.4% versus 50.9%, respectively, p 0.0001). For twins, the leading indication for TOP was central nervous system (CNS) abnormalities and it was more common compared with singleton pregnancies (26.1% versus 12.2%, respectively, p 0.0001). This was followed by chromosomal/genetic abnormalities (16.3% versus 40.4%, respectively, p 0.0001).We found a different distribution for fetal anomalies leading to TOP in twins versus singleton pregnancies. The main indication for TOP in the study group was structural malformations, with a predominance of CNS abnormalities.

Campylobacter is a gram-negative, microaerophilic, curved rod and a normal resident of the gastrointestinal flora and may be the cause of disease in animals. Transmission to humans occurs by ingestion of contaminated food or by direct contact with infected animals. In the past few decades, an increasing number of reports have implicated the presence of this organism in human abortions as well. An infectious mechanism due to primary placental inflammatory damage followed by secondary damage to the fetus following placental insufficiency and ischemia was suggested. The most common species of Campylobacter are Campylobacter jejuni and Campylobacter coli, which are classically associated with enteritis in humans. We present a rare case of mid-gestation intrauterine growth restriction (IUGR) associated with maternal bacteremia caused by C. coli infection. Our literature review focuses on Campylobacter infections occurring in the second and third trimesters of pregnancy. In all cases, mild maternal symptoms consisting of fever and weakness were presented. However, associated adverse fetal outcome, including abortions, IUGR or preterm labor may occur more frequently than anticipated. Our report strengthens the importance of awareness to this finding and focuses the need to consume properly cooked meat during pregnancy. © 2015 John Wiley & Sons, Ltd.