A Pellegrino

Comparison of hysteroscopic and hysterectomy findings for assessing the diagnostic accuracy of office hysteroscopy

OBJECTIVE To assess the diagnostic accuracy of office hysteroscopy by comparing the hysteroscopic findings with the histologic findings on the hysterectomy specimens. DESIGN Retrospective clinical study. SETTING University-affiliated hospital. PATIENT(S) Review of the hospital records of 443 patients who underwent office hysteroscopy and, within 2 months, hysterectomy. INTERVENTION(S) We compared the hysteroscopic findings (including targeted biopsies) with the histologic findings that were obtained after hysterectomy. The results of this study were then compared with those of a previous study in which we examined the diagnostic accuracy of dilatation and curettage (D&C). MAIN OUTCOME MEASURE(S) We evaluated the diagnostic accuracy of office hysteroscopy. RESULT(S) When compared with the histologic diagnosis of the uterus, the hysteroscopic findings showed a diagnostic sensitivity of 98%, a specificity of 95%, a positive predictive value (PPV) of 96%, and a negative predictive value (NPV) of 98%. Hysteroscopy was found to have a greater diagnostic accuracy than D&C: the sensitivity and the NPV of the two diagnostic procedures were statistically different. CONCLUSION(S) Office hysteroscopy is confirmed as a powerful diagnostic tool, but targeted biopsies, performed with a small diameter operative hysteroscope, must be performed in cases of suspect endometrium to confirm the image-based diagnosis.

Endometrial Biopsies Using Small-Diameter Hysteroscopes and 5F Instruments: How Can We Obtain Enough Material for a Correct Histologic Diagnosis?

STUDY OBJECTIVE To evaluate the quantity of biopsy tissue obtained by hysteroscopic grasp technique compared with classic punch technique. DESIGN Observational study (Canadian Task Force classification II-2). SETTING University hospital. PATIENTS One thousand two hundred seventy-six women. INTERVENTION Targeted biopsies performed in an office setting using two biopsy forceps, classic spoon and crocodile, and two methods, classic punch and grasp technique. MEASUREMENTS AND MAIN RESULTS With either biopsy forceps, the mean increase in amount of tissue obtained by grasp technique compared with punch technique was statistically significant (p <0.005). With grasp technique, the mean amount of tissue obtained was even larger with crocodile than with spoon forceps. CONCLUSION Targeted biopsy, when performed with the appropriate instrument and applying correct technique, can provide the pathologist with a large amount of tissue (mean 5.7 mm2) that is invariably adequate for histologic examination.

Caesarean scar pregnancy complicated by placenta percreta followed by suppurative appendicitis after conservative management with methotrexate

node chain or area and often asymptomatic. The histological examination is usually of hyaline vascular variant. UCD is usually curable by surgical excision of the mass and the prognosis is good. The systemic or multicentric variant of CD (MCD) is a less common and more aggressive form. Its corresponding histological pattern is the plasma cell variant, and rarely the plasmablastic type. It is frequently accompanied by systemic manifestations, such as fever and night sweats. Patients with MCD require systemic treatment and their prognosis is unfavourable (El-Osta and Kurzrock 2011; Ye et al. 2010; Talat and Schulte 2011). UCD is most commonly found in the mediastinum. However, it can develop anywhere lymphoid tissue is found. The distribution of localised Castleman ’ s disease has been reported as 65% in the mediastinum, 16% in the neck, 12% in the abdomen and 3% in the axilla (Bucher et al. 2005). The pelvic cavity is an unusual site for Castleman ’ s disease. The diagnosis of CD was still mostly dependent on the postoperative histological examination. For this patient, complaints, symptoms, physical examination and accessory examination were all nonspecific. Because of the relatively high incidence of adnexal masses in the female population, the preoperative diagnosis of the patient was gynaecological adnexal mass. But during the operation, we found the mass was localised behind the peritoneum. The diagnosis of the CD was according to the postoperative histological examination. For this kind of the solitary mass, exploratory laparoscopic operation is suitable. In this case, the laparoscopic operation has the advantage of good surgical fi elds and an easier to perform operation, compared with laparotomy. Laparoscopy off ers multiple advantages over traditional laparotomy, including smaller incisions, less blood loss, reduction in the need for analgesics, decreased morbidity and a more rapid recovery (Demir and Marchand 2012). The aetiology of CD is still not clear. The chronic inflammation, immunodeficiency state and autoimmune disorders (such as viral infection involving the human herpes virus 8, the Epstein – Barr virus or autoimmune haemolytic anaemia) are considered to be the possible causal factors of CD (Oksenhendler 2009). Although this patient was not examined for infection of the human herpes virus 8 or the Epstein – Barr virus, she did not have any manifestation of chronic inflammation, immunodeficiency state or autoimmune disorders. The possible susceptibility for her could be her family history of tumour. In conclusion, Castleman ’ s disease should be considered as a rare differential diagnosis in patients with a gynaecological adnexal mass. Preoperative and intraoperative differential diagnosis of CD is important. Exploratory laparoscopic operation is a suitable surgical choice.

Conventional fascial technique versus mesh repair for advanced pelvic organ prolapse: Analysis of recurrences in treated and untreated compartments.

117 women with severe pelvic organ prolapse (POP; stage > 2) were enrolled to elucidate a 24-month outcome of POP surgery, using conventional or mesh repair with 3 techniques. 59 patients underwent conventional repair and 58 underwent mesh repair. Two types of mesh were used: a trocar-guided transobturator polypropylene (Avaulta, Bard Inc.) and a porcine dermis mesh (Pelvisoft, Bard Inc.). Women with recurrences, who underwent previous unsuccessful conventional repair, were randomised. Primary outcome was the evaluation of anatomic failures (prolapse stage > 1) in treated and untreated compartments. Anatomic failure was observed in 11 of 58 patients (19%; CI 8.9–29) in the mesh group and in 16 of 59 patients (27.1%; p value = 0.3) in the conventional group. 9 of 11 failures in the mesh group (15.5%; CI 6.2–24.8) were observed in the untreated compartment (de novo recurrences), 14.3% in Pelvisoft and 16.7% in Avaulta arm, while only 1 recurrence in the untreated compartment (1.7%) was observed in the conventional group (odds ratio 10.6, p = 0.03).

Pivotal points in interstitial pregnancy: New insights in conservative medical treatment of non-ruptured interstitial pregnancy

We report the efficacy of a minimally invasive approach of the multidose protocol with methotrexate (MTX) in the management of three cases of interstitial pregnancy (IP), with elevated serum β-hCG in two cases. New considerations and management strategies are discussed. Successful termination of IP and in one case, a subsequent successful pregnancy, was achieved. The process led to the development of an enhanced understanding of diagnostic modalities and their limitations, with regard to the particular entities under discussion. We also focused attention on pivotal points and anatomical features in the management of this dangerous occurrence. Long-term results with careful follow-up were analysed by instrumental procedure. This hazardous type of ectopic pregnancy can be managed with systemic administration of MTX, also in patients with elevated β-hCG values. The present report underlines that an integrated approach in early diagnosis, multidose treatment and close follow-up, are essential forms of medical management.

Endometrial damage by antiestrogens in a postmenopausal breast cancer patient.

Tamoxifen, a selective estrogen receptor modulator (SERM), is used as an estrogen antagonist for all stages of breast cancer. Toremifene, a chlorinated derivative of tamoxifen, in a worldwide phase III trial demonstrated similar efficacy and safety for the treatment of advanced breast cancer (1). Tamoxifen’s clinical use is associated with a two to threefold increased risk of endometrial cancer. No conclusive clinical data regarding the effects of toremifene on endometrium are available today (1, 2). A case of a patient who undertook at first tamoxifen and then toremifene is reported.

Robotic sacrocolpopexy for posthysterectomy vaginal vault prolapse: a case series of 31 patients by a single surgeon with a long term follow-up.

BACKGROUND The aim of this paper was to evaluate the feasibility, short-term complications of robotic surgery and clinical outcomes in terms of long-term complications, pain relief and recurrence rate, for the treatment of vaginal vault prolapse (VVP). METHODS Prospective analysis of robotic-assisted laparoscopic sacrocolpopexy (RALS) performed between October 2011 and February 2015, in patients with advanced post-hysterectomy VVP and significant apical defects as defined by Baden- Walker Score ≥3. RESULTS Thirty-one consecutive of RALS were performed, with a mean follow-up of 27 months (range 2-48). Average total operative time was 185 minutes (range: 170-235). Estimated blood loss was 50 ml (range: 30-150). One case of cystotomy was reported, repaired with a 2.0 point. No others intra-operative complications occurred. Successful outcome was reported in 94% (29/31) of VVP repairs. CONCLUSIONS This series demonstrates optimal outcomes at long-term follow-up. RALS may provide the same long-term durability of open sacrocolpopexy with the benefit of a minimally invasive approach.

Diagnosis and management of a rare case of fetal mediastinal teratoma without non-immunological hydrops.

Teratomas are the most common fetal neoplasms, and represent 16.6% of all fetal tumours. Mediastinal teratomas usually occur in the anterior mediastinum and their most important clinical consequence is the compression of nearby structures leading to pulmonary hypoplasia, heart failure, fetal hydrops and polyhydramnios. It is generally diffi cult to distinguish between teratomas and other mediastinal space-occupying lesions such as congenital cystic adenomatoid malformation, pulmonary sequestration, intrapericardial teratoma, cardiac rhabdomyosarcoma and oesophageal duplication (Gul et al. 2004; Merchant et al. 2005). While ultrasound (US) usually permits adequate visualisation of the mass, the use of magnetic resonance imaging (MRI) may improve the assessment of the tumour extent, its content and the vascular structures and can distinguish calcifi cations from adipose tissue (Avni et al. 2009). We report a case of a mediastinal teratoma, fi rst diagnosed in the second trimester of pregnancy, complicated later by polyhydramnios without fetal hydrops.

Hysteroscopic endometrial evaluation in postmenopausal women taking tamoxifen for breast cancer

27. Hysteroscopic Endometrial Evaluation in Postmenopausal Women Taking Tamoxifen for Breast Cancer O Ceci, S Bettocchi, F Marello, RD Venere, AR Pellegrino, A Masciandaro, R Zaccaro. II Institute of Obstetrics and Gynecology, University of Bari, Bari, Italy. Objective. To evaluate endometrial modifications in postmenopausal women with breast cancer taking tamoxifen. Measurements and Main Results. Eighty-eight postmenopausal women (age 37-81 yrs) underwent TVUS and office hysteroscopy with eye-directed biopsies using a 5-ram continuous-flow operative office hysteroscope. Eighteen patients had received tarnoxifen for less than 12 months (range 4-11 too, group 1) and 70 for at least 12 months (range 12-72 mo, group 2). Transvaginal ultrasound revealed endometrial thickness greater than 5 mm in 62 women in group 1 and 7 in group 2. In group 1, hysteroscopy revealed 2 endometrial polyps, and in group 2 it found 26 endometrial polyps, 9 cases of endometrial hyperplasia, and 4 areas of focal adenocarcinoma. Twelve women in group 2 complained of abnormal uterine bleeding, whereas all patients in group 1 were asymptomatic. Conclusion. These data confirm the estrogenic effect of tamoxifen on endometrium. Endometrial evaluation by TVUS can suggest further diagnostic procedures (i.e., sonohysterography) but only hysteroscopy allows visualization of lesions and eye-directed biopsies. 28. Office Treatment of Large Endometrial Polyps Using the VersaPoint Bipolar Device O Ceci, F Marello, RD Venere, AR Pellegrino, L Laricchia, S Bettocchi. II Institute of Obstetrics and Gynecology, University of Bari, Bari, Italy. Objective. To demonstrate the possibility to treat fibrotic polyps larger than 1.5 cm in an office setting using a normal 5 mm operative hysteroscope without anesthesia instead of the resectoscope. Measurements and Main Results. Thirty-five women (age 21-63 yrs) with a history of AUB or sterility underwent resection of polyps with a 5-mm operative hysteroscope and 5F bipolar probe (VersaPoint) without anesthesia or analgesia. Only two postmenopausal women were asymptomatic, and polyps were occasionally discovered during evaluation for HRT. Polyps were sliced into pieces large enough to be extracted through the internal cervical ostium with the help of a 5F grasping forceps. Particular attention was paid to vaporization of a polyps base to avoid regrowth. In all patients polyps were larger than 1.5 cm. Patient discomfort was minimal: 29 women had none, 4 had mild discomfort comparable with menstrual pain, and the remaining 2 had light pain. Average operating time was 19 minutes. Follow-up at 3 months showed a normal uterine cavity in all patients, with no reappearance of pathology. Conclusion. Endometrial fibrotic polyps larger than 1.5 cm can be treated in an outpatient or office setting without significant discomfort and with minimal operating time. Resectoscopy should be considered only for specific, selected cases. 29. Is ThermaChoice an Office Procedure? 1j Chaddha, 2R McCorvey, 2B Love. 1Atlanta West Womens Center, Douglasville, Georgia; 2Womens Wellness Center, Montgomery, Alabama. Objective. To discuss whether ThermaChoice could become an office procedure. Measurements and Main Results. In most studies 30% to 90% of cases were done with local anesthesia and intravenous sedation. In fact, in one study 90% of patients had local anesthesia in the office setting. With general anesthesia, ThermaChoice procedures can be performed in less than 30 minutes, and with local anesthesia they can be done in less than 20 minutes. If these cases could be shifted to the office, 80% of the cost of the ThermaChoice procedure could be eliminated. Conclusion. If the cost associated with ThermaChoice could be reduced, it could easily become an office