Benito Chiofalo

Full-Thickness Excision versus Shaving by Laparoscopy for Intestinal Deep Infiltrating Endometriosis: Rationale and Potential Treatment Options

Endometriosis is defined as the presence of endometrial mucosa (glands and stroma) abnormally implanted in locations other than the uterine cavity. Deep infiltrating endometriosis (DIE) is considered the most aggressive presentation of the disease, penetrating more than 5 mm in affected tissues, and it is reported in approximately 20% of all women with endometriosis. DIE can cause a complete distortion of the pelvic anatomy and it mainly involves uterosacral ligaments, bladder, rectovaginal septum, rectum, and rectosigmoid colon. This review describes the state of the art in laparoscopic approach for DIE with a special interest in intestinal involvement, according to recent literature findings. Our attention has been focused particularly on full-thickness excision versus shaving technique in deep endometriosis intestinal involvement. Particularly, the aim of this paper is clarifying from the clinical and methodological points of view the best surgical treatment of deep intestinal endometriosis, since there is no standard of care in the literature and in different surgical settings. Indeed, this review tries to suggest when it is advisable to manage the full-thickness excision or the shaving technique, also analyzing perioperative management, main complications, and surgical outcomes.

Anxiety and depression in patients with endometriosis: impact and management challenges

Endometriosis is one of the most common gynecological diseases and affects ~10% of women in reproductive age. The most common clinical signs of endometriosis are menstrual irregularities, chronic pelvic pain (CPP), dysmenorrhea, dyspareunia and infertility. Symptoms of endometriosis often affect psychological and social functioning of patients. For this reason, endometriosis is considered as a disabling condition that may significantly compromise social relationships, sexuality and mental health. Considering this point, the aim of this narrative review is to elucidate the impact of anxiety and depression in the management of women with endometriosis. Psychological factors have an important role in determining the severity of symptoms, and women who suffer from endometriosis report high levels of anxiety, depression and other psychiatric disorders. In addition, endometriosis is one of the most important causes of CPP; women with endometriosis suffer from a wide range of pelvic pain such as dysmenorrhea, dyspareunia, nonmenstrual (chronic) pelvic pain, pain at ovulation, dyschezia and dysuria. Several studies have underlined the influence of CPP on quality of life and psychological well-being of women with endometriosis. Data suggest that the experience of pelvic pain is an important component of endometriosis and may significantly affect emotive functioning of affected women. It has been demonstrated that high levels of anxiety and depression can amplify the severity of pain. Further studies are needed to better understand the relationship between psychological factors and perception of pain. Treatment of endometriosis may be hormonal or surgical. Surgery is the primary treatment for more severe forms of endometriosis. There are few data in the literature about the influence of psychological factors and psychiatric comorbidities on the effectiveness of treatments. It is important to evaluate the presence of previous psychiatric diseases in order to select the most appropriate treatment for the patient.

Combined Systemic and Hysteroscopic Intra-Amniotic Injection of Methotrexate Associated with Hysteroscopic Resection for Cervical Pregnancy: A Cutting-Edge Approach for an Uncommon Condition

This case report of a 36-year-old woman with a diagnosis of cervical pregnancy describes a novel approach to this rare form of ectopic pregnancy, which was successfully treated with systemic and local methotrexate (MTX) therapy combined with hysteroscopic resection. After local and systemic administration of MTX, the patient underwent hysteroscopic resection of the cervical pregnancy using a 27 bipolar resectoscope with a 4-mm loop. The cervical pregnancy was completely treated, and satisfactory hemostasis was achieved with electrocoagulation. The reported case and literature review demonstrate that the combination of systemic and local (hysteroscopic) administration of MTX with hysteroscopic resection could offer the possibility of a safe, successful, minimally invasive, and fertility-sparing surgical treatment for cervical pregnancy.

Hysteroscopic Morcellation of Submucous Myomas: A Systematic Review

Hysteroscopic surgery is the actual gold standard treatment for several types of intrauterine pathologies, including submucous myomas (SMs). To date, the availability of Hysteroscopic Tissue Removal systems (HTRs) opened a new scenario. Based on these elements, the aim of this article is to review the available evidence about HTRs for the management of SMs. We included 8 papers (3 prospective studies and 5 retrospective studies). A total of 283 women underwent intrauterine morcellation of SM: 208 were treated using MyoSure and 75 using Truclear 8.0. Only 3 articles reported data about procedures performed in outpatient/office setting. Only half of the included studies included type 2 SMs. HTRs significantly reduced operative time compared to traditional resectoscopy in some studies, whereas others did not find significant differences. Despite the availability of few randomized controlled trials and the cost of the instrument, according to our systematic review, the use of HTRs seems to be a feasible surgical option in terms of operative time and complications. Nevertheless, the type of SM still remains the biggest challenge: type 0 and 1 SMs are easier to manage with respect to type 2, reflecting what already is known for the “classic” hysteroscopic myomectomy.

Fasting as possible complementary approach for polycystic ovary syndrome: hope or hype?

Polycystic ovary syndrome (PCOS) is a common endocrine system disorder among women of reproductive age. In several cases, PCOS women show infertility or subfertility and other metabolic alteration, such as insulin resistance (InsR), dyslipidaemia, hyperinsulinemia and obesity. Despite the aetiology of the syndrome is still far from be elucidated, it could be considered the result of concurrent endocrine modifications, lifestyle factors and genetic background. In particular, accumulating evidence suggests that InsR and compensatory hyperinsulinemia play a pivotal pathogenic role in the hyperandrogenism of many PCOS phenotypes, which in turn have a clear detrimental effect on chronic anovulation. Different forms of fasting, such as intermittent fasting (IF, including alternate day fasting, or twice weekly fasting, for example) and periodic fasting (PF, lasting several days or longer every 2 or more weeks) are currently being tested in several in vitro and in vivo studies. Changes in the circulating levels of Insulin Growth Factor-1 (IGF-1), Insulin-like Growth Factor-Binding Protein 1 (IGFBP1), glucose and insulin are typical effects of fasting which may play a key role on aging and metabolic homeostasis. Considering the paramount importance of InsR and compensatory hyperinsulinemia, different fasting regimens can reduce IGF-1, IGFBP1, glucose and insulin levels and consequently have beneficial effects on ovarian function, androgen excess and infertility in PCOS women.

Do miRNAs Play a Role in Fetal Growth Restriction? A Fresh Look to a Busy Corner

Placenta is the crucial organ for embryo and fetus development and plays a critical role in the development of fetal growth restriction (FGR). There are increasing evidences on the role of microRNAs (miRNAs) in a variety of pregnancy-related complications such as preeclampsia and FGR. More than 1880 miRNAs have been reported in humans and most of them are expressed in placenta. In this paper, we aimed to review the current evidence about the topic. According to retrieved data, controversial results about placental expression of miRNAs could be due (at least in part) to the different experimental methods used by different groups. Despite the fact that several authors have demonstrated a relatively easy and feasible detection of some miRNAs in maternal whole peripheral blood, costs of these tests should be reduced in order to increase cohorts and have stronger evidence. In this regard, we take the opportunity to solicit future studies on large cohort and adequate statistical power, in order to identify a panel of biomarkers on maternal peripheral blood for early diagnosis of FGR.

Evidence-Based and Patient-Oriented Inositol Treatment in Polycystic Ovary Syndrome: Changing the Perspective of the Disease

Evidence-Based and Patient-Oriented Inositol Treatment in Polycystic Ovary Syndrome: Changing the Perspective of the Disease Antonio Simone Laganà, Paola Rossetti, Fabrizio Sapia, Benito Chiofalo, Massimo Buscema, Gaetano Valenti, Agnese Maria Chiara Rapisarda, and Salvatore Giovanni Vitale Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina, Messina, Italy Unit of Diabetology and Endocrino-Metabolic Diseases, Hospital for Emergency Cannizzaro, Catania, Italy Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy Corresponding author: Antonio Simone Laganà, Unit of Gynecology and Obstetrics, Department of Human Pathology in Adulthood and Childhood “G. Barresi”, University of Messina, Messina, Italy. Tel: +39-0902212183, Fax: +39-0902937083, E-mail: antlagana@unime.it

Endometrial pathology in breast cancer patients: Effect of different treatments on ultrasonographic, hysteroscopic and histological findings

Breast cancer patients have an increased risk of endometrial pathology. To investigate whether the incidence of endometrial abnormalities and their clinicopathological features were affected by receiving tamoxifen (TAM), non-steroidal aromatase inhibitors (AIs) or no treatment (NT), 333 peri/postmenopausal breast cancer patients, who were referred to the Department of Gynecological, Obstetrical Sciences and Reproductive Medicine for gynecological assessment, were reviewed retrospectively. Transvaginal ultrasonographic (TVUS), hysteroscopic and histological findings were investigated. Endometrial histological findings included: atrophy in 61, 94.3 and 55.6% of cases in the TAM, AIs and NT groups, respectively; polyps in 30.9, 31.4 and 42.2% of cases in the TAM, AIs and NT groups, respectively; hyperplasia in 3% of patients in the TAM group and 11.1% of patients in the NT group; and cancer in 3.8% of cases in the TAM group and 11.1% of cases in the NT group. There was a significant correlation between the duration of TAM treatment and the severity of endometrial pathology. In all groups, there was a significant correlation between hysteroscopic and histological findings with regard to the diagnosis of endometrial atrophy, polyps, hyperplasia and cancer (P<0.001). In conclusion, these data revealed that there was a higher incidence of endometrial pathology in the NT group compared with the TAM group, which was significant for endometrial hyperplasia and cancer. The chance of developing high-risk histological subtypes of endometrial cancer was independent of TAM use. Lastly, although there was no significant difference in recurrent vaginal bleeding and mean endometrial thickness between the TAM and AIs groups, patients receiving AIs did not exhibit hyperplastic, dysplastic or neoplastic changes in the endometrium. This study indicates that breast cancer patients require screening for endometrial pathology; TVUS alone is useful in asymptomatic patients, however, in patients where the endometrial line is irregular or its thickness is >3 mm, hysteroscopy with directed biopsy is the appropriate diagnostic method.

Clinical dynamics of Dienogest for the treatment of endometriosis: from bench to bedside

Endometriosis is a common benign and proliferative chronic disorder, characterized by the presence of endometrial glands and stroma outside the uterus: in particular, ectopic endometrial tissue undergoes similar cyclic changes of the eutopic endometrium, following phase-specific hormonal stimuli. According to the European Society of Human Reproduction and Embryology (ESHRE) guidelines [1], endometriosis affects about 6–10% of reproductive-aged women with an average age at diagnosis ranging from 25 to 30 years. The most diffused classification was proposed and revised by the American Fertility Society, using a score system based on the presence of subtle, typical, cystic, or deep infiltrating endometriosis (DIE). Among the classical symptoms and signs, menstrual irregularities, chronic pelvic pain (CPP), dysmenorrhea, dyspareunia, and infertility can play a detrimental role on patient’s quality of life [2]. Despite the large amount of published articles, the pathogenesis of endometriosis still remains controversial due to the lack of robust evidence: immune, hormonal, genetic, and epigenetic factors may be all involved, and several theories have been proposed to explain it. Epigenetics may underlie the pathogenesis of endometriosis better than genetics: on one hand, accurate meta-analysis [3] failed to show robust evidence of a possible correlation between gene polymorphisms (CYP1A1, CYP2E1, EPHX1, AHR, ARNT, AHRR, NAT1, and NAT2) and endometriosis; on the other hand, epigenetic modifications could be considered causes or effects of the pro-inflammatory microenvironment and progesterone resistance, typical of the disease. Indeed, the altered expression of progesterone receptor or its diminished activity may lead to attenuated response to progesterone and decreased expression of progesterone-responsive genes [3]. During the recent past, the treatment of endometriosis consisted of combined oral contraceptives (COCs): nevertheless, it is widely accepted that endometriosis is an estrogen-dependent disease, since estrogens are able to enhance endometriotic cell proliferation and induce the differentiation of regulatory T cells, which further amplify the socalled ‘immune-escaping’ [4]. Based on these elements, to date, progestins (synthetic progestational agents) are used in the management of symptomatic endometriosis both as first-line therapy and after surgery. As recently reviewed by Angioni et al. [5], progestins are usually well tolerated and offer similar efficacy for the treatment of endometriosis-related CPP and prevention of recurrence with respect to other drugs. Nevertheless, ESHRE clearly stated that there is no overwhelming evidence to support particular treatments over others among hormonal contraceptives, progestagens and anti-progestagens, gonadotropinreleasing hormone (GnRH) agonists and antagonists, and aromatase inhibitors for endometriosis-associated CPP [1].

Evaluation of Maternal-Fetal Outcomes After Emergency Vaginal Cerclage Performed With Shirodkar-McDonald Combined Modified Technique

Background Several techniques of emergency vaginal cerclage have been proposed in case of unexpected and abrupt cervical incompetence (CI), in order to prolong the pregnancy as much as possible and to reduce the adverse maternal-fetal outcomes. The aim of our study was to evaluate the effectiveness of emergency cervical cerclage, performed with the combined modified Shirodkar-McDonald technique. Methods We selected 12 cases of emergency vaginal cerclage, performed between January 1, 2008 and June 30, 2013. The age of the patients was between 20 and 38 years (mean 29.0 ± standard deviation (SD) 5.69), parity between 0 and 2 (mean 0.7 ± SD 0.65), and gestational age at the time of admission ranged between 17 and 26 weeks (mean 21.0 ± SD 3.44). In all these cases, we used a combined modified Shirodkar-McDonald technique to perform the procedure. Results The neonatal survival rate was 83.3%. The cesarean section rate was 16.7%. The average pregnancy prolongation was 89.9 days, higher than that reported for other studies in the literature. Conclusions We can assume that the emergency vaginal cerclage performed with the combined modified Shirodkar-McDonald technique is the best option of surgical therapy for the treatment of unexpected and abrupt CI.