Emanuela Mistrangelo

Vaginal ultrasonographic and hysterosonographic evaluation of the low transverse incision after caesarean section : Correlation with gynaecological symptoms

Aim: We investigated whether there is a correlation between morphological changes of the lower uterine segment after caesarean section (CS), visualized by means of either a transvaginal sonography (TVS) or a sonohysterography (SHG), and the frequency of abnormal uterine bleedings reported by the women. Methods: By means of a random selection of our population, anamnesis, medical records, and TVS and SHG images of the lower uterine segment were collected in 217 women (116 with previous CS and 101 with previous vaginal birth), and an observational case-control study was performed. Results: The uterine incision was identified in almost all women after CS (102/116) using TVS. It was observed that abnormal uterine bleeding was significantly more frequent in the CS group in comparison with the group of women who delivered vaginally. A correlation between the presence of abnormal uterine bleeding and the presence of significant sonographic findings in the lower uterine transverse incision in the women after CS was found. In the CS group, TVS findings were confirmed by those obtained by SHG, and, with this technique, a triangular anechoic area at the presumed site of incision (the niche) was identified in 69 of the 116 women (59.5%). Conclusions: In this study, we found a correlation between abnormal uterine bleeding and sonographic findings in women after CS. This correlation appears to be more significant in women who had CS 5–10 years ago. A significant difference exists between the CS group and the group of women who delivered vaginally for both frequency of abnormal uterine bleeding and sonographic findings.

Safety and efficacy of vaginal hysterectomy in the large uterus with the LigaSure bipolar diathermy system

OBJECTIVE This study was undertaken to assess safety and efficacy of vaginal hysterectomy in case of large uterine size (> or = 250 g) using the LigaSure bipolar diathermy (Valleylab, Boulder, CO). STUDY DESIGN In a retrospective study, medical records of 102 patients who underwent vaginal hysterectomy and who had uterine weight (evaluated after surgery) 250 g or greater were reviewed. All hysterectomies were performed by using the LigaSure vessel sealing system to secure vascular pedicles (uterosacral-cardinal, uterine and ovarian and round ligaments). RESULTS Of the 102 vaginal hysterectomies, 99 were successfully performed (97.1%; 95% confidence interval, 91.6-99.4%), whereas a conversion from the vaginal to the abdominal route was required in 3 cases. The median uterine weight was 455 g (range, 241-1913 g). The weight of the largest uterus successfully removed vaginally was 1600 g, without intraoperative and postoperative complications. The median operative time was 50 minutes (range, 25-50 minutes). CONCLUSION The current study confirms that very large uterine volume does not represent a real obstacle to perform vaginal hysterectomy and that results in a safe and effective technique in cases of uterine weight 250 g or greater.

The value of sonohysterography in detecting intracavitary benign abnormalities

The aim of this retrospective study was to assess the diagnostic value and the usefulness of sonohysterography in the detection of uterine intracavitary benign abnormalities, compared with other diagnostic methods (transvaginal ultrasonography and diagnostic hysteroscopy). From January 2003 to December 2003, a total of 73 patients (47 premenopausal (middle age 38.9) and 26 postmenopausal women (middle age 60.5)) underwent transvaginal ultrasonography (TVS) and sonohysterography (SHG), consisting of an intrauterine infusion of saline solution during transvaginal ultrasound. The women referred to our Ultrasonography Center because of intermenstrual (38) or postmenopausal bleeding (19), or an abnormal or a poorly defined endometrial interface (16) as seen as baseline ultrasonography. The findings at TVS and SHG were compared with hysteroscopy (HS). In one case, the SHG was technically impossible to perform. In premenopausal group the sensitivity of SHG had been 100% in detecting submucosal fibroids, endometrial polyps and hyperplasia and 75% in detecting normal uterus. The specificity had been always 100%. In postmenopausal group the sensitivity of SHG had been 75% in detecting submucosal fibroids, 93.8% in endometrial polyps and 100% in hyperplasia and normal uterus. The specificity had been 100% in submucosal fibroids and hyperplasia and had been 90.0 and 95.5% in endometrial polyps and normal uterus, respectively. SHG allows to obtain a precise diagnosis of benign uterine pathology and it is more accurate in the diagnosis of intracavitary abnormalities than that obtained by TVS. Preoperative use of SHG may assist in choosing the best surgical treatment for the patient.

Prophylactic bilateral oophorectomy during vaginal hysterectomy for benign pathology

ObjectiveThe aim of this study was to assess the feasibility and safety of vaginal removal of ovaries at the time of vaginal hysterectomy.Materials and methodsAll patients candidate to hystero-salpingo-oophorectomy by transvaginal approach, between 1 March 2004 and 28 February 2007, were admitted in the study.ResultsOf the 472 women included in the study, 432 (91.5%) underwent hysterectomy and bilateral oophorectomy by vaginal approach. There was only one case of major vessel injury, but no patients required blood transfusion. All the operations were performed only by vaginal route and no conversion to the abdominal route was required.ConclusionThe need to perform oophorectomy should not be considered a contraindication to vaginal hysterectomy.

Perineal ultrasound evaluation of the urethrovesical junction angle and urethral mobility in nulliparous women and women following vaginal delivery

The objective of this study was to demonstrate the differences in the urethrovesical junction angle and urethral mobility by means of perineal ultrasounds in women following vaginal delivery with respect to nulliparous women. We have enrolled 34 women, 12 nulliparous (Group A) and 22 women in the post-partum period (Group B). The ultrasounds were employed to measure the urethrovesical junction angle (“urethro-pelvic” angle) and the urethral mobility. Data obtained show that the urethro-pelvic angle is narrower in Group A (97.3°) with respect to Group B (112.5°). Urethral mobility while coughing was significantly higher in Group B (30.4°) with respect to Group A (−2°). This study demonstrates the difference in the urethral support at rest and during cough in nulliparous versus recently delivered parous women.

Vaginal versus transabdominal hysterectomy: Is mode of hysterectomy to influence pelvic statics or is pelvic statics to influence mode of hysterectomy?

Background.  To check the hypothesis that the mobility of the urethrovesical junction in the preoperative phase is different in women that will undergo either vaginal, abdominal, or laparoscopic‐assisted vaginal hysterectomy.

Effect of presurgical local infiltration of levobupivacaine in the surgical field on postsurgical wound pain in laparoscopic gynecological surgery

Patients undergoing laparoscopic surgery require close attention to providing adequate pain management. This randomized, double-blind, controlled study was designed to determine whether infiltrating the surgical field preoperatively with levobupivacaine, which is as effective as bupivacaine but causes fewer cardiovascular and central nervous system problems, would reduce the frequency, intensity, and duration of postsurgical wound pain in women treated for benign gynecologic disorders. Thirty-seven women undergoing laparoscopic surgery for benign conditions received an injection of 7 mL of a solution containing 5 mg/mL levobupivacaine 15 minutes before skin incision, whereas 37 others received the same volume of physiological saline. All incisional sites were infiltrated. An open laparoscopy technique with open step-by-step access was used for laparoscopy. Pain intensity was estimated using a 10-point visual analog scale 6, 12, and 24 hours postoperatively. The 2 groups were similar with regard to demographic and intraoperative characteristics. Mean pain intensity was significantly lower in the levobupivacaine group than in control patients 6 and 12 hours after surgery. Actively treated patients required less analgesia postoperatively, and the mean time to ambulation was significantly less than in control subjects. Women treated with levobupivacaine also had a shorter mean postoperative stay, but this difference was not statistically significant. Postoperative pain after laparoscopic gynecologic surgery, performed under general anesthesia, is substantially less-especially in the first 12 hours-if the surgical field is exposed preoperatively to levobupivacaine solution. Patients managed in this way require less postoperative analgesia.