Emanuela Spagnolo

Vaginal cuff dehiscence after hysterectomy: a multicenter retrospective study

OBJECTIVE This study estimates the incidence of vaginal cuff dehiscence resulting from different approaches to hysterectomy. STUDY DESIGN This multicentric study was carried out retrospectively. We retrospectively analyzed 8635 patients; 37% underwent abdominal hysterectomy, 31.2% vaginal hysterectomy, and 31.8% laparoscopic hysterectomy. All the hysterectomies were considered, vaginal evisceration was registered and analyzed for time of onset, trigger event, presenting symptoms, details of prolapsed organs and type of repair surgery. Continuous variables were compared using the one-way analysis of variance between groups as all data followed a Gaussian distribution, as confirmed by the Kolmogorov-Smirnov test. Differences among subgroups were assessed using the Tukey-Kramer multiple comparisons test. Categorical variables were compared with two tailed Chi-square tests with Yates correction or Fishers exact test, as appropriate. Pearsons linear correlation was used to verify linear relationships between the dehiscence interval and patients age at surgery. RESULTS Thirty-four patients (0.39%) experienced vaginal evisceration. The laparoscopic route was associated with a significantly higher incidence of dehiscence (p<0.05). No differences were found between the 6027 patients (69.8%) who had closure of the vaginal cuff and the 2608 (30.2%) who had an unclosed cuff closure technique. CONCLUSION Vaginal evisceration after hysterectomy is a rare gynecological surgical complication. Sexual intercourse before the complete healing of the vaginal cuff is the main trigger event in young patients, while evisceration presents as a spontaneous event in elderly patients. Surgical repair can be performed either vaginally or laparoscopically with similar outcomes.

Segmental bowel resection for colorectal endometriosis: is there a correlation between histological pattern and clinical outcomes?

BACKGROUND Laparoscopic segmental resection as a treatment for intestinal endometriosis can be supported by favorable clinical outcomes, but carries a high risk of major complications. The purpose of this study is to evaluate histopathological patterns of colorectal endometriosis and investigate potential relationships between histological findings and clinical data. METHODS We consecutively included 47 patients treated with laparoscopic segmental resection because of symptomatic colorectal endometriosis. All patients underwent follow-up for a median of 18 months (range: 6-35). We examined the histological patterns of colorectal endometriosis and evaluated the relationships between histological findings (satellite lesions, positive margins and vertical infiltration) and clinical outcomes (incidence of recurrence, quality of life and symptom improvement). Moreover, we observed if satellite lesions could influence preoperative scores of the short form-36 health survey (SF-36) questionnaire and visual analogue score (VAS) for pain symptoms. RESULTS There were no statistically significant differences in terms of anatomical and pain recurrences, pain symptoms and quality of life improvement among patients with or without positive margins, satellite lesions and different degrees of vertical infiltration (P > 0.05). Furthermore, women with or without satellite lesions were no different in terms of preoperative VAS of pain symptoms and SF-36 scores (P > 0.05). CONCLUSIONS The presence of satellite lesions or positive resection margins does not seem to influence clinical outcomes of segmental colorectal resection. Similarly, satellite lesions do not appear to have a major role in determining preoperative clinical presentation. These results may be useful to reconsider the surgical strategy for bowel endometriosis.

Dysmenorrhea, Absenteeism from School, and Symptoms Suspicious for Endometriosis in Adolescents

STUDY OBJECTIVE To quantify in adolescents the prevalence of dysmenorrhea and other symptoms found to be suggestive of future diagnosis of endometriosis, in particular their impact on monthly absenteeism from school/work, activity impairment, and sexual life and to quantify the awareness of endometriosis in adolescents. DESIGN Cross-sectional study. SETTING Academic institution. PATIENTS Adolescents (n = 250) aged 14-20 years referring to 3 family Counseling services. INTERVENTIONS Participants completed an anonymous questionnaire. MAIN OUTCOME MEASURES Prevalence of dysmenorrhea and absenteeism from school/work during menses. Other outcomes were impairment of daily activities, dyspareunia, and awareness of endometriosis as a pathologic condition. RESULTS 68% (170/250) of the participants complain of dysmenorrhea, 12% (30/250) lose days of school/work monthly because of dysmenorrhea, 13% (33/250) complain of intermenstrual pain which limits daily activities, 27% (56/208) of the adolescents who are sexually active complain of dyspareunia, 82% (203/250) have never heard about endometriosis and 80% (200/250) would like to know more about it. A significant association was found between severe dysmenorrhea, absenteeism from school/work, and basic level of education. Absence from school/work during menses showed an adjusted odds ratio for severe dysmenorrhea about 28 times greater than those who did not declare absenteeism (95%CI 7.898-98.920, P<.000). CONCLUSIONS The rates of dysmenorrhea and school absenteeism caused by dysmenorrhea are high. According to recent studies these patients are at higher risk of further development of endometriosis, whereas the knowledge of the disease is low among the adolescents investigated, so those involved with adolescents both in the health profession and particularly in schools and Family Counseling Services should be educated about endometriosis and its symptoms to reduce the significant lag time between symptoms and diagnosis.

Urodynamic evaluation and anorectal manometry pre- and post-operative bowel shaving surgical procedure for posterior deep infiltrating endometriosis: a pilot study.

STUDY OBJECTIVE To analyze bowel and urinary function in patients with posterior deep infiltrating endometriosis (DIE) >30 mm in largest diameter at transvaginal ultrasound before and after surgical nerve-sparing excision. DESIGN Prospective observational study (Canadian Task Force classification III). SETTING Tertiary care university hospital in Bologna, Italy. PATIENTS Twenty-five patients with posterior DIE were included in the study between June 2011 and December 2012. Patients did not receive hormone therapy for at least 3 months before and 6 months after surgery. INTERVENTIONS Patients underwent urodynamic studies and anorectal manometry before and after nerve-sparing laparoscopic excision of the posterior DIE nodule. MEASUREMENTS AND MAIN RESULTS Intestinal and urinary function was evaluated in patients with bulky posterior DIE using urodynamic and anorectal manometry. Results of urodynamic studies and anorectal manometry were similar before and after nerve-sparing surgical excision of the posterior DIE nodule. Urodynamic studies demonstrated a high prevalence of voiding dysfunction, whereas anorectal manometry showed no reduction in rectoanal inhibitory reflex and hypertone of the internal anal sphincter. CONCLUSIONS Patients with posterior DIE >30 mm in greatest diameter demonstrate preoperative dysfunction at urodynamic study and anorectal manometry, probably due to DIE per se. The nerve-sparing surgical approach seems not to influence the motility or sensory capacity of the bladder and the rectosigmoid colon.

Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series

STUDY QUESTION In women with deeply infiltrating endometriosis (DIE) what is the prevalence of involvement of endometriotic tissue and fibrosis in ureteral endometriosis (UE), as assessed by histological staining? SUMMARY ANSWER In women with DIE, ureteral involvement is more often due to endometriotic tissue rather than fibrosis. WHAT IS KNOWN ALREADY In the current literature, histological evaluation of ureteral endometriosis is mainly based on the degree of wall infiltration by endometriosis instead of the tissue composition. A few studies reported ill-defined and contradictory histological data on the tissue composition of UE. STUDY DESIGN, SIZE, DURATION Retrospective observational study based on clinical records of women affected by DIE, laparoscopically treated for UE at a tertiary referral center, between January 2010 and March 2013. All cases of ureteral nodule excision or ureterectomy with histological examination of the specimens were included. Exclusion criteria were other identified causes of hydroureteronephrosis, medical therapy for a period of at least 3 months before surgery and previous surgery for DIE. PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 77 patients were included in the study and among them seven (9%) presented with bilateral ureteral involvement, giving a total of 84 cases of UE available for analysis. All patients had stage IV endometriosis. According, respectively, to the presence of endometrial glands and/or stroma cells or of fibrotic tissue only, the endometriotic UE and fibrotic UE groups were compared with regard to hydroureteronephrosis at pre-operative urinary tract computerized tomography scan, type of surgical procedure performed to treat UE (nodule removal or ureterectomy), association with other locations of the disease and post-operative complications (ureteral fistula or stenosis). MAIN RESULTS AND THE ROLE OF CHANCE For the 84 cases of UE, 65 (77%) and 19 (23%), respectively, showed endometriotic tissue and fibrotic tissue only. Presence of hydroureteronephrosis and endometriotic pattern of UE showed a significant association [endometriotic UE 44/65 (68%) versus fibrotic UE 8/19 (42%); P = 0.04]. Fibrotic pattern of UE and presence of concomitant recto-vaginal endometriosis showed a significant association [endometriotic group: 29/65 (45%) versus fibrotic group 18/19 (95%); P < 0.001]. LIMITATIONS, REASONS FOR CAUTION The retrospective and monocentric (tertiary referral center) study design. WIDER IMPLICATIONS OF THE FINDINGS Besides the distinction between extrinsic and intrinsic UE based on the degree of wall infiltration by endometriosis, a new classification according to the histological pattern of UE could be useful for clinicians, both in the diagnostic and therapeutic fields. STUDY FUNDING/COMPETING INTERESTS None.

Cephalad–caudad versus transverse blunt expansion of the low transverse uterine incision during cesarean delivery

It is imperative to have evidence-based guidelines for cesarean delivery. The aim of this meta-analysis was to evaluate the effectiveness of a cephalad-caudad compared to transverse blunt expansion of the uterine incision to reduce blood loss in women who underwent low-segment transverse cesarean delivery. We therefore performed a systematic search in electronic databases from their inception until March 2016. We included all randomized trials comparing cephalad-caudad versus transverse (control group) blunt expansion of the uterine incision in women who underwent a low transverse cesarean delivery. The primary outcome was postpartum blood loss, defined as the mean amount of blood loss (mL). Two trials (921 women) were analyzed. After the transverse uterine incision in the lower uterine segment with the scalpel, the uterine incision was then bluntly expanded by the designated method. Blunt expansion of the primary incision was derived by placing the index fingers of the operating surgeon into the incision and pulling the fingers apart laterally (transverse group) or cephalad (cephalad-caudad group). Women who were randomized in the cephalad-caudad group had lower: mean of postpartum blood loss, hemoglobin drop and hematocrit drop 24h after cesarean, unintended extension, uterine vessels injury, blood loss >1500mL and need for additional stitches. There was no statistically significant difference in the incidence of blood loss >1000mL, in the operating time and in post-operative pain. In conclusion, expansion of the uterine incision with fingers in a cephalad-caudad direction is associated with better maternal outcomes and, therefore, should be preferred to transverse expansion during a cesarean delivery.

Does laparoscopic shaving for deep infiltrating endometriosis alter intestinal function? A prospective study

5–12% of deep infiltrating endometriosis involves the digestive tract, especially the distal sigmoid colon and rectum. Bowel endometriosis surgery may be associated with neurological complications.

Parametrial dissection during laparoscopic nerve-sparing radical hysterectomy A new approach aims to improve patients' postoperative quality of life

(medial). 5,6 Our solution In our procedure, blunt opening of the medial and lateral pararectal spaces at the level of the rectal wings allows preservation of the mesoureter, as well as identification of the middle rectal artery and the origin of the parasympathetic pelvic splanchnic nerves at the sacral roots. The posterior parametrial planes can then be safely dissected, and the cardinal ligament can be completely transected while sparing the fibers distributed within the rectovaginal ligament (Figures 1 and 2). Subsequent visualization of the inferior hypogastric plexus at its origin permits preservation ofthevisceralafferentandefferentfibers that are directed to the uterus, the vagina, and the bladder. Unroofingoftheureteranddissection of the deep layer of the vesicouterine ligament toward the mesorectal planes opensadditionalanatomicalspace,facilitatingcompletedissectionofthevesicouterine ligament and the paravaginal portion of the paracervix. At the same time, the neural portions of the anterior parametriumareprotected—evenwhen

Laparoscopic treatment of interstitial twin pregnancy.

OBJECTIVE To describe a conservative management by laparoscopy of an unusual interstitial twin pregnancy. DESIGN Case report. SETTING University hospital. PATIENT(S) A 27-year-old woman, pregnant at 6th week of amenorrhea with interstitial twin pregnancy. INTERVENTION(S) The woman was submitted to two- and three-dimensional transvaginal ultrasound and to diagnostic hysteroscopy. Subsequently, we performed a laparoscopic procedure: conical exeresis of the uterine cornu using a monopolar hook without involving the uterine cavity. MAIN OUTCOME MEASURE(S) Conservation of the uterus, fertility preservation. RESULT(S) Successful conservative treatment of interstitial twin pregnancy. CONCLUSION(S) Conservative laparoscopic surgery can be used successfully in hemodynamically stable patients with an interstitial pregnancy.

OC08.02: The role of transvaginal ultrasound during resectoscopic myomectomy

Objectives: To document by transvaginal ultrasound how varies the distance between the submucous fibroids and the uterine serosa (myoma free margin or MFM) during resectoscopic myomectomy. Methods: We enrolled all patients with a hysteroscopically diagnosed G2 submucous fibroid undergoing a cold loop resectoscopic procedure from January to November 2009. MFM was evaluated by TVU pre-operatively (T0) and during the procedure. MFM was sonographically assessed after distension of the cavity for resectoscopic myomectomy (T1), after the beginning of myoma’s slicing (T2), during enucleation (T3) and at the end of the procedure (T4). Results: Overall, 10 patients were included in our study. The procedure was successfully performed without complications in all cases. The mean MFM at T0 was 6.58 ± 2.6 mm. This measurement decreased significantly at T1, but underwent progressive increase at steps T2 and T3. After complete enucleation of the fibroid (T4) the mean distance between the fovea and uterine serosa was 7.5 mm greater in comparison with preoperative MFM. Conclusions: MFM is a dynamic parameter and may considerably increase during hysteroscopic myomectomy. On this basis, even G2 submucous fibroids which appear very close to serosa on preoperative TVU may be eligible for resectopic removal.