Francesco Calonaci

A randomized controlled study comparing harmonic versus electrosurgery in laparoscopic myomectomy

OBJECTIVE To compare the effectiveness and safety of harmonic scalpel versus electrosurgery to reduce blood loss during laparoscopic myomectomy. DESIGN Prospective randomized controlled study. SETTING Tertiary referral centers for gynecological care. PATIENT(S) One hundred sixty consecutive premenopausal women with symptomatic uterine leiomyomata who were assigned to one of the two treatment groups (a total of 80 patients in each group): treatment with electrosurgery devices with a vasoconstrictive solution (50 mL of saline solution and 0.5 mL of epinephrine [1/2 vial of 1 mg/mL]; group A) or harmonic scalpel (group B). INTERVENTION(S) Laparoscopic myomectomy. MAIN OUTCOMES MEASURE(S) The global operative time, the time spent for myoma enucleation and for suturing uterine wall defects, and intraoperative blood loss as well as the surgical difficulty degree and postoperative pain at 24 and 48 hours after the laparoscopic procedure. RESULT(S) No relevant intra- or postoperative complications were observed in either group. The degree of pain 24 hours after surgery was significantly lower in patients in whom the harmonic scalpel was used. The degree of surgical difficulty did not differ between groups, but the global operative time was significantly shorter in the harmonic scalpel group. CONCLUSION(S) The use of the harmonic scalpel for laparoscopic myomectomy is associated with low total operative time, low intraoperative blood loss, and low postoperative pain, with no increase in surgical difficulty.

High serum follistatin levels in women with ovarian endometriosis.

BACKGROUND Follistatin is an activin-binding protein produced by several tissues, including endometrium and endometriotic implants. We aimed to quantify follistatin in patients with ovarian endometriosis and investigate its value as a diagnostic marker. METHODS Women undergoing laparoscopic excision of ovarian endometrioma (n = 52) or other benign ovarian cysts (n = 52) were studied, plus women with non-ovarian endometriosis (n = 11) and healthy controls (n = 27). Serum was collected from all subjects, and peritoneal and cystic fluid from a subset with endometrioma. Follistatin was measured by enzyme-linked immunosorbent assay. The diagnostic accuracy of follistatin to detect endometrioma was evaluated by receiver operating characteristic (ROC) curve and compared with cancer antigen (CA)-125. RESULTS Serum follistatin was increased in women with ovarian endometrioma (2080 +/- 94 pg/ml) compared with controls (545 +/- 49 pg/ml, P < 0.001), other benign ovarian cysts (795 +/- 60 pg/ml, P < 0.001) or non-ovarian endometriosis (1271 +/- 115 pg/ml, P < 0.001). Cystic fluid showed a higher concentration of follistatin (9850 +/- 4461 pg/ml) than peritoneal fluid (1885 +/- 261 pg/ml, P < 0.001) and serum (P < 0.001). Follistatin levels detected 48/52 cases of endometrioma (92% sensitivity) at 1433 pg/ml cut-off, corresponding to 92% specificity. CA-125 detected only 44% of endometriomas with 90% specificity. ROC curve comparison showed follistatin was more accurate than CA-125 to discriminate women with endometrioma either from controls or women with other benign ovarian cysts (P < 0.0001). CONCLUSIONS Serum follistatin is increased in women with endometriosis and allows clear distinction between endometrioma and other benign ovarian cysts. Follistatin has the sensitivity and specificity to become a useful clinical marker of ovarian endometrioma.

Plasma urocortin levels in the diagnosis of ovarian endometriosis.

OBJECTIVE: Urocortin is a neuropeptide, member of the corticotropin-releasing hormone family, that is produced by the human endometrium. Ovarian endometrioma is a prevalent gynecologic disorder still lacking specific serum markers. In the present study we measured systemic levels of urocortin to assess the diagnostic performance of its determination in distinguishing endometriomas from other benign ovarian cysts. METHODS: Plasma urocortin was measured by radioimmunoassay in women with ovarian endometrioma (n=40) and in women with benign, nonendometriotic ovarian cysts (n=40). The diagnostic accuracy of urocortin measurement was evaluated by receiver operating characteristic curve and compared with the standard marker, CA 125. To support the local origin of the peptide, we also evaluated its localization in endometriomas by immunohistochemistry and its concentrations in cyst fluid and peritoneal fluid of 12 women with endometrioma. RESULTS: Plasma urocortin levels were twice as high in women with endometrioma (median 49 pg/mL, interquartile range 41–63 pg/mL) than in the control group (19 [15–23] pg/mL, P<.001) and significantly higher in the cystic content of endometriomas than in the peritoneal fluid and plasma (P<.05). The peptide was immunolocalized in endometrioma glands and stromal capillary vessels. Elevated plasma urocortin levels detected 88% of the cases of endometrioma with 90% specificity, whereas CA 125 detected only 65% of the cases with the same specificity. CONCLUSION: Plasma urocortin is increased in women with endometriomas, and its measurement may be useful for the differential diagnosis of endometrioma compared with other benign ovarian cysts. LEVEL OF EVIDENCE: II

Surgical scar endometriosis after Cesarean section: A case report

Background. Cutaneous endometriosis is a rare condition. Case report. A 37-year-old woman came to our observation 3 years after Cesarean section for a nodule under the scar that became spontaneously painful during menstrual bleeding. Transabdominal ultrasound examination, serum CA125 determination and histopathological analysis of the nodule were performed. Ultrasound revealed the presence of an oval-shaped hypoechogenic neoformation, while the serum CA125 level was slightly increased, and a diagnosis of endometriosis was confirmed by the histopathological analysis of a surgical specimen. Conclusion. This is an interesting case of surgical scar endometriosis, and the etiopathogenetic mechanism of this location may be explained by a dissemination of endometrial tissue during the Cesarean section.

Tubal sterilization by laparoscopy or hysteroscopy: which is the most cost-effective procedure?

By using the activity-based cost/management (ABC/M) system we computed and compared costs needed for laparoscopic tubal sterilization (LTS) and Essure hysteroscopic tubal occlusion (EHTO). We found that total health costs related to consultation and presurgery did not differ between LTS and EHTO; EHTO has low recovery unit costs but is more costly for the operating theater, mainly due to Essure microinserts.

Predicting pregnancy after surgery for pelvic endometriosis: A multivariate analysis based on objective clinical data

BackgroundEndometriosis is a common disorder in women of reproductive age and is a major cause of pelvic pain and infertility. Counseling women with endometriosis about their reproductive future re...

Oral Contraceptives after Myomectomy: A Short Term Trial

Following myomectomy the rate of fertility is restored and pregnancy may be attempted with a good outcome. In the present study a 3 month treatment with OCs in a group of women after a myomectomy was evaluated. The drug compliance and side effects, the benefits of OC in order to reduce symptoms, to increase post-surgical hemoglobin levels and to avoid an early pregnancy after myomectomy were analyzed. A group of women (n = 55) each with myoma ≥5 cm was recruited: they presented menorrhagia, pelvic pain, dyspareunia and dysmenorrhae. After laparotomic myomectomy the women were divided into 3 groups. Group 1: women (n = 16) treated with pill A (15 mcg of ethynilestradiol + 60 mcg of gestodene); group 2: women (n = 23) treated with pill B (20 mcg of ethynilestradiol + 100 mcg of levonorgestrel); group 3: women (n = 16) treated with a placebo (oral calcium). After three months from myomectomy and treatment patients in each group reported a reduced menorrhagia, dismenorrhea and pelvic pain. Serum haemoglobin levels increased in all women (P < .05). No pregnancy occurred in any group and the compliance was good. A post surgery treatment by using oral contraceptives guarentees pregnancy prevention, associated with reduction of pain, and improvement of haematologic conditions.

Utilizzo degli ormoni placentari e fetali in diagnosi prenatale

In medicina la possibilita di poter disporre d’indicatori o markers predittivi di patologia ha permesso di mettere a punto degli screening da applicare, naturalmente, alla popolazione generale o ha consentito di mettere a punto una strategia per il controllo dello stato di benessere del prodotto del concepimento. La medicina prenatale ha stressato questa possibilita-necessita in quanto si occupa di un soggetto, il feto, che puo controllare soltanto attraverso l’organismo di un intermediario rappresentato dalla futura madre. Le prime proteine che destarono l’attenzione dei ricercatori furono Formone della gravidanza (hCG) ed il lattogeno placentare umano (hPL) [1], poi successivamente a caduta sono arrivati l’alfa-fetoproteina l’unica proteina conosciuta di origine esclusivamente fetale [2, 3],un’alfa-2-macroglobulina legata alla gravidanza chiamata PAPP-A [4, 5], l’estriolo sia totale con dosaggio urinario che quello libero o non coniugato plasmatico, che rappresenta l’8-10% del totale [6]. Negli anni ’70-’80 il primo obbiettivo ehe ci si pose fu quello di monitorizzare il prodotto del concepimento nella sua crescita fisiologica, nel suo stato di benessere e nei deficit di accrescimento.