Franco Borruto

The Vecchietti procedure for surgical treatment of vaginal agenesis: comparison of laparoscopy and laparotomy

Objective: Our goal was to describe the outcomes of women with vaginal agenesis who had surgical creation of a neovagina using the Vecchietti technique over a 20‐year period. We also sought to determine whether the laparoscopic approach would result in similar outcomes as laparotomy. Method: Retrospective analysis of 76 women with vaginal agenesis treated at the University of Verona Hospital between 1976 and 1996 with the Vecchietti procedure. Operative and postoperative records were reviewed, and sexual histories were obtained. Data were analyzed based on surgical approach and postoperative sexual satisfaction. Continuous data were analyzed with students t‐test, and categoric data were analyzed using Fishers exact test. Result: Those who underwent the Vecchietti procedure with a laparoscopic approach (N=7) had similar complication rates (0% vs. 13.0%, P=0.59) and postoperative neovaginal depth (74.9 mm vs. 73.7 mm, P=0.93) as those with laparotomy (N=69). Similar proportions of women reported inadequate vaginal lubrication (28.6% vs. 17.4%, P=0.61) and sexual satisfaction (100% vs. 78.3%) in the laparoscopy and laparotomy groups as well. Operative complications, neovaginal depth, or degree of lubrication were not good predictors of sexual satisfaction. Conclusion: Outcomes in those women who underwent the Vecchietti technique via the laparoscopic approach are comparable to those who underwent laparotomy.

Foetal and neonatal ovarian cysts: a 5-year experience.

BackgroundAbdominal cystic formations in newborns are relatively common and often diagnostic suspicion arises in this regard even before birth as a result of ultrasound scans carried out during pregnancy. The aim of this study is to highlight the problems posed by the prenatal diagnosis of abdominal cysts in order to outline the most appropriate therapeutic approach in case of suspected ovarian cysts.Materials and methodsBetween January 2003 and January 2007, 57 women were enrolled in this study for a prenatal ultrasound (US) that revealed the presence of an echo-rare or echo-free area in the foetal abdomen. After birth all babies underwent blood tests and abdominal US scans in order to confirm or identify the nature of the cyst. If abdominal US could not show the nature of the cystic formation, magnetic resonance imaging with sedation was performed. When the radiological tests were not useful to identify the nature of the cysts and surgery was then necessary, surgical procedures were performed with laparoscopy.ResultsUltrasounds were useful to identify the diameter of the cysts but not all their origins; also MRI confirmed the morphology and volume of the cysts, but could not give further details about their origin.DiscussionAbdominal ultrasound and finally laparoscopy used to treat and remove the cysts were useful to monitor all simple abdominal cysts. MRI seemed not to be useful for the treatment of this condition, especially in the pediatric age when mild sedation is required.

The laparoscopic Vecchietti technique for vaginal agenesis

Objective: To evaluate surgical, long‐term anatomic and functional results of the laparoscopic Vecchietti procedure to treat women with vaginal agenesis. MethodsRetrospective analysis of 86 women treated at the Department of Gynecology and Obstetrics at the University of Verona, Italy. Data were analyzed based on surgical results and postoperative sexual satisfaction. Depth and diameter of the neo‐vagina was determined. The characteristics of the neo‐vaginal mucosa were investigated by vaginoscopy. Patients reported frequency, satisfaction, and any difficulties found at intercourse. ResultsFunctional success was obtained in 98.1% and anatomic success in 100%. In all patients, at 1 year, the mucosa was pink, trophic, and moist. Two fingers were introduced easily into the neo‐vagina in all cases. All patients, which decided to have sexual intercourse, defined these as satisfying within 6 months. ConclusionsLaparoscopic procedure used in this study is simple, safe, and effective. Anatomical and functional results obtained suggest this laparoscopic procedure as the treatment of choice for this syndrome.

Umbilical endometriosis: A radical excision with laparoscopic assistance

BACKGROUND Umbilical endometriosis represents the most common site of cutaneous endometriosis. Although its treatment is typically surgical, in literature the approach used is variable and extends from diathermocoagulation to omphalectomy. Such superficial treatments for umbilical endometriosis can predispose the patient to a relapse of the disease. We here present seven cases of umbilical endometriosis treated with radical surgery with a laparoscopically-assisted approach, with a complete and long-term disease-free follow-up. CASES Seven cases of umbilical endometriosis, four of which relapsing from a prior superficial treatment, were treated radically with a laparoscopically-assisted approach, with a long-term disease-free follow-up. CONCLUSION Although a medical treatment can be considered, the treatment of choice in these patients should be that of excisional surgery so as to avoid lesion relapse and the risk of oncogenic transformation. Despite umbilical endometriosis is a rare finding, this relatively small case series treated by laparoscopically-assisted omphalectomy shows a complete resolution of the lesion and symptoms along with good aesthetic results at a long-term follow-up.

The Unicornuate Uterus with an Occult Adenomyotic Rudimentary Horn

We report 2 case of an atypical variant of unicornuate uterus in 2 adolescent patients with severe dysmenorrhea. Pelvic ultrasonography and magnetic resonance imaging identified a normal uterine contour. On the right side within the uterine fundus, a nodule was detected with a small hypoechogenic content. At laparoscopy the uterus and adnexae appeared to be normal. No endometriotic lesions were identified. Hysteroscopy identified a single regular cervical canal and a uterine cavity resembling that of a left unicornuate uterus, with a single regular left tubal ostium. Complete resection of the right uterine nodule along with an ipsilateral salpingectomy was performed. The nodule contained a small endometrial cavity and hematometra. Histologic study showed a cavitated adenomyotic uterine rudiment. The patients were discharged on the second postoperative day. No intraoperative or postoperative complications or recurrence of pelvic pain occurred.

Childbirth in the third millennium

The birth event has changed markedly with time. Now, in the third millennium, there are important medical issues, but also ethical aspects, which make us ask if this remarkable ‘medicalization’ of childbirth is right, whether the higher rate of cesarean sections practiced is acceptable, and whether it is always necessary to give birth in a hospital on an operating table. Continuing advances in obstetrics have led to a drastic reduction in maternal mortality and, consequently, have led to interest in fetal well-being, which was neglected in the past. The greater understanding of the physiopathology of the fetal condition has therefore led to a new concept of ‘fetus as a patient’ and as such subjected to diagnostic and therapeutic measures. This has led to a change in the attitude of patients and the media toward pregnancy, with an increasing desire to give birth to healthy (if not perfect) children and reduce (up to almost zero) the maternal risks related to pregnancy and childbirth. This refinement of diagnostic skills, however, still cannot yield adequate response to therapeutic measures. In other words, even if pregnancy and childbirth are physiological events in themselves, the absolute assurance of perfect health of both the mother and the unborn child is not yet feasible, as unpredictable or undetectable situations persist, which therefore are beyond the control of the physician and involve a certain degree of risk. This inevitably gives rise to medicolegal issues that end up affecting the daily work of obstetricians considerably, resulting in excessive medicalization of pregnancy and childbirth and increased interventionism. Obstetric practice has thus changed, from medical intervention only in case of disease to active surveillance and prevention, leading to the possible induction or acceleration of delivery if necessary. It has also significantly changed the management of birth, even as a consequence of improvement of diagnostics, besides surgical and anesthesiological techniques. Finally, it must be kept in mind that the characteristics of the women who present for childbirth have modified markedly over time. From the strictly homogeneous population of 20–30 years ago, today, we have moved to a multiethnic society, and in some hospitals, 25–30% of women, from very different cultures and traditions, will give birth, often without the necessary tests and checks during pregnancy. In conclusion, currently, the specialty of obstetrics is facing several new challenges and must prove capable of flexible 360° responses. It is not just a job because we must recreate a culture of birth: a new health organization, new players, new structures. Also, new parents understand that birth is not limited to half an hour during which the child is born, but that there is a before and especially an after that requires active cooperation with love and intelligence. All this respects the natural rights of women, but also recognizes the right of children to be reared with care and attention from a mother and a father who can help each other.

Human Papillomavirus: Natural History of a Viral Infection in the Genesis of a Cancer

Human Papillomaviruses (HPV) are small deoxy-ribonucleic acid (DNA) tumor viruses with an icosahedral virion structure associated with a wide spectrum of epithelial lesions, ranging from benign warts to invasive carcinomas. They have been difficult to study, in part because they have not yet been propagated in tissue culture. Fortunately, advances in molecular biology have allowed characterization of HPV genomes and identification of some HPV gene functions. In addition to their clinical importance, HPV represent an important tool for exploring virus-cell interactions, gene expression, cellular differentiation, and cancer. HPV infections are not only common, but also difficult to treat and prevent. Depending on the HPV type and location, the modes of HPV transmission may involve casual physical contact, sexual contact, and perinatal vertical transmission. HPV DNA genomes replicate at a low copy number in basal cells and, as most clinicians know, are difficult to eradicate. There is often a long latent period and subclinical infections, plus HPV DNA can be found in normal tissue adjacent to lesions. HPV can cause widely disseminated lesions, especially in the immuno-compromised host and in epidermodysplasia verruciformis (EV). In malignant lesions, HPV DNA is also found as fragments incorporated into the cellular genome. Unlike retroviruses such as Human Immunodeficiency Virus (HIV) that integrate into the cellular genome as part of their life cycle, HPV integration is a terminal event for viral replication. Such integration is critical, however, for viral-induced abnormal cell growth. Perhaps the most important implication of some ano-genital cancers is that they may be preventable. The data overwhelmingly suggests that avoidance of exposure to HPV, via abstinence or monogamy in both partners markedly reduces the risk of cervical cancer. A more realistic goal, however, is prevention of HPV transmission by the use of barrier method contraceptives, which may be protective against development of cervical carcinoma as reported byCripe (Pediatr Infect Dis J 9:836–844, 1990). Infection with HPV is the most common STD, afflicting approximately 80% of the population. HPV infection is an essential factor in cervical carcinogenesis and cervical carcinoma the second most common cause of cancer among women worldwide. In addition to cervical cancer, other malignancies in both men and women such as esophageal, oropharyngeal, and anal cancer have been causally associated with this virus. Other gender-specific HPV-related cancers include penile, vulvar, and vaginal cancer. Recent evidence also points to a possible role of other HPV infections in squamous cell carcinomas (SCC) of the skin. During the past 20 years, several types of HPV have been identified that cause specific types of cancers. The etiology of cancer of the cervix has been linked to several types of HPV, with a high preponderance of HPV-16. HPV-16 is the most common HPV type associated with a malignant phenotype regardless of organ of origin. HPV-16, together with HPV-18, accounts for approximately 70% of cervical cancers. Other non-oncogenic HPV types, including HPV types 6 and 11, are associated with over 90% of benign HPV-related lesions such as genital warts and juvenile respiratory papillomatosis as reported by Monk and Tewari (Gynecol Oncol 107:S6–S13, 2007).

Uptake of cervical cancer screening among the migrant population of Prato Province, Italy.

To determine the level of participation in cervical cancer screening among the migrant population of Prato Province, Italy.

Advances in fetal cardiology

The prevalence of congenital heart malformations as a whole (including diseases of little clinical significance) is 0.8% (8 of 1000 live births). The most frequent pathologies are malformations that prevent blood from reaching the lungs to take oxygen or block the normal supply of oxygenated blood to the body. The transposition of the great vessels (the aorta and pulmonary artery originate from the ‘wrong’ ventricles) is important as it represents the most severe neonatal heart disease. A separate issue, instead, is that of arrhythmias. The diagnosis is made around the 20th–21st week of gestation through a targeted ultrasound examination of fetal heart. This enables the recognition of the vast majority (around 85%) of clinically important congenital heart diseases (CHD) at birth. Nevertheless, targeted examinations are not possible for all pregnancies: the costs would not allow it. They are still available for patients who have recognized risk factors (they had children with previous CHD, they took teratogenic drugs, or they have diabetes), whereas pregnant women who have a very low risk are subjected to basic ultrasound examinations. An ultrasound examination allows at least suspicion of a significant proportion (30–40%) of important heart diseases. Progresses in the diagnostic field are continuous and the development of visualization techniques provides great opportunities. Four-dimensional (4-D) ultrasound that allows volumetrical viewing of the fetus, moving, to the most detailed facial expressions, appears to be promising in the diagnosis of CHD, which often escape the traditional ultrasound examination. Enabling better visualization of the heart, thanks to the ability to view it from different points and angles, volumetric ultrasound could aid the diagnosis of more heart diseases. Recognition of fetuses with heart disease may be useful for planning targeted interventions. The purpose of prenatal diagnosis is, first, to improve the prognosis without serious damages in the neonatal period. If necessary, there is the possibility of interventions on the fetus (which mainly consists of aortic or pulmonary valve and foramen ovale dilation), but they are still experimental cardiac procedures. In general, the first interventions take place on the newborn baby; therefore, the birth can be arranged at a cardiology and cardiac surgery unit, thus avoiding delays and dangerous transfers. Thanks to the timely diagnosis, today, 90% of operated babies survive and reach adulthood with a normal life expectancy (only for patients with univentricular heart, we impose limits on physical and working activity). Today, complex operations are possible even in low-birth-weight babies, with very good results, attempting to prioritize corrective radical rather than palliative solutions, which until recently were often the only options. As medical therapies play a marginal role in heart malformations, they are instead essential in the treatment of fetal tachyarrhythmias: these are quite rare diseases, which are also detectable by echocardiography, often isolated (i.e. not associated with cardiac malformations). These arrhythmias in the fetus are rapidly fatal if not effectively controlled and treated with specific drugs administered to the mother, so that in most cases, they resolve easily, without future problems.

Human Papillomavirus DNA Testing: What, How, and When

More than 20 years ago, a relationship between Human Papillomavirus (HPV) infection and cervical cancer was recognized. Since then, important strides in understanding the virus have been made, particularly in the following areas: modes of transmission and risk factors associated with transmission, the oncogenic potential of specific viral types and the mechanism by which they cause cancer, and the spectrum of infection, ranging from asymptomatic carrier states to overt warts, preneoplastic lesions, and invasive cancer. Sophisticated new tests for the detection of HPV for screening for cervical cancer precursors and invasive cancer and for the triage of abnormal cervical cytology also have been developed as reported by American College of Obstetricians and Gynecologists (Obstet Gynecol 105:905–918, 2005). Recent evidence has shown that the risk of malignant and premalignant cervical disease and HPV infections varies significantly with age. Furthermore, evidence now shows that treatment for cervical disease carries significant risk for future pregnancies. These factors have led to a reevaluation of the guidelines for the management of premalignant cervical disease as reported by American College of Obstetricians and Gynecologists (Obstet Gynecol 112:1419–1444, 2008). Understanding the immunology of HPV has allowed the development of new and more effective treatment modalities for HPV infection and the development of primary prevention modalities, including HPV vaccines as reported by American College of Obstetricians and Gynecologists (Obstet Gynecol 105:905–918, 2005). Invasive cervical cancer is the second most common female cancer worldwide, with about 493,000 new cases per year. About 273,000 women die from cervical cancer each year, 85% of which take place in developing countries. Cervical cancer has a slow progress from pre-invasive cervical intraepithelial neoplasia (CIN) to invasive phases, meaning that the disease can be diagnosed while in the phase of pre-invasive lesion, and treated successfully thanks to the regular screening of asymptomatic women. Additional diagnostic procedures for preinvasive lesions of the uterine cervix like deoxyribonuclaic acid (DNA) cytometry (flow cytometry) can point to dysplasia that can progress to severe stages, such as high-grade (HG) squamous intraepithelial lesions (H-SIL). If the level of chromosomal disturbance is higher (aneuploidy), it is more probable that H-SIL will develop. Laser screening of cells extracted with modern cytologic screening liquid-based cytology enables us to automatically measure ploidy (chromosome regularity, or irregularity) and polymerase chain reaction (PCR) provides analysis of HPV types. These methods are recommended for a routine check-up of borderline cervical lesions in order to anticipate ones likely to regress or progress as reported by Grubisic et al. (Coll Antropol 33:1431–1436, 2009). HPV also causes a proportion of other cancers, including vulvar, vaginal, anal, penile, and oropharyngeal cancers. Although cervical cancer screening, primarily with the Papanicolaou (Pap) smear, has reduced the incidence of this cancer in industrialized countries, cervical cancer remains the second most common cause of death from cancer in women worldwide, because the developing world has lacked the resources for widespread, high-quality screening. In addition to advances in Pap smear technology, the identification of HPV as the etiologic agent has produced two recent advances that may have a major impact on approaches to reduce the incidence of this disease. The first is the development of a preventive vaccine, the current versions of which appear to prevent close to 100% of persistent genital infection and disease caused by HPV-16 and HPV-18. Future second-generation vaccines may be able to protect against oncogenic infections by a broader array of HPV types. The second is the incorporation of HPV testing into screening programs. In women aged >30 years, HPV testing can identify HG CIN earlier than Pap smears with acceptable rates of specificity. These results, together with the high sensitivity of HPV testing, suggest that such testing could permit increased intervals for screening. An inexpensive HPV test in development, if successful, may be incorporated as part of an economically viable “screen-and-treat” approach in the developing world. The manner in which vaccination and screening programs are integrated will need to be considered carefully so that they are efficient in reducing the overall incidence of cervical cancer as reported by Lowy et al. (Cancer 113:1980–1993, 2008).