Gaspare Cucinella

Parasitic myomas after laparoscopic surgery: an emerging complication in the use of morcellator? Description of four cases

OBJECTIVE To report the development of parasitic myomas after the use of a morcellator. DESIGN Retrospective study. SETTING Tertiary care referral center for the treatment of benign gynecologic pathologies. PATIENT(S) Women undergoing surgery for uterine fibroids. INTERVENTION(S) Chart review. MAIN OUTCOME MEASURE(S) Presence of parasitic leiomyomas. RESULT(S) We identified four cases of parasitic myomas over the 3-year study period. Two out of the four were symptomatic. The prevalence of this complication, considering all women with whom the electric morcellator was used (n = 423) was 0.9% (95% CI, 0.3-2.2%). Considering exclusively the women who underwent myomectomy (n = 321), it was 1.2% (95% CI, 0.4-2.9%). CONCLUSION(S) Laparoscopic myomectomy with the use of a morcellator is associated with an increased risk of developing of parasitic myomas. A thorough inspection and washing of the abdominopelvic cavity at the end of the surgery should be performed to prevent this rare complication.

Vulvo-vaginal atrophy: A new treatment modality using thermo-ablative fractional CO2 laser

OBJECTIVE To evaluate the efficacy and feasibility of thermo-ablative fractional CO2 laser for the treatment of symptoms related to vulvo-vaginal atrophy (VVA) in post-menopausal women. METHODS From April 2013 to December 2013, post-menopausal patients who complained of one or more VVA-related symptoms and who underwent vaginal treatment with fractional CO2 laser were enrolled in the study. At baseline (T0) and 30 days post-treatment (T1), vaginal status of the women was evaluated using the Vaginal Health Index (VHI), and subjective intensity of VVA symptoms was evaluated using a visual analog scale (VAS). At T1, treatment satisfaction was evaluated using a 5-point Likert scale. RESULTS During the study period, a total of 48 patients were enrolled. Data indicated a significant improvement in VVA symptoms (vaginal dryness, burning, itching and dyspareunia) (P<0.0001) in patients who had undergone 3 sessions of vaginal fractional CO2 laser treatment. Moreover, VHI scores were significantly higher at T1 (P<0.0001). Overall, 91.7% of patients were satisfied or very satisfied with the procedure and experienced considerable improvement in quality of life (QoL). No adverse events due to fractional CO2 laser treatment occurred. CONCLUSION Thermo-ablative fractional CO2 laser could be a safe, effective and feasible option for the treatment of VVA symptoms in post-menopausal women.

Laparoscopic sacrocolpopexy in the treatment of vaginal vault prolapse: 8 years experience

OBJECTIVE The aim of this study was to evaluate the long-term results of a laparoscopic sacrocolpopexy for the treatment of vaginal vault prolapse. STUDY DESIGN Between January 1999 and January 2007, 165 laparoscopic sacrocolpopexy procedures, using a polypropylene mesh, were performed on women affected by vaginal vault prolapse. Intraoperative complications included: 5 bladder injuries and 3 sigmoid perforations. Postoperative complications included: 10 cases of fever, 5 cases of lumbosciatica, 15 cases of detrusor overactivity, 2 cases of vaginal haematoma, and 5 cases of minimal dispareunia. At 1, 6 and 12 months after surgery, a clinical evaluation was carried out for all patients. After this period, we contacted the women annually. RESULTS We treated 165 women, with an average age of 67 (range 58-76 years; S.D. 19.22), average parity of 3 (range 2-5), and average body mass index of 28 (range 24-30). In many of them, more than one additional procedure was performed. At a median follow-up of 43 months (range 6-96 months), out of a total of 138 patients (27 were lost at follow-up), we obtained successful treatment in 131 women (success rate of 94.9%), with a high rate of satisfaction from the procedure. Recurrent vaginal vault prolapse was registered in seven women (5.07%): in 3, the vaginal vault collapsed after a period ranging from 7 to 20 days, caused by the use of a Vyprol mesh (hence use of same was suspended), and in a further three women the mesh detached after less than 1 month. Finally, in one case, we reported an erosion between the first and the second follow-up and the mesh was visualized in the vagina. CONCLUSIONS Our study shows that laparoscopic sacrocolpopexy, in the hands of an expert surgeon, can be considered a safe, effective procedure for the treatment of vaginal vault prolapse, allowing long-term anatomical restoration (94.9% success rate).

Histologic analysis of specimens from laparoscopic endometrioma excision performed by different surgeons: Does the surgeon matter?

OBJECTIVE To evaluate whether the amount of ovarian tissue inadvertently removed along with the endometrioma cyst wall at laparoscopy differs in relation to the operating surgeons level of expertise. DESIGN Multicenter, prospective trial. SETTING Four tertiary care university hospitals. PATIENT(S) Fifty patients, aged 25 to 40 years, with monolateral ovarian endometriomas who underwent laparoscopic excision. INTERVENTION(S) Operation with the stripping technique by surgeons with specific expertise in endometriosis surgery in four centers (groups A, B, C, and D) and by residents with average training in laparoscopic surgery (group E). MAIN OUTCOME MEASURE(S) Histologic examination for the evaluation of the mean thickness of the cyst wall from each specimen, and the mean thickness and morphologic characteristics of any ovarian tissue removed. RESULT(S) No statistically significant differences were present in the rate of presence of ovarian tissue in the endometrioma wall specimens from the different groups (44%, 45%, 55%, 56%, and 60% in groups A, B, C, D, and E, respectively). For groups A+B+C+D versus group E, a statistically significant difference was found in the mean thickness of the tissue specimens (1.51 mm vs. 1.91 mm, respectively) and in the mean thickness of ovarian tissue inadvertently excised (0.49 mm vs. 0.97 mm, respectively). CONCLUSION(S) Level of expertise in endometriosis surgery is inversely correlated with inadvertent removal of healthy ovarian tissue along with the endometrioma capsule.

Gonadotrophin-releasing hormone analogue or dienogest plus estradiol valerate to prevent pain recurrence after laparoscopic surgery for endometriosis: a multi-center randomized trial.

To evaluate the efficacy of dienogest + estradiol valerate (E2V) and gonadotrophin‐releasing hormone analogue (GnRH‐a) in reducing recurrence of pain in patients with chronic pelvic pain due to laparoscopically diagnosed and treated endometriosis.

Isolated Endometriosis on the Rectus Abdominis Muscle in Women without a History of Abdominal Surgery: a Rare and Intriguing Finding

We report 2 rare cases of endometriosis on the rectus abdominal muscle diagnosed incidentally during an operation for inguinal hernia repair in women with no surgical history. Two women sought medical attention for a mass found in the pubic abdominal wall. Only 1 woman reported occasional pain. At physical examination in both women, an ovoid swelling in the right pubic area was felt. One woman experienced pain on palpation, and one reported slight discomfort. Ultrasonography demonstrated a heterogeneous hypoechogenic formation with indistinct edges; diagnosis was difficult. Routine clinical and instrumental (pelvic ultrasonography) gynecologic examination in both patients performed shortly before hospitalization had not revealed any macroscopic focus of endometriosis in the pelvic region. At surgery, a lesion consistent with the diagnosis of endometriosis was found, which was confirmed at histologic analysis. These cases could represent the consolidation of different theories of endometriosis diffusion. We suggest including endometriosis in the differential diagnosis of a symptomatic mass in the abdominal wall in women with and without a surgical history.

Prospective sonographic detection of spina bifida at 11–14 weeks and systematic literature review

Abstract Objective: To conduct a literature review to assess the effectiveness of first trimester ultrasonographic markers of spina bifida (SB) integrating data with our prospective experience. Methods: The analysis of the SB cases that we prospectively detected in the first trimester, between January 2012 and February 2014, and a systematic review of all the papers evaluating the effectiveness of SB ultrasonographic markers at 11–14 weeks, namely brain stem diameter (BS), fourth ventricle/intracranial translucency (IT), cisterna magna (CM), brain stem/occipital bone distance (BSOB), the ratio between BS and BSOB. Some studies assess only the effectiveness of IT, others include more parameters, and few include them all. Results: We prospectively detected four SB cases, three open (OSB) and one closed (CSB), in a low risk population undergoing first trimester screening. In the three OSB, CM (in 2/3 cases) and BSOB (3/3) distance were below the 5th percentile, BS and BS/BSOB ratio (3/3) were above the 95th percentile. In the CSB, all the measurements were within normal limits. Conclusion: The literature and our data agree that most fetuses with OSB demonstrate in the first trimester positive sonographic markers in the posterior fossa, but additional prospective studies are needed to establish the best protocol for OSB screening.

Interstitial Pregnancy: A ‘Road Map' of Surgical Treatment Based on a Systematic Review of the Literature

An electronic search concerning the surgical approach in cases of interstitial pregnancy from January 2000 to May 2013 has been carried out. Fifty three studies have been retrieved and included for statistical analysis. Conservative and radical surgical treatments in 354 cases of interstitial pregnancy are extensively described. Hemostatic techniques have been reported as well as clinical criteria for the medical approach. Surgical outcome in conservative versus radical treatment were similar. When hemostatic techniques were used, lower blood losses and lower operative times were recorded. Conversion to laparotomy involved difficulties in hemostasis and the presence of persistent or multiple adhesions. Laparoscopic injection of vasopressin into the myometrium below the cornual mass was the preferred approach.

Laparoscopic management of interstitial pregnancy: the “purse-string” technique

We report five cases of interstitial pregnancy, treated between 2004 and 2010, to evaluate surgical and obstetric outcome of laparoscopic cornual resection with a “purse‐string” technique. A hemostatic suture was passed at the base of the mass in a purse‐string fashion prior to resection, to minimize intraoperative blood loss. Subsequent pregnancies were analysed, with a mean follow‐up time of 48 months. The mean operating time was 39 min and mean blood loss 47 mL. Three of four patients who desired children delivered at term uneventfully. Laparoscopic cornual resection with a “purse‐string” technique appears to be useful for treatment of early interstitial pregnancy. The technique ensures effective and safe treatment, with satisfactory obstetric outcome.

Adenomyotic cyst in a 25-year-old woman: case report.

Adenomyotic cysts are uncommon findings, usually in the context of diffuse adenomyosis and <5 mm in diameter. Herein we report a 4.5-cm adenomyotic cyst in a 25-year-old nulliparous woman with severe dysmenorrhea and pelvic pain. Transvaginal ultrasonography and magnetic resonance imaging revealed a well-circumscribed hypoechogenic mass in the posterior uterine wall, well separated from the uterine cavity. Pathologic analysis demonstrated that the cyst was lined with endometrial epithelium and stroma and was surrounded by smooth muscle hyperplasia. In the literature, we found 30 reports of cysts with similar characteristics. Because this cyst has not been clearly defined, it has been called by various names including adenomyotic cyst, cystic adenomyosis, and cystic adenomyoma. We believe this lesion should not be called an adenomyoma, but is more correctly called an adenomyotic cyst or, depending on age at onset, a juvenile adenomyotic cyst.