Giuseppe Colafiglio

Laparoscopy vs Minilaparotomy in Women with Symptomatic Uterine Myomas: A Prospective Randomized Study

OBJECTIVE To compare outcomes in patients with symptomatic uterine myomas who underwent laparoscopic (LPS) or minilaparotomic (MLPT) myomectomy. DESIGN Prospective randomized study (Canadian Task Force classification II-2). SETTING University hospital. PATIENTS Eighty patients with no more than 3 uterine myomas of maximal diameter of 7 cm. INTERVENTION Either LPS or MLPT myomectomy. MEASUREMENTS AND MAIN RESULTS Mean blood loss, mean duration of postoperative ileus, and mean decrease in hemoglobin were significantly lower in the LPS compared with the MLPT group (p < .001). Mean operative time was not significantly longer in the LPS group compared with the MLPT group. Duration of hospitalization was significantly shorter in the LPS compared with the MLPT group (p < .001). No intraoperative complications were observed during MLPT. In 1 patient, conversion from LPS to MLPT was necessary because of difficulty in reconstructing the uterine wall. CONCLUSION Laparoscopic myomectomy is a suitable alternative to MLPT in women with 1 to 3 myomas. However, preoperative careful evaluation of the size and sites of the myomas is necessary to avert conversion and prevent complications.

Reliability of diagnostic fluid hysteroscopy in the assessment of cervical invasion by endometrial carcinoma: A comparative study with transvaginal sonography and MRI ☆

OBJECTIVE This study aimed at comparing the reliability of diagnostic fluid hysteroscopy, transvaginal sonography (TVS), and magnetic resonance imaging (MRI) to assess pre-operatively the presence of cervical involvement by endometrial carcinoma. METHODS Cervical involvement was assessed by diagnostic fluid mini-hysteroscopy, TVS and MRI before surgery in 100 patients with histological diagnosis of endometrial carcinoma. Results were compared with pathological examination on surgical specimen. The sensitivity, the specificity, the positive and negative predictive values, the accuracy, the positive and negative likelihood ratios (LR) of the three techniques for recognizing the cervical involvement by the carcinoma were calculated. RESULTS At histology cervical involvement was found in 15 cases. Compared to TVS and MRI, hysteroscopy showed the highest sensitivity (0.53, 0.67 and 0.93, respectively). The specificity of MRI was significantly higher than both hysteroscopy and TVS (0.95, 0.88 and 0.82, respectively). The diagnostic accuracy of hysteroscopy (0.89) and MRI (0.91) was similar and significantly higher than TVS (0.78). The LR for a positive result of MRI was 14.16, that was 2.08 and 4.68 times higher than that of hysteroscopy and TVS, respectively. CONCLUSIONS In conclusion, this study demonstrates that in women with endometrial carcinoma the exclusion of cervical canal involvement at hysteroscopy is more reliable than at MRI and TVS while MRI is the most reliable technique for predicting cervical involvement. In the pre-surgical work-up of patients affected by endometrial carcinoma hysteroscopy and MRI are both useful for staging and planning the correct surgical strategy.

Risk of long-term pelvic recurrences after fluid minihysteroscopy in women with endometrial carcinoma: a controlled randomized study.

Objective: Concerns exist about the risk of endometrial cancer cells spreading into the peritoneal cavity after fluid minihysteroscopy. The aim of our study was to evaluate the 5-year incidence of pelvic recurrences in women affected by early-stage endometrial carcinoma (stage IA or IB) who did or did not undergo preoperative hysteroscopy with low pressure (<70 mm Hg) saline uterine distention. Methods: A total of 140 women were randomized into two groups of 70 women who underwent or did not undergo diagnostic fluid minihysteroscopy before surgical staging. Women were followed up every 6 months for at least 5 years. Diagnosis of pelvic recurrence was based on a positive result at clinical examination and/or at vaginal cytology and/or at magnetic resonance imaging/positron emission tomography scan. Univariate analysis of disease-free survival was performed with the Kaplan-Meier method and survival curves were compared using the long-rank test. Results: No difference in peritoneal cytology was observed between the two groups (5.7% and 8.5% of cases in the hysteroscopy and control group, respectively). After a mean duration of follow-up of 62 months, 2 (2.85%) pelvic recurrences in the hysteroscopy group and 3 (4.28%) in the control group were found. No significant difference was found between the two groups when the recurrence rate was compared. Overall survival rates and disease-free survival projected by Kaplan-Meier curves were not significantly different for the two groups. Conclusions: Preoperative low-pressure fluid minihysteroscopy does not increase the risk of intraperitoneal transport of endometrial carcinoma cells during the examination or the risk of pelvic recurrence at the 5-year follow-up. It does not seem to modify the recurrence rate, disease-free survival, and overall survival, although multicenter randomized trials and long-term follow-up are required to evaluate the overall oncologic outcomes of this procedure.

Reliability of narrow-band imaging (NBI) hysteroscopy: a comparative study.

OBJECTIVE To evaluate the usefulness of narrow-band imaging (NBI) technology for improving the diagnostic reliability of hysteroscopy. DESIGN Prospective controlled clinical study (Canadian Task Force classification II-2). SETTING University hospital. PATIENT(S) Three hundred ninety-five outpatient women undergoing diagnostic hysteroscopy were enrolled. INTERVENTION(S) All patients underwent fluid minihysteroscopy with white light (WL) and NBI exploration with endometrial eye-directed biopsy. MAIN OUTCOME MEASURE(S) Hysteroscopic findings with WL and NBI were compared with histology, which was considered the gold standard. RESULT(S) Overall, the number of correct diagnoses with NBI was significantly higher than with WL. For differentiating normal from abnormal endometrial histopathology, the use of NBI showed a significantly higher specificity (0.93 vs. 0.78) and negative predictive value (0.92 vs. 0.81); NBI hysteroscopy significantly improved the sensitivity for the diagnosis of proliferative endometrium (0.93 vs. 0.78), chronic endometritis (0.88 vs. 0.70), low-risk hyperplasia (0.88 vs. 0.70), and high-risk hyperplasia (0.60 vs. 0.40). CONCLUSION(S) The use of NBI improved the reliability of diagnostic hysteroscopy. The high specificity and the low number of false negatives may reduce the number of unnecessary biopsies or of those performed in wrong areas. Moreover, compared with WL observation, NBI hysteroscopy showed significantly higher sensitivity for the detection of chronic endometritis and low-risk and high-risk hyperplasia.

Successful management of a cervical twin pregnancy: neoadjuvant systemic methotrexate and prophylactic high cervical cerclage before curettage.

OBJECTIVE To report our experience in managing a case of viable cervical twin pregnancy with systemic methotrexate and 2 weeks later with endocervical curettage after placing prophylactic high cervical cerclage. DESIGN Case report. SETTING University medical center. PATIENT(S) A 36-year-old woman, gravida 2, para 0, complaining of vaginal bleeding and pelvic pain, in whom cervical twin pregnancy was diagnosed at the sixth week of gestation. INTERVENTION(S) Systemic methotrexate was given as first-line treatment. Two weeks later because of persisting bleeding, endocervical curettage was performed after closing cervical arteries and placing but not tightening high cervical cerclage. MAIN OUTCOME MEASURE(S) Pregnancy termination, bleeding control, and preservation of fertility. RESULT(S) Notwithstanding the ligature of cervical arteries at curettage, heavy bleeding occurred, which was controlled rapidly by tightening the cerclage. Curettage then was completed successfully. Postoperative period was uneventful. Two years later the woman delivered vaginally. CONCLUSION(S) In case of cervical twin pregnancy methotrexate pretreatment and prophylactic placement of high cervical cerclage, but not ligature of cervical arteries, before curettage showed to be effective in terminating pregnancy ensuring effective bleeding control and preservation of fertility.

Peritoneal fluid concentrations of progesterone in women are higher close to the corpus luteum compared with elsewhere in the abdominal cavity

OBJECTIVE To investigate the potential role of peritoneal fluid activity for the local delivery of gonadal steroid hormones. DESIGN Prospective clinical study. SETTING University hospital. PATIENT(S) Nine women undergoing tubal sterilization during laparoscopic surgery. INTERVENTION(S) Peritoneal fluid was collected during laparoscopic surgery by means of sterile cotton swabs on the surface of the peritoneum facing the ovary with an active corpus luteum and on the contralateral side, at the right and left paracolic gutter, and at the pouch of Douglas; simultaneous systemic blood sampling was performed. MAIN OUTCOME MEASURE(S) P was quantified by competitive immunochemical assay. Final steroid concentrations were calculated relative to the standard recovery rate. RESULT(S) P concentrations in the peritoneum close to the corpus luteum were 4 times (range, 1.4-9.2) higher than in the other peritoneal samples and about 5 times (range, 3.9-9.5) higher than in the systemic blood. CONCLUSION(S) The results indicate that P enters the peritoneal cavity locally and may therefore influence the function of other nearby tissues, especially those of the ipsilateral fallopian tube and proximal region of the uterus. Indeed, the peritoneal cavity and its fluid contents may be a powerful yet overlooked component of the regulatory systems within the body.