Gloria Calagna

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.

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.

Prevention of intrauterine post-surgical adhesions in hysteroscopy. A systematic review

OBJECTIVE The purpose of the present review is to provide a survey of the various measures of preventing adhesions used in hysteroscopic surgery. STUDY DESIGN A systematic computerized literature search was conducted to provide a survey of the various measures used in hysteroscopic surgery to prevent adhesions. Finally, 29 studies were included in the analysis, showing a wide variety of methods and agents advocated in international literature. They are explained in various sections, based on the IUA prevention approach adopted (surgical technique, early second-look hysteroscopy, barrier method, pharmacological therapy). RESULTS The results of our review show that (i) use of surgical techniques which reduce the use of electrosurgery should be preferred whenever possible (Level of evidence: 4); (ii) an early second-look hysteroscopy would appear to be an effective preventive, as well as therapeutic, strategy regarding IUA but studies on the topic are too few for relevant evidence; (iii) barriers methods are the most widely used and, among these, gel barriers have been proven to have a significant clinical effect on IUA prevention, because of higher adhesiveness and prolonged residence time on the injured surface (Level of evidence: 1b); (iv) the role of hormonal and antibiotic therapy in the prevention of post-operative IUA is difficult to evaluate as it has been used in association with other prevention strategies in most studies included in our review. CONCLUSIONS Robust and high quality randomized trials to assess the effectiveness of different anti-adhesion therapies are still needed before one or more of these strategies may be strongly recommended for improving clinical outcomes in women treated by operative hysteroscopy.

Cold loops applied to bipolar resectoscope: A safe “one‐step” myomectomy for treatment of submucosal myomas with intramural development

To assess the safety and efficacy of cold loop myomectomy applied to bipolar resectoscope to perform “one‐step” myomectomy of submucosal myomas with intramural involvement.

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.

Is intravesical instillation of hyaluronic acid and chondroitin sulfate useful in preventing recurrent bacterial cystitis? A multicenter case control analysis.

OBJECTIVE Urinary tract infections (UTIs) are common in the female population and, over a lifetime, about half of women have at least one episode of UTI requiring antibiotic therapy. The aim of the current study was to compare two different strategies for preventing recurrent bacterial cystitis: intravesical instillation of hyaluronic acid (HA) plus chondroitin sulfate (CS), and antibiotic prophylaxis with sulfamethoxazole plus trimethoprim. MATERIALS AND METHODS This was a retrospective review of two different cohorts of women affected by recurrent bacterial cystitis. Cases (experimental group) were women who received intravesical instillations of a sterile solution of high concentration of HA + CS in 50 mL water with calcium chloride every week during the 1(st) month and then once monthly for 4 months. The control group included women who received traditional therapy for recurrent cystitis based on daily antibiotic prophylaxis using sulfamethoxazole 200 mg plus trimethoprim 40 mg for 6 weeks. RESULTS Ninety-eight and 76 patients were treated with experimental and control treatments, respectively. At 12 months after treatment, 69 and 109 UTIs were detected in the experimental and control groups, respectively. The proportion of patients free from UTIs was significantly higher in the experimental than in the control group (36.7% vs. 21.0%; p = 0.03). Experimental treatment was well tolerated and none of the patients stopped it. CONCLUSION The intravesical instillation of HA + CS is more effective than long-term antibiotic prophylaxis for preventing recurrent bacterial cystitis.

The Role of Hysteroscopy in the Diagnosis and Treatment of Adenomyosis

Uterine adenomyosis is a common gynecologic disorder in women of reproductive age, characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Dysmenorrhea, abnormal uterine bleeding, chronic pelvic pain, and deep dyspareunia are common symptoms of this pathological condition. However, adenomyosis is often an incidental finding in specimens obtained from hysterectomy or uterine biopsies. The recent evolution of diagnostic imaging techniques, such as transvaginal sonography, hysterosalpingography, and magnetic resonance imaging, has contributed to improving accuracy in the identification of this pathology. Hysteroscopy offers the advantage of direct visualization of the uterine cavity while giving the option of collecting histological biopsy samples under visual control. Hysteroscopy is not a first-line treatment approach for adenomyosis and it represents a viable option only in selected cases of focal or diffuse “superficial” forms. During office hysteroscopy, it is possible to enucleate superficial focal adenomyomas or to evacuate cystic haemorrhagic lesions of less than 1.5 cm in diameter. Instead, resectoscopic treatment is indicated in cases of superficial adenomyotic nodules > 1.5 cm in size and for diffuse superficial adenomyosis. Finally, endometrial ablation may be performed with the additional removal of the underlying myometrium.

Laparoscopic treatment of diaphragmatic endometriosis causing chronic shoulder and arm pain

1. Yamada T, Iwao N, Kasamatsu H,Mori H. A case of malignant lymphoma of the ovary manifesting like advanced ovarian cancer. Gynaecol Oncol. 2003;90:215–19. 2. Charlton I, Norris HS, King FM. Malignant reticuloendothelial disease involving the ovary as a primary manifestation: a series of 19 lymphomas and 1 granulocytic sarcoma. Cancer. 1974;34:397–407. 3. Manterroso V, Jaffe ES, Merino MJ, Medeiros CJ. Malignant lymphomas involving the ovary: a clinicopathologic analysis of 39 cases. Am J Surg Pathol. 1993;17:154–70. 4. Fox H, Langley FA, Govan ADT, Hill AS, Bennett MH. Malignant lymphoma presenting as an ovarian tumor: a clinicopathologic analysis of 34 cases. Br J Obstet Gynaecol. 1988;95:386–90. 5. Linden MD, Tubbs RR, Fishleder AJ, Hart WR. Immunotypic and genotypic characterization of non-Hodgkin’s lymphomas of the ovary. Am J Clin Pathol. 1988;90:156–62.