Kazimierz Pityński

Two- and Three-Dimensional Ultrasonography and Sonohysterography versus Hysteroscopy With Laparoscopy in the Differential Diagnosis of Septate, Bicornuate, and Arcuate Uteri

STUDY OBJECTIVE To estimate the diagnostic accuracy and to compare the diagnostic value of 3-dimensional sonohysterography (3D-SIS), 3-dimensional transvaginal ultrasonography (3D-TVS), 2-dimensional sonohysterography (2D-SIS), and 2-dimensional transvaginal ultrasonography (2D-TVS) (initial and expert diagnosis) in the differential diagnosis of septate, bicornuate, and arcuate uteri. DESIGN Prospective clinical study (Canadian Task Force II-2). SETTING University hospital and private hospital and clinic. PATIENTS A total of 117 women with a history of recurrent abortions or infertility and a 2D-TVS initial diagnosis of a septate, bicornuate, or arcuate uterus. INTERVENTIONS Expert 2D-TVS, 3D-TVS, 2D-SIS, and 3D-SIS performed by experienced examiners and hysteroscopy with laparoscopy to establish the final diagnosis. MEASUREMENTS AND MAIN RESULTS Hysteroscopy performed in conjunction with laparoscopy (HL) detected 23 arcuate, 60 septate, 22 bicornuate, and 12 normal uteri. 3D-SIS showed perfect diagnostic accuracy (100.0%) in general detection of uterine abnormalities, compared with initial 2D-TVS (77.8%), expert 2D-TVS (90.6%), 2D-SIS (94.0%), and 3D-TVS (97.4%). In the overall diagnosis of uterine anomalies, all of the diagnostic methods had statistically significantly better diagnostic value than initial 2D-TVS (p < .001), whereas 3D-SIS was the only method that was better than expert 2D-TVS (p < .001). CONCLUSIONS Although 3D-SIS was identical to HL, with the highest accuracy, there was no significant difference in diagnostic value between 3D-TVS with 2D-SIS and 3D-SIS or between expert 2D-TVS and 3D-TVS with 2D-SIS. The high diagnostic value of these ultrasonographic tools questions the need for endoscopy in the differential diagnosis of the most common congenital uterine anomalies.

Diagnostic accuracy of three-dimensional sonohysterography compared with office hysteroscopy and its interrater/intrarater agreement in uterine cavity assessment after hysteroscopic metroplasty.

OBJECTIVE To compare the diagnostic accuracy of three-dimensional sonohysterography (3D-SIS) and office hysteroscopy in uterine cavity assessment after hysteroscopic metroplasty (HM) and determine the interrater/intrarater agreement for 3D-SIS. DESIGN Prospective observational study. SETTING University hospital, private hospital, and clinic. PATIENT(S) One hundred forty-one women undergoing HM for septate uterus with a history of miscarriage and/or infertility. INTERVENTION(S) 3D-SIS and office hysteroscopy at 6-8 weeks after HM. MAIN OUTCOME MEASURE(S) Shape of the uterine cavity, length of the fundal notch (≥1 or <1 cm), and the presence of intrauterine adhesions were assessed, and the interrater/intrarater agreement of 3D-SIS was evaluated in 30 randomly selected patients. RESULT(S) Uterine abnormalities were detected with the use of hysteroscopy in 18 (12.8%) of 141 women. 3D-SIS was highly accurate (97.2%), sensitive (97%), and specific (100%), with a positive predictive value of 100% and a negative predictive value of 85%. The diagnostic values of hysteroscopy and 3D-SIS were not significantly different (McNemar test). 3D-SIS showed substantial interrater/intrarater agreement regarding overall uterine cavity evaluation (κ = 0.79 and 0.78, respectively). CONCLUSION(S) 3D-SIS demonstrated substantial interrater/intrarater agreement for the postoperative evaluation of the uterine cavity, being as diagnostically accurate as hysteroscopy. The use of second-look hysteroscopy may be limited to cases that require reoperation.

ORIGINAL ARTICLE: The Characterization of the Subpopulation of Suppressive B7H4+ Macrophages and the Subpopulation of CD25+ CD4+ and FOXP3+ Regulatory T-cells in Decidua during the Secretory Cycle Phase, Arias Stella Reaction, and Spontaneous Abortion – A Preliminary Report

Problem  The presence of immunosuppressive cells within the endometrium and decidua is crucial for establishing maternal immune tolerance against fetal antigens. We decided to evaluate the subpopulations of Treg cells and B7H4 macrophages in eutopic endometrium typified by Arias Stella reaction during the development of Fallopian tube pregnancy as well as in decidua at the time of spontaneous abortion (SA), and to compare these findings to those observed in the endometrium during the secretory cycle phase of healthy women.

Reply: Are the ESHRE/ESGE criteria of female genital anomalies for diagnosis of septate uterus appropriate?

Sir, We are following with interest the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy (ESHRE/ESGE) initiative to create a new classification of female genital tract congenital anomalies (Grimbizis et al. 2013). We applied the European criteria routinely using three-dimensional (3D) ultrasonography, while simultaneously classifying our patients based on the American Society for Reproductive Medicine (ASRM) criteria (Buttram et al. 1988), complemented by additional common morphometric criteria used to differentiate septate, bicornuate and arcuate uteri (Bermejo et al. 2010, Ludwin et al. 2013). We encountered three problems: (i) practical adaptation of the ESHRE–ESGE classification criteria for septate uterus diagnosis, (ii) an increased frequency of septate uterus diagnoses and all uterine congenital anomalies according to the ESHRE–ESGE compared with the ASRM classification (because a septate uterus was diagnosed in cases where uteri fulfilled previous morphometric criteria for arcuate and in some cases normal uteri) and (iii) potentially important clinical implications of the new classification. We believe that application of ESHRE–ESGE criteria may cause difficulties because (i) the thickness of the uterine wall as the reference value for the septate uterus diagnosis may vary in different regions of the uterus. Thus, it is important to determine where and how it should be measured and (ii) the original definition of septate uterus is an abnormally shaped uterine cavity. The ratio of myometrial thickness to the size of the internal fundal indentation may not reflect the actual anatomical relationships in the uterus and lead to false diagnoses (Fig. 1). Another drawback of the relative criteria is that they are not compatible with endoscopic techniques since myometrial thickness cannot be assessed. The application of the ESHRE/ESGE criteria may have serious clinical implications. The diagnosis of uterine septum on the basis of relative ESHRE/ESGE criteria is not supported by retrospective results and prospective studies of corrective surgery. This applies to eligibility for hysteroscopic metroplasty of patients with recurrent miscarriages who have a small internal fundal indentation; the proposed treatment may not improve obstetric results. A more serious concern is that prophylactic metroplasty may be performed in these cases prior to assist reproductive technology procedures. Additionally, the new classification may affect the assessment of anatomical results of corrective surgery, which could result in frequent repeat procedures, possibly without any significant effect on reproductive performance. This might affect the decision to re-operate in cases whereprevious retrospective studies suggested no indication for complementary metroplasty (residual septum

Transrectal Ultrasound-Guided Hysteroscopic Myomectomy of Submucosal Myomas With a Varying Degree of Myometrial Penetration

STUDY OBJECTIVE To predict the 1-step complete resection rate after transrectal ultrasound-guided hysteroscopic myomectomy and to determine the usefulness of intraoperative transrectal ultrasonography (TRUS) in monitoring hysteroscopic electroresection of submucosal myomas. DESIGN Prospective cohort study (Canadian Task Force classification II-1). SETTING University hospital. PATIENTS One hundred twenty women with symptomatic (abnormal uterine bleeding or reproductive disorder), single, submucosal myomas underwent hysteroscopic electroresection. Groups 1 and 2 were monitored, respectively, with or without TRUS. Anatomical inclusion criteria were myoma ≤5 cm and myometrial free margin ≥3 mm above the myoma. INTERVENTIONS Myomas were evaluated preoperatively via sonohysterograpy and were graded according to the guidelines outlined by the European Society of Hysteroscopy (ESH), including size and myometrial free margin, and according to the STEPW (size, topography, extension, penetration, and lateral wall) classification. On the basis of sonographic findings, patients with myomas >3 cm received gonadotropin-releasing hormone therapy for 1 to 3 months. Hysteroscopic myomectomy was performed with or without TRUS guidance. At 4 to 8 weeks after the initial procedure, postoperative transvaginal ultrasonography, sonohysterography, or second-look hysteroscopy was performed. MEASUREMENTS AND MAIN RESULTS In the TRUS group, a significantly higher percentage of 1-step complete resections was observed than in the group without TRUS (91% vs 73%) (p = .02). This was associated with a statistically significant difference in the subgroups of myomas that were deeply penetrating into the myometrium (89% vs 55%) (p < .01). One-way logistic analysis of data for all treated patients indicated the use of TRUS, as well as the ESH and STEPW classifications, as significant factors influencing the 1-step complete resection. At multivariable logistic regression analysis, use of TRUS (odds ratio [OR], 2.74; p < .001), myomas graded 0 or 1 according to ESH (OR, 3.55; p < .001), and size <3 cm (OR, 2.35; p < .05) were significantly associated with 1-step complete resection (area under the curve, 0.80; p < .001). In the TRUS group there were two significant predictors: size <3 cm (OR = 5.21; p < .05) and myometrial free margin <5 mm (OR, 0.18; p < .05). CONCLUSION Intraoperative use of TRUS during hysteroscopic myomectomy increases the chance of complete 1-step removal of submucosal myomas that deeply penetrate the myometrium.

Accuracy of hysterosalpingo-foam sonography in comparison to hysterosalpingo-contrast sonography with air/saline and to laparoscopy with dye

Study question What is the diagnostic accuracy of 2D/3D hysterosalpingo-foam sonography (HyFoSy) and 2D/3D-high-definition flow Doppler (HDF)-HyFoSy in comparison to laparoscopy with dye chromotubation (as the reference method) and 2D air/saline-enhanced hysterosalpingo-contrast sonography (HyCoSy) (as the initial index test)? Summary answer 2D/3D-HDF-HyFoSy had the best diagnostic accuracy and was the only method that did not significantly differ from the reference method, while both 2D/3D-HyFoSy and 2D/3D-HDF-HyFoSy had significantly higher accuracy than 2D-air/saline-HyCoSy. What is known already Previous studies on X-ray hysterosalpingography and laparoscopy and dye as the reference standard have undermined the impact of older commercial contrast agents on the accuracy of ultrasound tubal patency tests. Recently, HyFoSy was reported to have very high accuracy in a small pilot study in comparison to laparoscopy and dye, and had a very high positive predictive value (PPV) for medical tubal occlusion. A new Doppler sonographic technique, known as HDF imaging with better axial resolution, fewer blooming artifacts and higher sensitivity than color and power Doppler imaging, has been introduced. Study design, size, duration A prospective observational study was performed on 132 women (259 Fallopian tubes) consecutively enrolled between 2013 and 2015. Participants/materials, setting, methods This study included infertile women of reproductive age who previously had not been examined for tubal patency and who presented for the evaluation to the university hospital, private hospital and clinic at which this study was conducted. 2D-Air/saline-HyCoSy, 2D/3D-HyFoSy and 2D/3D-HDF-HyFoSy and laparoscopy were performed independently by experienced readers. During HyFoSy, the 3D mode was used for standardization of pelvic scanning and observations of contrast flow without diagnosis after volume acquisition. Sensitivity, specificity, negative and positive predictive value (NPV and PPV), negative and positive-likelihood ratio (LR- and LR+) and 95% CI were calculated. McNemars test and relative predictive values (a comparison of NPV and PPV) were used to compare all the index tests. Main results and the role of chance 2D-Air/saline-HyCoSy, 2D/3D-HyFoSy and 2D/3D-HDF-HyFoSy indicated that 46 (17.8%), 27 (10.4%) and 24 (9.2%) of the 259 tubes were occluded, respectively; additionally, inconclusive results were obtained for 8 (3%), 5 (1.9%) and 3 (1.2%) tubes, respectively. The reference method revealed 18 (6.9%) occluded Fallopian tubes. 2D-Air/saline-HyCoSy had a high NPV (99.5%) that was similar to that of 2D/3D-HyFoSy (99%) and 2D/3D-HDF-HyFoSy (99.6%) (P > 0.05), but had a very low PPV (30.4%). The use of 2D/3D-HyFoSy, especially 2D/3D-HDF-HyFoSy, which had a significantly higher PPV (48% and 71%, P < 0.05 and P < 0.01; respectively), resulted in fewer false positive and inconclusive findings than the use of 2D-air/saline-HyCoSy. The LR- and LR+ was 0.14 and 14.8, respectively, for 2D/3D-HyFoSy, 0.06 and 32.1, respectively, for 2D/3D-HDF-HyFoSy, and 0.08 and 6.9, respectively, for 2D-air/saline-HyCoSy. The number of inconclusive or positive results per patient was significantly fewer with 2D/3D-HyFoSy (odds ratio, OR = 0.5, CI = 0.3-0.95, P < 0.05) and 2D/3D-HDF-HyFoSy (OR = 0.4, 95% CI = 0.2-0.8, P < 0.01) than with 2D-air/saline-HyCoSy. Limitations, reasons for caution An unselected infertile population with a low prevalence of tubal occlusion is suitable for estimating the diagnostic accuracy of imaging tests only as a screening tool. Wider implications of the findings These findings can be used to establish a diagnostic strategy with high accuracy but minimum invasiveness and limited use of contrast agents and sophisticated technology. 2D-Air/saline-HyCoSy, which has a high NPV, is suitable as an initial test and basic screening method, but 2D/3D-HDF-HyFoSy, which has a significantly higher PPV, can be used as a standard to verify any questionable or positive results obtained with 2D HyCoSy. This strategy may signficantly reduce the need for laparoscopy as a reference standard. Study funding/competing interest(s) There was no external funding for this study, and the authors have no conflicts of interest to declare. Trial registration number N/A.

Sentinel node in gynaecological oncology

Summary Background The concept of sentinel node biopsy has been widely invastigated in various malignant tumoures and has become a standard method in such neoplastic diseases as penile cancer or melanoma. In tumours, where the lymphatic flow is more complicated and difficult to analyze, this concept still needs to be verified. Aim The aim of this paper is to present the validity of the above concept in sentinel node detection in vulvar, cervical and endometrial cancers. Materials/Methods Sentinel node detection was performed in 127 women with gynaecological malignances; 39 patients with vulvar cancer, 52 patients with cervical cancer and 36 patients with endometrial cancer. In sentinel node detection we used radioisotopes and a dye technique. After sentinel node dissection, in all cases, radical surgery with systemic lymphadenectomy was performed. The number and localization of the nodes classified as sentinel nodes were analyzed. Results The identification rate for sentinel node detection was 97.4% in vulvar cancer, 96.2% in cervical cancer and 88.9% in endometrial cancer. The sensitivity in this procedures was 100.0% in vulvar cancer, 94.0% in cervical cancer and 87.9% in endometrial cancer. Negative predictive value was 96.2% for vulvar cancer, 97.0% for cervical cancer and 100.0% for endometrial cancer. Conclusions The concept of sentinel node detection in gynaecological malignances requires more clinical date for its validation, but outcomes in vulvar cancer seem to be potentially most promising.

EXTRAORGANIC VASCULAR SYSTEM OF ADRENAL GLANDS IN HUMAN FETUSES

The injection method was used to study the origin and variability of the blood vessels forming the extraorganic vascular system of the adrenal glands. Studies were carried out on 40 human fetuses of a crown-rump length between 113 and 280 mm (14 to 28 weeks of fetal age). It was proved that the arterial blood supply during the fetal period is extremely variable in both the origin and the number of adrenal arteries, as well as in the asymmetry of the blood supply between the left and right adrenal glands. The three main origins of the suprarenal arteries are from the inferior phrenic artery, the abdominal aorta and the renal artery. The inferior phrenic artery is the main one supplying the suprarenal glands during the fetal period. A characteristic feature of the extraorganic venous system in fetal adrenal glands is the constant presence of the adrenal vein, including number, orifice and the main tributaries.

Vascular architecture of the human fetal adrenal gland: A SEM study of corrosion casts

The vascular architecture of adrenal glands was investigated in human fetuses aged from 16 to 24 weeks, using microcorrosion casts and scanning electron microscopy. The fetal adrenals showed an arrangement of blood vessels remarkably similar to that described in adult glands. There was a clear centripetal pattern from superficial arteries and their branches, via irregular capillaries of the subcapsular plexus and definitive cortex, and then via the radial sinusoids and venous sinuses of the fetal cortex, to the central vein. Rare medullary arterioles traversed the cortex to break up into small local capillary networks in the central region of the gland. Some superficial capillaries were drained by occasional subcapsular veins. No portal system was observed in the fetal adrenals.

Age-related trends in anti-Mullerian hormone serum level in women with unilateral and bilateral ovarian endometriomas prior to surgery

BackgroundEndometriosis is a well-known cause of infertility, and the anti-Mullerian hormone (AMH) is an accepted biomarker of ovarian reserve and response to artificial reproductive technology procedures. The present study was a prospective analysis of age-dependent AMH serum concentration in women with bilateral and unilateral ovarian endometriomas before therapy onset compared with healthy controls.MethodsThis prospective cross-sectional study included 384 women aged 18–48 years. AMH serum concentration was assessed between days 3 and 6 of the menstrual cycle in 78 patients with bilateral and 157 patients with unilateral ovarian endometriomas and compared with 149 healthy controls. Ovarian endometriosis was confirmed histopathologically, and data were presented as medians with interquartile range (IQR).ResultsStage III endometriosis was diagnosed in 53.2 %, stage IV in 18.3 %, stage V in 23.4 % and stage VI in 5.4 % of the patients. Patients with bilateral ovarian endometriomas showed the lowest median AMH levels compared with patients suffering from unilateral ovarian endometriosis (0.55; IQR: 0.59 vs. 2.00; IQR: 2.80; p < 0.001) and the control group (0.55; IQR: 0.59 vs. 2.84; IQR: 3.2; p < 0.001). Median AMH concentration values were not significantly different between patients with unilateral ovarian endometriosis and the healthy controls (2.00; IQR: 2.80 vs. 2.84; IQR: 3.2; p = 0.182). A strongly negative correlation between AMH levels and age was confirmed in healthy individuals (R = −0.834; p < 0.001) and women with unilateral ovarian endometriomas (R = −0.774; p < 0.001). Patients with bilateral ovarian endometriosis showed a significantly negative but only moderate correlation between AMH levels and age (R = −0.633; p < 0.001), which was significantly lower than in the healthy controls (R = −0.633 vs. R = −0.834; p = 0.006) but not in the patients with unilateral ovarian endometriosis (R = −0.663 vs. R-0.774; p = 0.093). Based on a multivariate regression analysis, only bilateral localization of ovarian endometrial cysts (p = 0.003) and patient age (p < 0.001), but not left/right localization of unilateral cyst or cyst volume, were negatively associated with AMH serum concentration.ConclusionAccording to our data, unilateral ovarian endometriosis had a moderately negative and nonsignificant effect on AMH-based ovarian reserve evaluated prior to surgery, irrespective of age. In contrast, the ovarian reserve was significantly reduced in women with bilateral ovarian endometriomas.