Loredana Maria Sosa Fernandez

Review of New Office-Based Hysteroscopic Procedures 2003–2009

Office operative hysteroscopy is a recent technique that enables treatment of uterine pathologic disorders in the ambulatory setting using miniaturized hysteroscopes with mechanical or electric instruments. The available international literature from 1990 to 2002 has clearly demonstrated that such technique enables performance of hysteroscopically directed endometrial biopsy and treatment of uterine adhesions, anatomic disorders, polyps, and small myomas safely and successfully without cervical dilation and the need for anesthesia. This review provides a comprehensive survey of further advancements of office operative hysteroscopy in the treatment of other gynecologic pathologic conditions that have not been included in the schema of treatment indications for office procedures proposed in 2002. A search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews identified articles published from 2003 to 2009. Eighteen articles were identified: 9 on hysteroscopic sterilization; 1 on office-based metroplasty, 8 on office-based treatment of some uncommon gynecologic pathologic conditions (e.g., hematometra, diagnosis and treatment of vaginal lesions, treatment of uterine cystic neoformations, bleeding from the cervical stump, diagnosis and treatment of endocervical ossification, and removal of uterovaginal packing). All performed procedures were carried out safely and successfully in the office setting, with high patient tolerance and minimal discomfort. The success of the procedures has been confirmed by resolution of symptoms and at follow-up ultrasonographic and hysteroscopic examinations. Currently, as a result of technologic advancements and increased operator experience, an increasing number of gynecologic pathologic conditions traditionally treated in the operating room may be treated safely and effectively using office operative hysteroscopy.

Effect of bariatric surgery on obesity-related infertility

BACKGROUND There is a strong association between obesity and infertility, and weight loss can increase fecundity in obese women. In an attempt to determine the effect of bariatric surgery on obesity-related infertility, we reviewed the fertility outcomes after intragastric balloon placement, adjustable gastric banding, sleeve gastrectomy, and gastric bypass in childbearing women with a diagnosis of infertility at a university hospital in Italy. METHODS This was a retrospective study of 110 obese infertile women. We evaluated the effectiveness of bariatric surgery in improving fertility, assessing the influence of age, surgical technique, co-morbidities (hypertension and diabetes), weight loss, and body mass index before and after surgery. RESULTS Of these 110 women who had tried unsuccessfully to become pregnant before weight loss, 69 became pregnant afterward. The pregnancies proceeded without complications and ended with a live birth. Only the weight loss (odds ratio 20.2, P = .001) and the achieved body mass index (P = .001) after surgery were the predictors of pregnancy. CONCLUSION Bariatric surgery might be effective in young infertile obese women who wish to become pregnant. Weight loss appears to be independent from the surgical technique in determining the increase in the pregnancy rate as well as the body mass index achieved at pregnancy.

Video-assisted ablation of pilonidal sinus: A new minimally invasive treatment—A pilot study

BACKGROUND We hypothesized that video-assisted ablation of pilonidal sinus could be an effective, minimally invasive treatment of pilonidal sinus. This new, minimally invasive treatment allows the identification of the sinus cavity with its lateral tracks, destruction and the removal of all infected tissue, and the removal of any hair. STUDY DESIGN All consecutive patients with primary sacrococcygeal pilonidal sinus were screened for enrolment in our study. We analyzed time off work, time to walk without pain, time to sitting on the toilet without pain, recurrences, wound infections, and patient satisfaction (pain, health status, and aesthetic appearance). RESULTS We analyzed 27 patients. All procedures were successful, with complete ablation of the sinus cavity. No infection and only 1 recurrence were recorded during the follow-up (1 year) with an immediate return to work and normal activities. In addition, patient satisfaction and aesthetic appearance were high. CONCLUSION Our results are encouraging and suggest that this technique may offer a very effective way to treat pilonidal sinus. Further studies are necessary to validate its use in daily practice.

Safety and Efficacy of Minimally Invasive Video-Assisted Ablation of Pilonidal Sinus: A Randomized Clinical Trial

IMPORTANCE Video-assisted ablation of pilonidal sinus (VAAPS) is a new minimally invasive treatment based on the complete removal of the sinus cavity with a minimal surgical wound. OBJECTIVE To validate the safety and efficacy of VAAPS. DESIGN, SETTING, AND PARTICIPANTS From January 1, 2012, through December 31, 2013, we enrolled 145 consecutive patients from an intention-to-treat population at a single academic center in Italy. The last date of follow-up for this analysis was December 31, 2014. Patients with chronic nonrecurrent pilonidal sinus were randomized to minimally invasive (76 patients) or conventional (69 patients) treatment of pilonidal sinus. INTERVENTIONS VAAPS and Bascom cleft lift procedure. MAIN OUTCOMES AND MEASURES The primary end point of the study was time off work. Secondary end points were the rates of operative success and perioperative complications (infection and recurrence), operative time, patient satisfaction, and intraoperative and postoperative pain ratings. RESULTS Of the 145 patients, 60 (78.9%) were male and 16 (21.1%) were female in the minimally invasive treatment group, and 54 (78.3%) were male and 15 (21.7%) were female in the conventional treatment group. The mean (SD) age of the patients was 25.5 (5.9) years in the minimally invasive treatment group and 25.7 (5.3) in the conventional treatment group. In the minimally invasive treatment group, mean (SD) time off work was significantly less compared with the conventional treatment group (1.6 [1.7] vs 8.2 [3.9] days; P < .001). Mean (SD) operative time was significantly longer in the minimally invasive treatment group (42.9 [9.8] minutes) vs the conventional treatment group (26.5 [8.7] minutes), P < .001. Although the overall complication rate was similar in both groups, there were fewer infections (1 [1.3%] vs 5 [7.2%]; P = .10) recorded in the minimally invasive treatment group. Similarly, patients enrolled in the minimally invasive treatment group expressed significantly less pain and higher satisfaction. CONCLUSIONS AND RELEVANCE In the new era of minimally invasive treatment surgery, pilonidal sinus could become a disease treated with an endoscopic approach. Although additional studies are needed to provide a definitive conclusion, our results encourage considering the adoption of this treatment as the most effective way to treat pilonidal sinus. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01963273.

Colorectal resection in deep pelvic endometriosis: Surgical technique and post-operative complications

AIM To investigate the impact of different surgical techniques on post-operative complications after colorectal resection for endometriosis. METHODS A multicenter case-controlled study using the prospectively collected data of 90 women (22 with and 68 without post-operative complications) who underwent laparoscopic colorectal resection for endometriosis was designed to evaluate any risk factors of post-operative complications. The prospectively collected data included: gender, age, body mass index, American Society of Anesthesiologists risk class, endometriosis localization (from anal verge), operative time, conversion, intraoperative complications, and post-operative surgical complications such as anastomotic dehiscence, bleeding, infection, and bowel dysfunction. RESULTS A similar number of complicated cases have been registered for the different surgical techniques evaluated (laparoscopy, single access, flexure mobilization, mesenteric artery ligation, and transvaginal specimen extraction). A multivariate regression analysis showed that, after adjusting for major clinical, demographic, and surgical characteristics, complicated cases were only associated with endometriosis localization from the anal verge (OR = 0.8, 95%CI: 0.74-0.98, P = 0.03). After analyzing the association of post-operative complications and each different surgical technique, we found that only bowel dysfunction after surgery was associated with mesenteric artery ligation (11 out of 44 dysfunctions in the mesenteric artery ligation group vs 2 out of 36 cases in the no mesenteric artery ligation group; P = 0.03). CONCLUSION Although further randomized clinical trials are needed to give a definitive conclusion, laparoscopic colorectal resection for deep infiltrating endometriosis appears to be both feasible and safe. Surgical technique cannot be considered a risk factor of post-operative complications.

Role of colonoscopy in the diagnostic work-up of bowel endometriosis

AIM To evaluate the accuracy of colonoscopy for the prediction of intestinal involvement in deep pelvic endometriosis. METHODS This prospective observational study was performed between September 2011 and July 2014. Only women with both a clinical and imaging diagnosis of deep pelvic endometriosis were included. The study was approved by the local ethics committee and written informed consent was obtained in all cases. Both colonoscopy and laparoscopy were performed by expert surgeons with a high level of expertise with these techniques. Laparoscopy was performed within 4 wk of colonoscopic examination. All hypothetical colonoscopy findings (eccentric wall thickening with or without surface nodularities and polypoid lesions with or without surface nodularities of endometriosis) were compared with laparoscopic and histological findings. We calculated the sensitivity, specificity, positive predictive value and negative predictive value for the presence of colonoscopic findings of intestinal endometriosis. RESULTS A total of 174 consecutive women aged between 21-42 years with a diagnosis of deep pelvic endometriosis who underwent colonoscopy and surgical intervention were included in our analysis. In 76 of the women (43.6%), intestinal endometrial implants were found at surgery and histopathological examination. Specifically, 38 of the 76 lesions (50%) were characterized by the presence of serosal bowel nodules; 28 of the 76 lesions (36.8%) reached the muscularis layer; 8 of the 76 lesions (10.5%) reached the submucosa; and 2 of the 76 lesions (2.6%) reached the mucosa. Colonoscopic findings suggestive of intestinal endometriosis were detected in 7 of the 174 (4%) examinations. Colonoscopy failed to diagnose intestinal endometriosis in 70 of the 76 women (92.1%). A colonoscopic diagnosis of endometriosis was obtained in all cases of mucosal involvement, in 3 of 8 cases (37.5%) of submucosal involvement, in no cases of muscularis layer involvement and in 1 of 38 cases (2.6%) of serosa involvement. The sensitivity, specificity, positive predictive and negative predictive values of colonoscopy for the diagnosis of intestinal endometriosis were 7%, 98%, 85% and 58%, respectively. CONCLUSION Being an invasive procedure, colonoscopy should not be routinely performed in the diagnostic work-up of bowel endometriosis.

The Potential Role of Endometrial Nerve Fibers in the Pathogenesis of Pain During Endometrial Biopsy at Office Hysteroscopy

We aimed to evaluate whether nerve fibers are present in the endometrial layer of patients submitted to office hysteroscopy and their potential contribution to the pathogenesis of pain during that procedure. Through a prospective case–control study performed in tertiary centers for women’s health, endometrium samples were collected during operative office hysteroscopy from 198 cycling women who previously underwent laparoscopy and/or magnetic resonance imaging investigation for infertility assessment. Samples were classified according to the degree of the pain patients experienced and scored from values ranging from 0 (absence of discomfort/pain) to 10 (intolerable pain) on a 10-cm visual analog scale (VAS). The presence of nerve fiber markers (S100, NSE, SP, VIP, NPY, NKA, NKB, NKR1, NKR2, and NKR3) in the endometrium was also evaluated by morphologic and immunohistochemical analyses. We found that S-100, NSE, NKR1, NK-A, NK-B, VIP, and NPY, were immunolocalized in samples of endometrium, in significantly (P < .01, for all) higher levels in samples collected from patients with VAS score > 5 (group A) than ≤ 5 (group B) and significantly (P < .0001 for all) positively correlated with VAS levels. A statistically significant (P = .018) higher prevalence of endometriosis and/or adenomyosis was depicted in patients of group A than group B. Data from the present study led us to conclude that nerve fibers are expressed at the level of the functional layer of the endometrium and may contribute to pain generation during office hysteroscopy, mainly in women affected by endometriosis and adenomyosis.

Varicocele repair in severe oligozoospermia: A case report of post-operative azoospermia.

Varicocele has been implicated as a cause in 35%-50% of patients with primary infertility and up to 81% of men with secondary infertility. Although a large number of reports have shown improvement in the semen parameters after correction of varicocele, other studies have suggested no benefit. We report the first case of azoospermia after surgery in a young infertile male patient with left-sided varicocele and severe oligozoospermia undergoing laparoscopic varicocelectomy. A pregnancy was only achieved with assisted reproductive technology because semen cryopreservation was performed before surgery. In the light of the above, the deterioration of sperm count after varicocele repair in patients with severe oligozoospermia could be due to irreversible impairment of spermatogenesis of such patients, together with the possible temporary damage of the surgical repair. This possible complication could therefore turn the severe oligozoospermia into an indication to perform cryopreservation before surgery, on both clinical and medico-legal grounds. Further research is needed before drawing definitive conclusions regarding the management of varicocele-related severe oligozoospermia.

‘See and treat’ outpatient hysteroscopy with novel fibreoptic ‘Alphascope’

This paper describes an experience with the Alphascope, a fibreoptic hysteroscopy system (Gynecare, Ethicon Womens Health and Urology). This prospective observational study was carried out at a tertiary hospital in Naples, Italy. The study population comprised patients undergoing outpatient hysteroscopy with the semi-rigid Versascope Hysteroscopy System using the Alphascope. 7-Fr gauge mechanical instruments and 5-Fr bipolar electrodes (Versapoint, Gynecare, Ethicon Inc., Somerville, NJ) were used for the operative procedures. Outpatient hysteroscopy was successful in 97% of cases. These were diagnostic in 41%, while operative hysteroscopy was performed in 59% of cases. The endoscopic view was subjectively defined by the operator as good/excellent in 95% of procedures. A total of 98% of patients expressed moderate/high degree of satisfaction and only 2% were dissatisfied. The system is successful in the outpatient setting in 95% of attempts.

Diagnostic Value of Abdominal Free Air Detection on a Plain Chest Radiograph in the Early Postoperative Period: a Prospective Study in 648 Consecutive Patients Who Have Undergone Abdominal Surgery

BackgroundTo the best of our knowledge, this is the first study to evaluate the predictive value of free air (on a plain radiograph) for bowel perforation in a large prospective cohort of surgical patients.MethodsAll consecutive patients undergoing abdominal surgery between January 2011 and June 2012 were screened for this study. We performed an upright chest radiograph on the second and third postoperative day. Thereafter, additional radiographic evaluations were performed every 2 days until the disappearance of abdominal free air.ResultsOf the 648 subjects enrolled in our study, free abdominal air was found in 65 subjects on the first radiographic evaluation (2 days after surgery), 51 on the second (3 days after surgery), three on the third (5 days after surgery), and none on the fourth (7 days after surgery). The presence of free abdominal air was associated with an increased risk of gastrointestinal perforation. The presence of free air was associated with a hazard ratio (HR) of 21.54 (95% CI 9.66–48.01, p<0.001) and a HR of 23.87 (95% CI 10.68–53.34, p<0.001) at 2 and 3 days after surgery, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value were 70, 93, 33, and 98%, respectively, at 2 days after surgery, and similar results were confirmed at 3 days after surgery.ConclusionWe believe that the presence of free air at 3 days after surgery should not be considered a common finding. Here, we demonstrate that the detection of free air has a remarkable predictive value for gastrointestinal perforation, which has been overestimated in previous experience.