Mario Vicino

Diagnostic inadequacy of dilatation and curettage

OBJECTIVE To assess the diagnostic inadequacy of dilatation and curettage (D&C) by comparing histologic findings with this technique with those obtained after hysterectomy. DESIGN Retrospective clinical study. SETTING University-affiliated hospital. PATIENT(S) Three hundred ninety-seven patients with abnormal uterine bleeding who underwent D&C and, within 2 months, hysterectomy because of histologic findings or persistence of symptoms. MAIN OUTCOME MEASURE(S) Comparison of histologic findings on D&C with those obtained after hysterectomy. RESULT(S) In 248 of 397 patients (62.5%), D&C failed to detect intrauterine disorders subsequently found at hysterectomy; the sensitivity was 46%, the specificity was 100.0%, the positive predictive value was 100.0%, and the negative predictive value was 7.1%. CONCLUSION(S) Dilatation and curettage is an inadequate diagnostic and therapeutic tool for all uterine disorders; this technique missed 62.5% of major intrauterine disorders, and all endometrial disorders were still present in the removed uterus.

Estimation of Birth Weight by Two-Dimensional Ultrasonography : A Critical Appraisal of Its Accuracy

OBJECTIVE: To assess the accuracy and characterize two-dimensional ultrasonographic formulas for the estimation of birth weight according to the type of fetal biometric parameters these formulas rely on to make fetal weight predictions. METHODS: A prospective recruitment of 589 pregnant women was carried out for this cross-sectional study. Different biometric parameters were taken ultrasonographically to estimate birth weight using 35 different formulas. Only those patients who delivered within 48 hours were considered for the analysis (n=441). Differences between the estimated and actual birth weight were assessed by percentage error, accuracy in predictions within ±10% and ±15% of error, and use of the Bland-Altman method. All formulas were assessed individually and clustered on the basis of the type of fetal biometric information that they incorporate. RESULTS: Twenty-nine formulas provided an overall mean absolute percentage error less than or equal to 10%, with overall predictions within ±10% and ±15% of the actual birth weight (69.2% and 86.5%, respectively). Twenty formulas showed a good accuracy (bias 0.50 or less) and low variability (mean standard deviation 1.2). Among the categorized algorithms, formulas based on head-abdomen-femur measurements showed the lowest mean absolute percentage error. Upon stratification for birth weight, the group of formulas that rely on abdomen and femur measurements performed best for fetuses weighing more than 3,500 g (P<.01). CONCLUSION: Our findings show that most formulas are relatively accurate at predicting birth weight up to 3,500 g, and all algorithms tend to underestimate large fetuses. LEVEL OF EVIDENCE: III

Uterine cavity assessment in infertile women: comparison of transvaginal sonography and hysteroscopy

OBJECTIVES To evaluate the diagnostic accuracy of transvaginal sonography (TVS) in detecting uterine cavity abnormalities in infertile patients, with reference to hysteroscopy as the gold standard method. STUDY DESIGN At the Institute of Obstetrics and Gynaecology, University of Bari, 134 infertile women were investigated with both TVS and hysteroscopy. In all cases endometrial biopsy was performed. Sensitivity, specificity, and positive and negative predictive values were calculated for TVS, considering hysteroscopic diagnosis as the gold standard. Statistical analysis was performed by using McNemar test. RESULTS There was one failed insertion of hysteroscope. Hysteroscopy diagnosed pathological findings in 58 out of 133 cases (44%). TVS was in agreement with 50 of the 58 (86%) of the pathological findings diagnosed at hysteroscopy. As a test for the detection of uterine cavity abnormalities, TVS in comparison with hysteroscopy had 84.5% sensitivity and 98.7% specificity, 98.0% positive predictive value and 89.2% negative predictive value. CONCLUSIONS TVS is able to diagnose polyps, septum and submucous fibroids with quite significant accuracy, while hysteroscopy is indicated for their confirmation and removal. Thus, hysteroscopy provides both diagnostic and therapeutic capabilities, but TVS permits to proceed directly to operative hysteroscopy avoiding the need for a separate diagnostic procedure.

Polycystic ovary syndrome: relationship between insulin sensitivity ,sex hormone levels and ovarian stromal blood flow

Polycystic ovary syndrome (PCOS) is the most common cause of menstrual disorders ,and is characterized by chronic anovulation ,hyperandrogenism and infertility. In recent years ,it has become apparent that PCOS is also associated with hyperinsulinemia that is probably central to the pathogenesis of PCOS. As a peculiar vascular pattern has been reported to be present in PCOS ,the aim of this study was to investigate intraovarian stromal vascularization in PCOS patients and its possible correlation with sex hormones ,gonadotropins and insulin levels. Twenty-eight oligomenorrheic or amenorrheic patients with PCOS and 14 eumenorrheic women with a PCOS-like ovarian pattern undergoing endocrine screening and ultrasound color Doppler intraovarian blood flow were recruited to the study. Ten healthy women with regular menses represented the control group. Hormonal assays (follicle-stimulating hormone (FSH) ,luteinizing hormone (LH) ,androstenedione ,testosterone ,sex hormone-binding globulin (SHBG) and estradiol), oral glucose tolerance test (OGTT) ,baseline and glucose-induced insulin levels ,and transvaginal ultrasonographic and color Doppler analysis (pulsatility index (PI) ,resistance index (RI) and velocity (Vmax) of ovarian stromal flow) were performed in all participants in the early proliferative phase. Endocrine values showed significant differences in PCOS patients compared with PCOS-like women and controls ,while PI and RI indices were significantly higher in controls. PCOS patients were divided into hyperinsulinemic (n = 16) and normoinsulinemic (n = 12). Androstenedione was significantly higher (p < 0.01) in the hyperinsulinemic than in the normoinsulinemic patients and controls ,while SHBG was significantly (p < 0.01) lower in the hyperinsulinemic group. Analysis of color Doppler intraovarian vascularization showed a significantly lower RI and a higher Vmax in the hyperinsulinemic subjects than in the normoinsulinemic PCOS patients and controls. An increased stromal blood flow was observed in the PCOS and PCOS-like patients by transvaginal color Doppler evaluation ,but this technique is not able to differentiate these two similar ovarian patterns. However, hyperinsulinemic PCOS patients had an increased vascularity of the ovarian stroma. A strong correlation between hyperinsulinemia ,hyperandrogenism and low SHBG levels was evidenced ,and a hyperinsulinemia-induced mechanism for ovarian stromal angiogenesis is discussed.

Neoadjuvant Chemotherapy: An Alternative Option of Treatment for Locally Advanced Cervical Cancer

Although the incidence of cervical cancer has declined in both North America and Europe, it still represents the second most common cancer in women and the fifth most common malignancy worldwide. Most patients in the developed countries present with disease either confined to the cervix or with limited extension beyond it. Historically, the standard treatment was usually radiotherapy or radical hysterectomy with node dissection. In 1999, five randomized clinical trials performed by the Gynecologic Oncology Group, the Radiation Therapy Oncology Group and the Southwest Oncology Group have demonstrated a significant outcome advantage when cisplatin-based chemotherapy was administered during radiation in patients with cervical cancer. In the current review, we will analyze the role of neoadjuvant chemotherapy followed by radiotherapy and surgery as an alternative option treatment to the standard chemoradiation for locally advanced cervical cancer (stage Ib2 or larger).

Laparoscopic cornual excision in a viable large interstitial pregnancy without blood flow detected by color Doppler ultrasonography

Interstitial pregnancy is a rare but very dangerous event that occurs in about 1% of ectopic pregnancies. Methotrexate is recommended as first-line therapy (1); however, laparoscopic cornual excision is an acceptable alternative, especially in the presence of a large viable interstitial pregnancy (2). Transvaginal and color Doppler ultrasonography have both improved the possibility of early diagnosis and the ability to follow the course of the disease after medical treatment (3).

Successful establishment of pregnancy by superovulation and intrauterine insemination with sperm recovered by a modified Hotchkiss procedure from a patient with retrograde ejaculation

OBJECTIVE To improve the quality of the sperm recovered from the bladder in a patient with retrograde ejaculation who already had failed to conceive after several attempts at IUI with sperm recovered by conventional techniques. SETTING University Hospital. PATIENTS A couple with male infertility due to retrograde ejaculation caused by the Zielke operation, a spinal fixation procedure performed to correct severe kyphoscoliosis. INTERVENTION Superovulation and IUI of sperm recovered from the bladder using a modified Hotchkiss procedure involving the introduction into the bladder of Earles balanced salt solution (EBSS) buffered with Hepes in sufficient quantity to bring the urinary pH and osmolarity to those of fresh ejaculate. MAIN OUTCOME MEASURES Urine pH and osmolarity at baseline and after dilution with EBSS buffered with HEPES. Concentration, motility, and progression score of the sperm recovered from the bladder. RESULTS Good sperm samples were achieved. Pregnancy was established when IUI was performed in association with superovulation induction. CONCLUSIONS Determination of urine pH and osmolarity appears to be a useful method for choosing the ideal sperm recovery procedure. The modified Hotchkiss procedure described seems to be a promising alternative method for recovering sperm for artificial insemination.

Predictive value of serum androstenedione basal levels on the choice of gonadotropin or laparoscopic ovarian electrocautery as ovulation induction in clomiphene citrate-resistant patients with polycystic ovary syndrome

Therapeutic approaches to chronic anovulation from polycystic ovaries in clomiphene-resistant infertile patients are under debate. This study discusses evidence that supports the possible predictive value of serum basal level of androstenedione in the choice of the better therapy between laparoscopic ovarian electrocautery and ovulation induction. Lower androstenedione levels seem to be correlated with a better ovarian response after ovulation induction with gonadotropins, while high androstenedione levels are associated with a higher incidence of conception after laparoscopic ovarian electrocautery. Obesity does not seem to represent a hindrance to laparoscopic treatment.

Fibrotic tissue in the endometrioma capsule: surgical and physiopathologic considerations from histologic findings

Ovarian tissue inadvertently excised along with endometriomas was associated with the presence of pericystic fibrosis and serum levels of CA-125, representing the only clinical parameter for predicting follicle loss before surgery. A consecutive series of 91 ovarian endometriotic cysts were studied, and an inverse relationship between serum CA-125 and the thickness of the fibrotic tissue of the endometrioma capsule was demonstrated.

Transforming Growth Factor-β1 in Hemangioma of the Ovary

Hemangioma of the ovary is extremely rare. We report the case of a 32-year-old woman who complained of pelvic pain due to a large right adnexal mass. On surgical exploration a 10 × 8 cm hemangioma of the ovary was resected. Expression of transforming growth factor-β1 was studied, and the possible role of this molecule in the development of the tumor is discussed.