N. Di Donato

Endometriosis of the abdominal wall: ultrasonographic and Doppler characteristics

To describe the sonographic and clinical features of abdominal wall endometriosis (AWE), a frequently misdiagnosed condition.

Comparison of transvaginal sonography and double-contrast barium enema for diagnosing deep infiltrating endometriosis of the posterior compartment

To compare the diagnostic accuracy of transvaginal sonography (TVS) and double‐contrast barium enema (DCBE) in the preoperative detection of deep infiltrating endometriosis (DIE) of the posterior compartment.

Controversies in Surgical Staging of Endometrial Cancer

Endometrial cancer is the most common gynaecological malignancy and its incidence is increasing. In 1998, international federation of gynaecologists and obstetricians (FIGO) required a change from clinical to surgical staging in endometrial cancer, introducing pelvic and paraaortic lymphadenectomy. This staging requirement raised controversies around the importance of determining nodal status and impact of lymphadenectomy on outcomes. There is agreement about the prognostic value of lymphadenectomy, but its extent, therapeutic value, and benefits in terms of survival are still matter of debate, especially in early stages. Accurate preoperative risk stratification can guide to the appropriate type of surgery by selecting patients who benefit of lymphadenectomy. However, available preoperative and intraoperative investigations are not highly accurate methods to detect lymph nodes and a complete surgical staging remains the most precise method to evaluate extrauterine spread of the disease. Laparotomy has always been considered the standard approach for endometrial cancer surgical staging. Traditional and robotic-assisted laparoscopic techniques seem to provide equivalent results in terms of disease-free survival and overall survival compared to laparotomy. These minimally invasive approaches demonstrated additional benefits as shorter hospital stay, less use of pain killers, lower rate of complications and improved quality of life.

Question mark form of uterus: a simple sonographic sign associated with the presence of adenomyosis.

Adenomyosis as the presence of ectopic endometrial glands and stroma within the myometrium is an elusive condition that is challenging to diagnose due to the similarity between its clinical symptoms and ultrasound characteristics and those of other frequent benign conditions such as leiomyomatosis1. Over recent years, transvaginal sonography (TVS) has been recommended as an appropriate tool for visualization of adenomyosis, with a sensitivity of 65–81% and a specificity of 65–100%2. We performed a prospective study between January 2012 and January 2014 including 50 symptomatic fertile women who were scheduled to undergo elective hysterectomy because of symptoms of endometriosis/adenomyosis. Adenomyosis was diagnosed on TVS, in accordance with previous studies3,4, in the presence of one or more of the following criteria: heterogeneous myometrium, irregular cystic areas, hypoechoic linear striations, asymmetry of uterine walls and poor definition of the endometrial–myometrial junctional zone (JZ). Moreover, a novel sign, which we called ‘question mark Figure 1 Transvaginal ultrasound image and representative diagram showing the question mark form of the uterus as a marker for adenomyosis.

Histological evaluation of ureteral involvement in women with deep infiltrating endometriosis: analysis of a large series

STUDY QUESTION In women with deeply infiltrating endometriosis (DIE) what is the prevalence of involvement of endometriotic tissue and fibrosis in ureteral endometriosis (UE), as assessed by histological staining? SUMMARY ANSWER In women with DIE, ureteral involvement is more often due to endometriotic tissue rather than fibrosis. WHAT IS KNOWN ALREADY In the current literature, histological evaluation of ureteral endometriosis is mainly based on the degree of wall infiltration by endometriosis instead of the tissue composition. A few studies reported ill-defined and contradictory histological data on the tissue composition of UE. STUDY DESIGN, SIZE, DURATION Retrospective observational study based on clinical records of women affected by DIE, laparoscopically treated for UE at a tertiary referral center, between January 2010 and March 2013. All cases of ureteral nodule excision or ureterectomy with histological examination of the specimens were included. Exclusion criteria were other identified causes of hydroureteronephrosis, medical therapy for a period of at least 3 months before surgery and previous surgery for DIE. PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 77 patients were included in the study and among them seven (9%) presented with bilateral ureteral involvement, giving a total of 84 cases of UE available for analysis. All patients had stage IV endometriosis. According, respectively, to the presence of endometrial glands and/or stroma cells or of fibrotic tissue only, the endometriotic UE and fibrotic UE groups were compared with regard to hydroureteronephrosis at pre-operative urinary tract computerized tomography scan, type of surgical procedure performed to treat UE (nodule removal or ureterectomy), association with other locations of the disease and post-operative complications (ureteral fistula or stenosis). MAIN RESULTS AND THE ROLE OF CHANCE For the 84 cases of UE, 65 (77%) and 19 (23%), respectively, showed endometriotic tissue and fibrotic tissue only. Presence of hydroureteronephrosis and endometriotic pattern of UE showed a significant association [endometriotic UE 44/65 (68%) versus fibrotic UE 8/19 (42%); P = 0.04]. Fibrotic pattern of UE and presence of concomitant recto-vaginal endometriosis showed a significant association [endometriotic group: 29/65 (45%) versus fibrotic group 18/19 (95%); P < 0.001]. LIMITATIONS, REASONS FOR CAUTION The retrospective and monocentric (tertiary referral center) study design. WIDER IMPLICATIONS OF THE FINDINGS Besides the distinction between extrinsic and intrinsic UE based on the degree of wall infiltration by endometriosis, a new classification according to the histological pattern of UE could be useful for clinicians, both in the diagnostic and therapeutic fields. STUDY FUNDING/COMPETING INTERESTS None.

Heterotopic interstitial pregnancy successfully treated with ultrasound-guided potassium chloride injection in the ectopic embryo

Discussion Neural tube defects (NTDs) are quite common congenital malformations and the incidence ranges 1.5 – 4/1,000 pregnancies in Turkey (Posaci et al. 1992). It is known that twinning is associated with increased risk of NTDs, but the majority of twinning is discordant for NTDs. Th e incidence of discordant NTDs in a twin pregnancy is 1.6/1,000 (Windham and Sever 1982). However, concordant NTDs in a twin pregnancy are very rare. In a large study, its incidence was reported as 1/32,000 (Hay and Wehrung 1970). Th e present case had monochorionic diamniotic twinning with two male fetuses both aff ected with NTDs. Th ere was a strong familial association of twinning with either monochorionic or dichorionic with the same sex and NTDs (Budhiraja et al. 2002; Garabedian and Fraser 1994). It has been hypothesised that delayed ovulation or delayed fertilisation results in an over-ripe ova, believed to lack cohesion, caused splitting of the zygote (Harlap et al. 1985). Of interest in this case is the fact that there was no history of NTDs and no relatives with NTDs, in addition to the woman having two children without any congenital malformations. It is known that several factors may be associated with NTDs, such as: genetic factors; environmental factors; maternal age; low socioeconomic status; folic acid defi ciency; alcohol abuse; hyperthermia in early pregnancy; hyperglycaemia and medication (Chen 2008). Her obstetric history revealed that she had no risk factors for NTDs, except that she did not take folic acid supplementation during early pregnancy. Unfortunately, we could not learn whether or not the patient has the methylenetetrahydrofolate reductase (MTHFR) gene mutation because she did not consent to the analysis being performed. Th is is the main drawback of our manuscript. However, her family history revealed that she had no relatives with pregnancies complicated with NTDs. Folic acid supplementation is very important to prevent NTDs. In twin pregnancies, the need for folic acid increases. Lack of folic acid supplementation in presented cases may promote the development of NTD.

A case report of a large placental lake in a woman affected by complex cardiac disease

A 32-year-old woman, gravida 1, para 0, was referred to our pregnancy ultrasound unit at 20 weeks’ gestation for obstetrics ultrasound because of her cardiac disease history. She was affected by a ...

Uterine Suspension: A New Laparoscopic Technique

Laparoscopic surgery is a frequently performed surgical technique in a gynecological field. Total Laparoscopic Hysterectomy (TLH) for large uteri is a difficult procedure technically. In this study, We report our experience with large uteri and present a case of TLH performed on a uterus weighting 3550g. From 2012 to 2013, We performed TLH procedures for 962 cases, TLH in case of uteri weighing over one kilogram was 60 cases. The median uteri weight was 1050g (1000-4545g) The median operative time and blood loss were 119 minutes(62-315 minutes) and 334ml (10-1380ml). The convention to abdominal hysterectomy was only one case (1.7%). The experience and specialized techniques are necessary to performe TLH for large uteri safely and fast.