Pierluigi Giampaolino

A case of mesonephric adenocarcinoma of the vagina with a 1-year follow-up

Mesonephric adenocarcinoma deriving from remnants of vaginal mesonephric ducts is one of the rarest tumors of the female genital tract with only three cases reported till date in international literature. Differential diagnosis from other aggressive tumors is complex and controversies exist in the literature regarding the biological behavior, prognosis, and optimal management strategies of these tumors. A 58-year-old woman presented with a large mass extending from the right adnexal region to the perineum and labia majora. CA125 was increased. A radical excision of the lesion with pelvic and para-aortic lymphadenectomy was performed. A well-capsulated mesonephric adenocarcinoma in a background of vaginal mesonephric remnants was diagnosed. Tumor cells showed immunoreactivity for pancytokeratin, cytokeratin (CK), CD 10, epithelial membrane antigen, vimentin, and calretinin; indeed they were negative for carcinoembryonic antigen, CK 20, estrogen receptor, and progesterone receptor. No evidence of lymph node involvement or metastatic disease was observed. The patient did not receive any adjuvant therapy and is alive and clinically free of disease at 1-year follow-up. In spite of the aggressive biological behavior attributed in literature to mesonephric carcinomas, which is probably due to the complex differential diagnosis with other müllerian tumors, the favorable course of our patient further supports the hypothesis that malignant mesonephric carcinomas may not behave aggressively and that radical surgery alone may be curative

Serum anti-Mullerian hormone levels after ovarian drilling for the second-line treatment of polycystic ovary syndrome: a pilot-randomized study comparing laparoscopy and transvaginal hydrolaparoscopy.

Abstract Aim of the study was to asses and compare serum anti-Mullerian harmone (AMH) levels after laparoscopic ovarian drilling (LOD) and transvaginal hydrolaparoscopy (THL) ovarian drilling in clomifene citrate (CC)-resistant polycystic ovary syndrome (PCOS) patients; secondary outcome was to evaluate postoperative pain to estimate the acceptability of procedures. A total of 246 patients with CC-resistant PCOS were randomized into two groups: 123 underwent LOD and 123 underwent THL ovarian drilling. AMH serum levels were evaluated before and after the procedure; moreover, women were asked to rate pain on a visual analog scale (VAS) from 0 (no pain, perfectly acceptable) to 10 (unbearable pain, completely unacceptable). In both groups, postoperative serum AMH levels were significantly reduced compared to preoperative levels (6.06 ± 1.18 and 5.84 ± 1.16 versus 5.00 ± 1.29 and 4.83 ± 1.10; p < 0.0001). Comparing postoperative serum AMH levels, no statistically significant difference was observed between the two surgical technique. After the procedure, mean pain VAS score was significantly higher for women who underwent LOD ovarian drilling in comparison to THL (3.26 ± 1.1 versus 1.11 ± 0.5; p < 0.0001). In conclusion, THL ovarian drilling is comparable to the LOD in terms of reduction in AMH, but it is preferred by patients in terms of acceptability. These results could support to use of THL ovarian drilling in the treatment of patients with CC- resistant PCOS.

Endometrioma size is a relevant factor in selection of the most appropriate surgical technique: a prospective randomized preliminary study.

OBJECTIVES To assess and compare the ovarian reserve in patients with different-sized endometriomas undergoing cystectomy or ablative surgery in order to determine the best surgical approach to safeguard healthy ovarian tissue. STUDY DESIGN Prospective randomized study on 48 patients with unilateral single ovarian endometriomas. Patients were allocated into two groups based on endometrioma size: <5cm (n=26, Group A, small endometriomas) and ≥5cm (n=22, Group B, large endometriomas). Each group was randomized to coagulation or excision treatment (1:1 ratio) before the procedure. Anti-Müllerian hormone (AMH) levels were evaluated before surgery and 3 months after surgery. RESULTS Both ablation and excision resulted in a significant reduction in AMH level regardless of endometrioma size. A significant interaction effect was observed between endometrioma size and type of surgical technique (analysis of covariance p for interaction=0.039): in Group A, no significant difference was found between the two surgical techniques (-17.6±4.7% vs -18.2±10.6%), whereas in Group B, the excision group showed a significantly greater percentage decrease in AMH level compared with the ablation group (-24.1±9.3% vs -14.8±6.7%, p=0.011). CONCLUSIONS Both ablative and excision treatment of endometriomas have a negative effect on ovarian function. Endometrioma size is associated with the magnitude of ovarian reserve damage following excision treatment, but in the case of ablative treatment, the decrease in AMH serum level is independent of the size of the cyst. In surgical treatment of large endometriomas, the decrease in AMH level is more consistent and much more severe following cystectomy than ablation.

Comparison of bidirectional barbed suture Stratafix and conventional suture with intracorporeal knots in laparoscopic myomectomy by office transvaginal hydrolaparoscopic follow-up: a preliminary report.

OBJECTIVES To compare surgical outcomes of different types of intracorporeal sutures for laparoscopic posterior myomectomy, by a prospective randomized study. STUDY DESIGN Prospective randomized study on 47 patients with single posterior intramural myoma (4-7cm in diameter) undergoing laparoscopic myomectomy. The patients enrolled were divided into two groups, one operated using conventional suture in double strand, and the other with bidirectional barbed suture Stratafix. The main outcome measures were suturing time, peri-operative variables, and post-operative adhesions in both groups. RESULTS The mean operative time was shorter with the Stratafix™ than with the conventional suture (66.3±8.2 vs. 73±8min; p=0.005). Suturing time was significantly shorter in the Stratafix™ than in the control group (8.8±2.4 vs. 15.5±2.8min; p=0.001). Intraoperative bleeding was significantly less in the Stratafix group (p=0.0012). Conversely, there was no statistically significant difference for postoperative adhesions between the two groups (26.7% vs. 21.4% p=0.5). CONCLUSIONS The use of barbed suture may reduce operative time, suturing time, and blood loss. No difference in post operative adhesions was found.

“In patient” medical abortion versus surgical abortion: patient’s satisfaction

Abstract Objective: To compare patients’ satisfaction with medical and surgical abortion, implementing the Italian guidelines on medical abortion entailing an “in patient” procedure. Methods: A total of 1832 pregnant chose between surgical (vacuum aspiration) or medical abortion (mifepristone p.o. followed after 3 days by sublingual misoprostol) and expressed their expected satisfaction on a visual analog scale (VAS). A total of 885 women chose surgical and 947 medical abortion. The primary end-point was satisfaction VAS score 20 days after the procedure. Secondary end-points were: difference between pre- and post-abortion VAS score; difference in satisfaction VAS scores according to parity and previous abortion; incidence of side effects. Results: VAS score was high in each group but significantly higher for the 1-day surgical than for the 3-day medical abortion procedure (7.9 ± 1.0 versus 7.2 ± 1.2; p < 0.0001). In the surgical group the VAS score increased after the treatment (6.9 ± 1.6 versus 7.9 ± 1.0, p < 0.0001), while it decreased in the medical group (7.5 ± 1.0 versus 7.2 ± 1.2; p < 0.0001). Multiparous women reported higher satisfaction with medical abortion; women with a previous abortion preferred surgical abortion. Conclusions: Both procedures are considered satisfactory by the patients. Performing medical abortion as a 3-day “in patient” procedure, decreased women’s satisfaction scores from their baseline expectations.

Synthetic cyanoacrylic glue in the prevention of post-operative lymphocele after pelvic lymphadenectomy in patients with uterine malignancies: A prospective, single-blind, preliminary study

OBJECTIVES Lymphoceles are among the most common post-operative complications of pelvic lymphadenectomy, with a reported incidence of 1% to 29% in gynecology oncology. Several studies evaluated the effectiveness of biological glues on reducing lymphoceles, but no data on gynecological patients are available. We evaluated the effectiveness of cyanoacrylic glues (n-butyl cyanoacrylate) (Glubran 2 - GEM s.r.l., Italy) in preventing lymphocele on 30 patients who underwent pelvic lymphadenectomy for endometrial or cervical cancer. METHODS Single-blind prospective randomized study. Patients were divided into 2 groups: pelvic lymphadenectomy plus n-butyl cyanoacrylate (treatment group: 44 patients) and pelvic lymphadenectomy without n-butyl cyanoacrylate (control group: 44 patients). Primary endpoint was incidence of pelvic lymphocele in the two groups 30 days after surgery, and evaluated with pelvic ultrasound and RMI examination. Secondary endpoints evaluated drainage volume of lymphorrhea 36, 48, 72 and 96 h after surgery. RESULTS 15% in the treatment group and 36.6% in the control group had lymphocele 1month after the procedure (p<0.03; RR 0.4 [95% CI 0.152-0.999]). Concerning the secondary outcome in group A the amount of lymphorrhea presented a constant significant decrease during evaluation; on the contrary, in group B, after an initial decrease at 48 h, the amount of lymphorrhea remained unchanged; at all considered times the amount of lymphorrhea resulted significantly greater in controls. CONCLUSION Intraoperative application of n-butyl cyanoacrylate seems to reduce lymph production after pelvic lymphadenectomy, providing a useful additional treatment option for reducing drainage volume and preventing lymphocele development after pelvic lymphadenectomy.

Transvaginal Bilateral Sacrospinous Fixation after Second Recurrence of Vaginal Vault Prolapse: Efficacy and Impact on Quality of Life and Sexuality

Objective Our aim was to study the efficacy of transvaginal bilateral sacrospinous fixation (TBSF) and its impact on quality of life (QoL) and sexual functions in women affected by second recurrences of vaginal vault prolapse (VVP). Materials and Methods We performed a prospective observational study on 20 sexually active patients affected by second recurrence of VVP, previously treated with monolateral sacrospinous fixation. TBSF was performed in all the patients. They had been evaluated before the surgery and at 12-month follow-up through pelvic organ prolapse quantification (POP-Q) system, Short Form-36 (SF-36), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Results At 12-month follow-up, 18 out of 20 (90%) patients were cured of their recurrent VVP. No major intra- and postoperative complications occurred. We found a significant improvement in 4/5 POP-Q landmarks (excluding total vaginal length), SF-36, and PISQ-12 scores. Conclusion According to our data analysis, TBSF appears to be safe, effective, and able to improve both QoL and sexual functions in patients affected by second recurrence of VVP after previous monolateral sacrospinous fixation.

Impact of transvaginal hydrolaparoscopy ovarian drilling on ovarian stromal blood flow and ovarian volume in clomiphene citrate-resistant PCOS patients: a case-control study

Abstract Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in gynecology. In PCOS patients vascularization parameters are altered. Transvaginal hydrolaparoscopy (THL) is a mini-invasive approach for ovarian drilling in PCOS patients. In this study, we assessed the effect of ovarian drilling using THL on ovarian volume (OV) and vascularization index (VI) using 3D power Doppler ultrasonography in CC-resistant PCOS patients. A case-control study on 123 CC-resistant PCOS women who underwent THL ovarian drilling was performed. Patients underwent 3D ultrasound and power Doppler to measure VI, flow index (FI), vascularization flow index (VFI) and to evaluate OV before and after the procedure, at six months, and on the early follicular phase of the menstrual cycle. After THL ovarian drilling, OV and power Doppler flow indices were significantly reduced compared to pre-operative values (OV: 7.85 versus 11.72 cm3, p < 0.01; VI: 2.50 versus 4.81, p < 0.01; VFI: 1.10 versus 2.16, p < 0.01; FI: 32.05 versus 35.37, p < 0.01). In conclusion, THL ovarian drilling seems to reduce OV and 3D power Doppler indices, and could therefore be a viable alternative to LOD in PCOS patients resistant to medical therapy.

Multiple bowel stenosis and perforation as long-term complications of chemoradiotherapy for advanced cervical cancer in a young woman: case report

BACKGROUND Although combined treatment (chemoradiotherapy) appears to improve the overall and progression-free survival of patients wih locally advanced cervical cancer, some acute toxicity is increased (hematological toxicity, nausea, vomiting) while the long-term side effects are unclear. CASE A 35-year-old Caucasian woman with a diagnosis of advanced cervical cancer (FIGO stage IIIB) was treated with neoadjuvant chemoradiotherapy not followed by radical surgery. She underwent whole pelvic radiation therapy for a total of 40 Gy in fractions of 2.5 Gy given 4 times per week for 4 consecutive weeks followed by 2 sessions of intracavitary brachytherapy starting within 7 days of completion of external beam radiotherapy (3500 mg/h and 2500-3000 mg/h). Cis-DDP IV was administered at a dose of 25 mg/m2 on day 1 and then weekly until completion of the radiotherapeutic protocol. After several months the patient presented persistent gastrointestinal symptoms and an X-ray showed findings consistent with bowel occlusion. The patient underwent emergency surgery and multiple bowel stenosis with perforation was diagnosed. DISCUSSION This is the first report in which neoadjuvant chemoradiotherapy is associated with the late complication of multiple stenosis and bowel perforation in a young woman with advanced cervical cancer. Considering that despite the large number of studies about non-cisplatin agents there is not enough evidence to justify treatment with alternative agents, this case report might provide new important data regarding the late morbidity of cisplatin-based concurrent chemoradiation.

Treatment of asymptomatic uterine rupture of caesarean scar pregnancy in patient with advanced gestational age: case report

Pierluigi Giampaolino, Luigi Della Corte, Piero Venetucci, Felice D’Antuono, Ilaria Morra, Carmine Nappi and Giuseppe Bifulco Department of Public Health, University of Naples Federico II, Naples, Italy; Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy; Department of Morphological and Functional Diagnostics, Radiotherapy, Forensic Medicine, University of Naples Federico II, Naples, Italy