Raffaele Tinelli

Total laparoscopic hysterectomy versus abdominal hysterectomy with lymphadenectomy for early-stage endometrial cancer: A prospective randomized study

OBJECTIVE The aim of this study was to compare, in a series of 159 women the feasibility, safety and morbidity of total laparoscopic hysterectomy (LPS) and abdominal hysterectomy with lymphadenectomy (LPT) for early-stage endometrial cancer and to assess disease-free survival and recurrence rate. METHODS 159 patients with clinical stage I endometrial cancer were enrolled in a prospective randomized trial and treated with LPS or LPT approach. The para-aortic lymphadenectomy was performed in all cases with positive pelvic lymph nodes discovered at frozen section evaluation, in patients with poorly differentiated tumors with myometrial invasion greater than 50% (ICG3), and non-endometrioid carcinomas. RESULTS The mean operative time was 136 min+/-31 (95% CI 118-181) in the LPS group and 123 min+/-29 (95% CI 111-198) in the LPT group (P<0.01). The mean blood loss was 50 ml+/-12 in the LPS group (95% CI 20-90) and 145 ml+/-35 in the LPT group (95% CI 60-255) (P<0.01). The mean length of hospital stay was 5.1+/-1.2 in the LPT group (95% CI 1-7) and 2.1+/-0.5 in the LPS group (95% CI 1-5) (P<0.01). CONCLUSIONS Laparoscopy is a suitable procedure for the treatment of patients with early endometrial cancer and may offer the potential benefits of decreased discomfort with decreased convalescence time without compromising the degree of oncological radicality required; however, it does not seem to modify the disease-free survival and the overall survival, although multicenter randomized trials and long-term follow-up are required to evaluate the overall oncologic outcomes of this procedure.

Chronic Endometritis Due to Common Bacteria Is Prevalent in Women With Recurrent Miscarriage as Confirmed by Improved Pregnancy Outcome After Antibiotic Treatment

Recurrent miscarriage (RM) is defined as 3 or more miscarriages before 20 weeks’ pregnancy. In recent years, interest has been focused on chronic endometritis (CE), a subtle inflammation thought to be associated with RM. We aimed to evaluate the relationships between CE and RM. The records of 360 women with unexplained RM were retrospectively analyzed. Data from hysteroscopy, endometrial histology, endometrial culture, and polymerase chain reaction for chlamydia, performed before and after antibiotic treatment for CE, were analyzed. The occurrence of successful pregnancies within 1 year after treatment was also evaluated. Results showed that 208 (57.8%) women with RM showed CE at hysteroscopy; 190 (91.3%), positive at hysteroscopy, were also positive at histology, and 142 (68.3%) had positive cultures. Common bacteria were found in 110 (77.5%) patients. Mycoplasma and Ureaplasma were found in 36 (25.3%) patients and Chlamydia in 18 patients (12.7%). In 102 (71%) women, antibiogram-based antibiotic treatment normalized hysteroscopy, histology, and cultures (group 1); while in 40 (28.2%) patients, CE was still present at hysteroscopy (group 2). In 16 of the 66 patients positive at hysteroscopy, but not at cultures, the hysteroscopy becomes normal (group 3) after a Centers for Disease Control and Prevention-based therapy; while in 50 women, CE was still present (group 4). One year after treatment, group 1 showed a significantly higher number of pregnancies (78.4%) compared to group 2 (17.5%; P < .001) and group 4 (15.3%; P = .005). The CE is frequent in women with RM. Antibiotic treatment seems to be associated with an improved reproductive outcome.

Laparoscopy versus minilaparotomy in women with symptomatic uterine myomas: short-term and fertility results

OBJECTIVE To retrospectively compare the feasibility, safety, morbidity, and pregnancy outcome of laparoscopy (LPS) and minilaparotomy (LPT) in the treatment of symptomatic uterine myomas. DESIGN Retrospective, nonrandomized study. SETTING Advanced Gynecological Endoscopy Center, Malzoni Medical Center, Avellino, Italy. PATIENT(S) 680 nonconsecutive patients with symptomatic uterine myomas. INTERVENTION(S) 350 women underwent LPS, and 330 underwent LPT myomectomy. MAIN OUTCOME MEASURE(S) Operative time, blood loss, hospital stay, pregnancy rate, and spontaneous abortion rate. RESULT(S) The mean operative time was 63 +/- 21 minutes (95% CI, 48-143) in the LPS group and 57 +/- 23 minutes (95% CI, 38-121) in the LPT group. The mean length of hospital stay was statistically significantly greater in the LPT group (3.1 +/- 0.5; 95% CI, 1-5) than the LPS group (2.1 +/- 0.8; 95% CI, 1-4). The overall spontaneous pregnancy rate after myomectomy was 53%; the pregnancy rate after LPS myomectomy (56%) was not statistically significantly higher than the rate for LPT (50%). CONCLUSION(S) Laparoscopy showed a lower morbidity than reported for the open approach and was characterized by less blood loss and a shorter postoperative hospitalization with an higher pregnancy rate. The operating time was not much longer in the laparoscopic group, and the intraoperative and postoperative complications appeared acceptable and not more than what is traditionally expected with the open approach.

Laparoscopy vs Minilaparotomy in Women with Symptomatic Uterine Myomas: A Prospective Randomized Study

OBJECTIVE To compare outcomes in patients with symptomatic uterine myomas who underwent laparoscopic (LPS) or minilaparotomic (MLPT) myomectomy. DESIGN Prospective randomized study (Canadian Task Force classification II-2). SETTING University hospital. PATIENTS Eighty patients with no more than 3 uterine myomas of maximal diameter of 7 cm. INTERVENTION Either LPS or MLPT myomectomy. MEASUREMENTS AND MAIN RESULTS Mean blood loss, mean duration of postoperative ileus, and mean decrease in hemoglobin were significantly lower in the LPS compared with the MLPT group (p < .001). Mean operative time was not significantly longer in the LPS group compared with the MLPT group. Duration of hospitalization was significantly shorter in the LPS compared with the MLPT group (p < .001). No intraoperative complications were observed during MLPT. In 1 patient, conversion from LPS to MLPT was necessary because of difficulty in reconstructing the uterine wall. CONCLUSION Laparoscopic myomectomy is a suitable alternative to MLPT in women with 1 to 3 myomas. However, preoperative careful evaluation of the size and sites of the myomas is necessary to avert conversion and prevent complications.

The role of hysteroscopy with eye-directed biopsy in postmenopausal women with uterine bleeding and endometrial atrophy.

Objective:To determine the diagnostic accuracy of transvaginal ultrasonography (TVS) and hysteroscopy for the diagnosis of endometrial pathology in postmenopausal women with abnormal uterine bleeding (AUB). Design:This prospective nonrandomized study was conducted on 752 postmenopausal women with AUB who underwent TVS and outpatient hysteroscopy with eye-directed biopsy. Histologic diagnoses were compared with the ultrasonographic and hysteroscopic findings, and the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were determined. Results:In three cases of atrophic endometrium on hysteroscopy, histologic examination revealed endometrial carcinoma. TVS using an endometrial thickness of less than 4 mm as the cutoff showed sensitivity of 89%, specificity of 86%, a positive predictive value of 82%, a negative predictive value of 92%, and diagnostic accuracy of 87%. Hysteroscopy was technically successful in all women and revealed sensitivity of 98%, specificity of 91%, a positive predictive value of 88%, a negative predictive value of 98%, and diagnostic accuracy of 94%. Conclusions:Hysteroscopy is a significantly more accurate diagnostic method for the detection of endometrial pathology than TVS, has better specificity, and should be considered for all patients with AUB with an endometrial thickness of more than 4 mm. Hysteroscopy shows great efficiency in the diagnosis of focal abnormalities of the endometrium, which are unlikely recognized by ultrasonography and should be indicated in cases of AUB with an endometrial thickness less than 4 mm on ultrasonography because of the possibility of missing infrequent (0.8%) but relevant endometrial pathologies. Among such women showing abnormal or suspicious lesions, it is necessary to perform hysteroscopy with eye-directed biopsy because some cases of endometrial carcinoma could be missed.

Poor reliability of vaginal and endocervical cultures for evaluating microbiology of endometrial cavity in women with chronic endometritis.

Background: Chronic endometritis (CE) is a subtle pathology causing infertility and abnormal uterine bleeding. We evaluated the reliability of vaginal and cervical cultures for detecting infectious agents at the endometrial level. Methods: In a prospective diagnostic study, 181 women diagnosed with CE and 100 controls underwent vaginal, endocervical and endometrial sampling. Cultures for common bacteria, Neisseria gonorrhoeae, yeast and Ureaplasma urealyticum and PCR for Chlamydia trachomatis were performed. Results: The prevalent infectious agents at the endometrial level were common bacteria(59.7% of cases); U. urealyticum was detected in 11.0% and C. trachomatis in only 2.8%. The concordance rate between endocervical and endometrial specimens for common bacteria was 48.3%; 100% for C. trachomatis and 58.3% for U. urealyticum. The concordance rate between vaginal and endometrial cultures for common bacteria was 50.2%, only 16.7% for C. trachomatis and 48.8% for U. urealyticum. For common bacteria both vaginal and cervical cultures showed low sensitivities of 0.30 and 0.19, respectively. Conclusion: Common bacteria and U. urealyticum were the prevalent infectious agents in the uterine cavity of women diagnosed with CE. Both vaginal and endocervical cultures had low concordance with endometrial cultures. Only C. trachomatis test at cervical level had high concordance with endometrial findings.

New trends of progestins treatment of endometriosis.

Abstract The management of endometriosis with OC or progestins is generally safe, effective and well-tolerated and should constitute the first line of medical treatment in symptomatic patients who do not want to have children. Progestins, synthetic progestational agents, have been used in the management of symptomatic endometriosis both as primary therapy and as an adjunct to surgical time. A variety of oral agents have been employed in this regard and investigators have demonstrated differing degrees of benefit. The lack of a standardized instrument to evaluate painful symptoms makes comparative analysis more difficult. Concern about efficacy and side effect has pushed the research on the development of new well-tolerated drugs and to develop new administration routes to minimize general side effects. Aim of the present review is to present the results of clinical studies on new trends of progestins in the treatment of endometriosis. Chinese abstract 口服避孕药或孕激素治疗子宫内膜异位症一般安全、有效且耐受性良好，应该成为有症状无生育要求妇女的一线治疗方法。孕激素及孕激素合剂已成为症状性子宫内膜异位症的主要治疗方法，同时也可作为手术期的辅助治疗。如今多种口服药物已应用于临床并使子宫内膜异位症患者不同程度的受益。但由于缺乏评估疼痛程度的标准化方法，使得比较分析较困难。因此对药物有效性和副反应的关注促进我们研发新型且耐药性良好的药物，同时设计出新型的给药途径来降低常见的副作用。本综述主要目的是介绍孕激素在治疗子宫内膜异位症临床研究结果方面的新趋势。

Hormonal carcinogenesis and socio-biological development factors in endometrial cancer: A clinical review

Objective. Endometrial cancer is one of the most common invasive gynecologic malignancies in developed countries and the eighth leading cause of cancer death in women; it typically arises in the sixth or seventh decade of life. The aim of this review was to evaluate possible roles of genetic and socio‐biological factors in type I endometrial cancer, largely confined to pre‐ and perimenopausal women, with a history of estrogen exposure and/or endometrial hyperplasia. Methods. An extensive literature review, from 1990 to 2007 was performed on modifiable risk factors for type I endometrial cancer. Additionally, carcinogenesis mechanisms, biomarker and hormonal and biomolecular approaches to cancer detection, progression and monitoring and socio‐biological factors were reviewed. Results. Several socio‐biological and lifestyle characteristics, such as hormone replacement therapy, glycemic index, obesity, alcohol use, antipsychotic medication, melatonin, physical activity and variants in hormone metabolism genes have been identified as risk factors for developing endometrial cancer of type I, the majority of which are associated with excess estrogens causing continued stimulation of the endometrium. There is a genetic link to non‐polyposis colorectal cancer syndrome, but association of endometrial cancer risk to other genetic polymorphisms has yielded conflicting results. Conclusions. Many factors linked to hormonal imbalance, such as obesity, weight change, body size, alcohol, hyper‐androgenic states, glycemic index and antidepressant agents, influence the endometrial cancer risk, central to which are endogenous and exogenous estrogen hyperstimulation of the endometrium. Conversely, smoking cigarettes, diet, physical activity and melatonin production seem to reduce the risk of cancer development. Other external factors fit well with the unopposed estrogen theory, but more studies are needed to investigate modifiable and added risk factors for endometrial cancer.

Feasibility, safety, and efficacy of conservative laparoscopic treatment of borderline ovarian tumors

OBJECTIVE To outline the most recent information regarding conservative laparoscopic surgery for young women with borderline ovarian tumors. DESIGN Review article. SETTING Advanced Gynecological Endoscopy Center, Malzoni Medical Center, Avellino, Italy. PATIENT(S) Young women with low-stage borderline ovarian tumors who wish to preserve their fertility. INTERVENTION(S) Conservative laparoscopic surgery with unilateral salpingo-oophorectomy or cystectomy. MAIN OUTCOME MEASURE(S) Recurrence rate and outcomes. RESULT(S) Laparoscopic cystectomy may have more chance of preserving a womans fertility compared with adnexectomy because of the removal of less ovarian tissue. Its greatest danger is the risk of inadvertently leaving behind some malignant cells. Therefore, this procedure should be reserved for patients with previous unilateral salpingo-oophorectomy or when bilateral lesions are present to preserve at least some ovarian tissue. CONCLUSION(S) When borderline ovarian tumors are identified at surgery by intraoperative histology, the recommended conservative treatment should be laparoscopic salpingo-oophorectomy. Recurrence can be noted after this type of treatment, but the cases of recurrent disease can be detected with close follow-up and treated accordingly. For these reasons, careful selection of candidates for this kind of treatment is, of course, necessary and close follow-up is required. If these restrictions are rigorously applied, then fertility-sparing surgery may be considered a safe option for this pathology, but all laparoscopic procedures should be reserved for oncologic surgeons trained in extensive laparoscopic procedures.

Is early stage endometrial cancer safely treated by laparoscopy? Complications of a multicenter study and review of recent literature

BACKGROUND To compare the complications after total laparoscopic hysterectomy (LPS) and abdominal hysterectomy with lymphadenectomy (LPT) for early stage endometrial cancer in a series of 226 women and to assess the disease-free survival and the recurrence rate. PATIENTS AND METHODS Two hundred and twenty six patients with clinical stage I endometrial cancer were enrolled in a multicenter study and underwent surgical staging consisting of inspecting the intraperitoneal cavity, peritoneal washing, total hysterectomy, bilateral salpingo-oophorectomy, and in all cases we performed systematic bilateral pelvic lymphadenectomy by LPS or LPT approach. RESULTS One patient of the LPS group had an uretero-vaginal fistula and another patient had an ureteral stricture temporarily treated with a stent. One patient of the LPS group had a bowel perforation due to dense adhesions with the peritoneum under the umbilicus, resolved with a bowel resection and an end-to-end anastomosis. In three patients of the LPS group we observed a vaginal cuff dehiscence and in one case a pelvic lymphocyst was reported. CONCLUSIONS The low intraoperative and postoperative complications rate, observed in the LPS group, highlights the feasibility, safety and efficacy of this surgical approach. The operating time was longer in the LPS group but the recurrence rate and the complication rate appear similar and not more than what is traditionally expected with the LPT approach, although further studies and cost-benefit analyses are required to determine whether the use of LPS improves the outcome over standard LPT and whether the advantages of this technique could be extended to a larger proportion of patients.