Roberta Granese

Parasitic myomas after laparoscopic surgery: an emerging complication in the use of morcellator? Description of four cases

OBJECTIVE To report the development of parasitic myomas after the use of a morcellator. DESIGN Retrospective study. SETTING Tertiary care referral center for the treatment of benign gynecologic pathologies. PATIENT(S) Women undergoing surgery for uterine fibroids. INTERVENTION(S) Chart review. MAIN OUTCOME MEASURE(S) Presence of parasitic leiomyomas. RESULT(S) We identified four cases of parasitic myomas over the 3-year study period. Two out of the four were symptomatic. The prevalence of this complication, considering all women with whom the electric morcellator was used (n = 423) was 0.9% (95% CI, 0.3-2.2%). Considering exclusively the women who underwent myomectomy (n = 321), it was 1.2% (95% CI, 0.4-2.9%). CONCLUSION(S) Laparoscopic myomectomy with the use of a morcellator is associated with an increased risk of developing of parasitic myomas. A thorough inspection and washing of the abdominopelvic cavity at the end of the surgery should be performed to prevent this rare complication.

Effects of genistein aglycone in osteoporotic, ovariectomized rats: a comparison with alendronate, raloxifene and oestradiol

Genistein aglycone positively affects bone loss in postmenopausal women, but bone quality data are still lacking. To clarify this, we investigated the effects of genistein compared with alendronate, raloxifene and oestradiol in an animal model of established osteoporosis.

Laparoscopic sacrocolpopexy in the treatment of vaginal vault prolapse: 8 years experience

OBJECTIVE The aim of this study was to evaluate the long-term results of a laparoscopic sacrocolpopexy for the treatment of vaginal vault prolapse. STUDY DESIGN Between January 1999 and January 2007, 165 laparoscopic sacrocolpopexy procedures, using a polypropylene mesh, were performed on women affected by vaginal vault prolapse. Intraoperative complications included: 5 bladder injuries and 3 sigmoid perforations. Postoperative complications included: 10 cases of fever, 5 cases of lumbosciatica, 15 cases of detrusor overactivity, 2 cases of vaginal haematoma, and 5 cases of minimal dispareunia. At 1, 6 and 12 months after surgery, a clinical evaluation was carried out for all patients. After this period, we contacted the women annually. RESULTS We treated 165 women, with an average age of 67 (range 58-76 years; S.D. 19.22), average parity of 3 (range 2-5), and average body mass index of 28 (range 24-30). In many of them, more than one additional procedure was performed. At a median follow-up of 43 months (range 6-96 months), out of a total of 138 patients (27 were lost at follow-up), we obtained successful treatment in 131 women (success rate of 94.9%), with a high rate of satisfaction from the procedure. Recurrent vaginal vault prolapse was registered in seven women (5.07%): in 3, the vaginal vault collapsed after a period ranging from 7 to 20 days, caused by the use of a Vyprol mesh (hence use of same was suspended), and in a further three women the mesh detached after less than 1 month. Finally, in one case, we reported an erosion between the first and the second follow-up and the mesh was visualized in the vagina. CONCLUSIONS Our study shows that laparoscopic sacrocolpopexy, in the hands of an expert surgeon, can be considered a safe, effective procedure for the treatment of vaginal vault prolapse, allowing long-term anatomical restoration (94.9% success rate).

Genistein Aglycone Does Not Affect Thyroid Function: Results from a Three-Year, Randomized, Double-Blind, Placebo-Controlled Trial

CONTEXT AND OBJECTIVE Genistein aglycone positively affects postmenopausal symptoms. However, questions about its long-term safety on the thyroid gland still remain. DESIGN The parent study was a randomized, double-blind, placebo-controlled trial involving 389 osteopenic, postmenopausal women for 24 months. A subcohort (138 patients) continued therapy for an additional year. SETTING Patients received ambulatory care. PATIENTS AND INTERVENTIONS Participants received 54 mg of genistein aglycone daily (n = 71) or placebo (n = 67), plus calcium and vitamin D(3) at therapeutic doses. Circulating thyroid hormones (TSH, free T(3), free T(4)) and autoantibodies (thyroid peroxidase, thyroglobulin, and thyroid microsomal antigen) were assessed in 40 genistein and 37 placebo subjects who completed 3 yr. Thyroid hormone receptor (THRalpha and THRbeta) and retinoid receptor (RARalpha, RARgamma, and RXRalpha) expression from peripheral blood monocytes was also evaluated at baseline, 12, 24, and 36 months in all 3-yr completers. RESULTS Genistein administration over 3 yr did not affect serum thyroid hormones or autoantibodies. In addition, there were no differences in THRalpha, THRbeta, RARalpha, RARgamma, or RXRalpha mRNA expression between groups. CONCLUSION These data suggest that genistein aglycone intake does not significantly increase the risk of clinical or subclinical hypothyroidism at the dose of 54 mg/d.

Correlation between dioxin and endometriosis: an epigenetic route to unravel the pathogenesis of the disease

IntroductionEnvironmental toxicants can act as endocrine disrupters on the female reproductive system. 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) is resistant to degradation and due to its lipophilic nature, accumulates in the fat tissue and in the food chain. Human and animal exposure to TCDD affects levels of the steroid receptors and steroid-responsive gene expression and has an impact on metabolism and serum transport of steroids. Gene expression is commonly altered in endometriosis and in the eutopic endometrium of women with the disease. Aberrantly expressed genes include those associated with the regulation of transcription, proliferation, sex steroid metabolism, apoptosis, cell cycle, the immune response and cell adhesion.MethodsIn this paper, we review the evidence about TCDD’s effect on eutopic and ectopic endometrium, in order to unravel the machinery behind the dysregulation of immune and hormonal homeostasis caused by this environmental toxicant.ConclusionThe evidence collected in this review suggests that TCDD could modulate transcription at multiple levels, including the epigenetic level, and via microRNAs, thus disturbing the physiologic processes mediated through the aryl hydrocarbon receptor pathways. Exposure to TCDD also modulates the immune response by influencing the production and action of endometrial cytokines and chemokines, destroying mucosal immunity of the reproductive tract and re-directing the tissue distribution and behavior of leukocytes. Despite this large body of evidence, current human-based epidemiological studies on the association between TCDD and endometriosis remain controversial.

Genistein Aglycone: A Dual Mode of Action Anti-Osteoporotic Soy Isoflavone Rebalancing Bone Turnover Towards Bone Formation

Osteoporosis is characterized by reduced bone mass and structural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk. Bone loss further increases in postmenopausal women when the ovaries stop making estrogens. Women undergoing treatment for osteoporosis require long-term dosing therapeutic regimens, that offer no symptomatic relief, and may cause side effects. To avoid this problem, many therapeutic alternatives have been proposed. Epidemiological data support a robust relationship between soy isoflavones, fracture incidence and bone mineral density in osteoporotic, postmenopausal women. These suggest that a high isoflavone intake, restores the metabolic balance of bone formation and resorption. However, this matter is still controversial and several reports show negative results, probably because different doses and/or isoflavones have been used. Although it is difficult to identify the specific isoflavone most involved in preventing or restoring bone loss, a review of current literature based on new encouraging preclinical and clinical data, indicates that aglycone genistein appears to be the most effective isoflavone in preserving bone health. Genistein aglycone, through a peculiar anti-osteoporotic dual mode of action, can positively regulate bone cell metabolism rebalancing bone turnover towards bone formation. Genistein in fact stimulates osteoblast and inhibits osteoclast function, mainly through the osteoprotegerin-sRANKL system. The positive results achieved by genistein aglycone intake, in terms of efficacy and safety, have stimulated the development of specially formulated medical food products for the clinical management of postmenopausal bone loss.

Full-Thickness Excision versus Shaving by Laparoscopy for Intestinal Deep Infiltrating Endometriosis: Rationale and Potential Treatment Options

Endometriosis is defined as the presence of endometrial mucosa (glands and stroma) abnormally implanted in locations other than the uterine cavity. Deep infiltrating endometriosis (DIE) is considered the most aggressive presentation of the disease, penetrating more than 5 mm in affected tissues, and it is reported in approximately 20% of all women with endometriosis. DIE can cause a complete distortion of the pelvic anatomy and it mainly involves uterosacral ligaments, bladder, rectovaginal septum, rectum, and rectosigmoid colon. This review describes the state of the art in laparoscopic approach for DIE with a special interest in intestinal involvement, according to recent literature findings. Our attention has been focused particularly on full-thickness excision versus shaving technique in deep endometriosis intestinal involvement. Particularly, the aim of this paper is clarifying from the clinical and methodological points of view the best surgical treatment of deep intestinal endometriosis, since there is no standard of care in the literature and in different surgical settings. Indeed, this review tries to suggest when it is advisable to manage the full-thickness excision or the shaving technique, also analyzing perioperative management, main complications, and surgical outcomes.

Unus pro omnibus, omnes pro uno: A novel, evidence-based, unifying theory for the pathogenesis of endometriosis

The theory of retrograde menstruation as aetiopathogenesis of endometriosis formulated by John Sampson in 1927 shows clear shortcomings: this does not explain why retrograde menstruation is a physiological process that affects 90% of women, while endometriosis occurs in only 10% of cases; it also does not explain the endometriotic foci distant from the pelvis, nor explains the cases of endometriosis in male patients. The immunological alterations of the peritoneal fluid explains the effects of disease, such as the inhibition of the physiological processes of cytolysis, but does not explain the cause. There is evidence to support the hypothesis that ectopic müllerian remnants of the endometrium, endocervix and endosalpinx are items from the genital ridge leaked during organogenesis. It is known that tissues derived from coelomatic epithelial and mesenchymal cells have the potential to metaplastically differentiate into epithelium and stroma. In addition, the phenotype of the ectopic endometrial cells is significantly different from those ectopic. There is scientific evidence that, during organogenesis, the genes of the Homeobox and Wingless family play a fundamental role in the differentiation of the ducts of Muller and development of the anatomical structure of the urogenital tract. We present here a hypothesis that deregulation of genes and the Wnt signaling pathway Wnt/β-catenin leads to aberrations and deregulation within the mesoderm, thus, may cause aberrant placement of stem cells. In addition, immune cells, adhesion molecules, extracellular matrix metalloproteinase and pro-inflammatory cytokines activate/alter peritoneal microenvironment, creating the conditions for differentiation, adhesion, proliferation and survival of ectopic endometrial cells.

Natural Killer T cell subsets in eutopic and ectopic endometrium: a fresh look to a busy corner

PurposeInvariant Natural Killer T cells (iNKT) are a specialized subset of T cells that use their T cell receptor to recognize self and foreign lipids presented by CD1d as cognate antigens. iNKT have been shown to have either protective or harmful roles in many pathological states, including microbial infection, autoimmune disease, allergic disease and cancer. Accumulating evidence seems to suggest that this unique T cell subset combines both classically innate and adaptive immunologic characteristic. Considering these recent data, the aim of work was to review the current knowledge about iNKT in eutopic and ectopic endometrium.MethodsNarrative overview, synthesizing the findings of literature retrieved from searches of computerized databases.ResultsCurrently, the immune paradigm of reproduction is gradually changing shape: recent data confirmed that cytokine milieu influences the development and plasticity of different subtype of mononuclear cells, and in turn it can be influenced by the cytokine production of the latter. Among the different NKT cell populations, the recently characterized iNKT seems to share actions typical both of innate and adaptive immunity, being capable of secreting Th1 as well as Th2 cytokine pattern. Moreover, several subtypes of iNKT were identified, who partially express the same master transcription factors of the corresponding T cells counterpart.ConclusionsAlthough the data about iNKT’s actions in eutopic and ectopic endometrium are still scarce, it is possible to hypothesize that future investigation can shed light on this point, thus allowing a better knowledge about the regulation of these two microenvironments.

Gonadotrophin-releasing hormone analogue or dienogest plus estradiol valerate to prevent pain recurrence after laparoscopic surgery for endometriosis: a multi-center randomized trial.

To evaluate the efficacy of dienogest + estradiol valerate (E2V) and gonadotrophin‐releasing hormone analogue (GnRH‐a) in reducing recurrence of pain in patients with chronic pelvic pain due to laparoscopically diagnosed and treated endometriosis.