Vincenzo Pinto

Reliability, feasibility, and safety of minihysteroscopy with a vaginoscopic approach: experience with 6,000 cases

OBJECTIVE To assess the reliability, feasibility, and safety of lens-based minihysteroscopy. DESIGN Retrospective comparative study. SETTING Academic research environment. PATIENT(S) Women with different indications for hysteroscopy. INTERVENTION(S) Six thousand seventeen outpatient diagnostic hysteroscopies with a minihysteroscope (2.7-mm outer diameter [OD] telescope with 3.5-mm OD single-flow diagnostic sheath) and 4,204 with traditional hysteroscope (4-mm OD telescope with 5-mm OD single-flow diagnostic sheath). All hysteroscopies were performed using a vaginoscopic approach and saline to distend the uterus. MAIN OUTCOME MEASURE(S) Rate of successful introduction of the hysteroscope, rate of satisfactory examinations, pain intensity experienced using an arbitrary pain scale (0 = no pain; 1 = low pain; 2 = moderate pain; 3 = severe pain), and number of side effects and complications. RESULT(S) In the minihysteroscopy, group rates of successful introduction and satisfactory examinations were significantly higher than in the traditional hysteroscope group (99.52% vs.72.53% and 98.53% vs. 92.33%, respectively), while pain and vagal reactions were significantly lower (0.10 +/- 0.34 vs.1.09 +/- 0.53 and 2.25% vs.17.12%, respectively). CONCLUSION(S) Hysteroscopy with lens-based minihysteroscopes was easier, less painful, more reliable, and safer than with 5-mm hysteroscopes. Minihysteroscopy with a vaginoscopic approach is a very well tolerated, effective, and safe outpatient procedure.

Tolerability of the mini-pan-endoscopic approach (transvaginal hydrolaparoscopy and minihysteroscopy) versus hysterosalpingography in an outpatient infertility investigation

OBJECTIVE To compare the acceptance and tolerability of the mini-pan-endoscopic approach (transvaginal hydrolaparoscopy [THL] combined with minihysteroscopy) versus hysterosalpingography (HSG) for evaluating tubal patency and the uterine cavity in an outpatient infertility investigation. DESIGN Randomized controlled study. SETTING University hospital. PATIENT(S) Twenty-three infertile patients without obvious pelvic pathology. INTERVENTION(S) Women were randomly divided into two groups. One group underwent minihysteroscopy and THL with tube chromoperturbation as first investigation and HSG within the following 7 days, while in the other group the investigation sequence was inverted. Women reported pain experienced before and at the end of procedures. MAIN OUTCOME MEASURE(S) Mean duration of procedures, level of pain experienced, diagnostic agreement about tubal patency and uterine cavity normality. RESULT(S) THL and minihysteroscopy took significantly more time but was significantly less painful than HSG. Regarding tubal patency, in 95.5% of cases THL agreed with HSG. In one case, HSG diagnosed a bilateral obstruction of tubes, whereas at THL a bilateral spreading of methylene blue was seen. Agreement on intrauterine pathologies between minihysteroscopy and HSG was poor (43%); the number of intrauterine abnormalities found at hysteroscopy was significantly greater than at HSG. CONCLUSION(S) THL in association with minihysteroscopy provided more information and was better tolerated than HSG in an outpatient infertility investigation.

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.

Effects of tibolone on plasma levels of nitric oxide in postmenopausal women.

OBJECTIVE To determine the effects of tibolone on nitric oxide (NO) plasma levels in postmenopausal women. DESIGN Randomized, double-blind, placebo-controlled, cross-over trial. SETTING Healthy volunteers in an academic research environment. PATIENT(S) Eighteen healthy women who have been in postmenopause for 1-4 years. INTERVENTION(S) Women received either tibolone 2.5 mg/day (group A) or placebo (group B) for 1 month; then the treatment was inverted for the second month. MAIN OUTCOME MEASURE(S) Plasma concentration of NO stable oxidation products and blood pressure were evaluated at baseline, month 1, and month 2. RESULT(S) Baseline concentration of NO metabolites were similar in both groups. At month 1, mean concentration of NO metabolites increased significantly in group A alone. At the end of month 2, NO metabolite levels in group A returned to baseline, whereas in group B they increased significantly. CONCLUSION(S) Tibolone induced a sustained increase in plasma levels of NO in postmenopausal women, suggesting that tibolone may exert a direct cardiovascular protective effect in postmenopausal women.

Reliability of diagnostic fluid hysteroscopy in the assessment of cervical invasion by endometrial carcinoma: A comparative study with transvaginal sonography and MRI ☆

OBJECTIVE This study aimed at comparing the reliability of diagnostic fluid hysteroscopy, transvaginal sonography (TVS), and magnetic resonance imaging (MRI) to assess pre-operatively the presence of cervical involvement by endometrial carcinoma. METHODS Cervical involvement was assessed by diagnostic fluid mini-hysteroscopy, TVS and MRI before surgery in 100 patients with histological diagnosis of endometrial carcinoma. Results were compared with pathological examination on surgical specimen. The sensitivity, the specificity, the positive and negative predictive values, the accuracy, the positive and negative likelihood ratios (LR) of the three techniques for recognizing the cervical involvement by the carcinoma were calculated. RESULTS At histology cervical involvement was found in 15 cases. Compared to TVS and MRI, hysteroscopy showed the highest sensitivity (0.53, 0.67 and 0.93, respectively). The specificity of MRI was significantly higher than both hysteroscopy and TVS (0.95, 0.88 and 0.82, respectively). The diagnostic accuracy of hysteroscopy (0.89) and MRI (0.91) was similar and significantly higher than TVS (0.78). The LR for a positive result of MRI was 14.16, that was 2.08 and 4.68 times higher than that of hysteroscopy and TVS, respectively. CONCLUSIONS In conclusion, this study demonstrates that in women with endometrial carcinoma the exclusion of cervical canal involvement at hysteroscopy is more reliable than at MRI and TVS while MRI is the most reliable technique for predicting cervical involvement. In the pre-surgical work-up of patients affected by endometrial carcinoma hysteroscopy and MRI are both useful for staging and planning the correct surgical strategy.

Interleukin-6, interleukin-1β, and tumor necrosis factor α in menstrual effluents as biomarkers of chronic endometritis.

OBJECTIVE To assess the relationship between chronic endometritis (CE) and proinflammatory cytokine levels in menstrual effluents and to develop a simple noninvasive test for screening CE. DESIGN Case-control study. SETTING Academic center. PATIENT(S) Sixty-four women referred to our center for infertility. INTERVENTION(S) Office hysteroscopy; endometrial biopsy; collection of menstrual blood at subsequent cycle. MAIN OUTCOME MEASURE(S) Interleukin (IL) 6, IL-1β, and tumor necrosis factor (TNF) α concentrations in menstrual effluents. RESULT(S) Thirty-six out of 64 infertile women had histologically proven CE. The remaining 28 women were included as controls. IL-6, IL-1β, and TNF-α levels were markedly higher in menstrual effluents of women with CE compared with control subjects. Receiver operating characteristic curve analysis revealed a good CE screening capacity for all of the cytokines. The combined evaluation of either IL-6/TNF-α or IL-6/IL-1β increased the diagnostic capacity of the test, which reached a 100% sensitivity and a negative predictive value of 100 when at least one cytokine was found to exceed its cutoff value; it also reached a 100% specificity and a positive predictive value of 100 in cases of positivity of both cytokines. Logistic regression analysis confirmed the IL-6/TNF-α-based model as a significant predictor of CE. CONCLUSION(S) Proinflammatory cytokine levels are increased in menstrual effluents of women with CE. A test dosing IL-6 and TNF-α seems to have a high screening capacity for CE.

Absorption and preferential vagina-to-uterus distribution after vaginal administration of 99mTc-pertechnetate in postmenopausal women

OBJECTIVE To investigate in vivo and in humans the mechanisms and kinetics of vagina-to-uterus distribution. DESIGN Controlled clinical study. SETTING Volunteers in an academic research environment. PATIENT(S) Six postmenopausal women undergoing transabdominal hysterectomy were selected. INTERVENTION(S) Women received 0.2 mL of (99m)Tc-pertechnetate vaginally. In three patients the cervical canal was previously sealed by means of surgical glue. Six postmenopausal women who had received (99m)Tc-pertechnetate intravenously for a thyroid scintigraphy were considered as a control. MAIN OUTCOME MEASURE(S) Radioactivity was assessed every 30 minutes for 6 hours in the pelvis and in body regions where (99m)Tc-pertechnetate normally accumulates (thyroid, salivary glands, and stomach). RESULT(S) Uterine activity appeared after 60 minutes and peaked between 120 to 210 minutes. These same times were observed in the patients who had a sealed cervix. Thyroid uptake appeared after 180 minutes and peaked between 210 and 330 minutes. Uterine uptake did not occur in any of the intravenous patients; their thyroid uptake was rapid, appearing after 30 minutes. CONCLUSION(S) Preferential vagina-to-uterus distribution, at least in postmenopausal women, is not simply due an intracanalicular passage but is mediated by absorption of substances and probably by a countercurrent transfer mechanism.

Endometrial preparation with estradiol plus dienogest (Qlaira) for office hysteroscopic polypectomy: randomized pilot study

STUDY OBJECTIVE To estimate the effectiveness of Qlaira for endometrial preparation in women undergoing hysteroscopic polypectomy in the office setting. DESIGN Randomized clinical pilot study (Canadian Task Force classification II-2). SETTING Academic research environment. PATIENTS Seventy-four cycling women undergoing hysteroscopic polypectomy (polyp size <1.5 cm). INTERVENTIONS Women were randomized to be operated on during the proliferative phase (cycle day 5-7) of a spontaneous cycle (group A) or after 9 to 11 days of Qlaira intake (group B). Polypectomy was performed by using forceps and bipolar electrodes when required. MEASUREMENTS AND MAIN RESULTS The quality of visualization of the uterine cavity during the procedure (visual analog score [VAS] 0-5, bad to optimal), total surgeon satisfaction (VAS 0-5, very difficult to easy to perform), and total patient satisfaction (VAS 0-5, severe pain to no pain) were compared. Endometrial thickness before and at the end of the procedure was significantly less in women in group B. Mean duration of interventions was shorter in group B than in group A. In addition, vision quality, and surgeon and patient satisfaction rates were significantly higher in women in group B. CONCLUSIONS At 10 days before surgery, administration of Qlaira is effective for preparation of the endometrium for hysteroscopic polypectomy in the office setting. With preoperative administration of Qlaira, the surgical procedure can be performed more easily and faster, and both surgeon and patient satisfaction rates are improved.

Laparoscopic Diagnosis and Treatment of Pelvic Benign Multicystic Mesothelioma Associated with High CA19.9 Serum Concentration

We report a case of benign multicystic mesothelioma in a 20-year-old woman referred because of amenorrhea. She underwent pelvic transabdominal ultrasound, which disclosed a micropolycystic appearance of the ovaries and a fluid collection in the pouch of Douglas. Tumor serum markers revealed an increase in CA19.9. Abdominal and pelvic computed tomography scans confirmed the presence of ascites. Laparoscopy disclosed small, thin-walled, translucent cysts in the Douglas cavity. The cysts were free-floating in a yellowish, sticky, gelatinous material. Microscopically, cystic lesions showed mesothelium-lined cystic spaces surrounded by a delicate thin fibrovascular wall. With immunohistochemistry, the tumor cells were strongly positive for cytokeratin and calretinin. These aspects were suggestive of benign multicystic mesothelioma. Electron microscopy confirmed the mesothelial nature of this tumor. Serial evaluation of the CA19.9 concentration showed a progressive decrease in the serum marker in the normal range. The patient is now well and symptom-free with no recurrence 24 months after surgery. The association between benign multicystic mesothelioma and increased CA19.9 serum concentration has been described only once, in a man. To our knowledge, this is the second case of benign multicystic mesothelioma associated with increased CA19.9 serum concentration and the first diagnosed in a woman. In the present case, a minimally invasive laparoscopic approach enabled not only histologic diagnosis of benign multicystic mesothelioma but also its surgical treatment. Although benign multicystic mesothelioma is a rare pathologic entity, it is important that sonologists include it in the differential diagnosis of diseases that manifest with ascites. Furthermore, all surgeons should be aware of the macroscopic and laparoscopic appearance of the lesion, and its generally benign course.

Systemic Vascular Hemodynamic Changes due to 17-β-Estradiol Intranasal Administration

Purpose: According to the literature, estradiol has a direct vasodilator action by means of endothelium-derived relaxing factor synthesis. The present study aims to evaluate the acute hemodynamic effects of intranasal 17-β-estradiol on cerebral and lower limb arterial circulation in postmenopausal women. Methods: Sixteen healthy women in natural menopause (mean age: 54 ± 3 years) were investigated for at least 6 months, each receiving 300 µg of intranasal 17-β-estradiol. We evaluated the heart rate, systolic/diastolic blood pressure, peak systolic velocity, end-diastolic velocity, and velocity–time integral (VTI) at the level of internal carotid and posterior tibial arteries, before and after 30, 60, and 180 minutes of drug administration. Results: After intranasal 17-β-estradiol administration, the internal carotid artery VTI showed statistically significant (P < .05) variations at all the time intervals after administration of the drug (30, 60, and 180 minutes) when compared with “time zero” (T0, ie, the speed recorded at baseline before drug administration). No significant variation was found at the posterior tibial artery. The systolic/diastolic blood pressure and heart rate did not significantly differ before and after drug administration. Conclusions: The administration of a single intranasal dose of 17-β-estradiol in healthy postmenopausal women increased cerebral perfusions, whereas the effect on peripheral circulation was much more limited.