Hysteroscopic myomectomy with the IBS® Intrauterine Bigatti Shaver: A Retrospective Comparative Analysis of the impact of rotational speed and aspiration flow rate.

Background: Myoma removal remains a challenge hysteroscopically including for the "IBS®" Intrauterine Bigatti Shaver technique. Objective: To evaluate whether the Intrauterine IBS® instrument settings and the myoma size and type are prognostic factors for the complete removal of submucous myomas using this technology. Materials and Methods: This study was conducted at the San Giuseppe University Teaching Hospital Milan, Italy; Ospedale Centrale di Bolzano - Azienda Ospedaliera del Sud Tirolo Bolzano, Italy (Group A) and the Sino European Life Expert Centre-Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China (Group B). In Group A: surgeries were performed between June 2009 and January 2018 on 107 women using an IBS device set to a rotational speed of 2,500 rpm and an aspiration flow rate of 250ml/min. In Group B: surgeries were performed between July 2019 and March 2021 on 84 women with the instrument setting to a rotational speed of 1,500 rpm and aspiration flow rate of 500 ml/min. Further subgroup analysis was performed based on fibroid size:<3 cm and 3-5 cm. Both Groups A and B were similar in terms of patient age, parity, symptoms, myoma type and size. Submucous myomas were classified according to the European Society for Gynaecological Endoscopy classification. All patients underwent a myomectomy with the IBS® under general anaesthesia. The conventional 22 Fr. Bipolar Resectoscope was used in cases requiring conversion to the resection technique. All surgeries were planned, performed and followed by the same surgeon in both institutions. Main outcome measures: Complete resection rates, total operation time, resection time and used fluid volume. Results: Complete resection with the IBS® Shaver was seen in 93/107 (86.91%) in Group A versus 83/84 (98.8 %) in Group B (P=0.0021). Five patients (5.8%) in Subgroup A1 (<3 cm) and nine patients (42.9%) in Subgroup A2 (3cm~5cm) could not be finished with the IBS (P<0.001, RR=2.439), while in Group B only one case (8.3%) in Subgroup B2 (3cm~5cm) underwent a conversion to bipolar resectoscope (Group A: 14/107=13.08% vs. Group B: 1/84=1.19%, P=0.0024). For <3cm myomas (subgroup A1 versus B1) there was a statistically significant difference in terms of resection time (7.75±6.363 vs. 17.28±12.19, P<0.001), operation time (17.81 ± 8.18 vs. 28.19 ±17.614, P<0.001) and total amount of fluid used (3365.63 ± 2212.319 ml vs. 5800.00 ± 8422.878 ml, P<0.05) in favour of Subgroup B1. For larger myomas, a statistical difference was only observed for the total operative time (51.00±14.298 min vs. 30.50±12.122 min, P=0.003). Conclusion: For hysteroscopic myomectomy using the IBS®, 1,500rpm rotational speed and 500ml/min aspiration flow rate are recommended as these settings result in more complete resections compared to the conventional settings. In addition, these settings are associated with a reduction in total operating time. What is new?: Reducing the rotational speed rate from 2500 rpm to 1500 rpm and increasing the aspiration flow rate from 250 ml/min to 500 ml/min improve complete resection rates and reduce operating times.

Intrauterine Bigatti Shaver (IBS ® ) successful placental remnants removal, after caesarean section for a cervical pregnancy with placenta accreta.

Placenta accreta located in a caesarean section scar is difficult to remove. The Intrauterine Bigatti Shaver (IBS®) has already been proven to be effective in placental remnant removal. Our case report highlights that the IBS® is also a safe method to remove placental remnants attached to a previous caesarean section scar performed for a cervical pregnancy and associated with placenta accreta.

Embryonic shell shape as an early indicator of pollution in marine gastropods.

Gastropods shell shape has been proposed as a good indicator of environmental changes while geometric morphometric (GM) is a powerful tool to detect such changes. Shell shape pattern in adults of the marine gastropod Buccinanops deformis was proved to be correlated with imposex incidence and maritime traffic in populations of Patagonia. We explore through GM the shell shape variation of B. deformis intracapsular embryos in pre-hatching stages of development, in two populations with contrasting maritime traffic and imposex incidence. Embryonic shell shape from polluted and unpolluted areas was significantly different in apex, lateral, aperture and siphonal channel. The same shell shape pattern was observed previously in B. deformis adult specimens. Our results demonstrate that the embryonic shell shape is an early biomarker that could be used as a tool to detect the response to environmental pollution studying abundant egg capsules laid in the field but protecting reproductive adults.

PAHs contamination in edible gastropods from north Patagonian harbor areas.

PAHs are persistent pollutants released into the environment by fossil fuels burning and leak during petroleum operations. Associated with suspended particles upon entering marine ecosystem are accumulated by benthic fauna. Human exposure occurs mainly from ingestion such as gastropods consumption. The objective was to determine PAHs in sediments and in the marine gastropod Buccinanops globulosus in sites with different maritime and urban influences. In sampling sites located 20 km from the harbor, PAHs were non-detected; while in harbor gastropods, the level of PAH4 was exceeded according to international normative. Level of dibenzo[a,h]anthracene in sediments was between the ISQG and PEL. Since these are the first results of PAHs in edible gastropods in South America, we concluded that PAHs can be dangerous for consumers according to ingestion frequency. Integrative studies are necessary to evaluate the interaction among pollutants in maritime areas and the incidence in human health due to shellfish consumption.

Hysteroscopic tissue removal systems for the treatment of intrauterine pathology: a systematic review and meta-analysis.

BACKGROUND: The use of mechanical tissue removal systems is more frequently implemented as the first line approach for the treatment of intrauterine pathology. Scientific evidence is provided that their use is easier and faster than the conventional resectoscope. It is necessary to objectively evaluate the results on tissue removal systems for the treatment of endometrial pathology as the reports in the literature are still conflicting. OBJECTIVE: To review and compare mechanical hysteroscopic tissue removal systems (Truclear®, Myosure® or IBS®) versus conventional bipolar and monopolar resectoscopy for the treatment of polyp and myoma removal. Operation time, completeness of tissue removal, complication rate, fluid deficit, tolerability and learning curve were evaluated. METHODS: Electronic databases PubMed; Medline and Web of Science were searched for papers published from 1st January 2010 to 1st May 2019 using terms: ("hysteroscopic" or "hysteroscopy" or "hysteroscopic surgery") and ("myoma" or "polyps"). Studies were included if they were retrospective, observational and prospective randomized clinical controlled trials if they investigated the techniques between the tissue removal systems (Truclear®, Myosure® or IBS®) and conventional resectoscopy for the treatment of intrauterine pathology. Data were extracted from the included studies by two independent reviewers. Meta-analysis was performed by Rev Man 5 software (Cochrane Collaboration, London, UK). Results: Overall, 498 patients were analysed from five studies in which there was no difference in age and size of pathology treated either by the hysteroscopic tissue removal systems and the conventional resectoscope. Hysteroscopic tissue removal systems showed a significantly higher success rate of complete endometrial pathology removal (P=0.002) and a significantly shorter operation time for polyp removal (P<0.0001) compared to conventional resectoscopy. No significant differences, in terms of complications rate, were found (P=0.09). The fluid deficit was significantly higher in the tissue removal system group, compared to conventional resectoscopy (P=0.02). CONCLUSION: Hysteroscopic tissue removal systems showed a major advantage in successful removal of the pathology and total operation time. It is likely that the tissue removal systems are more accessible and have a lower complication profile including perforation, via falsa and bleeding due to its specific action mechanism and shorter operation time but higher-quality trials will be required to confirm this hypothesis.

Operative hysteroscopy with the Bigatti shaver (IBS ®) for the removal of placental remnants.

BACKGROUND: About 15-20% of pregnant women will miscarry spontaneously during the first trimester. Traditionally, the surgical treatment of placental remnants has been dilation and curettage (D&C). However, because of its 'blind' nature there is a risk of serious complications, such as infection, adhesion, uterine perforation, or bowel injury. Hysteroscopy, with direct visualization of the uterine cavity, decreases these complications. In this retrospective case series we evaluated the efficacy and the feasibility of operative hysteroscopy using the Intrauterine Bigatti Shaver (IBS ® ) for the treatment of placental remnants, both, in a University hospital in Italy and in a private hospital in Iran. MATERIALS AND METHODS: From December 2013 to April 2018 a retrospective medical records review, of patients undergoing placental remnant removal with the IBS ® , was performed. Sixty-five patients suspected of retained products of conception (RPOC) underwent operative hysteroscopy during this period using the IBS ® . Placental remnants were confirmed histologically in 52 cases (80%). The median age of the patients was 36 years. Placental remnants were observed after 42 early miscarriages, 5 terminations of pregnancy, 4 vaginal deliveries and 1 cesarean delivery. Thirty-two patients had abnormal uterine bleeding, 15 were asymptomatic and 5 had subfertility after miscarriage. Most cases (90%) were diagnosed by transvaginal ultrasound. RESULTS: The median interval between surgery and the end of pregnancy was 56 days (a range of 15-90 days). The size of placental remnants was between 15 and 30mm. Three women showed a cavity filled with placental tissue residual (more than 4cm). The median resection time was 4.5 minutes and the median total surgery time was 6.6 minutes. Median fluid deficit [saline solution] was 240 ml. In two cases there was excessive intraoperative bleeding, and one patient required a conversion to bipolar resectoscope for hemostatic reasons. No perforation or postoperative complications occurred. There was no need for second-look operative hysteroscopy and postoperative ultrasound confirmed complete evacuation of the RPOC. Only one patient had a minor adhesion. CONCLUSION: The IBS ® seems to be an effective and safe instrument for the removal of placental remnants. It allows for short operation time with a high success and low complication rate.

The 19 Fr. Intrauterine Bigatti Shaver (IBS®): a clinical and technical update.

In this case report we describe the first two surgeries conducted with the 19 Fr. IBS®. The indication for operative hysteroscopy in both patients was the removal of polyps. The size of the polyps was between 15 mm and 20 mm with a mean resection time of 40 seconds. Normal saline solution (500 ml) was used with a negative fluid loss (100 ml). Both operations were successfully performed under general anaesthesia and no speculum, no tenaculum and no dilatation of the cervical canal were necessary.

Shell shape as a biomarker of marine pollution historic increase.

Buccinanops globulosus is a TBT sensitive marine gastropod, classified as a good indicator of imposex incidence and used as a model to study adverse contamination effects. Population and maritime industries has incremented pollution in Nuevo gulf harbor since 1970s, promoting morphological changes in B. globulosus shell shape. We study the shell shape of the species comparing present day's specimens from the harbor zone with those collected in the same zone before the increasing of maritime activity and pre-Hispanic archaeological Middens. We demonstrated that harbor pollution produces globular shell shape in B. globulosus, an effect that probably allows gastropods to isolate themselves from the external adverse environment. On the contrary, shells from pre-Hispanic periods, unpolluted sites and those collected before the expansion of maritime activities, presented an elongated shell shape. Our study confirms that shell shape variation in marine gastropods can be used as a biomarker of harbor pollution.

Sustained response following sorafenib therapy in an older adult patient with advanced renal cancer on hemodialysis: a case report.

The prognosis for patients with renal cell carcinoma is very poor, with a five-year survival rate of less than 10%. Sorafenib is an orally administered multikinase inhibitor that blocks intracellular kinases in the Raf/MEK/ERK pathway involved in tumor proliferation, and also kinases responsible for angiogenesis, including VEGFr-2, VEGFr-3, Flt-3, PDGFr-ß and c-KIT. As a consequence of its limited renal clearance, sorafenib appears to be suitable for patients with advanced kidney cancer and terminal renal failure. The case of a 72-year-old male patient on hemodialysis and receiving sorafenib treatment for mRCC is reported.

[On-line hemodiafiltration with endogenous reinfusion (HFR). Experience of a Centre]. / Emodiafiltrazione con reinfusato on-line di liquido endogeno: esperienza di un Centro.

PURPOSE: Hemodiafiltration reinfusion (HFR) treatment is a dialysis technique that uses the endogenous reinfusion fluid and performs, simultaneously and separately, the three mechanisms of extracorporal depuration: diffusion, convection and adsorption. This study aimed to evaluate clinical and biochemical data of a group of six patients submitted to a dialytic HFR method for >6 months. METHODS: Six patients with a mean age of 53.8 +/- 11 yrs (five males, one female), treated with standard bicarbonate dialysis for a mean of 79.2 months, underwent HFR for a mean period of 14.9 +/- 6 months. Filters used were: a) in all patients polysulfone with 0.7 m2 of surface for the convection; b) polysulfone with 1.7 m2 in one patient, and modified cellulose with 2.0 m2 in five patients for diffusion; c) hydrophobic interaction resin and uncovered mineral carbon 240 mL for the adsorption. For all patients dialysis duration was 240 min and the amount of reinfusion fluid was 2.5 L/h as a mean, calculated according to blood flow and hematocrit (Hct), keeping a filtration fraction <22%. We evaluated, at different times, the following parameters: a) patient weight; b) Hct and erythropoietin (EPO) doses; c) parathyroid hormone (PTH); d) phosphatemia and doses of administered vitamin D; e) homocysteine (Hcy) and Beta2-microglobulin (Beta2-m); f) and albuminemia and transferrinemia as nutritional parameters. RESULTS: We observed an increase in Hct, with a reduction in EPO dosage, and an increase in albumin and transferrin levels, an improvement in nutritional indexes and in patient well-being. The mild increase in Hct with the same EPO dose was present in spite of a switch to intravenous (i.v.) administration from subcutaneous administration. There was low morbidity and only one hospitalization due to an infectious episode. CONCLUSIONS: HFR allows an amino acid saving and pro-inflammatory middle molecule removal, resulting in a better clinical situation for progressively critical uremic patients.

Danazol versus a gonadotropin-releasing hormone agonist as preoperative preparation for hysteroscopic metroplasty.

OBJECTIVE: To compare the efficacy of danazol and a GnRH agonist as preoperative preparation for hysteroscopic metroplasty in women with septate uterus. DESIGN: Prospective randomized clinical study. SETTING: Tertiary care center. PATIENTS: Thirty patients with septate uterus. INTERVENTIONS: The patients were randomized to treatment with danazol 600 mg/d for 2 to 4 weeks (n = 15) or with leuprolide acetate depot 3.75 mg for 2 months (n = 15) as preoperative therapy for hysteroscopic metroplasty. MAIN OUTCOME MEASURES: At the intervention the hysteroscopist evaluated difficulty in dilation of the cervical canal, presence of endometrial fragments, bleeding, difficulty in maneuvering the resectoscope, and operating time. RESULTS: Both the treatments were well tolerated. Metroplasty was simpler overall in the danazol group and also faster in introducing the resectoscope through the cervical canal and maneuvering it in the uterine cavity were both easier. Bleeding was modest in both groups and the anatomic outcome of the operation was similar. CONCLUSION: Short preoperative preparation with danazol results in favorable operating conditions at limited costs with minimal side effects.

Experimental model for neoangiogenesis in adhesion formation.

This study presents an animal model for the observation of adhesion formation, from a vascular viewpoint. In 60 Wistar rats, a 4 cm midline incision was made and a 0.5 cm square piece of silastic 0.2 mm thick was fixed on the right side of the peritoneum with two separate angular stitches of nylon 9/0. The rats were randomized in six groups of 10 animals and were operated on again on days 2, 4, 6, 8, 10 and 12 respectively. Biopsies for scanning electron microscopy were obtained by resecting a 2 x 2 cm square of parietal peritoneum around and covering the silastic patch. Foreign body reaction induced by the silastic patch and ischaemia caused by stitching are the stimuli for adhesion formation. The results showed a gradual progression in the type and tenacity of adhesion formation. The maximal degree of peritoneal reactive angiogenesis was noted between days 8 and 12, together with a decrease and a redistribution in the extent of adhesions. In the early stages, vascularization is part of the organization of adhesions while their extent is limited. Two parallel mechanisms take part in trauma healing: while omento-parietal adhesions are vascularized, new peritoneal tissue with its vascular network develops and covers the silastic surface and the traumatized area. This theory is supported by the presence of fibroblasts differentiating into mesothelial cells on day 8. Theoretically, a valid treatment in preventing adhesion formation should increase the peritoneal neoangiogenesis and the repair of peritoneal lesions, but at the same time prevent the vascularization of adhesions. The present model offers the possibility of testing the effect of any treatment or device for preventing post-operative adhesions in a relatively short time.

Determinants of reproductive prognosis after ectopic pregnancy.

The reproductive prognosis of 115 women desiring pregnancy who underwent surgery for ectopic pregnancy between 1985 and 1990 at the Clinica Luigi Mangiagalli, was analysed after a median follow-up period of 26 months (range 2-83). Probability of reproductive events was assessed by a product-limit model. Women who underwent surgery for ectopic pregnancy had a 54% probability of becoming pregnant (cumulative pregnancy rate, CPR), and a 36% probability of giving birth to a child (cumulative livebirth rate, CLB) during the 3 years after surgery. These percentages dropped with history of previous ectopic pregnancy (respectively 33%, P = 0.07, and 7%, P < 0.05). Increasing age at surgery and presence of adhesions in the contra-lateral tube seemed to be associated with poor reproductive prognosis (CPR = 40% and CLB = 12% for women aged > or = 35 years and CPR = 37% and CLB = 20% in women with adhesions in the contralateral tube), but these findings were not statistically significant. No association emerged between fertility and parity or type of surgery. The recurrence rate of ectopic pregnancy was 20%. No significant association emerged between recurrence of ectopic pregnancy and age, history of previous pregnancy, history of previous ectopic pregnancy, non-intact contra-lateral tube and salpingotomy.

Lack of effect of deflazacort, a novel glucocorticoid, on basal and TRH-stimulated prolactin and thyrotropin levels in healthy subjects.

The possible relationship between cortisol inhibition induced by deflazacort, a new glucocorticoid, and impairment of prolactin (PRL) and thyrotropin (TSH) secretion in healthy volunteers has been investigated. In 8 healthy subjects deflazacort pretreatment partly inhibited cortisol secretion but did not affect basal or TRH-stimulated secretion of PRL and TSH in comparison to placebo. After dexamethasone, there was the anticipated complete suppression of cortisol secretion, no change in PRL secretion, either in basal conditions or after TRH, and significant inhibition of the TSH response to TRH. No significant change in GH, aldosterone or renin secretion was observed after deflazacort or dexamethasone.

Serotonergic regulation of cortisol secretion in dogs.

The role of serotonin (5-HT) in the control of serum cortisol secretion was studied in 50 conscious beagle dogs. A significant rise in corticosteroids was observed after 1.5 and 3 mg/kg (P less than 0.01) iv fenfluramine, an indirect serotonergic agonist, as well as after 2 (P less than 0.05) and 3 mg/kg (P less than 0.01) iv quipazine, a direct agonist of 5-HT receptors. Both drugs exhibited a dose-related effect. A lower dose of fenfluramine, 0.5 mg/kg, was ineffective when administered iv, but raised serum cortisol (P less than 0.05) after direct injection into a lateral cerebral ventricle, through a chronically implanted brain cannula. The marked increases in corticosteroid concentration produced by the highest fenfluramine and quipazine doses were completely abolished by pretreatment with ketanserin, an antagonist of 5-HT2 receptors, which did not affect cortisol secretion when administered alone. These data suggest that brain serotonergic system plays a role in the control of cortisol secretion in conscious dogs.