The challenge of preoperative identification of uterine myomas: Is ultrasound trustworthy? A prospective cohort study.

PURPOSE: To correlate preoperative ultrasound examination with intraoperative and anatomo-pathological findings, including estimation of number, localization and size of uterine myomas, uterine diameters and volume. METHODS: A prospective study on 126 women undergoing surgery for uterine myomatosis at Campus Bio-medico between May 2013 and April 2014. The patients were divided into two groups: one submitted to hysterectomy and the other submitted to open myomectomy. Ultrasound scans were performed 1 day before surgery by the same expert sonographer. The number of myomas at ultrasound was compared to intraoperative visualization and anatomo-pathological findings. Wilcoxon Test was applied to compare data registered with each technique. RESULTS: There was no significant difference between the number of myomas recorded at visualization and at ultrasound, while there was a significant difference between visualization and anatomo-pathology (p = 0.0006). The analysis showed a non-significant difference between myoma number at ultrasound and at anatomo-pathology in the two groups, if the number of myomas was less than or equal to six. Contrarily, we observed a significant difference if the number of myomas was more than six (p = 0.003). CONCLUSIONS: Our data show that ultrasound has limits in identifying the exact number of uterine myomas. This mapping is particularly needed in a minority of patients with usually desiring fertility who need a debulking procedure due to the large size and/or number of myomas or myoma location causing symptomatology. In patients with more than six myomas, voluminous uterus, a second-level examination such as Magnetic Resonance may be helpful.

Influence of pneumoperitoneum pressure on surgical field during robotic and laparoscopic surgery: a comparative study.

PURPOSE: Studies on the influence of CO2 pneumoperitoneum on the abdominal cavity during robotic procedures are lacking. This is the first study to evaluate surgical field modifications related to CO2 pressure, during laparoscopic and robotic surgery. METHODS: Consecutive patients scheduled for laparoscopic or robotic hysterectomy were enrolled in the study. To evaluate the level of operative field visualization, a dedicated form has been designed based on the evaluation of four different areas: Douglas space, vesico-uterine fold and, bilaterally, the broad ligament. During the initial inspection, an assistant randomly set the CO2 pressure at 15, 10 and 5 mmHg, and the surgeon, not aware of the CO2 values, was asked to give an evaluation of the four areas for each set pressure. RESULTS: In laparoscopic group, CO2 pressure significantly influenced the surgical field visualization in all four areas analyzed. The surgeon had a good visualization only at 15 mmHg CO2 pressure; visualization decreased with a statistically significant difference from 15 to 5, 15-10 and 10-5 mmHg. In robotic group, influence of CO2 pressure on surgical areas visualization was not straightforward; operative field visualization remained stable at any pressure value with no significant difference. CONCLUSIONS: Pneumoperitoneum pressure significantly affects the visualization of the abdomino-pelvic cavity in laparoscopic procedures. Otherwise, CO2 pressure does not affect the visualization of surgical field during robotic surgery. These findings are particularly significant especially at low CO2 pressure with potential implications on peritoneal environment and the subsequent post-operative patient recovery.

Use of music to reduce anxiety during office hysteroscopy: prospective randomized trial.

STUDY OBJECTIVE: To investigate the effects of music on anxiety and perception of pain during office hysteroscopy. DESIGN: Prospective randomized trial (Canadian Task Force classification I). SETTING: Major university medical center. INTERVENTIONS: Three hundred fifty-six patients were enrolled between July 2012 and January 2013. Hysteroscopy was performed in a dedicated ambulatory room, using vaginoscopy and without any type of anesthesia. A Bettocchi hysteroscope 5 mm in diameter was used. All procedures were performed by the same surgeon, a gynecologist with special interest in hysteroscopy. MEASUREMENTS AND MAIN RESULTS: Data collected included age, body mass index, number of vaginal deliveries, educational achievement level, and history of endometrial surgery (curettage and/or hysteroscopy). For each patient, vital parameters such as blood pressure, heart rate, and respiratory rate were recorded 15 minutes before the procedure and during hysteroscopy after traversing the cervix. Wait time before surgery and the duration of the procedure were also recorded. A completed Italian version of the state anxiety questionnaire (State-Trait Anxiety Inventory) and a visual analog scale (VAS) were administered to each patient before and after the procedure. The t test and Mann-Whitney U test was used when appropriate to compare the 2 groups. Statistical significance was accepted at p = .05. During surgery, systolic blood pressure and heart rate were significantly lower in the music group compared with the no music group. Women in the music group experienced significantly lower anxiety after hysteroscopy and less pain during the procedure, and a significant decrease in both anxiety and pain scores after hysteroscopy. Postoperative State-Trait Anxiety Inventory form Y1 and VAS scores were significantly lower in the music group. CONCLUSION: Music can be useful as a complementary method to control anxiety and reduce perception of pain. The patient is more relaxed and experiences less discomfort.

Surgical treatment of rectovaginal endometriosis with extensive vaginal infiltration: results of a systematic three-step vagino-laparoscopic approach.

OBJECTIVE: Recto-vaginal endometriosis remains a surgical challenge. We propose a systematic surgical approach combining vaginal and laparoscopic steps for patients affected by deep endometriosis infiltrating the vaginal wall. STUDY DESIGN: This is a prospective observational study, performed at Campus Bio-Medico of Rome, University Teaching Hospital. All consecutive patients, from 2008 to 2011, affected by symptomatic deep recto-vaginal endometriosis with full thickness vaginal wall involvement, underwent a systematic surgical approach, based on three consecutive surgical steps: vaginal route, laparoscopic approach and final vaginal excision. All patients included in the study were scheduled for two years' follow-up with pelvic examination, transvaginal ultrasound and visual analog scale (VAS) evaluation of symptoms (dysmenorrhea, dyspareunia and chronic pelvic pain) at 3, 6, 12 and 24 months. RESULTS: Thirty-four patients were enrolled. No major complications were registered. Complications included superficial vascular lesions in two cases (5.9%), ureteral stenosis two weeks after surgery in one patient (2.9%), and bowel obstruction for paralytic ileus in one patient (2.9%). A de novo endometrioma was found at 12 months after surgery and a recurrent endometrioma was evident at 24 months. For all symptoms evaluated, there was a significant improvement within 3 months after surgery (p<0.05) and no statistically significant difference during follow-up (at 3, 6, 12 and 24 months). CONCLUSION: The proposed systematic surgical approach consisting of three consecutive steps could simplify the approach to deep endometriosis while at the same time increasing the quality of endometriosis surgery, with important benefit for the women affected.

A comparison of three different entry techniques in gynecological laparoscopic surgery: a randomized prospective trial.

OBJECTIVE: Laparoscopic entry techniques vary and still remain debated. We conducted a randomized control trial to compare three entry techniques. STUDY DESIGN: Women aged 18-70 years, nominated for laparoscopic surgery at University of Rome Campus Bio-Medico, were randomized into three different groups: Veress needle (VER), Direct trocar insertion (DIR) and Open technique (OP). For each group, minor complications (extra-peritoneal insufflation, trocar site bleeding, omental injury and surgical site infection), failed entry and time of entry of the main trocar were evaluated. Major complications were also considered. Between-group comparisons were performed using chi-square test. Significance P value was <0.05. RESULTS: A series of 595 consecutive procedures were included: 193 in the VER group, 187 in the DIR group and 215 in the OP group. Minor complications occurred in 36 cases: extraperitoneal insufflation (n=6) in the VER group only, site bleeding (n=2 in the VER group, n=2 in the DIR group and n=1 in the OP group), site infection (n=5 in the VER and n=6 in OP group), and omental injury (n=6 in the VER group and n=3 in the DIR group). Failed entry occurred in 4 cases of the VER group and 1 case of the DIR group. Mean time of entry was 212.4, 71.4 and 161.7s for the VER, DIR and OP groups respectively. Among major complications, one bowel injury resulted following the Veress technique. CONCLUSIONS: In our series, DIR and OP entry presented a lower risk of minor complications compared with VER. In addition, time of entry was shorter in DIR than with OP entry.

Quality of life in patients with endometrial cancer treated with or without systematic lymphadenectomy.

OBJECTIVE: To compare the quality of life (QoL) of women affected by endometrial cancer treated with surgery with or without systematic lymphadenectomy. STUDY DESIGN: Consecutive patients affected by stages I and II endometrial cancer and treated with surgery between 2008 and 2011 were selected. Eligible subjects were divided into two groups: Group A consisted of 36 patients who had hysterectomy plus bilateral salpingo-oophorectomy without lymphadenectomy; Group B consisted of 40 patients who had hysterectomy plus salpingo-oophorectomy plus pelvic and aortic lymphadenectomy. The EORTC Quality of Life Questionnaire-Cancer Module (QLQ-C30) and Quality of Life Questionnaire-Endometrial Cancer Module (QLQ-EN24) were administered to selected patients. All data were recorded and then analyzed using the scoring manual of the EORTC Quality of Life Group. RESULTS: Among symptom scales, only lymphedema gave a statistically significant difference among two groups, with a score of 10.64 ± 17.43 in Group A and 21.66 ± 24.51 in Group B (p=0.0285). The p value obtained comparing the "Global Health Status" (items 29 and 30) in Group A and in Group B was not statistically significant. CONCLUSION: Lymphadenectomy did not influence negatively global health status, but lymphadenectomy maintained its importance in determining a patient's prognosis and in tailoring adjuvant therapies. We therefore support its practice as part of the surgical procedure in patients affected by high risk endometrial cancer.

REM (risk of endometrial malignancy): a proposal for a new scoring system to evaluate risk of endometrial malignancy.

PURPOSE: It is often difficult to distinguish a benign endometrial disease from a malignancy and tools to help the physician are needed to triage patients into high and low risk of endometrial cancer. The purpose of this study was to obtain a predictive model to assess the risk of endometrial malignancy (REM) in women with ultrasound endometrial abnormalities. EXPERIMENTAL DESIGN: Women, between ages 45 to 80 years, diagnosed through ultrasound with endometrial abnormalities and scheduled to have surgery were enrolled on a prospective study at the Department of Gynaecologic Oncology of Campus Bio-Medico, University of Rome. Preoperative clinical, ultrasound and laboratory characteristics were taken into account. Logistic regression algorithm was used to categorize patients into low- and high-risk groups for endometrial cancer. RESULTS: A total of 675 patients were considered for the analysis: 88 with endometrial cancer and 587 with benign endometrial disease. We divided the patients into two groups: training set (TS) and verification set (VS). Preoperative age, symptom, HE4 levels, and ultrasound endometrial thickness were found statistically significant, and were included into a multivariate logistic regression model to determine the probability to have endometrial cancer. In the TS, REM reported 93.3% sensitivity and 97.1% specificity [positive predictive value (PPV), 0.83; negative predictive value (NPV), 0.98; AUC, 0.957; 95% confidence interval (CI), 0.908-0.984]. In the VS, REM reported 89.3% sensitivity and 95.4% specificity (PPV, 0.73; NPV, 0.98; AUC, 0.919; 95% CI, 0.829-0.970). CONCLUSIONS: Our data support the use of REM to triage patients into low- and high-risk groups for endometrial cancer, even if an external validation of the model is needed.

Can the preoperative HE4 level predict optimal cytoreduction in patients with advanced ovarian carcinoma?

OBJECTIVE: Optimal surgical outcome has been proved to be one of the most powerful survival determinants in the management of ovarian cancer patients. Actually, for ovarian cancer patients there is no general consensus on the preoperatively establishment of cytoreducibility. METHODS: Between January 2011 and June 2012 patients affected by suspicious advanced ovarian cancer, referred to the Department of Gynecology of Campus Biomedico of Rome were enrolled in the study. All patients had serum CA125 and HE4 measured preoperatively. After a complete laparoscopy to assess the possibility of optimal debulking surgery defined as no visible residual tumor after cytoreduction (RT=0), patients were submitted to primary cytoreductive surgery (Group A) or addressed to neoadjuvant chemotherapy (Group B). RESULTS: After diagnostic open laparoscopy, 36 patients underwent optimal primary cytoreductive surgery (Group A) and 21 patients were addressed to neoadjuvant chemotherapy (Group B). In our population, based on ROC curve, the HE4 value of 262pmol/L is the best cut-off to identify patients candidates to optimal cytoreduction with a sensitivity of 86.1% and a specificity of 89.5% (PPV=93.9% and NPV=77%). In addition, CA125 has a sensitivity of 58.3% and a specificity of 84% at cut-off of 414 UI/mL (AUC is 0.68, 95% C.I.=0.620 to 0.861). CONCLUSION: Our data indicate that preoperative HE4 is a better predictor for optimal cytoreduction compared to CA125. The best combination in predicting cytoreduction is HE4≤262 pmol/L and ascites <500mL with a sensitivity of 100% and a specificity of 89.5% (PPV=94% and NPV=100%).

The role of novel biomarker HE4 in endometrial cancer: a case control prospective study.

The aim of the study was to explore the clinical value of serum human epididymis secretory protein E4 (HE4) and CA125 in endometrial carcinoma. From January 2010 to April 2012, serum specimens were collected from consecutive cases of endometrial carcinoma and from cases of uterus benign disease (control group). The CA125 normal value is considered less than 35 U/mL. Two HE4 cutoff are considered: less than 70 pmol/L and less than 150 pmol/L. The specificity analysis was performed using the Mann-Whitney test for the CA125 and HE4 series. The level of statistical significance is set at p < 0.05. The sensitivity of CA125 in detecting endometrial cancer is 19.8 %, whereas the sensitivity of HE4 is 59.4 and 35.6 % for 70 and 150 pmol/L cutoff, respectively. Thus the specificity of HE4 is 100 % (positive predictive value = 100 %, negative predictive value = 71.52 and 61.31 % considering the two HE4 cutoff, respectively), whereas the CA125 specificity is 62.14 % (positive predictive value = 33.9 %, negative predictive value = 44.14 %) in detection of endometrial cancer. Combining CA125 and HE4, the sensitivity to detect endometrial cancer is 60.4 and 34.6 %, at HE4 cutoff of 70 and 150 pmol/L, respectively, with a specificity of 100 %. HE4 may be a new tool for preoperative evaluation and postoperative surveillance of endometrial cancer patients, with a positive predictive value = 100 %. HE4 at cutoff of 70 pmol/L yields the best sensitivity and specificity.

Epidemiology and risk factors of amniotic band syndrome, or ADAM sequence.

Amniotic band sequence (ABS) is the term applied to a wide range of congenital anomalies, most typically limb and digital amputations and constriction rings, that occur in association with fibrous bands (1). These alterations may be associated or not with cutaneous and visceral abnormalities.This work, which is a literature review, examines several studies that relate to cases of amniotic band syndrome (SBA). In particular, our attention was focused on the causes and pathogenesis of the SBA. These for the most part are still unknown, but from what we observe in different jobs, are due to a mechanism of vascular damage. Therefore in this paper we examine chemical risk factors, like smoking, drug use, maternal hyperglycemia, mechanical risk factors such as the puncture of the amniotic sac after amniocentesis. We also speak of the altitude as a risk factor related to blood pressure, of the increased incidence of disease in primigravid, in women with a low level of education, in which the pregnancy was not planned, and then we talk of a higher incidence in young fathers and of the role of familiarity.

Prenatal diagnosis of a fetus with a ring chromosome 20 characterized by array-CGH.

OBJECTIVE: a fetus with a ring chromosome 20 is presented. METHODS: at 16 weeks' gestation, ultrasound examination evidenced no apparent structural malformation. Amniocentesis was performed for maternal anxiety. RESULTS: chromosome analysis identified a ring chromosome 20 and array-CGH demonstrated that the ring including micro-deletion of the short arm in 20p13, that was extended for about 632.2 kb and a micro-deletion of the long arm in 20q13.33 region. CONCLUSION: this is the first case of a ring chromosome 20 diagnosed prenatally. This reinforces the importance of offering amniocentesis with a-CGH to make more accurate prenatal diagnosis.

Thyroid physiology and common diseases in pregnancy: review of literature.

Thyroid diseases are common during pregnancy and an adequate treatment is important to prevent adverse maternal and fetal outcomes. Subclinical diseases are very frequent but not easily recognized without specific screening programs. In this article we try to summarize the knowledge on the physiologic change of the thyroid and pathological function during pregnancy; we also try to describe the best way of diagnosis and treatment of thyroid dysfunction.

Intraoperative contact ultrasonography during open myomectomy for uterine fibroids.

OBJECTIVE: To evaluate the benefit of intraoperative ultrasound applied directly to the uterine serosa during surgery for uterine fibroids. DESIGN: Prospective study. SETTING: University hospital, tertiary care. PATIENT(S): Women admitted for open myomectomy due to uterine fibroids. INTERVENTION(S): Intraoperative ultrasound (IUS) and intraoperative palpation were performed to detect the number of residual fibroids at the end of surgery, then the number of fibroids was recorded at anatomopathology examination. MAIN OUTCOME MEASURE(S): Residual fibroids detected at IUS and intraoperative palpation at the end of open myomectomy. RESULT(S): The comparison between the number of residual fibroids at IUS and at intraoperative palpation was statistically significant. CONCLUSION(S): Intraoperative ultrasound is more efficient than palpation in detecting residual leiomyomata at the end of open myomectomy.

A gastrointestinal stromal tumor presenting as a pelvic mass: A case report.

Gastrointestinal stromal tumors (GISTs) represent 0.1-1% of gastrointestinal malignancies. They are commonly asymptomatic and found incidentally during laparoscopy, surgical procedures or radiological studies. Diagnosis is based on histology and immunohistochemistry, while the role of imaging studies is not diagnosis-specific. We present the case of a 38-year-old patient complaining of an increase in her abdominal circumference. Consequently, a vaginal examination, a transvaginal ultrasound and an MRI of the abdomen and pelvis were carried out. It should be noted that a preoperative diagnosis of GISTs is uncommon, due to the rarity and many presentations of the disease. Ultrasound and MRI are not able to differentiate a GIST from ovarian cancer. However, if a pelvic mass is detected, the possibility of a non-gynaecological tumor has to be considered.

Update on lymphadenectomy in early and advanced ovarian cancer.

PURPOSE OF REVIEW: Pelvic and para-aortic lymphnode sampling is an integral part of the staging system of ovarian cancer. The issue concerning lymphadenectomy in the management of the disease is still debated, however. The purpose of this paper is to review the role of systematic lymphadenectomy in patients affected by early and advanced-stage ovarian cancer. RECENT FINDINGS: Some retrospective studies have revealed an increased survival rate in early-stage ovarian cancer patients after lymphadenectomy. Recently, the first randomized prospective trial, on lymphadenectomy in advanced-stage disease, was published. It evidenced an improvement in progression-free survival in patients who had undergone lymphadenectomy. SUMMARY: Systematic lymphadenectomy has a diagnostic value in early-stage ovarian cancer, thanks to the possibility of accurate clinical staging. As up to 22% of women, who were presumed to have early-stage ovarian cancers, are upstaged during the lymphadenectomy procedure, accurate staging can help to avoid unnecessary postoperative chemotherapy. In patients affected by advanced ovarian cancer, systematic lymphadenectomy statistically significantly improves progression-free survival and reduces recurrence rates despite a higher incidence of postoperative complications. As improvement of overall survival is not statistically significant, further studies are needed to balance risks and benefits of systematic lymphadenectomy in advanced-stage disease.