Expanding the limits of vaginal surgery: Transvaginal vesicolithotomy for an incarcerated procidentia: A case report and literature review.

Bladder stones are rare in women. This report presents the case of a woman with a massive bladder stone and incarcerated procidentia. The 75-year-old woman presented to the outpatient clinic with procidentia and recurrent urinary tract infections. Preoperative imaging led to the diagnosis of cystolithiasis. After multidisciplinary counseling the patient underwent a vaginal hysterectomy with bilateral oophorectomy and transvaginal vesicolithotomy. A bladder biopsy was performed to rule out any malignancy. After three days, the patient was discharged with a Foley catheter; 15 days later, the bladder catheter was removed. She had an uncomplicated postoperative course. The presence of cystolithiasis and pelvic organ prolapse remains a challenge both in diagnosis and in treatment. The literature lacks solid evidence on the optimal management of these cases. Although there are no recommendations or consensus for their treatment, it seems that the one-step vaginal approach is preferable to the abdominal route.

The Study of Microbiome of the Female Genital Area in Relation to Pelvic Floor Dysfunction: A Systematic Review.

INTRODUCTION AND HYPOTHESIS: The aim of this article is to present a systematic literature review focused on microbiome diversity in women experiencing pelvic floor dysfunction. METHODS: Utilizing PubMed/MedLine and Scopus, 25 pertinent studies were meticulously selected for this review. RESULTS: A key theme identified is the potential of microbiomes as diagnostic tools. The findings consistently highlight Lactobacillus as recurrent microbiota. Additionally, Gardnerella, Streptococcus, Prevotella, Aerococcus, Staphylococcus, Proteus, and Bifidobacterium species were frequently observed. This suggests the influential role of these microorganisms in shaping female urological and reproductive health. A deeper understanding of these predominant bacterial genera could offer invaluable insights into healthy physiological states and various disorders. The complex relationship between microbial compositions and diverse health conditions paves the way for novel diagnostic and therapeutic approaches. As we further explore the complexities of microbiomes, their role becomes increasingly crucial in transforming women's health care. CONCLUSIONS: These findings emphasize the need for personalized care, integrating the microbiome into a comprehensive health assessment and treatment framework. This review lays the groundwork for future medical strategies where the microbiome is a pivotal element in both preventive and therapeutic care.

Sonographic vascularity indices' study in ectopic pregnancies, after methotrexate treatment.

Objectives: Ectopic pregnancy is a crucial problem in Gynaecology. Previous studies concerning the medical treatment of ectopic pregnancies, have used only ß-hCG (beta- human chorionic gonadotropin) values, to monitor the successful response to treatment. The current study was a PhD (Doctorate of Philosophy) thesis research, which has evaluated the vascularity indices' changes. The values of vascularity indices could be used, in combination with ß-hCG values and the gestational sac dimensions, in every medically treated ectopic pregnancy. The results could be used, for monitoring the course of all medically treated ectopic pregnancies. Study design: 72 women of reproductive age have taken part in the study. They have been admitted due to secondary amenorrhea, positive ß-hCG test, with or without vaginal bleeding. The participants took part voluntarily and were allocated in two groups. The first group consisted of 37 women, who were possible normal or threatened intrauterine pregnancies (control group). The second group consisted of 35 women, whose sonographic findings suggested ectopic pregnancy, and qualified for methotrexate treatment (study group). Sonographic control and measurement of the vascularity indices (PI - RI) (Pulsatility index - Resistance index) of the ectopic pregnancy was conducted, in combination with ß-hCG values for every admitted or outpatient woman.The dimensions of the gestational sac of both groups were measured during four consecutive periods of time. The control group has shown progressively increasing sac dimensions, whereas, in the study group sac dimensions were more stable or growing gradually smaller. The exception where those ectopic pregnancies that ruptured, which have also shown a gradual enlargement of the sac. Results: The endometrial thickness of the study group was gradually decreasing up to 76 % per day, and the more eminent, but not statistically significant decrease, was observed in the single dose regiment of methotrexate. Moreover, the quantitative PI and RI were evaluated, and the main finding was that there were no statistically significant decreases in any of the two groups. Concerning the study group, methotrexate treatment was successful, since there was a decrease of up to 80 %, whereas a clearly significant correlation was found between the ß-hCG levels and the RI. Conclusion: The vascularity indices could be used safely, in combination with ß-hCG levels and the decrease of the gestational sac dimensions, as criteria for the evaluation of response to medical treatment of ectopic pregnancies.

Lower Urinary Tract Symptoms in Greek Women After Menopause: The LADY Study.

INTRODUCTION AND HYPOTHESIS: The genitourinary syndrome of menopause (GSM), apart from symptoms related to vulvovaginal atrophy (VVA), also consists of lower urinary tract symptoms (LUTS). Based on the common embryological origin of the genital and lower urinary system, the presence of estrogen receptors, and the high prevalence of VVA and LUTS in the menopausal population, the two conditions can coexist. This study is aimed at investigating the prevalence and risk factors of LUTS in a sample of Greek peri- and postmenopausal women. METHODS: Four hundred and fifty (450) women, aged 40-70 years, attending three outpatient gynecology clinics for routine examination, completed a structured interview and responded to a validated questionnaire (International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms, ICIQ-FLUTS). RESULTS: Urinary urgency or frequency affected 51.6% and dysuria 43.6% of the participants. Mild urgency or frequency was described by 25.6%, moderate by 14.4%, and severe by 11.6% of the women. Mild dysuria was reported by 26.26%, moderate by 5.8%, and severe by 11.6%. Age, weight, BMI, and number of pregnancies and abortions correlated with a higher ICIQ-FLUTS score. Women with moderate/severe symptoms of VVA, such as irritation, a burning sensation, and pruritus of the vulva or vagina, had a higher ICIQ-FLUTS score than women without such symptoms (beta coefficient 2.42, CI 1.204, 3.635, p < 0.001). CONCLUSIONS: Lower urinary tract symptoms are very common among peri- and postmenopausal women and are linked to symptoms of VVA. Our data support the need for prompt evaluation of women transitioning to menopause, as these symptoms compromise the quality of life.

Cuff meshoma post-laparoscopic sacrocolpopexy: vaginal-endoscopic mesh excision.

INTRODUCTION AND HYPOTHESIS: The objective was to present endoscopic images of a meshoma and describe the complete excision of a complicated mesh after sacrocolpopexy (SCP) using a combined vaginal-endoscopic technique. METHODS: We present a video documentation of an innovative technique. A 58-year-old woman was referred with painless, foul-smelling vaginal discharge and recurrent vaginal mesh erosions. She had undergone a laparoscopic SCP 12 years ago and her symptoms had begun 5 years ago. A pre-operative MRI scan revealed a cuff meshoma and an inflammatory sinus around the mesh extending from the cuff to the sacral promontory. Under general anesthesia, a 30° hysteroscope was inserted transvaginally into the sinus, where the retained mesh was seen in the form of a shrunken meshoma, and then the mesh arms were recognized extending cephalad into a sinus tract. Under direct endoscopic visualization, the mesh was carefully mobilized at its highest point with the use of laparoscopic grasping forceps. Then, the mesh was dissected with hysteroscopic scissors in close proximity to the bone. No peri-operative complications were recognized. RESULTS: A combined vaginal-endoscopic approach was successfully used to remove an eroded mesh and cuff meshoma after SCP. CONCLUSION: This procedure offers a minimally invasive, low-morbidity, and rapid-recovery approach.

Surgical results in POP/UI surgery after using PVDF compared to other materials. A systematic review and meta-analysis.

OBJECTIVES: Synthetic materials have been used for the surgical treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP). During the last 25 years, these materials were composed mostly of polypropylene (PP), whereas recently the use of polyvinylidene difluoride (PVDF) is of increasing interest due to its characteristics. This study aimed to compare the results after SUI/POP surgery using PVDF versus PP materials by synthesizing the data of relevant existing literature. STUDY DESIGN: This systematic review and meta-analysis included clinical trials, case-control studies, or cohort studies written in the English language. The search strategy included the electronic databases MEDLINE, EMBASE, and Cochrane, and grey literature (congresses IUGA, EUGA, AUGS, FIGO). All studies have to provide numeric data or odds ratios (OR) of developing a specific outcome in surgeries with PVDF compared with outcomes of other used materials. No restrictions of race or ethnicity were applied, nor chronological restrictions. Exclusion criteria were studies that included patients with cognitive impairment, dementia, stroke, or central nervous system trauma. All studies were screened by two reviewers, initially by title and abstract, and afterward by full text. Disagreements were resolved through mutual consent. All studies were assessed for their quality and bias risk. Data were extracted using a data extraction form formulated in a Microsoft Excel spreadsheet. Our results were divided into studies dealing only with SUI patients, studies dealing only with POP patients, and cumulative analysis of variables expressed in both SUI and POP surgery. The primary outcomes were the rates of post-operative recurrence, mesh erosion, and postoperative pain after surgery with PVDF compared to PP. The secondary outcomes were post-operative sexual dissatisfaction, overall satisfaction rates, hematoma, urinary tract infection, de novo urge incontinence, and reoperation rate. RESULTS: No differences in the post-operative rates of SUI/POP recurrence, mesh erosion, and pain were found after surgery with PVDF vs surgery with PP. Patients after SUI surgery with PVDF tapes had statistically significant lower rates of de-novo urgency compared to the PP group [OR = 0.38 (0.18, 0.88), p = 0.01]; patients after POP surgery with PVDF materials had statistically significant lower rates of de-novo sexual dysfunction compared to the PP group [OR = 0.12 (0.03, 0.46), p = 0.002]. CONCLUSIONS: This study provided evidence that the use of PVDF in SUI/POP surgeries could be a valid alternative to PP. However our results are limited by uncertainty due to the overall low quality of the existent data. Further research and validation would contribute to better surgical techniques.

Maternal diabetes and the role of neonatal reticulocyte hemoglobin content as a biomarker of iron status in the perinatal period.

Aims: We aimed to evaluate the effects of maternal diabetes on neonatal iron status, measuring erythrocyte indices including hemoglobin, hematocrit, reticulocytes, mean corpuscular volume (MCV), percent (%) hypochromia, ferritin, and additionally mean reticulocyte hemoglobin content (MCHr) as an early marker of iron deficiency, and examine the association between neonatal MCHr, red cell indices, and ferritin. Materials and Methods: We conducted a hospital-based prospective cohort study in a tertiary neonatal unit of a University Hospital from 2018 to 2020. We enrolled 126 maternal-infant pairs of mothers whose pregnancy was associated with diabetes and 74 maternal-infant pairs from uncomplicated pregnancies. Erythrocyte indices were analyzed within the first twelve hours after birth. Erythrocyte parameters were compared between infants of the diabetes and the non-diabetic group. We examined the correlation of the neonatal MCHr with perinatal characteristics, including gestation, birth weight, maternal body mass index, the erythrocytic indices, maternal diabetes, maternal obesity, prematurity, small-for-gestational-age status, maternal preeclampsia, and maternal anemia. Finally, we evaluated the discordance between neonatal MCHr and neonatal ferritin. Results: Infants of the diabetes group had a significantly lower MCHr (32.6 pg vs. 34.2 pg, p=0.003) compared with infants of uncomplicated pregnancies. Neonatal MCHr was significantly correlated with maternal hypochromia (r=-0.237, p=0.004) and neonatal MCV (r=0.674, p<0.001). Neonatal MCHr was significantly associated with maternal diabetes [standardized coefficients 0.21, 95% confidence interval (CI) 0.05-0.58, p=0.003) and maternal preeclampsia (standardized coefficients 0.17, 95% CI 0.02-0.92, p=0.019), after adjusting for maternal anemia, maternal obesity, prematurity, and small-for-gestational-age status. Those results were consistent also when analyzing maternal-infant pairs with pre-existing diabetes, and maternal-infant pairs with gestational diabetes. There was significant discordance between neonatal MCHr and neonatal ferritin (p=0.001). Conclusions: MCHr was significantly lower in infants of mothers whose pregnancy was associated with diabetes compared with infants of non-diabetic mothers and correlated with neonatal and maternal red cell indices of iron deficiency. Since there was significant discordance between neonatal MCHr and ferritin during the first postnatal day, it is possible that MCHr could be used as a screening test for iron deficiency, especially in infants.

Risk factor analysis in women who underwent trial of labor after cesarean section: a multicenter study in Germany

Objective: Rising caesarean delivery (CD) rates throughout the world are accompanied with high rates of severe maternal complications. The aim of the present study was to analyze the outcome of trial of labor after caesarean section (TOLAC) in a Western population and identify factors associated with the success of vaginal birth after caesarean section (VBAC). Material and Methods: A retrospective study was performed at two large obstetric departments in Germany from 2008 to 2018. Women with singleton pregnancies, a history of only one previous CD with a low transverse incision, a viable fetus in cephalic presentation, and gestational age >32 weeks were included in the study. The characteristics and outcome of successful VBAC and failed TOLAC were compared. A subgroup analysis addressed gestational age, interpregnancy interval, fetal macrosomia, body mass index, and maternal age. Results: Of 1,546 patients, 62.3% achieved VBAC while 37.7% had a secondary CD. Independent factors associated with the success of TOLAC were a history of vaginal birth in previous pregnancies (p<0.001) and the use of oxytocin (p<0.001), whereas preterm birth between gestational week 32 and 37 signified a higher risk of failed TOLAC (p=0.04). The success of VBAC did not differ significantly for patients older than 40 years of age, those with a shorter interpregnancy interval than 12 months, and fetal macrosomia with birth weight exceeding 4000 grams. Maternal and neonatal outcomes were poorer in women with failed TOLAC. Conclusion: Nearly two thirds of women with a history of CD achieve VBAC in Germany. Previous vaginal birth and the augmentation of labor with oxytocin are positively associated with the achievement of VBAC and no major perinatal complications. The decision to have a TOLAC should be encouraged in the majority of patients. Further studies are needed to evaluate the feasibility of TOLAC in preterm delivery.

Surgical excision of vaginal cysts presenting as pelvic organ prolapse: a case series.

Vaginal cysts are rare, benign, predominantly cystic lesions of the anterior vaginal wall, with a prevalence of 1 in 200 women. Large vaginal cysts can occasionally present as symptomatic genital prolapse; these cases may be challenging to diagnose due to their rare clinical appearance. In symptomatic large vaginal cysts, surgical excision via vaginal approach is the recommended management with good anatomical results and patient satisfaction. The series of three consecutive adult women were referred for bothersome bulging prolapse. They were found to have a sizeable vaginal cyst at the anterior wall, associated with other symptoms. All patients (mean age 37±8.5 years) underwent total trans-vaginal surgical excision of the lesion. They were followed up in the out-patient department at six weeks and six months with no recurrences mentioned. Vaginal cysts are usually solitary, small, and asymptomatic; however, they can increase in size, easily mimic other pathologies, and are misdiagnosed as cystocele. Therefore, complete surgical vaginal excision of the symptomatic vaginal lesion is feasible and constitutes a good management option.

The use of urinary biomarkers in the diagnosis of overactive bladder in female patients. A systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), and other proteins are related to overactive bladder (OAB) syndrome, as their urinary concentrations are significantly different from those of the general non-OAB population. This review aims to systematically assess whether NGF, BDNF, and other urinary by-products can be used as potential biomarkers to manage women with OAB. METHODS: This was a systematic review and metanalysis that was conducted according to PRISMA guidelines. Studies were identified by electronic search of Medline, Scopus, ScienceDirect, Embase, and Cochrane Register until October 2020. The included studies investigated the correlation of OAB with NGF, BDNF, and other potential biomarkers in symptomatic women and their controls. RESULTS: Twelve studies (581 female OAB patients and 394 female controls) were included. Urinary NGF, NGF/Cr, BDNF/Cr, ATP/Cr, and PGE2/Cr ratios were identified as potential biomarkers in female OAB patients. Results of the meta-analysis indicated that uNGF [standard mean difference (SMD) 1.45, 95% CI 0.53-2.36], NGF/Cr ratio (SMD 1.23, 95% CI 0.67-1.78), BDNF/Cr ratio (SMD 0.78, 95% CI 0.006-1.50), and BDNF/Cr ratio (RR 0.78, 95% CI 0.006-1.50) were increased in female OAB patients compared to healthy controls, whereas no difference was found for the PGE2/Cr and ATP/Cr ratios. Current data are inadequate to assess any other potential biomarkers, such as urinary MDA, ATP, and cytokines, in the management of OAB in female patients. CONCLUSIONS: uNGF, NGF/Cr, and BDNF/Cr ratio could be used in the assessment of female OAB patients. Further studies are needed to specify OAB urinary titer levels in OAB subgroups and healthy women and their potential as diagnostic and management tools in OAB women.

Functional and Reproductive Outcomes Following Surgical Management of Congenital Anomalies of the Cervix: A Systematic Review.

OBJECTIVE: The purpose of this systematic review was to evaluate surgical treatment for malformations of the cervix in terms of short- and long-term postoperative function and relevant reproductive outcomes. DATA SOURCES: International Prospective Register of Systematic Reviews (ID No CRD42019128899). Electronic databases were searched for eligible studies up to October 2019 on Medline/PubMed (1966-2019), Scopus/Elsevier (1950-2019), and Google Scholar (up to 2019). Search terms included "congenital cervical malformations/anomalies," "uterocervical aplasia/dysgenesis/agenesis," "cervical aplasia/dysgenesis/ agenesis," "müllerian anomalies/dysgenesis/agenesis," "utero-vaginal anastomosis," "cervical reconstruction," "uterocervical reconstruction/canalization," "cervical canalization," "reproductive/pregnancy/functional outcome," "menstruation," "pregnancy," and "regular periods." METHODS OF STUDY SELECTION: Studies were chosen and included with clear description of preoperative diagnosis via sonography, magnetic resonance imaging, and surgical confirmation; assessment and clear description of gynecologic anatomy and any concomitant anomalies; meticulous description of the operative technique; follow-up of at least 6 weeks postoperatively; and postoperative end points including menstrual and reproductive outcomes. We included randomized controlled trials, case-control studies (both prospective and retrospective), and case reports. Data registries, studies without clearly described primary or secondary outcomes, and studies not in the English language were excluded from the analyses. TABULATION, INTEGRATION, AND RESULTS: The literature search returned 745 studies; 546 records were initially excluded (397 not related to the topic, 15 not related to humans, 134 non-English language); 111 full-text articles were further excluded (patients underwent hysterectomy or no surgery); 88 studies with a total of 249 patients were suitable for analysis. Almost all patients had preoperative amenorrhea (248/249, 99.6%). Postoperatively, of 249 patients, resolution of menstruation occurred in 228 patients (91.6%), and hysterectomy was performed in 22 patients (8.8%); overall, there were 30 (12.0%) conceptions that resulted in 27 (10.8%) viable and 24 (9.6%) term pregnancies. Indications for hysterectomy were stenosis of the genital tract and sepsis. Coexisting vaginal agenesis and use of full thickness skin graft for creation of neocervix was associated with negative surgical outcomes. CONCLUSION: This review suggests that conservative surgical approaches result in better clinical and reproductive outcomes than more aggressive reconstructive surgeries for patients with malformations of the cervix.

Transperineal excision of a sizeable angiofibroma of the ischiorectal fossa. A case report.

Cellular angiofibroma is a recently described rare benign soft-tissue tumor more commonly presenting in middle-aged women, often mimicking malignancy. The vulva is most common location. Complete local excision is the best curative treatment and usually there is no recurrence after surgery. We describe a 49-year-old woman with a painless tumor in the left ischiorectal fossa. It was a random finding in a routine computed tomography (CT) scan after resection of ear melanoma 3 years previously. Ultrasonography showed a solid mass, and further magnetic resonance imaging (MRI) suggested a rhabdomyosarcoma. Altogether, these findings indicated malignant disease. An uncomplicated simple excision of the tumor was done in the operating theatre. The mass measured 7×5×5 cm and the histopathological examination found that it was a cellular angiofibroma, a benign lesion. There were no postoperative complications. This case report highlights the need for multidisciplinary team management of rare tumors such as cellular angiofibromas.

Current knowledge about the management of congenital cervical malformations: a literature review.

The prevalence of congenital cervical agenesis or dysgenesis ranges from 1/80,000 to 1/100,000, and in about 50% of these cases it coexists with congenital vaginal agenesis. This narrative review summarizes the contemporary knowledge in the field of conservative surgical restoration of the reproductive tract. The management of congenital cervical malformations aims to [1] provide relief from the obstructive symptoms, [2] establish normal sexual function, and [3] preserve the uterus for future fertility. In cases of cervical agenesis and vaginal aplasia, the surgical approach involves the creation of neovagina, the creation of neocervix, and then subsequent restoration of the continuity of the genital tract. In cases where vagina is not congenitally absent, the surgical approach involves either a direct uterovaginal anastomosis or initial creation of neocervix and then subsequent restoration of the continuity of the genital tract. The neocervix can be surgically created with small intestinal submucosa, split-thickness skin graft, full-thickness skin graft, peritoneal flap, or vaginal mucosa lined with a polytetrafluoroethylene graft. Most of the published cases report long-term menstruation and sporadic pregnancies. Conservative surgery of cervical congenital malformations could serve as a first-line treatment. Sexual function and menstruation are established in the majority of patients. Extirpatory surgery may be preserved for surgical failures after initial restoration of the continuity of uterus-cervix-vagina or in cases with more complex anatomy.

The Outcome of Fertility-Sparing and Nonfertility-Sparing Surgery for the Treatment of Adenomyosis. A Systematic Review and Meta-analysis.

OBJECTIVE: The purpose of this systematic review was to identify the operative issues and specific dysmenorrhea and menorrhagia outcomes in women who had undergone fertility-sparing surgery, as well as determine the expected outcome for extirpative surgery. DATA SOURCES: PROSPERO (ID no. 125692). Search was conducted for eligible studies up to March 31, 2019, on MEDLINE/PubMed (1966-2019), Scopus/Elsevier (1950-2019), and Google Scholar (up to 2019). The search terms applied for the search strategy were as follows: adenomyosis, adenomyomas, uterus-sparing surgery, fertility-sparing surgery, pain, dysmenorrhea, menorrhagia, uterine volume, adenomyotic volume, case-control studies, cohort studies, and prospective studies. METHODS OF STUDY SELECTION: A total of 443 studies were initially identified. Exclusion criteria was as follows: (1) inadequate description of preoperative adenomyosis or absence of postoperative histology confirmation of adenomyosis, (2) no statement of use of a standardized instrument for measurement of pain, bleeding, or adenomyotic/uterine volume, (3) follow-up <12 months postoperatively, (4) study population <20 women, and (5) non-English language. TABULATION, INTEGRATION, AND RESULTS: Nineteen studies with a total of 1843 patients with adenomyosis were included. Twelve studies were further analyzed in the meta-analysis. Complete excision of adenomyosis was associated with improvement in pain, menorrhagia, and reduction of uterine volume by a factor of 6.2, 3.9, and 2.3, respectively; the partial excision of adenomyosis was associated with improvement in pain, menorrhagia, and reduction of uterine volume by a factor of 5.9, 3.0, and 2.9, respectively; the studies with a mixed volume of patients with complete and partial excision of adenomyosis reported improvement in pain, menorrhagia, and reduction of uterine volume by a factor of 4.0, 6.3, and 5.1, respectively. CONCLUSION: The surgical treatment of adenomyosis results in the satisfactory control of pain and bleeding, as well as in the reduction of uterine volume. Further research is warranted to investigate the long-term control of symptoms to identify any parameters related to the recurrence of adenomyosis, as well as to compare the conservative surgical treatment of adenomyosis with other treatment options.

Predictive factors of Hyperemesis Gravidarum: A systematic review.

PURPOSE: Hyperemesis gravidarum (HG) is the main cause of hospitalization during the first trimester of pregnancy. Although it has been associated with serious complications, little is known about its predictive factors. The aim of this systematic review was to search for and critically appraise the studies that investigate the predictive factors for HG. METHODS: Search strategy included PubMed, CENTRAL and EMBASE databases (till December 2017). All studies examining risk factors for HG were included. Screening of available studies was carried out by two reviewers, as well as the quality assessment of the included studies, based on the Newcastle-Ottawa Scale for observational studies. RESULTS: The search located 308 articles, of which 14 observational studies (four low-, eight medium- and two high-quality), involving 1400 women who met the eligibility criteria. In four studies, there was no association between Helicobacter (H.) Pylori infection and HG, in contrast to two studies which demonstrated such an association. Pre-pregnancy body mass index (BMI), adipose tissue, maternal age, leptin, ghrelin, beta-chorionic gonadotropin (ß-hCG), total (T4) and free thyroxine (fT4) correlated with HG in various studies, and could be considered as predictive markers. Regarding the high-quality evidence, a cohort study associated leptin and nephatin-1 with HG, whereas a cross-sectional study found no association between H. pylori infection and HG. CONCLUSIONS: More studies of high quality and adequate sample size have to be carried out to identify the predictive factors for HG.

Clinical presentation and management of atypical polypoid adenomyomas: Systematic review of the literature.

The aim of this study is to investigate clinical behavior of Atypical Polypoid Adenomyomas (APAs) and to describe the rates of (i) recurrences, (ii) their association with endometrial hyperplasia and (iii) with endometrial cancer. All studies that reported the outcome of the clinical management of patients with histologically proven APAs were included. A review of the English literature since 1970 was systematically performed (PROSPERO No CRD42018080003). A quality assessment tool was used to assess the scientific value of all the studies. Main contribution of this review is the proposal of new definitions regarding the clinical behaviour of APAs: Cure, Residual or persistent APA, Recurrent APA, Synchronous endometrial hypeprasia, Subsequent endometrial hyperplasia, Synchronous endometrial cancer, and Subsequent endometrial cancer, are terms elucidated in the context of this review. Their rates after initial diagnosis and treatment of APAs are presented as the main outcome measures. 63 studies and 350 patients were included in the systematic review. Fifteen studies that reported 208 patients who did not have hysterectomy as initial treatment were included for further quantitative assessment. The cure rate of APAs in cases where uterus was preserved was 51.0% (106/208), the residual rate of APA was 20.2% (42/208), the recurrence rate of APA was 35.1% (73/208), the concurrent endometrial hyperplasia rate was 7.2% (15/208), the concurrent endometrial cancer rate was 4.8% (10/208), the subsequent endometrial hyperplasia rate of was 6.7% (14/208), and the subsequent endometrial cancer rate of was 10.1% (21/208). Moreover, 56.4% of the patients with APA who opted for uterine sparing treatment and wished to conceive they had a viable pregnancy. The use of hysteroscopic techniques at the initial management of APAs is related with significantly decreased residual rate, and signicantly increased cure rates. In this review, the recurrence rate and the association of APAs with cancer appeared to be higher compared to the previously reported in the literature rates. APAs comprise an intriguing clinical entity that needs individualized treatment, considering the increased association to serious gynecological diseases. Hysterectomy is the appropriate treatment, however uterus-sparing surgery can be offered to selected patients.

Three-dimensional ultrasound in the diagnosis and the classification of congenital uterine anomalies using the ESHRE/ESGE classification: a diagnostic accuracy study.

STUDY OBJECTIVE: To estimate the diagnostic accuracy of three-dimensional ultrasonography (3D US) compared to hysteroscopy/laparoscopy, in the investigation of uterine congenital anomalies using the ESHRE/ESGE classification of female genital tract congenital anomalies. DESIGN: Prospective blind, comparative, cohort study. SETTING: University Tertiary Hospital and affiliated private Hospital. PATIENTS AND METHODS: Sixty-two women consecutively referred with a suspected diagnosis of uterine congenital anomalies. The ESHRE/ESGE classification of congenital anomalies of the female genital tract was used for the description of abnormal findings. INTERVENTIONS: All patients underwent (1) 3D US and (2) hysteroscopy with laparoscopy to establish the final diagnosis. RESULTS: Concordance between 3D US and hysteroscopy with laparoscopy about the type and the classification of uterine anomaly was verified in 61 cases, including all those with septate uterus, dysmorphic uterus, bicorporeal, hemi-uterus or unicorporeal, and aplastic uterus and one out of two with normal uterus. For the diagnosis of septate uteri, which was the most common anomaly, the sensitivity of 3D US was 100%, the specificity was 92.3%, the PPV was 98% and the NPV was 100%, with kappa index 0.950. For bicorporeal, dysmorphic uterus, hemi-uteri or unicorporeal and aplastic uterus the sensitivity, specificity, PPV and NPV were all 100% with K = 1.00. Overall, 3D US showed perfect diagnostic accuracy (Kappa index = 0.945) in the detection of congenital uterine anomalies. CONCLUSION: 3D US appears to be a very accurate method for the diagnosis of congenital uterine anomalies.

Split Hand Foot Malformation Syndrome: A Novel Heterozygous FGFR1 Mutation Detected by Next Generation Sequencing.

BACKGROUND: Split-hand/foot malformation syndrome is a rare, clinically and genetically het-erogeneous group of limb malformations characterized by absence/hypoplasia and/or median cleft of hands and/or feet. It may occur as an isolated abnormality or it may be associated with a genetic syn-drome. CASE REPORT: In the present case, isolated split-hand/split-foot malformation was diagnosed by prenatal ultrasound at 24 weeks in a male singleton fetus, with deep median cleft of the right hand, syndactyly and hypoplasia of phalanges in both hands, and oligodactyly of the right foot. During consultation, the father of the fetus revealed that he also had an isolated right foot dysplasia. The parents chose elective termination and autopsy confirmed prenatal ultrasound findings. Genetic testing of the aborted fetus with QF-PCR analysis for common aneuploidies and array comparative genomic hybridization (aCGH) showed a male genomic pattern, without aneuploidies or chromosomal imbalances. Further investigation with next generation sequencing of 49 clinically relevant genes revealed a novel heterozygous FGFR1 mutation c.787_789del (p.Ala263del) in the fetus; the father was heterozygous to the same mutation. CONCLUSION: A novel heterozygous FGFR1 mutation causing split-hand/foot malformation syndrome is reported. Accurate genetic diagnosis allowed detailed counseling to be provided to the couple, including the underlying cause, recurrence risks, and detailed management plan with preimplantation genetic diag-nosis for future pregnancies.

Implementation of Fetal Cardiac Guidelines for the Routine Second-Trimester Heart Examination: A Feasibility Study.

PURPOSE: This study aimed to explore the feasibility of implementation of the ISUOG 2013 guidelines on routine second-trimester examination of the fetal heart. MATERIALS AND METHODS: This was a prospective study in 357 women with singleton pregnancy undergoing their routine second-trimester scan. The fetal heart was examined using B-mode in different planes according to the guidelines. Potential maternal and fetal factors that can affect the rates of diagnostic-quality imaging for each of the recommended views were tested, using regression analysis. The intra- and interobserver agreement was analyzed in stored video loops. RESULTS: Most cardiac structures could be successfully examined with rates at or close to 100 %. Structures with a successful examination rate of ≤ 85 % included the ventricular wall fine details (55.2 %), tricuspid valve insertion (82.6 %), aortic root with clear walls (77.9 %), pulmonary artery walls (65.8 %) and clear view of the great artery walls (66.7 %). Common factors affecting the likelihood of successful examination of these structures included maternal BMI, skin-to-crux distance and the orientation of the cardiac axis. A post-hoc analysis indicated that a lack of pre-defined criteria for diagnostic quality was a constant reason for the interobserver variation. CONCLUSION: Most of the cardiac views can be consistently and reliably obtained, with maternal habitus being the primary factor limiting the quality of visualization. As offline interpretation may be subjective, using pre-defined quality criteria for the assessment of the images might improve interrater agreement.

Gastrointestinal and Urinary Tract Endometriosis: A Review on the Commonest Locations of Extrapelvic Endometriosis.

Extrapelvic endometriosis is a rare entity that presents serious challenges to researchers and clinicians. Endometriotic lesions have been reported in every part of the female human body and in some instances in males. Organs that are close to the uterus are more often affected than distant locations. Extrapelvic endometriosis affects a slightly older population of women than pelvic endometriosis. This might lead to the assumption that it takes several years for pelvic endometriosis to "metastasize" outside the pelvis. All current theories of the pathophysiology of endometriosis apply to some extent to the different types of extrapelvic endometriosis. The gastrointestinal tract is the most common location of extrapelvic endometriosis with the urinary system being the second one. However, since sigmoid colon, rectum, and bladder are pelvic organs, extragenital pelvic endometriosis may be a more suitable definition for endometriotic implants related to these organs than extrapelvic endometriosis. The sigmoid colon is the most commonly involved, followed by the rectum, ileum, appendix, and caecum. Most lesions are confined in the serosal layer; however, deeper lesion can alter bowel function and cause symptoms. Bladder and ureteral involvement are the most common sites concerning the urinary system. Unfortunately, ureteral endometriosis is often asymptomatic leading to silent obstructive uropathy and renal failure. Surgical excision of the endometriotic tissue is the ideal treatment for all types of extrapelvic endometriosis. Adjunctive treatment might be useful in selected cases.