Chronic Uterine Inversion in 54 Year Old Woman: Case Report.

Introduction: Uterine inversion is a disease characterized by the folding of the uterine fundus into the uterine cavity or beyond the cervix. It is a rare complication following parturition. Acute uterine inversion presents immediately following vaginal delivery. Prevalence of acute uterine inversion is 1 in 20,000-50,000 cases. Chronic uterine inversion is a rare disease presentation in post-menopausal women. It is commonly associated with uterine pathology like leiomyoma, leiomyosarcoma, or endometrial polyps. It is very rare without associated factors. In the post-menopausal age group, the diagnosis is confirmed with high index of suspicion and physical examination. Typically, inverted uterine fundus is a leading point of protrusion but it could be the uterine cervix in uterine prolapse. Case Presentation: A 54 year old woman came to our hospital with the complaint of a painless mass in her vagina of 3 years duration. Three years ago, she encountered a protrusion of mass through her vagina, which gradually grew in size over time. On physical examination, uterine fundus was the leading point of the mass and it protruded 7 cm below the hymenal ring. As a result, she was diagnosed with chronic uterine inversion and underwent an abdominal hysterectomy. She was discharged home improved. We report this case because of an unidentified factor eliciting the uterine inversion, late presentation of the disease and difficulty in surgical treatment. Conclusion: Chronic uterine inversion is a rare disease presentation especially when there is no associated uterine pathology like leiomyoma. It is seen in a broad range of age groups, from reproductive to postmenopausal. A strong index of suspicion and physical examination are used to reach the diagnosis. Surgical technique should be anticipated to be difficult as it is a rare case, outside the experience of most surgeons.

Robotic-assisted benign hysterectomy compared with laparoscopic, vaginal, and open surgery: a systematic review and meta-analysis.

The potential benefits and limitations of benign hysterectomy surgical approaches are still debated. We aimed at evaluating any differences with a systematic review and meta-analysis. PubMed, MEDLINE, and EMBASE databases were last searched on 6/2/2021 to identify English randomized controlled trials (RCTs), prospective cohort and retrospective independent database studies published between Jan 1, 2010 and Dec 31, 2020 reporting perioperative outcomes following robotic hysterectomy versus laparoscopic, open, or vaginal approach (PROSPERO #CRD42022352718). Twenty-four articles were included that reported on 110,306 robotic, 262,715 laparoscopic, 189,237 vaginal, and 554,407 open patients. The robotic approach was associated with a shorter hospital stay (p < 0.00001), less blood loss (p = 0.009), and fewer complications (OR: 0.42 [0.27, 0.66], p = 0.0001) when compared to the open approach. The main benefit compared to the laparoscopic and vaginal approaches was a shorter hospital (R/L WMD: - 0.144 [- 0.21, - 0.08], p < 0.0001; R/V WMD: - 0.39 [- 0.70, - 0.08], p = 0.01). Other benefits seen were sensitive to the inclusion of database studies. Study type differences in outcomes, a lack of RCTs for robotic vs. open comparisons, learning curve issues, and limited robotic vs. vaginal publications are limitations. While the robotic approach was mainly comparable to the laparoscopic approach, this meta-analysis confirms the classic benefits of minimally invasive surgery when comparing robotic hysterectomy to open surgery. We also reported the advantages of robotic surgery over vaginal surgery in a patient population with a higher incidence of large uterus and prior surgery.

The incidence and risk factors of occult malignancy in patients receiving vaginal hysterectomy for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess the incidence and risk factors for premalignant and malignant pathology in patients receiving vaginal hysterectomy (VH) and pelvic floor repair (PFR) for pelvic organ prolapse (POP). METHODS: We performed a retrospective cohort study of pathological results after VH and PFR of 569 women at our institution from January 2011 through December 2020. Age, body mass index (BMI), POP-Q stage, and preoperative ultrasound results were evaluated as risk factors for occult malignancy. RESULTS: Six of the 569 patients (1.1%) had unanticipated premalignant uterine pathology and 2 (0.4%) had unanticipated malignant uterine pathology (endometrial cancer). There was no significant difference in the incidence of premalignant or malignant uterine pathology according to age, BMI, and POP-Q stage. However, if endometrial pathology is confirmed on preoperative ultrasonography, the probability of confirming malignant pathology increases (OR 4.63; 95% CI 1.84-51.4; p=0.016). CONCLUSION: The incidence of occult malignancy during VH for POP was significantly lower than that found in hysterectomy owing to benign disease. In the case of POP patients, for whom uterine-conserving surgery is not absolutely contraindicated, it can be performed. However, if endometrial pathology is confirmed by preoperative ultrasonography, uterine-conserving surgery is not recommended.

A Controversial Old Topic Revisited: Should Diagnostic Hysteroscopy Be Routinely Performed Prior to the First IVF Cycle? A Systematic Review and Updated Meta-analysis.

OBJECTIVE: This systematic review and meta-analysis aimed to analyze the impact of performing diagnostic hysteroscopy before the first in vitro fertilization (IVF) cycle on the clinical pregnancy rate and live birth. DATA SOURCES: PubMed-MEDLINE, Embase, Web of Science, The Cochrane Library, Gynecology and Fertility Specialized Register of Controlled Trials, and Google Scholar were consulted from inception to June 2022 using combinations of the relevant Medical Subject Headings terms and keywords. The search included major clinical trial registries such as ClinicalTrials.gov and the European EudraCT registry without language restrictions. In addition, manual cross-reference searches were also performed. METHODS OF STUDY SELECTION: All randomized and controlled clinical trials, prospective and retrospective cohort studies, and case-control studies comparing the probability of pregnancy and live birth among patients who underwent diagnostic hysteroscopy with possible treatment of any abnormal findings before the IVF cycle and patients who underwent the IVF cycle directly have been considered for inclusion. Studies with insufficient information on the results of interest or without the necessary information to perform the pooled analysis, those without a control group or with end points considered different than those of interest, were excluded. The review protocol was registered in PROSPERO (CRD42022354764). TABULATION, INTEGRATION, AND RESULTS: A total of 12 studies were included in the quantitative synthesis, reporting the reproductive outcomes of 5056 patients undergoing ART treatment for the first time. Selected studies included 6 randomized controlled trials, 1 prospective cohort study, 3 retrospective cohort studies, and 2 case-control studies. The likelihood of clinical pregnancy of patients undergoing hysteroscopy before IVF was significantly higher than those without hysteroscopy (odds ratio [OR], 1.49; 95% confidence CI 1.16-1.91; I2 = 69%). (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.22-1.88; I2 59%). Eight studies included live birth rate; no statistically significant differences were found between the 2 groups for this outcome (OR,1.24; 95% CI, 0.94-1.64; I2 = 62%). Subsequently, a sensitivity analysis was performed, including only randomized clinical trials. Clinical pregnancy OR of patients undergoing hysteroscopy before starting the IVF cycle remained significantly higher than the control group (OR,1.62, 95% CI, 1.15-2.29; I2 = 62%). Risk of bias assessment was performed using the Grading of Recommendations Assessment, Development, and Evaluation. CONCLUSION: The available scientific evidence suggests that performing routine hysteroscopy before the first IVF attempt improves the clinical pregnancy rate; however, the live birth rate is unaffected.

Exploring Surgical Strategies for Uterine Fibroid Treatment: A Comprehensive Review of Literature on Open and Minimally Invasive Approaches.

Background and Objectives: Uterine myomas represent one of the most prevalent pathologies affecting the female population. These benign neoplasms originate from the smooth muscular cells of the uterus, and they can be either single or multiple. Often associated with debilitating symptoms such as pelvic heaviness, pain, constipation, and urinary dysfunctions, the surgical management of myomectomy exhibits considerable variability. This diversity in approaches is influenced by factors such as the number and size of myomas, the patient's age, and overall clinical conditions. This study aims to elucidate and compare the advantages and disadvantages of different surgical approaches, specifically endoscopic procedures versus open surgery, providing valuable insights for clinical decision making. Materials and Methods: A comprehensive bibliographic search spanning from 2013 to 2023 was systematically conducted across databases including Medline, Embase, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov. The search utilized keywords such as "myomectomy laparoscopic and open", "myomectomy open and minimally invasive", "myomectomy open and laparoscopic", and "myomectomy open vs. laparoscopic." The research methodology, along with predetermined inclusion and exclusion criteria, was established prior to the search, ensuring a systematic and rigorous approach. Subsequently, data analysis was carried out. Results: Following the study selection process, 25 articles met the eligibility criteria for inclusion in this analysis. The average numbers of myomas were 3.7 (ranging from 1 to 13.7) and 5.4 (ranging from 1 to 13.5) for the minimally invasive surgery and open surgery groups, respectively. In terms of myoma size, the total averages across studies were 7 cm (ranging from 4.8 to 14) for the minimally invasive group and 8 cm (ranging from 3.9 to 11.2) for the open surgery group. The average pregnancy and delivery rates were 29.7% (ranging from 1.8 to 100) for the minimally invasive group and 28.5% (ranging from 1.8 to 100) for the open surgery group. Regarding complications, the average rate was 14.2% (ranging from 0 to 50) for the endoscopic group and 22.3% (ranging from 0 to 60.3) for the laparotomic group. Conclusions: In conclusion, a critical factor influencing the choice of surgical approach is primarily the size and quantity of fibroids. The mini-laparotomic approach emerges as a viable alternative to endoscopy, demonstrating favorable surgical outcomes and aesthetic results. Interestingly, the type of surgical procedure appears to have no significant impact on the pregnancy rate.

Combination of B-Mode Ultrasound and Doppler Ultrasound in Approaching to Uterine Intracavitary Pathologies Among Women Above 40 Years with Abnormal Uterine Bleeding: A Multicenter-Based Study from Vietnam.

Objectives: To determine the role of B-mode ultrasonography combined with Doppler ultrasonography in diagnosing uterine intracavitary pathology in perimenopausal and postmenopausal women with abnormal uterine bleeding (AUB). Patients and Methods: This prospective observational study included 150 women aged >40 years with AUB hospitalized at Hue University Hospital and Hue Central Hospital between 6/2016 and 6/2019. All participants were investigated by B-mode transvaginal ultrasound and Doppler transvaginal ultrasound, and the result of sonography was compared to the histopathological endpoint. Results: The morphological features, structure, margin, border line of the endometrial-mass lesion, intracavitary uterine fluid, and Doppler signal clearly differed between benign and malignant intracavitary pathologies (P < 0.0001). However, echogenicity had a limited value in distinguishing between uterine intracavitary pathologies (P = 0.1). The sensitivity and specificity of the pedicle sign in diagnosing endometrial polyps were 50.0% and 97.6%, respectively; for the circular pattern in subendometrial fibroids were 46.2% and 100.0%, respectively; for the multiple vessel pattern in endometrial cancer were 64.0% and 96.0%, respectively, and for the scattered-vessel pattern in endometrial hyperplasia were 43.96% and 56.43%, respectively. Conclusions: Ultrasound B-mode combined with Doppler as a noninvasive tool was significantly valuable in the diagnostic procedures for uterine intracavitary pathology in perimenopausal and postmenopausal women with AUB. It could also help differentiate malignant diseases from benign endometrial changes.

Correlation between hysterosalpingography diagnosis and final hysterolaparoscopy with dye-test diagnosis in women with utero-tubal infertility: A cross-sectional study of the implication for which test should be the first-line investigation.

Objective: To assess the accuracy of hysterosalpingography in diagnosis of uterine and/or tubal factor infertility, using hysterolaparoscopy with dye test as the gold standard with an implication for which test should be the first-line investigation. Methods: A prospective cross-sectional study of 96 women who underwent hysterosalpingography and hysterolaparoscopy with dye test. All women within reproductive age group with utero-tubal infertility who underwent both hysterosalpingography and hysterolaparoscopy with dye-test procedure were included. The outcome measures were proportions of tubal blockage and intrauterine pathology. Individual and overall mean accuracy were calculated for hysterosalpingography, using hysterolaparoscopy with dye test as the gold standard. Patient had procedure of hysterosalpingography first and both laparoscopic surgeons and patients were blinded to the outcome of hysterolaparoscopy with dye test until analysis. Statistical significance was set at p < 0.05. Results: Overall, 128 women were assessed for eligibility while 96 women finally completed the study. Hysterosalpingography demonstrated diagnostic accuracy of 77.8% (p < 0.001), 76.3% (p < 0.001) and 78.3% (p < 0.001) for right, left and bilateral tubal blockage, respectively. Overall accuracy of hysterosalpingography tubal factor assessment was 77.4 ± 0.8% (95% confidence interval = 76.5% to 78.4%). Hysterosalpingography showed an accuracy of 85.7%, 86.6% and 76.7% for right, left and bilateral hydrosalpinx, respectively, given overall diagnostic accuracy of 83.0 ± 5.1% (95% confidence interval = 77.9% to 88.1%). Overall accuracy of hysterosalpingography in diagnosing intrauterine pathology was 68.5 ± 9.8% (95% confidence interval = 53.9% to 83.1%). Conclusion: Hysterosalpingography detects tubal blockade and intrauterine pathology poorly compared to hysterolaparoscopy with dye test. Hysterosalpingography may face unpredictable clinical situations biased by technological error, leading to unsuccessful evaluation and uncertain diagnosis. Although the cost-effectiveness, risk of surgery or anaesthesia flaws hysterolaparoscopy with dye test. Hysterosalpingography should not be the first-line utero-tubal assessment tool rather hysterolaparoscopy with dye test.

Saponin-rich extract of Tribulus terrestris alleviates systemic inflammation and insulin resistance in dietary obese female rats: Impact on adipokine/hormonal disturbances.

Tribulus terrestris saponins (TTS) have been longley used as an overall tonic and recent studies showed they influence inflammatory conditions. We examined the ameliorative effect of a commercial formula of a saponin-rich extract of TT in a model of dietary obesity in female rats focusing on their ability to control the inflammatory burden, insulin resistance (IR), adipokine expression and the related reproductive system pathologies. Female rats were fed with high fat diet (HFD) for 14 weeks to launch diet-induced obesity; they were assigned as: the obese control female rats (OFR) which received no treatment and TTS (5 and 10 mg/kg/day) treated rats; they were compared to a normal rat group. We determined the IR index, serum/tissue inflammatory cytokines, and adipose tissue adipokine expression and examined the secondary ovarian pathologies. Body weight gain, serum triglycerides and IR (>5-fold) in the OFR group were greater than the normal group; TTS lessened these parameters compared with the OFR group. TTS, at 10 mg/kg dose, ameliorated mRNA expression of leptin and visfatin genes in addition to serum inflammatory cytokine levels. Moreover, TTS corrected the hyperprolactinemia and other hormonal disturbances and ameliorated the ovarian pathologies. This study highlighted that the anti-inflammatory properties of TTS helped in alleviation of IR and body weight gain in OFR. Upon correction of obesity manifestations, the gonadal hormone dysregulations and ovarian pathologies were subsequently ameliorated. We can consider TTS as a promising candidate that may alleviate the inflammatory burden, IR and adipokine expression in obesity and hence prevent the secondary gonadal complications in female subjects if appropriate clinical studies are available.

Hysterolaparoscopy: A Gold Standard for Diagnosing and Treating Infertility and Benign Uterine Pathology.

BACKGROUND: Combined hysteroscopy and laparoscopy is a valuable method for diagnosing and treating infertility and benign uterine pathology. Both procedures are minimally invasive, reliable, and safe, with a low complication rate. AIM: In this review, we expose the efficiency and safety of hysterolaparoscopy in the management of infertility and other benign uterine pathologies. METHOD: We performed a systematic literature review on several databases: PubMed®/MEDLINE, PMC, Crossref.org, and Web of Science in the last 10 years. INCLUSION CRITERIA: Women of reproductive age with primary or secondary infertility and/or benign uterine pathology. EXCLUSION CRITERIA: pre-puberty, menopause, couple with male infertility. CONCLUSION: Hysterolaparoscopy is a useful tool to assess infertility and simultaneously diagnose and treat pelvic and uterine lesions.

Genital Chlamydia infection in hyperlipidemic mouse models exacerbates atherosclerosis.

BACKGROUND AND AIMS: Atherosclerosis is a chronic inflammatory disease, and recent studies have shown that infection at remote sites can contribute to the progression of atherosclerosis in hyperlipidemic mouse models. In this report, we tested the hypothesis that genital Chlamydia infection could accelerate the onset and progression of atherosclerosis. METHODS: Apolipoprotein E (Apoe-/-) and LDL receptor knockout (Ldlr-/-) mice on a high-fat diet were infected intra-vaginally with Chlamydia muridarum. Atherosclerotic lesions on the aortic sinuses and in the descending aorta were assessed at 8-weeks post-infection. Systemic, macrophage, and vascular site inflammatory responses were assessed and quantified. RESULTS: Compared to the uninfected groups, infected Apoe-/- and Ldlr-/- mice developed significantly more atherosclerotic lesions in the aortic sinus and in the descending aorta. Increased lesions were associated with higher circulating levels of serum amyloid A-1, IL-1ß, TNF-α, and increased VCAM-1 expression in the aortic sinus, suggesting an association with inflammatory responses observed during C. muridarum infection. Genital infection courses were similar in Apoe-/-, Ldlr-/-, and wild type mice. Further, Apoe-/- mice developed severe uterine pathology with increased dilatations. Apoe-deficiency also augmented cytokine/chemokine response in C. muridarum infected macrophages, suggesting that the difference in macrophage response could have contributed to the genital pathology in Apoe-/- mice. CONCLUSIONS: Overall, these studies demonstrate that genital Chlamydia infection exacerbates atherosclerotic lesions in hyperlipidemic mouse and suggest a novel role for Apoe in full recovery of uterine anatomy after chlamydial infection.

Uterine pathology in transmasculine persons on testosterone: a retrospective multicenter case series.

BACKGROUND: As part of transition, transmasculine persons often use testosterone gender-affirming hormone therapy; however, there is limited data on its long-term effects. The impact of exogenous testosterone on uterine pathology remains unclear. While testosterone achieves amenorrhea in the majority of this population, persistence of abnormal uterine bleeding can be difficult to manage. Excess androgens in cisgender females are associated with pathologic uterine processes such as polycystic ovary syndrome, endometrial hyperplasia, or cancer. There are no guidelines for management of abnormal uterine bleeding or endometrial surveillance in this population. OBJECTIVE: The aim of this study was to describe the characteristics of uterine pathology after the initiation of testosterone in transmasculine persons. MATERIALS AND METHODS: A retrospective, multicenter case series was performed. Uterine pathology reports of transmasculine persons who received testosterone and subsequently underwent hysterectomy were reviewed. The endometrial phase and endometrial thickness were recorded. RESULTS: A total of 94 subjects met search criteria. The mean age of participants was 30 ± 8.6 years, and the mean interval from initiation of testosterone to hysterectomy was 36.7 ± 36.6 months. Active endometrium was found in the majority of patients (n = 65; 69.1%). One patient had complex hyperplasia without atypia. There were no cases of endometrial cancer. CONCLUSION: Despite amenorrhea in the majority of transmasculine persons on testosterone, endometrial activity persists with predominantly proliferative endometrium on histopathology. Individualized counseling for abnormal uterine bleeding is encouraged in this patient population.

Pictorial essay of ultrasound-reconstructed coronal plane images of the uterus in different uterine pathologies.

Imaging in the major planes (horizontal, coronal, and sagittal) of the uterus is important for determining anatomy and allowing the findings to be standardized, and for evaluating and diagnosing different pathological conditions in clinical practice. Examination of the coronal plane is an important step in identifying uterine pathologies and their relationships to the endometrial canal. Three-dimensional (3D) ultrasound reveals the normal anatomy better and improves the depiction of abnormal anatomy, as the coronal plane of the uterus can easily be obtained using 3D reconstruction techniques. Our pictorial essay demonstrates that adding 3D ultrasound to a routine gynecological workup can be beneficial for clinicians, enabling a precise diagnosis to be made. In addition, the volumes obtained and stored by 3D ultrasound can allow students or residents to become more familiar with normal and abnormal pelvic structures. Clin. Anat. 31:373-379, 2018. © 2017 Wiley Periodicals, Inc.

Histopathologic findings in uteri and ovaries collected from clinically healthy dogs at elective ovariohysterectomy: a cross-sectional study.

Opinions on ovariohysterectomy (OHE) of bitches vary depending on region and country. In this descriptive, prospective cross-sectional study, uterine tracts and ovaries exhibiting gross pathologic findings (n = 76) were collected post-surgery from a reference population of 3,600 bitches (2.11% incidence) that underwent elective OHE during September to November 2013 and evaluated by histopathology examination. Data were evaluated by using descriptive statistics and chi-squared tests. Bitches were of crossbred background with average age 5 years (range 0.6-8.0 years) and most were nulliparous (69.7%) with no anamnesis of reproductive diseases (81.6%). Frequencies of proestrus, estrus, and diestrus were 42.1%, 6.6%, and 19.7%, respectively. The presence of mammary gland masses (5.3%) significantly correlated with histopathologic findings in ovaries and age of the bitch (p ＜ 0.05). Predominant uterine histopathologies included cystic endometrial hyperplasia, periglandular fibrosis, lymphoplasmocytary endometritis, and adenomyosis (19.7%, 14.5%, 4.0%, and 2.6%, respectively). In ovaries, hyperplasia of rete ovarii, follicular cysts, oophoritis, adenoma of the rete ovarii, cysts of superficial structures, and granulosa cell tumors (10.5%, 10.5%, 7.9%, 4.0%, 2.6%, and 2.6%, respectively) were observed. The results reveal the presence of subclinical pathologies in healthy bitches, suggesting that OHE at an early age is beneficial for prevention of reproductive pathologies.

Histopathologic findings in uteri and ovaries collected from clinically healthy dogs at elective ovariohysterectomy: a cross-sectional study

Opinions on ovariohysterectomy (OHE) of bitches vary depending on region and country. In this descriptive, prospective cross-sectional study, uterine tracts and ovaries exhibiting gross pathologic findings (n = 76) were collected post-surgery from a reference population of 3,600 bitches (2.11% incidence) that underwent elective OHE during September to November 2013 and evaluated by histopathology examination. Data were evaluated by using descriptive statistics and chi-squared tests. Bitches were of crossbred background with average age 5 years (range 0.6–8.0 years) and most were nulliparous (69.7%) with no anamnesis of reproductive diseases (81.6%). Frequencies of proestrus, estrus, and diestrus were 42.1%, 6.6%, and 19.7%, respectively. The presence of mammary gland masses (5.3%) significantly correlated with histopathologic findings in ovaries and age of the bitch (p < 0.05). Predominant uterine histopathologies included cystic endometrial hyperplasia, periglandular fibrosis, lymphoplasmocytary endometritis, and adenomyosis (19.7%, 14.5%, 4.0%, and 2.6%, respectively). In ovaries, hyperplasia of rete ovarii, follicular cysts, oophoritis, adenoma of the rete ovarii, cysts of superficial structures, and granulosa cell tumors (10.5%, 10.5%, 7.9%, 4.0%, 2.6%, and 2.6%, respectively) were observed. The results reveal the presence of subclinical pathologies in healthy bitches, suggesting that OHE at an early age is beneficial for prevention of reproductive pathologies.

Adenomiose uterina em gata associada à piometra / Uterine adenomyosis in a queen associated to pyometra

Adenomyosis, a non-neoplastic myometrial proliferation, is a rare pathologic condition in domestic animals, of unknown etiology. There is a lack of information about the clinical and pathological features of this disease in cats, therefore just a few reports in that species. The study describes a case of adenomyosis in a feline female. A cat, six years old, undefined breed, not spayed, had abdominal swelling history and vaginal discharge. Clinically, upon abdominal palpation, a diffuse increase suggesting a uterine change was found. The vulva had sanguine-purulent exudates. The choice was for the neutering surgical. Uterine macroscopy revealed cystic endometrial hyperplasia/pyometra in uterine horns, and the presence of a diffuse mass on uterine corpus. Fragments of the mass were sent for histopathological analysis, which revealed adenomyosis of the uterine corpus. The patient exhibited adequate post-operative recovery. The adenomyosis should be considered as a differential diagnosis of uterine neoformation in domestic cats.(AU)

Peri-incisional and intraperitoneal ropivacaine administration: a new effective tool in pain control after laparoscopic surgery in gynecology: a randomized controlled clinical trial.

BACKGROUND: A proportion of patients undergoing laparoscopic gynecological surgery experiences excessive post-operative pain, which results in high rescue analgesic treatment and prolonged hospitalization. The aim of our study was to evaluate the efficacy of intraoperative topical ropivacaine in the control of post-operative pain in the first 48 h after operative laparoscopy for benign adnexal or uterine pathologies . METHODS: We conducted a prospective, randomized, double-blind, placebo-controlled clinical trial. Patients received a standard dose of topical ropivacaine (injected at the three portal sites and atomized in the abdominal cavity) or placebo. The primary outcome was the evaluation of post-operative pain intensity 6 h after surgery. Secondary outcomes included the intensity of pain during the 48 h after surgery, shoulder tip pain and the request for rescue analgesics during the first 48 h after surgery, time to discharge from recovery room, time to mobilizing on the ward and time to return to daily activities. Patients were divided in two groups (Group_A: benign adnexal pathologies; Group_B: benign uterine diseases) and assigned to Subgroup_1 (receiving ropivacaine) and Subgroup_2 (receiving placebo). RESULTS: A total of 187 women were included: 93 in Group_A and 94 in Group_B. Forty-seven patients entered Subgroup_A1, 46 Subgroup_A2, 48 Subgroup_B1 and 46 Subgroup_B2. Subgroup_A1 experienced lower post-operative pain at 4 (p = 0.008) and 6 h (p = 0.001) as well as a faster return to daily activities (p = 0.01) in comparison with Subgroup_A2. Both Subgroup_A1 and Subgroup_B1 showed lower shoulder tip pain (respectively, p = 0.032 and p = 0.001) as well as shorter time to mobilizing on the ward after surgery (respectively, p = 0.001 and p = 0.01). The remaining variables analysis did not show significant results. CONCLUSIONS: Combined topical analgesia with ropivacaine could represent a new safe and effective tool in the control of post-operative pain in gynecological laparoscopic surgery. Given the greater benefits for adnexal surgery, this strategy may be more suitable for this class of patients.

[Role of office hysteroscopy in the diagnosis and treatment of uterine pathology]. / Rola minihisteroskopii w diagnostyce i leczeniu patologii jamy macicy.

Nowadays endoscopic techniques are one of the basic diagnostic and operative methods in gynecology. Laparoscopy and hysteroscopy are the most popular of them. Office hysteroscopy is a modern diagnostic and therapeutic method feasible in an outpatient room because no necessity of anesthesia. It is the first-line procedure in the infertility diagnosis and treatment of uterine pathology such as polyps, submucosal fibroids and adhesions. Limitation of this method is the cervical canal atresia. Contraindications to it are: pregnancy, uterine bleeding, active inflammation of pelvic organs, cervical cancer. Due to the high sensitivity and specificity, simplicity of execution and no need for patient hospitalization, office hysteroscopy becomes important diagnostic and therapeutic procedure in uterine pathologies.

Comparison of transvaginal ultrasonography and hysteroscopy in the diagnosis of uterine pathologies.

A thorough evaluation of the uterine cavity is frequently required in gynecology practice. The aim of this study was to compare the diagnostic values of transvaginal ultrasound examination and hysteroscopy in detecting uterine abnormalities in a group of patients within a range of menopausal status and symptomatology. This study included 285 patients admitted with complaints of abnormal uterine bleeding, postmenopausal bleeding, lower abdominal pain, abnormal vaginal discharge or for a routine gynecological examination. All patients had available transvaginal ultrasonography and hysteroscopy data for evaluation. A biopsy was obtained from all patients during the hysteroscopy session. Sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratio were calculated for both methods and compared, considering the histopathological diagnosis as the gold standard. The mean age of the patients was 49.5±12.9 years (range, 24-89 y). Majority of the patients admitted for abnormal uterine bleeding (n=198, 69.4%). For the diagnosis of polyps of any size, hysteroscopy had better sensitivity (p<0.001), however, specificities did not differ (p=1.0). On the other hand, hysteroscopy did not have a sensitivity advantage over TVU in diagnosing polyps greater than 1 cm (p=0.077), although this time hysteroscopy had better specificity (p<0.001). Combined approach did not offer diagnostic advantage for any of the specific pathologies. Although TVU represents a practical approach for the initial evaluation of uterine pathologies, hysteroscopy seems to offer better diagnostic value for uterine pathologies in general, and uterine polyps in particular.

Diagnostic accuracy of endometrial thickness for the detection of intra-uterine pathologies and appropriateness of performed hysteroscopies among asymptomatic postmenopausal women.

OBJECTIVE: To measure the diagnostic accuracy of endometrial thickness for the detection of intra-uterine pathologies among asymptomatic postmenopausal women, and to test the diagnostic accuracy and appropriateness of performed hysteroscopies. STUDY DESIGN: Prospective study of 268 asymptomatic postmenopausal women with endometrial thickness ≥4 mm referred to diagnostic hysteroscopy. The diagnostic accuracy of various endometrial thickness cut-off values was tested. Histological and hysteroscopic results were compared to measure the diagnostic accuracy of outpatient hysteroscopies. RESULTS: No endometrial thickness cut-off values had optimal diagnostic accuracy [positive likelihood ratio (LR+) >10 and negative likelihood ratio (LR-) <0.1]. The best endometrial thickness cut-off value for the detection of all intra-uterine pathologies was ≥8 mm (LR+ 10.05 and LR- 0.22). An endometrial thickness cut-off value ≥10 mm did not miss any cases of endometrial cancer. The success rate of diagnostic hysteroscopy was 89%, but 97% of these revealed a benign intra-uterine pathology. The diagnostic accuracy of hysteroscopy was optimal for all intra-uterine pathologies, except endometrial hyperplasia (LR- 0.52). CONCLUSION: Using an endometrial thickness cut-off value ≥4 mm, only 3% of performed hysteroscopies were useful for the detection of pre-malignant or malignant lesions. Despite the finding that endometrial thickness did not show optimal diagnostic accuracy, using the best cut-off value (≥8 mm) may be helpful to decrease the number of false-positive results. No cases of endometrial cancer were diagnosed in asymptomatic postmenopausal women with endometrial thickness <10mm.

Factors associated with uterine endometrial hyperplasia and pyometra in wild canids: implications for fertility.

The ability to safely and effectively manage reproduction is central to the success of AZA captive-breeding programs. Although the AZA Wildlife Contraception Center routinely monitors contraceptive safety, there have been no studies that compare the effects of contraceptive use to separation of males from females, the other option for preventing reproduction. We used retrospective medical records and pathology reports submitted by AZA and related facilities for the seven AZA-managed canid species to assess rates of uterine pathology relative to female reproductive life histories. Our results showed that the prevalence of both pyometra and endometrial hyperplasia (EH) was associated not only with treatment with the two most common contraceptives (Suprelorin® and MGA implants) but also with the number of years barren (i.e., not producing a litter and not contracepted). Rates of pyometra and EH were especially high in African painted dogs and red wolves, but lowest in swift and fennec foxes. The number of years producing a litter had a low association, suggesting it could be protective against uterine pathology. A more recently developed Suprelorin® protocol using Ovaban® to prevent the initial stimulation phase, followed by implant removal when reversal is desired, may be a safer contraceptive option. These results concerning the relationship between reproductive management and uterine health have important implications for AZA-managed programs, since the unsustainability of many captive populations may be due at least in part to infertility. Managing a female's reproductive lifespan to optimize or maintain fertility will require a reconsideration of how breeding recommendations are formulated.