Forty-two normomenstruating adolescents with Müllerian obstructive anomalies: Presentation, pitfalls in the dagnosis and surgical management.

INTRODUCTION: We analyzed the frequency, presentation and pitfalls in the diagnosis and surgical management of a large group of normomenstruating adolescents with obstructive reproductive tract anomalies. MATERIAL AND METHODS: Retrospective analysis of prospectively collected data. Of the 143 outpatients referred for severe dysmenorrhea and persistent pelvic pain, 42 (29.3%) young women with obstructive Müllerian anomalies and regular menstrual flow were identified. These patients were divided into four groups: (1) patients with duplicate uterine cavities, obstructed hemivagina and ipsilateral renal agenesis (n = 34); (2) patients with unicornuate uterus and noncommunicating cavitated rudimentary horn (n = 5); (3) patients with accessory cavitated uterine mass (n = 2); (4) patients with partially obstructed transverse vaginal septum (n = 1). All 42 patients were conservatively treated via laparoscopy and 35/42 patients had also vaginal surgery. RESULTS: Of the four groups, patients in groups 2 and 3 (n = 7) were conservatively managed by laparoscopy alone; for patients in groups 1 and 4 (n = 35), laparoscopy and the vaginal approach were used. Patients of group 1 were treated by resecting the obstructed vaginal septum with drainage of retained collections. In patients in group 2, surgery consisted of the removal of the rudimentary horn. Patients of group 3 were treated by the removal of myometrial neoformations. In the patient in group 4, treatment consisted of removal of the septum. All surgical procedures were successful and no major complications were recorded. Follow-up reports highlighted the disappearance of obstruction and clear improvement in pain symptoms. CONCLUSIONS: Unilateral obstructive anomalies of the female genital tract are difficult to identify. Early diagnosis allows the preservation of reproductive activity and avoids potential complications.

Assessment of Chestnut Gall Toughness: Implications for a Biocontrol Agent.

(1) Torymus sinensis, the biocontrol agent of the Asian chestnut gall wasp Dryocosmus kuriphilus, is univoltine, but in NW Italy a small percentage of individuals exhibits a prolonged diapause, mainly as late instar larva. (2) In 2020, the diapause was investigated to evaluate its trend over the years. Due to the low survival rate of diapausing T. sinensis adults, the seasonal variation in the galls' toughness was evaluated, thus assuming that dry galls over time can negatively affect emergence. The window of vulnerability of the gall wasp galls was also evaluated in controlled conditions. (3) The results showed that the average number of second year T. sinensis emerging per 100 cells was 0.41 ± 0.05, and dead adults accounted for 4.1 ± 0.23 per 100 cells. Gall toughness resulted in lower values for galls collected in May and June, and then gradually increased over time. In general, no difference was detected in the wall toughness of galls formed during the previous year when compared to current-year dry galls. Oviposition was recorded on all the tested galls collected in May and June, and no difference in the number of oviposition events was detected. Conversely, no oviposition was observed in July. Comparing the number of oviposition events by T. sinensis and the gall toughness, a negative correlation was found (R2 = -0.99). (4) The present findings contribute descriptive information on this gall's structural traits, and the influence on gall wasp management is also discussed.

Pelvic endometriosis and hydroureteronephrosis.

OBJECTIVE: To assess whether routine renal ultrasonography may be recommended in all patients with pelvic endometriosis, in order to avoid silent ureteral involvement of the disease. DESIGN: Retrospective descriptive study. SETTINGS: Tertiary center for the treatment of endometriosis at the Department of Obstetrics and Gynecology of the State University of Milan, Milan, Italy. PATIENT(S): Seven-hundred-fifty patients with a primary diagnosis of endometriosis, between January 2005 and July 2007. INTERVENTION(S): Routine urinary ultrasound; recording of patient history, signs, and symptoms; gynecologic examination; blood and urinary analyses; magnetic resonance imaging; spiral multislice computerized tomography. MAIN OUTCOME MEASURE(S): Symptoms and signs of ureterohydronephrosis; diagnosis of ureterohydronephrosis. RESULT(S): Twenty-three patients (3%) of all 750 patients with endometriosis had associated ureterohydronephrosis diagnosed at renal ultrasound. Symptoms secondary to ureteral and renal involvement were present in 10 patients (43.5%); 6 reported lumbar pain (26.1%) and 4 patients (17.4%) had renal colic. CONCLUSION(S): In our study, the high number (56.5%) of asymptomatic ureteral involvement in patients with known pelvic endometriosis seems to warrant the need for further investigations regarding the possibility to avoid the high percentage of silent renal losses. Unfortunately there appears to be no specific risk factor to allow for early suspicion nor a validated preventive diagnostic and therapeutic program. It remains to be evaluated whether urinary ultrasound ensures a beneficial cost-benefit ratio if employed on a routine basis.

The laparoscopic Vecchietti's modified technique in Rokitansky syndrome: anatomic, functional, and sexual long-term results.

OBJECTIVE: The objective of the study was to assess the anatomical and functional long-term follow-up results of the laparoscopic Vecchietti approach for the creation of a neovagina in the Rokitansky syndrome. STUDY DESIGN: One hundred ten patients underwent clinical follow-up visits at 1, 3, 6, and 12 months after surgery and every 6 months thereafter. The following were performed: evaluation of the quality of sexual intercourse, vaginal and rectal examinations, vaginoscopy, Schiller's test, and vaginal cytology with microbiologic testing. Functional results were assessed by using Rosen's Female Sexual Function Index questionnaire, of which the results were analyzed comparing normal age-matched controls. RESULTS: Four patients were lost to follow-up. Anatomic and functional success was achieved in 104 of 106 (98%) and 103 of 106 (97%) patients, respectively. Female Sexual Function Index scores were comparable with those of controls. CONCLUSION: Vecchietti's technique is simple, safe, and effective and allows normal and satisfying sexual intercourse, comparable with that of normal controls.

Use of an endoscopic ultrasound probe for the evaluation of the Müllerian rudiments in patients with Rokitansky syndrome.

OBJECTIVE: To assess the use of an endoscopic ultrasound probe in the evaluation of the uterine horns in a series of patients who were undergoing laparoscopy for the creation of a neovagina. DESIGN: Prospective study. SETTING: Department of Obstetrics and Gynecology in a tertiary care and referral center for Rokitansky syndrome. PATIENT(S): Thirty patients with Rokitansky syndrome who were undergoing laparoscopically assisted creation of a neovagina. INTERVENTION(S): Preoperative assessment with a pelvic transabdominal ultrasound scan and pelvic magnetic resonance imaging (MRI). An endoscopic ultrasound probe was used to study the uterine horns during laparoscopy. MAIN OUTCOME MEASURE(S): Presence or absence of the uterine rudiments, presence or absence of the endometrial cavity, and Doppler ultrasound vascularization of the rudiments. RESULT(S): Of the 24 uterine horns sized >or=2 cm that were identified at endoscopic ultrasound, 22 and 19, respectively, had been recognized at MRI and transabdominal ultrasound scan. The endoscopic ultrasound probe diagnosed 12 cavitated horns, of which 9 and 7 were seen at MRI and transabdominal ultrasound scan, respectively. CONCLUSION(S): Our experience shows the feasibility and accuracy of the endoscopic ultrasound probe in evaluating the structure of the rudimentary uterine horns in Rokitansky syndrome.

Evaluation of a new questionnaire for the presurgical diagnosis of bladder endometriosis.

BACKGROUND: The main objective was to evaluate the diagnostic accuracy of a new questionnaire for the presurgical diagnosis of bladder endometriosis in patients with a high suspicion index for this disease. METHODS: We included all patients of age <40 years undergoing laparoscopy or laparotomy for chronic pelvic pain. We partially modified the American Urologic Association Symptom Index with the aim of identifying bladder endometriosis among 157 women undergoing surgery for chronic pelvic pain. All patients underwent preoperative ultrasonography; selected patients, with suspected bladder endometriosis, underwent computed tomography and cystoscopy. The physicians performing both the preoperative evaluation and surgery were blinded to the questionnaires' results. RESULTS: A total of 127 (81%) patients had pelvic endometriosis, 14 (8.9%) had bladder endometriosis. The questionnaires' score for patients with and without bladder endometriosis was 21 +/- 8.7 and 4.6 +/- 5.7, respectively (P < 0.0001). The area under the receiver operating characteristic curve was 0.951. With a cut-off of 9, sensitivity was 93% and specificity 88%. CONCLUSIONS: The questionnaire proved to be effective in identifying bladder endometriosis, allowing a proper diagnostic work-up and surgical treatment, and minimizing the risk of recurrence. In this primary referral centre for endometriosis the prevalence of the disease was high-therefore it may achieve a lower diagnostic accuracy when evaluated on a population of women with a lower prevalence of bladder endometriosis.

Laparoscopic findings and pelvic anatomy in Mayer-Rokitansky-Küster-Hauser syndrome.

OBJECTIVE: To describe analytically the anatomic variety and laparoscopic findings observed in patients with Rokitansky syndrome throughout an 11-year span. METHODS: We analyzed the laparoscopic and chart records of 106 consecutive patients who underwent surgery for the creation of a neovagina, according to the modified laparoscopic Vecchietti procedure. RESULTS: A hypoplastic vagina was observed in 61 women. Müllerian remnants, laterally displaced in the pelvis, were identified in 92 cases; 42 (25.9%, 95% confidence interval [CI] 19.2-33.3) of 162 müllerian remnants were cavitated and contained endometrial mucosa. Ovaries were extrapelvic in 17 (16.0%, 95% CI 9.6-24.4) cases. Anomalies of the urinary tract were identified in 32 (30.2%, 95% CI 21.7-39.9) patients; unilateral renal agenesis was the most frequent finding (18 cases; 18%, 95%CI 10.4-25.5). CONCLUSION: Rokitansky syndrome has a wide variability of anatomic presentations, and, as the do other congenital anomalies of the female genital tract, it represents a continuum of embryonic malformations, which occur at different stages of development.

Neovaginal mucosa after Vecchietti's laparoscopic operation for Rokitansky syndrome: structural and ultrastructural study.

OBJECTIVE: This study was undertaken to evaluate structural and ultrastructural characteristics of the mucosa of neovaginae created by Vecchietti's laparoscopic operation for Rokitansky syndrome. STUDY DESIGN: Vaginoscopy and Schiller test were performed 3, 6, and 12 months after the operation in 106 patients. A biopsy specimen of the neovagina obtained 12 to 18 months after surgery in 19 patients was examined by light, scanning electron, and transmission electron microscopy. RESULTS: At vaginoscopy, the neovaginal mucosa appeared smooth, lacking the folds that characterize the normal vagina; 12 months after the operation, an iodium-positive epithelium was present in all neovaginae. Mild ultrastructural modifications, as compared with normal vaginal mucosa, were reduced maturation, inflammatory infiltration, and tendency to superficial desquamation. CONCLUSION: At a 12-month follow-up, the mucosa of neovaginae created by the Vecchietti technique is comparable to the normal vaginal mucosa, with mild structural and ultrastructural modifications that we believe might be due to reduced vascularization.

Laparoscopic creation of a neovagina with the laparoscopic Vecchietti operation: comparison of two instrument sets.

OBJECTIVE: To compare safety and effectiveness of two different instrument sets for the laparoscopic Vecchietti operation for the creation of a neovagina. DESIGN: Descriptive study. SETTING: Tertiary referral center. PATIENT(S): Twenty-six women with Rokitansky syndrome. Twelve consecutive patients had surgery with the kit recently developed by Storz (group 1) and 14 consecutive patients had surgery with the original kit of Vecchietti (group 2). INTERVENTION(S): Laparoscopic Vecchietti operation and clinical and instrumental follow-up for all patients. MAIN OUTCOME MEASURE(S): All the parameters reflecting safety, effectiveness, and compliance that were systematically measured for all patients. RESULT(S): Patients in group 1 had a wider vagina at device removal and experienced less vaginal bleeding than patients in group 2, and the removal of the device was simpler. Patients in group 1 had a shorter vagina at device removal and retained the device and the Foley catheter for a longer period than patients in group 2. Diameter and length of neovagina at 1-month follow-up were comparable in the two groups. CONCLUSION(S): The availability of this new instrument set represents a small but significant improvement in the creation of a neovagina by the laparoscopic Vecchietti operation in women with Rokitansky syndrome.

Laparoscopic excision of recurrent endometriomas: long-term outcome and comparison with primary surgery.

OBJECTIVE: To compare the laparoscopic excision of primary versus recurrent ovarian endometriomas. DESIGN: Descriptive study. SETTING: Tertiary referral center for the treatment of endometriosis. PATIENT(S): Between 1993 and 2002, 359 consecutive patients: 305 primary surgeries (group A) and 54 reoperations for a recurrent endometrioma in the same ovary of the primary cyst (group B). INTERVENTION(S): Laparoscopic stripping of the cyst wall. Follow-up evaluations every 6 months, including clinical and ultrasonographic evaluations and a questionnaire for pain symptoms (mean follow-up time, +/- standard deviation: 35.4 +/- 27.6 months). MAIN OUTCOME MEASURE(S): Recurrence of pain symptoms, sonographic recurrence of endometriomas, need for a new medical or surgical treatment, and reproductive outcome. RESULT(S): In groups A and B, respectively, the 5-year cumulative rates were not statistically significantly different: pain recurrence 20.5% versus 17.4%; ultrasonographic recurrence 18.9% versus 15.1%; retreatment requirement 19.4% versus 17.3%; and pregnancy 40.8% versus 32.4%. Although the difference was not statistically significant, compared with patients of group A, the women of group B underwent assisted reproduction techniques more frequently (50% vs. 32.2%) and had more irregular menstrual cycles associated with follicle-stimulating hormone levels > or = 14 IU/mL in the early follicular phase (5.5% vs. 1.3%). CONCLUSION(S): After laparoscopic excision of recurrent ovarian endometriomas, the recurrence of pain and the reproductive outcome are comparable with those found after primary surgery.

Medical management of endometriosis.

Current approved medical therapies for endometriosis rely on drugs that suppress ovarian steroids and induce a hypoestrogenic state, which determines the atrophy of the ectopic endometrium. Gonadotropin-releasing hormone analogs such as danazol, progestogens and estrogen-progestin combinations have all proven effective in relieving pain and reducing the extent of endometriotic implants. However, symptoms often recur after discontinuation of therapy and hypoestrogenism-related side effects limit the long-term use of most medications. Recently, knowledge of the pathogenesis of endometriosis, particularly at the molecular level, has grown substantially, providing a rational basis for the development of new drugs with precise targets that may be safely administered over the long term.