Large myoma receiving multiple collateral primary parasitic blood supply.

We describe a rare case of a pedunculated myoma receiving multiple de-novo developed parasitic collateral blood supply from the adjacent organs. The main feeding vessels arise from the omentum and the bladder.

Total laparoscopic hysterectomy in patients with deep endometriosis: Different technical and postoperative considerations, in comparison with a procedure performed for other benign indications.

OBJECTIVE: Total laparoscopic hysterectomy (TLH) may be indicated in patients with deep infiltrative endometriosis (DIE) to treat severe chronic pelvic pain symptoms, recurrences, or co-existing uterine disease. This study discusses the challenges and specific operative and postoperative considerations in patients submitted to TLH and excision of DIE, in comparison with those undergoing a procedure for other benign indications. MATERIALS AND METHODS: Patients undergoing TLH and excision of DIE were included (N = 18, group 1). These were matched with cases, treated with TLH for other benign indications during the same period (2010-2019), at a 2:1 ratio (N = 36, group 2). The two groups were compared with regards to their characteristics, and intraoperative and postoperative data, including operative time, estimated blood loss (EBL), hospital stays, and rates of complications. RESULTS: In group 1, median DIE nodule size was 2.5 cm (range: 1.3-4.2). Simple hysterectomy was performed in 10, and a more extended procedure in 8 cases. All nodules were removed from the bowel wall using the shaving technique. Average EBL was significantly higher (p = .027), and duration of surgery and hospital stays longer (p = .003, and p = .0001, respectively), in group 1 vs. group 2. The rates of long-term (L-T) complications were higher in group 1 but not to a significant level (p = .087). Analysis within the DIE group showed that operative time was significantly related to nodule size, type of hysterectomy (p = .021), presence of adenomyosis (p = .041), uterine size ≥12weeks (p = .039), and the occurrence of L-T complications (p = .016). Increasing nodule size and an extended procedure (p = .005) increased significantly the EBL, which had also a significant effect on the risk of L-T complications (p = .006). CONCLUSIONS: TLH in DIE patients is a different, complex and potentially more dangerous procedure compared with TLH for other benign indications. Thorough knowledge of retroperitoneal anatomy, a clear operative plan, and excellent laparoscopic skills are necessary for concomitant radical excision of lesions, with low rates of adverse events.

Primary Fallopian Tube Cancer in an 89-Year-Old Patient.

Fallopian tube cancer is an extremely rare gynecological condition, accounting for just 1 to 2% of all female tract malignancies. The mean age of diagnosis is similar to that of ovarian cancer, between 60 and 75 years, but it can affect a wide spectrum of ages. Advanced age and family history of ovarian and breast cancer are the main risk factors, since they are associated with increased incidence of this uncommon entity. In this study, we report a rare case of an elderly, 89-year-old patient that presented to our clinic due to vaginal bleeding.

The Use of Platelet-rich Plasma as a Novel Nonsurgical Treatment of the Female Stress Urinary Incontinence: A Prospective Pilot Study.

OBJECTIVES: The aim of the study was to evaluate the efficacy and safety of platelet-rich plasma (PRP) for the treatment of stress urinary incontinence (SUI). METHODS: This was a prospective observational pilot study conducted in a tertiary referral unit, enrolling women with SUI booked for SUI surgery. A total of 20 consecutive women met the inclusion criteria and attended all follow-ups. All participants underwent 2 PRP injections into the lower one third of the anterior vaginal wall at 4- to 6-week intervals. At baseline, they underwent urodynamic studies, a 1-hour pad test, and completed the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms and King's Health Questionnaire. At follow-up visits (1, 3, and 6 months), patients underwent the 1-hour pad test and completed the King's Health Questionnaire, International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms, and Patient Global Impression Scale of Improvement. Primary outcome was to evaluate posttreatment SUI. Secondary outcomes included assessment of patient-reported questionnaires, assessment of urine loss (1-hour pad test), and the level of discomfort during injections (visual analog scale score). Statistical analysis was performed before PRP and 1, 3, and 6 months after the last treatment. RESULTS: A significant improvement in SUI symptoms was observed 3 months after treatment with a further improvement at 6 months. A mean reduction of 50.2% in urine loss was observed in the 1-hour pad test. At the 6-month follow-up, 80.0% of women reported to be at least improved. No adverse effects were observed. CONCLUSIONS: Platelet-rich plasma injections were both effective and safe at least in the short term and could be offered as an alternative outpatient procedure for the treatment of SUI. However, these encouraging findings warrant further investigation with randomized controlled trials.

Misoprostol vs vasopressin as a single hemostatic agent in laparoscopic myomectomy: Comparable, or just better than nothing?

AIM: Laparoscopic myomectomy may be associated with considerable blood loss, especially in patients in whom no specific hemostatic measures are used. We conducted this retrospective comparative study to investigate whether misoprosol is an effective and safe alternative to vasopressin when used as single hemostatic agent in laparoscopic myomectomy. METHODS: Two hundred cases undergoing laparoscopic myomectomy (-ies), were included. Of these, 50 pre-treated with vaginal misoprostol 400mcg 1 h before surgery (group 1), were compared with two historic consecutive groups: 100 patients treated with intraoperative intra-myometrial injection of dilute vasopressin (20 IU/100 mL normal saline) (group 2), and 50 treated without use of any hemostatic agent (group3). RESULTS: Mean procedure length did not differ significantly between the three groups (127.9 vs 100.6 vs 130.8 min). Mean estimated blood loss (EBL) was 179.7 ± 200.0 mL in group 1, compared with 147.8 ± 171.8 mL in group 2 (P = 0.793) and 321.8 ± 246.0 mL in group 3, respectively (P < 0.001). EBL was lower in group 2 in most of the study's subgroups of patients stratified according to size and number of fibroids compared with group 1, with the exception of patients with ≥4 fibroids, and ≥7 cm in size. In these subgroups, misoprostol appeared more effective. Neither agent was associated with serious adverse events. CONCLUSION: Vaginal misoprostol can be effective in reducing blood loss during laparoscopic myomectomy. Although rates of EBL are, in general, higher compared with those obtained with vasopressin, they are significantly reduced compared with those observed when no hemostatic agent is used. In extended procedures, vaginal misoprostol, due to its prolonged uterotonic action, may be associated with reduced blood loss compared with vasopressin.

Vasopressin during Laparoscopic Myomectomy: Does It Really Extend Its Limits?

STUDY OBJECTIVE: Τo investigate whether the use of vasopressin played an important role in the safe expansion of the indications of laparoscopic myomectomy in our practice. DESIGN: A retrospective comparison of prospectively collected data (Canadian Task Force classification II2). SETTING: A gynecologic endoscopy unit in a tertiary university hospital. PATIENTS: One hundred fifty patients undergoing laparoscopic myomectomy; 50 were treated without the use of any vasoconstrictive agent (group 1), and 100 were treated with intraoperative intramyometrial injection of dilute vasopressin (20 IU/100 mL normal saline) (group 2). INTERVENTIONS: Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: We compared the 2 groups in terms of size, number, and type of myomas; estimated blood loss (EBL); procedure length; transfusion rates; laparoconversion rates; and rates of complications. Two cases in group 1 (4%) were laparoconverted versus none (0%) in group 2. Overall, the mean EBL was 321.8 ± 246.0 mL in group 1 compared with 147.8 ± 171.8 mL in group 2, respectively (p <.001). Additionally, EBL was significantly lower in the vasopressin group in all of the study's subgroups of patients stratified according to the size and number of myomas. Procedure length did not differ significantly between the 2 groups (130.8 ± 49.5 vs 115.6 ± 49.4 minutes, p = .078). The risk factors for prolongation of the procedure included size and number of myomas independently of vasopressin. The rates of hypercapnea and subcutaneous emphysema were higher in group 1. The risk factors for hypercapnea and subcutaneous emphysema included the size and intramural position of the largest myoma. Vasopressin was not associated with serious cardiovascular adverse events. CONCLUSIONS: Vasopressin is effective in reducing blood loss during laparoscopic myomectomy. Although experienced surgeons may achieve comparable operation times without vasopressin, even in the most challenging cases, blood loss may still be considerable. The occurrence of hypercapnea is higher in untreated cases and may contribute to laparoconversion.

Assessment of Uterocervical Angle Width as a Predictive Factor of Preterm Birth: A Systematic Review of the Literature.

BACKGROUND: Uterocervical angle (UCA) has been recently proposed as a potential marker that could accurately predict preterm birth (PTB). The purpose of the present systematic review is to accumulate current evidence and provide directions for future research. MATERIALS AND METHODS: We used the Medline (1966-2018), Scopus (2004-2018), Clinicaltrials.gov (2008-2018), EMBASE (1980-2018), Cochrane Central Register of Controlled Trials CENTRAL (1999-2018), and Google Scholar (2004-2018) databases in our search. RESULTS: Eleven studies were finally included in the present systematic review that evaluated data from 3,018 women. The significant heterogeneity in terms of outcome reporting and outcome reporting measures (use of optimal cut-off values) precluded meta-analysis. However, existing data support that second trimester UCA measurement might be used as a predictive factor of PTB <34 weeks, as at least two studies in unselected singleton pregnancies and two studies in pregnancies with an ultrasonographically shortened cervix seem to support this hypothesis. The most commonly reported cut-off values were 105° and 95°. CONCLUSIONS: UCA measurement during the second trimester of pregnancy may be a useful method of determining women at risk of delivering preterm. However, more studies are needed to assess the reproducibility of these findings and reach conclusive evidence.

Genital lichen sclerosus in childhood and adolescence-a retrospective case series of 15 patients: early diagnosis is crucial to avoid long-term sequelae.

Lichen sclerosus is a chronic skin disease, mainly localised at the introitus and perineum. When the condition remains untreated, gradual atrophy of skin structures leads to permanent scarring, making early diagnosis and treatment crucial. We reviewed all patients diagnosed with lichen sclerosus presenting to a tertiary referral centre for paediatric and adolescent gynaecology between January 2011 and December 2015 to assess disease presentation and response to treatment. We identified 15 cases, with a mean age at diagnosis of 8.8 years. Their main presenting symptoms were vulvar pruritus and vulvar soreness. Seven girls had already atrophic changes, and in four girls, this amounted to clitoral phimosis, labial resorption or labial adhesion formation. The median delay in diagnosis was 7 months. Thirteen patients received local treatment with potent corticosteroids, responding well to treatment. However, 4 girls relapsed within 2 to 36 months. Two adolescents required surgical treatment, one because of urinary retention and the second because of dyspareunia caused by clitoral entrapment. CONCLUSIONS: There was a delay in diagnosis in most patients and this resulted in irreversible genital skin changes, which would have been preventable, had treatment been instituted promptly. The response to treatment with local corticosteroids was usually effective, leading to both symptom alleviation and prevention of disease progression. Atrophic changes and skin complications however were not reversed. What is Known: • Lichen sclerosus affects women of all ages, including girls, particularly prior to adolescence. • Lichen sclerosus responds well to local corticosteroid treatment. What is New: • In the majority of patients with lichen sclerosus there was a long delay between onset of symptoms and diagnosis. • Nearly half of the children diagnosed with lichen sclerosus had irreversible atrophic genital skin changes at the time of first presentation. These changes may have been prevented by a timely diagnosis and intervention.

Laparoscopic Cystectomy In-a-Bag of an Intact Cyst: Is It Feasible and Spillage-Free After All?

This prospective study was conducted to assess the feasibility of laparoscopic cystectomy of an intact adnexal cyst performed inside a water proof endoscopic bag, aiming to avoid intraperitoneal spillage in case of cyst rupture. 102 patients were recruited. Two of them were pregnant. In 8 of the patients the lesions were bilateral, adding up to a total of 110 cysts involved in our study. The endoscopic sac did not rupture in any case. Mean diameter of the cysts was 5.7 cm (range: 2.3-10.5 cm). In 75/110 (68.2%) cases, cystectomy was completed without rupture, whereas in the remaining 35/110 (31.8%) cases the cyst ruptured. Minimal small spillage occurred despite every effort only in 8/110 (7.2%) cases with large (>8 cm) cystic teratomas. There were no intraoperative or postoperative complications. We concluded that laparoscopic cystectomy in-a-bag of an intact cyst is feasible and oncologically safe for cystic tumors with a diameter < 8 cm. Manipulation of larger tumors with the adnexa into the sac may be more difficult, and in such cases previous puncture and evacuation of the cyst contents should be considered.

Posterior Deep Infiltrating Endometriotic Nodules: Operative Considerations according to Lesion Size, Location, and Geometry, during One's Learning Curve.

We conducted this prospective cohort study to standardize our laparoscopic technique of excision of posterior deep infiltrating endometriosis (DIE) nodules, according to their size, location, and geometry, including 36 patients who were grouped, according to principal pelvic expansion of the nodule, into groups with central (group 1) and lateral (group 2) lesions, and according to nodule size, into ≤2 cm (group A) and >2 cm (group B) lesions, respectively. In cases of group 1 the following operative steps were more frequently performed compared to those of group 2: suspension of the rectosigmoid, colpectomy, and placement of bowel wall reinforcement sutures. The opposite was true regarding suspension of the adnexa, systematic ureteric dissection, and removal of the diseased pelvic peritoneum. When grouping patients according to nodule size, almost all of the examined parameters were more frequently applied to patients of group B: adnexal suspension, suspension of the rectosigmoid, systematic ureteric dissection, division of uterine vein, colpectomy, and placement of bowel wall reinforcement sutures. Nodule size was the single most important determinant of duration of surgery. In conclusion, during the building-up of one's learning curve of laparoscopic excision of posterior DIE nodules, technique standardization is very important to avoid complications.

The validation of international consultation on incontinence questionnaires in the Greek language.

AIMS: The objective of this study was to validate four specific International Consultation on Incontinence Questionnaires (ICIQ) modules in the Greek language: (i) the ICIQ-FLUTS long form (ICIQ-FLUTS-LF), (ii) the ICIQ-FLUTS, (iii) the ICIQ-FLUTS-SEX, and (iv) the ICIQ-Vaginal Symptoms Questionnaire (ICIQ-VS), originally validated in English. METHODS: The English questionnaires were initially translated into Greek, then back-translated into English and final modifications were made after testing the questionnaires on a sample of patients. To validate the translated questionnaires, the following tests were undertaken: Content/face validity, internal consistency (reliability) and stability (test-retest reliability). RESULTS: A total of 122 women participated in the study. Eighty-nine presented with pelvic organ prolapse (POP) and/or urinary incontinence (UI) symptoms and 33 attended an outpatient gynecological clinic without POP/UI symptoms. All modules showed excellent content/face validity (missing values 0-2.5%). Cronbach's alpha test for internal consistency showed satisfactory to excellent reliability (0.876 for ICIQ-FLUTS-LF, 0.85 for ICIQ-FLUTS, and 0.83 for ICIQ-VS), with the exception ICIQ-FLUTS-SEX which was 0.69. The test-retest reliability showed moderate to near-perfect agreement (weighted kappa value 0.52-0.99). CONCLUSIONS: The Greek versions of the ICIQ-FLUTS-LF, ICIQ-FLUTS, and ICIQ-VS questionnaires were successfully validated. Our data showed that the ICIQ FLUTS-SEX questionnaire, as it stands in its current English version, cannot be reliably used to assess sex symptoms in the Greek female population.