Is dienogest the best medical treatment for ovarian endometriomas? Results of a multicentric case control study.

Ovarian endometriomas are common manifestations of endometriosis. Surgical excision has been shown to potentially decrease ovarian reserves. In this prospective study, we included 81 patients with ovarian endometriosis. 40 were treated with 2 mg of dienogest daily (DNG) and 41 were treated with cyclic oral estro-progestins (ethinyl estradiol 30 mcg [EE] plus dienogest 2 mg) (DNG + EE). Aim of the study was the effect of the treatment on the size of the endometriotic cysts. Further, in the symptomatic patients, follow-up included an evaluation of chronic pain before and during treatment. Both treatments were able to significantly decrease the pain in symptomatic patients with no statistical differences. The mean visual analog scale score at enrollment was 65 ± 14 and 70 ± 18, and there was significant improvement (19 ± 15, p < .001, DNG; 18 ± 12, p < .001, DNG + EE). The size of the endometrioma cysts were significantly reduced in the DNG group. The mean cyst diameter was 52 ± 22 mm at baseline and 32 ± 12 mm after six months of treatment (p < .001), yielding a 75% volume reduction in DNG group. The decrease in the size of endometrioma cysts observed in the women treated with only progestin could be noteworthy, as it may reduce the negative impacts on the affected ovary and avoid surgery.

Effects of chronic endometritis therapy on in vitro fertilization outcome in women with repeated implantation failure: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the impact of antibiotic therapy for chronic endometritis (CE) on IVF outcome. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Infertile women with history of recurrent implantation failure, defined as two or more failed ETs, undergoing one or more IVF cycle(s). INTERVENTION(S): The review was registered in PROSPERO (CRD42017062494) before the start of the literature search. Observational studies were identified by searching electronic databases. The following comparators were included: women with CE receiving antibiotics vs. untreated controls; women with cured CE vs. women with persistent CE; and women with cured CE vs. women with normal endometrial histology (negative for CE). The summary measures were reported as odds ratio (OR) with 95% confidence interval (CI). MAIN OUTCOME MEASURE(S): Clinical pregnancy rate (CPR), ongoing pregnancy rate/live birth rate (OPR/LBR), implantation rate (IR), miscarriage rate. RESULT(S): A total of 796 patients (from five studies) were included. Women receiving antibiotic therapy (without the histologic confirmation of CE cure) did not show any advantage in comparison with untreated controls (OPR/LBR, CPR, and IR). Patients with cured CE showed higher OPR/LBR (OR 6.81), CPR (OR 4.02), and IR (OR 3.24) in comparison with patients with persistent CE. In vitro fertilization outcome was comparable between women with cured CE and those without CE (OPR/LBR, CPR, and IR). Miscarriage rate was not significantly different between groups. CONCLUSION(S): Chronic endometritis therapy may improve IVF outcome in patients suffering from recurrent implantation failure. A control biopsy should always confirm CE resolution before proceeding with IVF.

Endometrial scratch injury before intrauterine insemination: is it time to re-evaluate its value? Evidence from a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To assess the impact of endometrial scratch injury (ESI) on the outcomes of intrauterine insemination (IUI) stimulated cycles. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Infertile women undergoing one or more IUI stimulated cycles. INTERVENTION(S): Randomized controlled trials (RCTs) were identified by searching electronic databases. We included RCTs comparing ESI (i.e., intervention group) during the course of IUI stimulated cycle (C-ESI) or during the menstrual cycle preceding IUI treatment (P-ESI) with controls (no endometrial scratch). The summary measures were reported as odds ratio (OR) with 95% confidence-interval (CI). MAIN OUTCOME MEASURE(S): Clinical pregnancy rate, ongoing pregnancy rate, multiple pregnancy rate, ectopic pregnancy rate, miscarriage rate. RESULT(S): Eight trials were included in the meta-analysis, comprising a total of 1,871 IUI cycles. Endometrial scratch injury was associated with a higher clinical pregnancy rate (OR 2.27) and ongoing pregnancy rate (OR 2.04) in comparison with the controls. No higher risk of multiple pregnancy (OR 1.09), miscarriage (OR 0.80), or ectopic pregnancy (OR 0.82) was observed in patients receiving ESI. Subgroup analysis based on ESI timing showed higher clinical pregnancy rate (OR 2.57) and ongoing pregnancy rate (OR 2.27) in patients receiving C-ESI and no advantage in patients receiving P-ESI. CONCLUSION(S): Available data suggest that ESI performed once, preferably during the follicular phase of the same cycle of IUI with flexible aspiration catheters, may improve clinical pregnancy and ongoing pregnancy rates in IUI cycles. Endometrial scratch injury does not appear to increase the risk of multiple pregnancy, miscarriage, or ectopic pregnancy.

Uterine fibroid size modifications during pregnancy and puerperium: evidence from the first systematic review of literature.

PURPOSE: The influence of pregnancy on uterine fibroid size still remains an unsolved dilemma. Basing on current knowledge, physicians are not able to inform patients about the likelihood of uterine fibroids to modify their size during pregnancy. Study aim was to summarize available evidence concerning the size modifications of uterine fibroids during each trimester of pregnancy and during puerperium. METHODS: The review was reported following the PRISMA guidelines and registered in PROSPERO (registration number: CRD42017071117). A literature search was conducted in electronic database (PubMed, Embase, Sciencedirect, the Cochrane library and Clinicaltrials.gov) until July 2017. All studies evaluating fibroids' changes during pregnancy and puerperium by ultrasound or magnetic-resonance-imaging were included. Descriptive characteristics of studies and patients were collected. The modifications of uterine fibroid diameter and volume were the outcome measures. RESULTS: Concerning the first trimester of pregnancy, all authors reported a significant growth of uterine fibroids. Contradictory evidence was found about uterine fibroid modifications during the second and third trimesters, mainly supporting a slowdown during mid pregnancy and a subsequent size reduction during late pregnancy. Concerning the overall modifications during pregnancy and puerperium, poor evidence quality suggests that uterine fibroids do not modify their volume/slightly enlarge during pregnancy and subsequently reduce in size during puerperium. CONCLUSIONS: Uterine fibroids seem to be subject to a non-linear trend of modifications during pregnancy and puerperium, which may vary from myoma to myoma. Adequate evidence supports uterine fibroid systematic enlargement during the first trimester of pregnancy, while inconsistent evidence is available about the changes of uterine fibroids during second and third trimesters. In addition, the overall modifications of myomas during pregnancy and puerperium remain unclear.

Laparoscopic uterine artery bipolar coagulation plus myomectomy vs traditional laparoscopic myomectomy for "large" uterine fibroids: comparison of clinical efficacy.

PURPOSE: Laparoscopic myomectomy is the uterus-preserving surgical approach of choice in case of symptomatic fibroids. However, it can be a difficult procedure even for an experienced surgeon and can result in excessive blood loss, prolonged operating time and postoperative complications. A combined approach with laparoscopic uterine artery occlusion and simultaneous myomectomy was proposed to reduce these complications. The aim of this study was to evaluate the safety and efficacy of the combined laparoscopic approach in women with symptomatic "large" intramural uterine fibroids, compared to the traditional laparoscopic myomectomy alone. METHODS: Prospective nonrandomized case-controlled study of women who underwent a conservative surgery for symptomatic "large" (≥ 5 cm in the largest diameter) intramural uterine fibroids. The "study group" consisted of women who underwent the combined approach (laparoscopic uterine artery bipolar coagulation and simultaneous myomectomy), while women who underwent the traditional laparoscopic myomectomy constituted the "control group". A comparison between the two groups was performed, and several intraoperative and postoperative outcomes were evaluated. RESULTS: No significant difference in the overall duration of surgery between women of the "study group" and "control group" emerged; however, a significantly shorter surgical time for myomectomy was observed in the "study group". The intraoperative blood loss and the postoperative haemoglobin drop were significantly lower in the "study group". No difference in the postoperative pain between groups emerged, and the postoperative hospital stay was similar in the two groups. CONCLUSIONS: The laparoscopic uterine artery bipolar coagulation and simultaneous myomectomy is a safe and effective procedure, even in women with symptomatic "large" intramural uterine fibroids, with the benefit of a significant reduction in the intraoperative blood loss when compared to the traditional laparoscopic myomectomy.

Bladder endometriosis: a summary of current evidence.

Bladder endometriosis is a specific form of endometriosis characterized by the presence of endometrial glands and stroma in the detrusor muscle. Such disease may involve different sites of the bladder, most frequently the base and the dome, with various grade of infiltration. Bladder nodules typically coexists with other localizations of deep pelvic endometriosis, resulting in a wide variety of abdominal and urinary symptoms that may be overlooked by clinicians. In spite of advances in understanding the genetic and molecular development of endometriosis, the clinical approach to bladder lesions is very challenging and may require the use of different diagnostic tools in order to set up a comprehensive diagnostic workup and direct towards the most appropriate treatment. The aim of this paper was to portray the state of art of diagnosis and management of bladder endometriosis, starting from the current evidence about epidemiology, pathophysiology, clinical signs and providing all the available strategies for medical and surgical treatment.

A novel hysteroscopic approach for ovarian cancer screening/early diagnosis.

The lethality of epithelial ovarian cancer (EOC) may be due to common misconceptions regarding etiology and the absence of effective screening and early diagnostic tools. Reviews of histopathological surveys performed on the resected fallopian tubes of breast cancer (BRCA) mutation carriers, who underwent risk-reducing salpingo-oophorectomy, unexpectedly revealed the presence of occult carcinomas of the fallopian tubes. This finding prompted studies that demonstrated the most accredited theory of type II EOC development, which suggests that a large proportion of these tumors are derived from the fallopian tube. At present, no diagnostic tools or screening programs have been demonstrated to be effective or cost-effective in improving the outcome of EOC; it is therefore imperative that the scientific community unite its efforts in the identification of a valid screening and/or early diagnostic method for the treatment of this lethal gynecological malignancy. To this end, the present paper proposes a novel tool for the screening/early diagnosis of EOC: The 'Tuba-check'. This novel approach is based on the possibility of acquiring specimens for tubal lumen cytology via hysteroscopy in a minimally-invasive outpatient setting. The present study protocol aimed to validate the technical feasibility and oncological accuracy of the proposed approach, commencing with a cohort of patients with an expected increased oncological risk, including BRCA mutation carriers or those with a gene expression profile of 'BRCA-ness'. If the data collected by the present study protocol validates this approach, the 'Tuba-check' may, in the near future, be extended for the treatment of all women, therefore reducing the number of victims of epithelial ovarian carcinoma.

Feasibility of hysteroscopic endometrial polypectomy using a new dual wavelengths laser system (DWLS): preliminary results of a pilot study.

PURPOSE: Currently, endometrial polyps may be successfully treated in an outpatient setting with 5 Fr mechanical and bipolar instruments. Our aim is to evaluate the benefits of minimally invasive techniques in hysteroscopy, focusing on the use of a new dual wavelengths laser system in the treatment of endometrial polyps in an outpatient setting. METHODS: Between September 2012 and December 2014, all consecutive patients of reproductive and menopausal age with ultrasound diagnosis of endometrial polyp with maximum diameter ≤2.5 cm were eligible to participate in a prospective study. They underwent a hysteroscopic procedure with excision of the polyp using a new dual wavelengths laser system. All procedures were performed on an outpatient basis without anesthesia. RESULTS: Laser polypectomy was successfully performed in 219 out of 225 (97.3%). Success of surgery was not influenced by the initial location of polyp. No main complications were reported during or immediately after the procedure. 6 and 12 months follow-up with ultrasound scan did not show any persistence or recurrence of the pathology. CONCLUSIONS: Our preliminary findings seem to support the safety and the effectiveness of the laser hysteroscopic endometrial polypectomy. However, further studies are mandatory to validate its use in daily hysteroscopic practice.

Salpingectomy before assisted reproductive technologies: a systematic literature review.

Salpingectomy is largely used in case of hydrosalpinx in infertile women scheduled for assisted reproductive technologies (ART), whereas there is no consensus on its role in absence of hydrosalpinx. The current is a systematic literature review to collate all available evidence regarding salpingectomy as fertility enhancement procedure before ART in infertile patients. Our primary endpoint was to assess the impact of the surgical procedure on ovarian reserve, and secondary outcomes were to evaluate its benefits and harms on ART outcomes. We identified 29 papers of which 16 reporting data on the impact of tubal surgery on ovarian reserve and 24 (11 previously included) on ART outcomes. Available data suggested an absence of variation in ovarian reserve markers after unilateral salpingectomy while contradictory results were reported for bilateral surgery. Considering ART outcomes, data reported a significant improvement in ongoing pregnancy/live-birth rate in treated subjects without significant reduction in ovarian response to gonadotropin stimulation. In case of tubal disease, a surgical approach based on unilateral salpingectomy may be considered safe, without negative effects on ovarian reserve and ovarian response to controlled ovarian stimulation whilst having a positive effect on pregnancy rate. Data regarding bilateral salpingectomy and ovarian reserve are conflicting. Further trials are needed to confirm both the benefits of salpingectomy before ART and the safety of bilateral salpingectomy on ovarian reserve, and to clarify the role of uni- or bilateral surgery in case of tubal blockage without hydrosalpinx.

Laparoscopic treatment of early-stage endometrial cancer with and without uterine manipulator: Our experience and review of literature.

OBJECTIVE: The aim of this study was to retrospectively compare in a series of 110 patients with early-stage endometrial cancer recurrence rate and surgical outcomes after total laparoscopic (LPS) hysterectomy with lymphadenectomy performed with or without uterine manipulator. STUDY DESIGN: 110 patients with clinical stage I endometrial cancer were enrolled in a retrospective study and underwent surgical staging comprised of LPS hysterectomy, bilateral salpingo-oophorectomy, and in all cases we performed systematic bilateral pelvic lymphadenectomy with uterine manipulator (Group 1, 55 patients) or without (Group 2, 55 patients). RESULTS: The rate of positive cytology and LVSI did not significantly differ between Group 1 and Group 2. 1 patient of the Group 1 had a bladder injury and another patient of Group 2 had an ureteral stricture temporarily treated with a stent. 1 patient of the Group 1 had a bowel occlusion due to a port site hernia under the left 10 mm port, resolved with a bowel resection and an end-to-end anastomosis. In 1 patient of the Group 1 and 2 patients of Group 2 we observed a vaginal cuff dehiscence and in 1 case of Group 2 a pelvic lymphocyst was reported. Postoperative fever was reported in 3 patients of the Group 1 and in 5 patients of group 2 (p = 0.07). CONCLUSIONS: Our study confirms that use of uterine manipulator for laparoscopic treatment of endometrial cancer does not increase positive peritoneal citology, LVSI and recurrence rate.

A multicenter study comparing surgical outcomes and ultrasonographic evaluation of scarring after laparoscopic myomectomy with conventional versus barbed sutures.

OBJECTIVE: To compare clinical outcomes after laparoscopic myomectomy using traditional interrupted sutures (TIS) versus continuous barbed suture (CBS) for treatment of symptomatic uterine myomas. METHODS: In a multicenter retrospective study, data were obtained for women with uterine myomas who underwent laparoscopic myomectomy at three centers between January 1, 2009 and January 31, 2015. Suturing of the uterine wall had been performed initially using TIS; CBS were used from January 31, 2012. RESULTS: Overall, laparoscopic myomectomy was performed using CBS for 360 women and using TIS for another 360. The mean operative time was 52±19min using CBS and 67±21min using TIS groups (P=0.001). The mean blood loss was 135±35mL in the CBS group and 215±55mL in the TIS group (P=0.006). The mean decrease in hemoglobin was 1.2±0.2g/L in the CBS group and 1.2±0.2g/L in the TIS group (P=0.072). CONCLUSION: Laparoscopic myomectomy using CBS is a suitable alternative to TIS in the treatment of uterine myomas for women with up to three tumors.

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.

Fertility-enhancing hysteroscopic surgery.

Anatomical uterine element and functional components play a fundamental role in the enhancing of fertility are the major actors. Uterine pathologies, including congenital or acquired lesions, have been reported in 21 to 47% of patients undergoing in vitro fertilization cycles. Hysteroscopy is an important procedure in the study of one of the most important element of fertility: the uterus, even if its use in the world of infertility is discussed. There are many studies on safety and feasibility of the procedure and on patient compliance, but there is no consensus on its systemic use. This study, thanks to the wide literature about the use of hysteroscopic surgery to enhance fertility in most of the congenital and acquired problems affecting women in fertility age, allows defining that diagnostic and operative hysteroscopy is a rapid and safety technology to improve fertility.

Endometrial ablation: first- vs. second-generation techniques.

INTRODUCTION: Endometrial ablation is a procedure that surgically destroys (ablates) the lining of the uterus (endometrium). The goal of endometrial ablation is to reduce menstrual flow. In some women, menstrual flow may stop completely. In some cases, endometrial ablation may be an alternative to hysterectomy. There are several techniques used to perform endometrial ablation, including electrical or electrocautery ablation, in which an electric current travels through a wire loop or rollerball is applied to the endometrial lining to cauterize the tissue; hydrothermal ablation, in which heated fluid is pumped into the uterus and destroys the endometrial lining via high temperatures; balloon therapy ablation, in which a balloon at the end of a catheter is inserted into the uterus and filled with fluid, which is then heated to the point that the endometrial tissues are eroded away; radiofrequency ablation in which a triangular mesh electrode is expanded to fill the uterine cavity, at which point the electrode delivers an electrical current and destroys the endometrial lining; cryoablation (freezing), in which a probe uses extremely low temperatures to freeze and destroy the endometrial tissues; and microwave ablation, in which microwave energy is delivered through a slender probe inserted into the uterus and destroys the endometrial lining. EVIDENCE ACQUISITION: The purpose of this systematic review was to evaluate the feasibility, safety, and efficacy of endometrial ablation performed with first- and second-generation techniques. A literature search in PubMed from January 2000 to September 2015 was performed using the keywords endometrial ablation, menorrhagia, and heavy menstrual bleeding. Results were restricted to systematic reviews, randomized control trials (RCT)/controlled clinical trials, and observational studies written in English from January 2000 to September 2015. EVIDENCE SYNTHESIS: There is no evidence that either broad category is more effective than the other in reducing HMB, and there is no evidence that rates of satisfaction differ significantly. CONCLUSIONS: The overall results of the presented studies suggest that endometrial ablation is an effective therapy for menorrhagia in women with bleeding disorders.

Different stimulation protocols for oocyte cryropreservation in oncological patients: a retrospective analysis of single university centre.

OBJECTIVE: To analyze the results obtain in cancer patients who receive the same controlled ovarian stimulation protocol, started in two different moments of the menstrual cycle, follicular or luteal phase. The stimulation is performed before cancer treatment in order to preserve fertility through oocytes cryopreservation. STUDY DESIGN: The study is a retrospective analysis about 25 cancer patients at our centre, Department of Reproductive Medicine of University of Pisa, in order to preserve their fertility before cancer treatment. Patients are divided into two groups depending on the menstrual cycle phase, follicular or luteal phase, at the moment of first examination. Standard stimulation protocol with gonadotropins is administered in the follicular group, whereas in the second group we use GnRH (gonadotropin-releasing hormone) antagonist before gonadotropins administration in order to have a rapid luteolysis. The outcome measures are the number of days needed before starting procedure, duration of stimulation, cumulative dosage of gonadotropins number of oocyte retrieved and percentage of mature oocytes. RESULTS: Any difference showed between two groups based on days of stimulation, total amount of gonadotropins administered and the number of good mature quality oocytes was retrieved. The real difference is the number of days needed to start the procedure, lesser in the luteal group. CONCLUSIONS: This study suggests that oocytes can be obtained before cancer treatment, irrespective of menstrual cycle phase without compromising the efficacy of procedure. Moreover, starting ovarian stimulation anytime during menstrual cycle allows the patients to not postpone the beginning of cancer treatment. Different stimulation protocols, according to different kinds of disease, are available in order to obtain the maximum results without any complication for patients.

Single-port versus conventional multiport access prophylactic laparoscopic bilateral salpingo-oophorectomy in high-risk patients for ovarian cancer: a comparison of surgical outcomes.

Bilateral salpingo-oophorectomy (BSO) in carriers of BRCA1 and BRCA2 mutations is widely recommended as part of a risk-reduction strategy for ovarian or breast cancer due to an underlying genetic predisposition. BSO is also performed as a therapeutic intervention for patients with hormone-positive premenopausal breast cancer. BSO may be performed via a minimally invasive approach with the use of three to four 5 mm and/or 12 mm ports inserted through a skin incision. To further reduce the morbidity associated with the placement of multiple port sites and to improve cosmetic outcomes, single-port laparoscopy has been developed with a single access point from the umbilicus. The purpose of this study was to evaluate the surgical outcomes associated with reducing the risks of salpingo-oophorectomy performed in a single port, while comparing multiport laparoscopy in women with a high risk for ovarian cancer. Single-port laparoscopy-BSO is feasible and safe, with favorable surgical and cosmetic outcomes when compared to conventional laparoscopy.

Ultrasound techniques in the diagnosis of deep pelvic endometriosis: algorithm based on a systematic review and meta-analysis.

OBJECTIVE: To collate all available evidence with respect to ultrasound techniques in the management of deep pelvic endometriosis (DPE) and compare the sensitivity and specificity of each to determine the most suitable site-specific method. We aim to provide clinicians with information to improve the diagnosis and management of patients with DPE. DESIGN: Systematic review of the literature and meta-analysis. SETTING: Not applicable. PATIENT(S): None. INTERVENTIONS(S): Review of MEDLINE, EMBASE, ScienceDirect, Cochrane Library. MAIN OUTCOME MEASURE(S): For each study we calculated the sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and positive/negative likelihood ratio regarding DPE sites. We then compared the specificity and sensitivity of each technique. Forest plots with the corresponding 95% confidence interval using fixed/random effects for each approach (both separately and summarized according to the weight of any single study) were used. RESULT(S): A key word search strategy identified 441 manuscripts, 35 of which were eligible for the review (32 for meta-analysis). Standard transvaginal sonography (TVS) showed specificity greater than 85% for all DPE sites, despite sensitivity ranging between 50% (bladder, vaginal wall, and rectovaginal septum) and 84% (rectosigmoid). Modified techniques such as bladder site tenderness-guided TVS showed a value of 97.4% for both sensitivity and specificity. Rectal endoscopy-sonography and rectal water contrast TVS were both superior to TVS in detecting rectosigmoid endometriosis with sensitivities and specificities over 92%. Promising data were reported by using rectal water contrast TVS for rectovaginal septum disease (sensitivity, 97.1%; specificity, 99.3%). CONCLUSION(S): The summary of data regarding diagnostic specificity and sensitivity of TVS in women undergoing surgery for deep endometriosis may allow us to conclude that TVS should remain the first-line method in the evaluation of patients with suspicion of DPE. When TVS is insufficient, second-line "modified-techniques" should be considered. Choosing the most effective technique is a challenge and should be based on patient history and clinical signs/symptoms.

Inflammatory cytokine expression following the use of bipolar electrocoagulation, ultracision harmonic scalpel and cold knife biopsy.

Electrical surgical devices may determine tissue damage through lateral thermal spread and activation of inflammatory processes. Several tissue effects are associated with the use of different surgical instruments. The aim of the present study was to compare tissue damage following the application of cold knife biopsy, bipolar electrocoagulation and the ultracision harmonic scalpel, through the analysis of inflammatory gene mediator expression. Three fragments of the round ligament (length 0.5 cm) were obtained from 22 females who had undergone total or subtotal laparoscopic hysterectomy using three different modes of resection: Cold knife biopsy, bipolar electrocoagulation and ultracision harmonic scalpel. The tissue fragments were examined by quantitative polymerase chain reaction (qPCR) analysis of selected cytokines. Gene expression analysis demonstrated large standard deviations due to individual variability among patients and indicated variability in the concentrations of cytokines in the three different samples. The quantity of cytokine mRNA in the cold knife biopsy samples was generally greater than those obtained by other techniques. Tumor necrosis factor-α expression was significantly higher in the sample obtained with the ultracision harmonic scalpel and bipolar electrocoagulation (P=0.033) when compared with cold knife biopsy. The inflammatory response was analyzed by the quantification of gene expression through the use of qPCR. The ultracision harmonic scalpel and bipolar electrocoagulation triggered the inflammatory cascade and resulted in an increased production of cytokines compared with cold knife biopsy.