Comparative analysis of endometrial, vaginal, and gut microbiota in patients with and without adenomyosis.

INTRODUCTION: Alterations in microbiota composition have been implicated in a variety of human diseases. Patients with adenomyosis present immune dysregulation leading to a persistent chronic inflammatory response. In this context, the hypothesis that alterations in the microbiota may be involved in the pathogenesis of adenomyosis, by affecting the epigenetic, immunologic, and biochemical functions of the host, has recently been postulated. The aim of the present study was to compare the microbiota composition in the vagina, endometrium, and gut of individuals with and without adenomyosis. MATERIAL AND METHODS: Cross-sectional study including 38 adenomyosis patients and 46 controls, performed between September 2021 and October 2022 in a university hospital-based research center. The diagnosis of adenomyosis was based on sonographic criteria. Fecal, vaginal, and endometrial samples were collected. Study of the microbiota using 16S rRNA gene sequencing. RESULTS: Patients with adenomyosis exhibited a significant reduction in the gut microbial alpha diversity compared with healthy controls (Chao1 p = 0.012, Fisher p = 0.005, Observed species p = 0.005). Beta-diversity analysis showed significant differences in the compositions of both gut and vaginal microbiota between adenomyosis patients and the control group (Adonis p-value = 0.001; R2 = 0.03 and Adonis p-value = 0.034; R2 = 0.04 respectively). Specific bacterial taxa were found to be either overrepresented (Rhodospirillales, Ruminococcus gauvreauii group, Ruminococcaceae, and Actinomyces) or underrepresented in the gut and endometrial microbiota of adenomyosis patients compared with controls. Distinct microbiota profiles were identified among patients with internal and external adenomyosis phenotypes. CONCLUSIONS: The study revealed reduced gut microbiota diversity in adenomyosis patients, accompanied by distinct compositions in gut and vaginal microbiota compared with controls. Overrepresented or underrepresented bacterial taxa were noted in the gut and endometrial microbiota of adenomyosis patients, with variations in microbiota profiles among those with internal and external adenomyosis phenotypes. These findings suggest a potential association between microbiota and adenomyosis, indicating the need for further research to comprehensively understand the implications of these differences.

Risk factors for irreversible unilateral loss of renal function in patients with deep endometriosis.

Deep endometriosis (DE) can be more aggressive than other types of endometriosis, and may even lead to irreversible severe complications such as complete unilateral loss of renal function. We aimed to describe the clinical and radiologic characteristics of DE patients diagnosed with irreversible unilateral loss of renal function due to unilateral ureteral stenosis and evaluate risk factors for developing this loss. This retrospective cohort study included 436 patients who underwent laparoscopic DE surgery. We evaluated two groups of patients according to preserved (Non-Renal Loss Group; n = 421) or irreversible unilateral damaged renal function (Renal Loss Group; n = 15). Preoperative epidemiologic variables, clinical characteristics, radiologic findings and surgical treatments of all the patients were collected. The Renal Loss Group had a higher infertility rate and a higher proportion of asymptomatic patients. The following radiological variables showed statistically significant differences between the two groups: mean endometrioma diameter, the presence of intestinal DE and negative sliding sign. Multivariate analysis showed that infertility, being asymptomatic, having intestinal DE or torus uterinus/uterosacral ligament DE and a negative sliding sign significantly increased the risk of loss of renal function. Therefore, among patients with these clinical and/or radiological variables, severe urinary tract obstruction should be specifically ruled out.

Assessing vaginal wall thickness by transvaginal ultrasound in breast cancer survivors: A pilot study.

AIM: There is need for a straightforward objective measure to evaluate vaginal wall changes related to hypoestrogenism. The aim of this pilot study was to evaluate a transvaginal ultrasound procedure for the quantification of vaginal wall thickness in order to differentiate between healthy premenopausal women and postmenopausal women with genitourinary syndrome of menopause using ultra-low-level estrogen status as a model. METHODS: We performed a prospective, two-arm, cross-sectional pilot study comparing vaginal wall thickness measured by transvaginal ultrasound in postmenopausal breast cancer survivors using aromatase inhibitors with genitourinary syndrome of menopause (GSM group) and healthy premenopausal women (control or C group) from October 2020 to March 2022. After intravaginal introduction of 20 cm3 of sonographic gel, vaginal wall thickness was measured by transvaginal ultrasound in the anterior, posterior, and right and left lateral walls (four quadrants). The study methods followed the STROBE checklist. RESULTS: According to the results of a two-sided t-test, the mean vaginal wall thickness of the four quadrants in the GSM group was significantly less than that of the C group (2.25 mm vs 4.17 mm, respectively; p < 0.001). Likewise, the thickness of each of the vaginal walls (anterior, posterior, right and left lateral) statistically differed between the two groups (p < 0.001). CONCLUSION: Transvaginal ultrasound with intravaginal gel may be a feasible objective technique to assess genitourinary syndrome of menopause, showing clear differences in vaginal wall thickness between breast cancer survivors using aromatase inhibitors and premenopausal women. Possible correlations with symptoms or treatment response should be assessed in future studies.

Clinical and sonographic impact of oral contraception in patients with deep endometriosis and adenomyosis at 2 years of follow-up.

Nowadays, combined oral contraceptives (COCs) are successfully employed for the treatment of endometriosis (END) and adenomyosis (AD) in a large proportion of patients. However, literature focusing on the clinical and sonographic response to treatment in the long-term follow-up of patients with deep endometriosis (DE) and AD is scarce. The aim of this study was to evaluate the changes in the symptoms and the sonographic exams at 12 and 24 months of follow-up in patients who had received a flexible extended COC regimen containing 2 mg of dienogest/30 µg ethinyl estradiol. This prospective, longitudinal, observational study included women diagnosed with DE and AD presenting no surgical indication and were candidates to treatment with COCs. The presence and severity of dysmenorrhea, non-menstrual pelvic pain, deep dyspareunia, dyschezia and dysuria were evaluated using the Numerical Rating Scale (NRS) at baseline, and at 12 and 24 months of treatment. Transvaginal ultrasound was also performed at these check points searching for criteria of AD and reporting the size of the DE nodules and ovarian endometriomas (OE). Sixty-four patients were included. A significant decrease in the number of patients with severe dysmenorrhea and non-menstrual pelvic pain was reported during follow-up. The mean NRS score for dysmenorrhea, non-menstrual pelvic pain, deep dyspareunia, dyschezia and dysuria was also significantly lower at follow-up. There was a significant reduction in the sonographic number and type of AD criteria during follow-up after treatment. Similarly, a significant decrease in the size of OE and uterosacral ligament involvement in DE was observed at the 12-month follow-up, with a further, albeit not statistically significant, decrease in the 12- to 24-month follow-up. Additionally, torus and rectosigmoid DE decreased in size, although the reduction was not statistically significant at any study point. This prospective study suggests a clinical and sonographic improvement after a flexible extended COC regimen in DE and AD patients, which was significant at 12 months of follow-up. The improvement was more evident in AD and OEs compared with DE. Further research with a longer follow-up, larger sample size and comparison with other treatments is needed.

Factors Associated with a Post-Procedure Spontaneous Pregnancy after a Hysterosapingo-Foam-Sonography (HyFoSy): Results from a Multicenter Observational Study.

BACKGROUND: Tubal patency testing constitutes an essential part of infertility work-up. Hysterosalpingo-foam-sonography (HyFoSy) is currently one of the best tests for assessing tubal patency. The objective of our study was to evaluate the post-procedure rate of spontaneous pregnancy among infertile women submitted for an HyFoSy exam with ExEm® foam and the factors associated with this. METHODS: Multicenter, prospective, observational study performed at six Spanish centers for gynecologic sonography and human reproduction. From December 2015 to June 2021, 799 infertile women underwent HyFoSy registration consecutively. The patients' information was collected from their medical records. Multivariable regression analyses were performed, controlling for age, etiology, and time of sterility. The main outcome was to measure post-procedure spontaneous pregnancy rates and the factors associated with the achievement of pregnancy. RESULTS: 201 (26.5%) women got spontaneous conception (SC group), whereas 557 (73.5%) women did not get pregnant (non-spontaneous conception group, NSC). The median time for reaching SC after HyFoSy was 4 months (CI 95% 3.1-4.9), 18.9% of them occurring the same month of the procedure. Couples with less than 18 months of infertility were 93% more likely to get pregnant after HyFoSy (OR 1.93, 95% CI 1.34-2.81; p < 0.001); SC were two times more frequent in women under 35 years with unexplained infertility (OR 2.22, 95% CI 1.07-4.65; P0.033). CONCLUSION: After HyFoSy, one in four patients got pregnant within the next twelve months. Couples with shorter infertility time, unexplained infertility, and women under 35 years are more likely to achieve SC after HyFoSy.

Effect of Fractional Carbon Dioxide vs Sham Laser on Sexual Function in Survivors of Breast Cancer Receiving Aromatase Inhibitors for Genitourinary Syndrome of Menopause: The LIGHT Randomized Clinical Trial.

Importance: Survivors of breast cancer present more severe symptoms of genitourinary syndrome of menopause (GSM) than patients without history of breast cancer. Recently, new treatments, such as vaginal laser therapy, have appeared, but evidence of their efficacy remains scarce. Objective: To assess the safety and efficacy of carbon dioxide (CO2) vs sham vaginal laser therapy after 6 months of follow-up in survivors of breast cancer with GSM receiving aromatase inhibitors. Design, Setting, and Participants: This prospective double-blind sham-controlled randomized clinical trial with two parallel study groups was performed during October 2020 to March 2022 in a tertiary referral hospital. Survivors of breast cancer using aromatase inhibitors were assessed for eligibility, and eligible patients were randomized into the 2 treatment groups. Follow-up was conducted at 6 months. Data were analyzed in July 2022. Interventions: All patients from both groups were instructed to use the first-line treatment (FLT) based on nonhormonal moisturizers and vaginal vibrator stimulation. Patients for each group were allocated to 5 monthly sessions of fractional CO2 laser therapy (CLT) or sham laser therapy (SLT). Main Outcomes and Measures: The primary outcome was sexual function, evaluated through Female Sexual Function Index (FSFI) score. Other subjective measures of efficacy included a visual analog scale of dyspareunia, vaginal pH, a Vaginal Health Index, quality of life (assessed via Short-Form 12), and body image (assessed with the Spanish Body Image Scale). Objective measures of efficacy included vaginal maturation index, vaginal epithelial elasticity (measured in Pascals) and vaginal epithelial thickness (measured in millimeters). Measures were assessed before and after the intervention. Tolerance (measured on a Likert scale), adverse effects, and estradiol levels were recorded. Results: Among 211 survivors of breast cancer assessed, 84 women were deemed eligible and 72 women (mean [SD] age, 52.6 [8.3] years) were randomized to CLT (35 participants) or SLT (37 participants) and analyzed. There were no statistically significant differences between groups at baseline. At 6 months, both groups showed improvement in FSFI (mean [SD] score at baseline vs 6 months: CLT, 14.8 [8.8] points vs 20.0 [9.5] points; SLT, 15.6 [7.0] points vs 23.5 [6.5] points), but there was no significant difference between CLT and SLT groups in the improvement of sexual function evaluated through the FSFI test overall (mean [SD] difference, 5.2 [1.5] points vs 7.9 [1.2] points; P = .15) or after excluding women who were not sexually active (mean [SD] difference, 2.9 [1.4] points vs 5.5 [1.1] points; P = .15). There were also no differences between improvement of the 2 groups at 6 months of follow-up in the other assessed subjective outcomes, including dyspareunia (mean [SD] difference, -4.3 [3.4] vs -4.5 [2.3]; P = .73), Vaginal Health Index (mean [SD] difference, 3.3 [4.1] vs 5.0 [4.5]; P = .17), body image (mean [SD] difference, -3.7 [4.5] vs -2.7 [4.8]; P = .35), and quality of life (mean [SD] difference, -0.3 [3.6] vs -0.7 [3.2]; P = .39). Similarly, there were no differences in improvements in objective outcomes, including vaginal pH (mean [SD] difference, -0.6 [0.9] vs -0.8 [1.2]; P = .29), vaginal maturation index (mean [SD] difference, 10.2 [17.4] vs 14.4 [17.1]; P = .15), vaginal epithelial thickness (mean [SD] difference, 0.021 [0.014] mm vs 0.013 [0.012] mm; P = .30), vaginal epithelial elasticity (mean [SD] difference, -1373 [3197] Pascals vs -2103 [3771] Pascals; P = .64). There were significant improvements in the overall analysis regardless of group in many outcomes. The 2 interventions were well tolerated, but tolerance was significantly lower in the CLT group than the SLT group (mean [SD] Likert scale score, 3.3 [1.3] vs 4.1 [1.0]; P = .007). No differences were observed in complications or serum estradiol levels. Conclusions and Relevance: In this randomized clinical trial, vaginal laser treatment was found to be safe after 6 months of follow-up, but no statistically significant differences in efficacy were observed between CLT and SLT. Trial Registration: ClinicalTrials.gov identifier: NCT04619485.

Predictive factors of preoperative sentinel lymph node detection in intermediate and high-risk endometrial cancer.

BACKGROUND: In endometrial cancer (EC), sentinel lymph node (SLN) mapping has emerged as an alternative to systematic lymphadenectomy. Little is known about factors that might influence SLN preoperative detection. The aim of our study was to evaluate the clinical and technical variables that may influence on the success of SLN detection in preoperative lymphatic mapping in patients with intermediate and high-risk EC when performing transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR). METHODS: Between March 2006 and March 2017, we prospectively enrolled patients with histologically confirmed EC with intermediate or high-risk of lymphatic involvement. All women underwent SLN detection by using TUMIR approach. After radiotracer injection, pelvic and abdominal planar and SPECT/CT images were acquired to obtain a preoperative lymphoscintigraphic mapping. Pattern of drainage was registered and analyzed to identify the factors directly involved in drainage. Sonographer learning curves to perform TUMIR approach were created following Cumulative Sum and Wright methods. Univariate and multivariate analyses were performed using logistic regression. RESULTS: During study period, 123 patients were included. SLN preoperative detection rate was 70.7%. Age under 75 years at diagnosis (P<0.01), radiotracer injection above 4 mL -high-volume- (P<0.01), and tumoral size below 2 cm (P=0.04) were associated with higher SLN preoperative detection rate. Twenty-five procedures were necessary to attain an adequate performance in TUMIR approach. CONCLUSIONS: The higher SLN preoperative detection rate in women with intermediate and high-risk endometrial cancer after TUMIR approach was related with younger age, smaller tumors and high-volume injection of radiotracer. Sonographers are required to perform 25 procedures before acquiring an expertise in radiotracer injection.

Midterm postoperative results of mid-urethral slings. Role of ultrasound in explaining surgical failures.

INTRODUCTION: Surgical treatment for stress urinary incontinence (SUI) with mid-urethral sling (MUS) is considered to have a high success rate. However, between 5% and 20% of MUS fail, with inadequate surgical implantation being a possible cause of SUI persistence or recurrence. Misplacement of a MUS can be determined by pelvic floor ultrasound (PF-US). The aim of this study was to investigate the role of PF-US in patients with persistent or recurrent urinary incontinence (UI) symptoms after MUS surgery for SUI with a midterm follow-up. MATERIALS AND METHODS: A historical cohort study including women undergoing MUS surgery for SUI between 2013 and 2015 was designed. The primary outcome was to correlate the sonographic parameters of MUS with SUI cure (negative International Continence Society-Uniform Cough Stress Test, Incontinence Questionnaire-Short Form < 5 points and no symptoms of SUI), at 5 years postsurgery. Secondary outcomes were changes of maximum urethral closure pressure (MUCP) and symptoms of urgency urinary incontinence (UUI) at 1 and 5 years after surgery. RESULTS: Eighty-seven patients (80 transobturator-MUS, 7 retropubic-MUS) were included. At 5 years all patients referred improvement of UI and objective cure of SUI was demonstrated in 81.2%. The MUS was sonographically correct in 67 (98.5%) of the 68 patients with cure of SUI. The MUS was considered incorrectly placed in only 4 (28.6%) of the 14 patients with noncured SUI. MUCP decreased from 61.9 to 48.8 cmH2 O at 5 years of follow-up (p < 0.01) and up to 53% of women had UUI symptoms after surgery, with a nonsignificant decrease compared to baseline. CONCLUSION: Patients cured of SUI had sonographically correct MUS by PF-US. Less than one-third of cases of SUI persistence or recurrence after MUS surgery could be explained by a sonographically incorrect sling. Low urethral resistance and/or UUI symptoms could help to explain the remaining failures. Complete functional and anatomic studies, including urodynamics and PF-US, should be performed before deciding on the next management strategy in patients with SUI persistence or recurrence after MUS.

Readjustable Sling in Women With Stress Urinary Incontinence and Hypomobile Urethra: Understanding the Mechanisms of Closure by Transperineal Ultrasound.

OBJECTIVES: To assess the postsurgical sonographic parameters of a readjustable sling (RAS) according to urinary incontinence (UI) symptoms after surgery and compare this RAS sonographic pattern with mid-urethral slings (MUS). METHODS: Observational, prospective multicenter study, including women undergoing stress urinary incontinence (SUI) surgery with RAS (Remeex®). The primary outcome was the association between UI symptoms and sonographic parameters measured by two-dimensional transperineal and high-frequency endovaginal ultrasound. We measured static parameters (bladder neck funneling, RAS position, symmetry, distance to the urethral lumen), and the movement of the sling on Valsalva. UI symptoms were measured with the postsurgical Incontinence Questionnaire-Short Form (ICIQ-UI-SF) questionnaire. We created two control groups including patients with transobturator-MUS (TOT-MUS) and retropubic-MUS (RT-MUS) to compare postsurgical sonographic parameters of RAS with MUS. RESULTS: Among the 55 women with RAS included, the postoperative ICIQ-UI-SF scores were significantly higher in patients with bladder neck funneling (15.0 (3.9) vs 10.6 (6.7); P = .020) and in those with discordant movement of RAS on Valsalva (14.6 (5.7) vs 10.3 (6.7); P = .045). Compared with the 109 women with TOT-MUS and the 55 with RT-MUS, RAS was more often located in the proximal urethra and farther from the urethral lumen. CONCLUSIONS: Postsurgical pelvic floor ultrasound demonstrated that in women with complex SUI and hypomobile urethra who underwent RAS (Remeex®) surgery, the presence of bladder neck funneling and discordant movement on Valsalva correlate with the persistence of UI symptoms. In these women, RAS is more often located in the proximal urethra and farther from the urethral lumen at rest in comparison with MUS.

Adenomyosis is an independent risk factor for complications in deep endometriosis laparoscopic surgery.

Deep endometriosis (DE) occurs in 15-30% of patients with endometriosis and is associated with concomitant adenomyosis in around 25-49% of cases. There are no data about the effect of the presence of adenomyosis in terms of surgical outcomes and complications. Thus, the aim of the present study was to evaluate the impact of adenomyosis on surgical complications in women with deep endometriosis undergoing laparoscopic surgery. A retrospective cohort study including women referred to the endometriosis unit of a referral teaching hospital. Two expert sonographers preoperatively diagnosed DE and adenomyosis. DE was defined according to the criteria of the International Deep Endometriosis Analysis group. Adenomyosis was considered when 3 or more ultrasound criteria of the Morphological Uterus Sonographic Assessment group were present. Demographical variables, current medical treatment, symptoms, DE location, surgical time, hospital stay and difference in pre and post hemoglobin levels were collected. The Clavien-Dindo classification was used to assess surgical complications, and multivariate analysis was performed to compare patients with and without adenomyosis. 157 DE patients were included into the study; 77 (49.05%) had adenomyosis according to transvaginal ultrasound (TVS) and were classified in the A group, and 80 (50.95%) had no adenomyosis and were classified in the noA group. Adenomyosis was associated with a higher rate of surgical complications: 33.76% (A group) vs. 12.50% (noA group) (p < 0.001). Multivariate analysis showed a 4.56-fold increased risk of presenting complications in women with adenomyosis (CI 1.90-11.30; p = 0.001) independently of undergoing hysterectomy. There was a statistically significant association between the number of criteria of adenomyosis present in each patient and the proportion of patients presenting surgical complications (p < 0.001). Adenomyosis is an independent preoperative risk factor for surgical complications in DE surgery after adjustment for known demographic, clinical and surgical risk factors.

Assessment of Quality of Life, Sexual Quality of Life, and Pain Symptoms in Deep Infiltrating Endometriosis Patients With or Without Associated Adenomyosis and the Influence of a Flexible Extended Combined Oral Contraceptive Regimen: Results of a Prospective, Observational Study.

BACKGROUND: The quality of life of women with deep infiltrating endometriosis (DIE) is impaired and may improve with combined oral contraceptives (COCs). AIM: To compare the overall and sexual quality of life of patients diagnosed with DIE with or without associated adenomyosis (AD) with that of healthy controls and determine the influence of a COC containing 2 mg dienogest/30 µg ethinyl estradiol on these aspects. METHODS: We enrolled 42 women diagnosed with DIE; 31 diagnosed with DIE + AD by transvaginal ultrasound, and 39 non-AD/DIE controls. All patients were interviewed regarding pain symptoms (dysmenorrhea, dyspareunia, dyschezia, and dysuria), heavy menstrual bleeding using the Pictorial Blood Loss Assessment Chart, quality of life using the Short Form-36 questionnaire (SF-36), and sexual quality of life using the Sexual Quality of Life-Female questionnaire (SQOL-F) and the Brief Profile of Female Sexual Function (B-PFSF) before starting COCs and after 12 months of treatment. OUTCOMES: There was significant improvement in overall and sexual quality of life after treatment in DIE and DIE + AD patients. RESULTS: Non-AD/DIE controls showed significantly higher scores in the B-PFSF, the SQOL-F and the SF-36 questionnaires (P < .05) at baseline versus the other groups. DIE + AD patients showed poorer quality of sexual life and greater intensity in pain symptoms compared with DIE patients. After 12 months of treatment, there was a significant improvement in overall and sexual quality of life in the DIE and DIE + AD groups, with improvement in sexual quality of life being slightly greater in DIE + AD patients compared with DIE patients. Pain symptoms also decreased in both groups. CLINICAL IMPLICATIONS: Patients with DIE + AD showed greater impairment in overall and sexual quality of life compared with patients with isolated DIE which seems to improve with a COC containing 2 mg dienogest/30 µg ethinyl estradiol. STRENGTHS & LIMITATIONS: Strengths include the long-term follow up, assessment of the impact of two associated conditions, and administration of the same COC in all patients. Limitations include the relatively small sample size, and the fact that we did not assess the effectiveness of a flexible extended COC regimen containing 2 mg dienogest/30 µg ethinyl estradiol since the groups were different at baseline. CONCLUSION: Patients diagnosed with DIE with or without AD have a decreased quality of life which may improve with a COC containing 2 mg dienogest/30 µg ethinyl estradiol. Further research is needed to confirm our results. Alcalde AM, Martínez-Zamora MÁ, Gracia M, et al. Assessment of Quality of Life, Sexual Quality of Life, and Pain Symptoms in Deep Infiltrating Endometriosis Patients With or Without Associated Adenomyosis and the Influence of a Flexible Extended Combined Oral Contraceptive Regimen: Results of a Prospective, Observational Study. J Sex Med 2022;19:311-318.

Assessment of Sexual Quality of Life and Satisfaction in Couple Relationships Among Women With Deep Infiltrating Endometriosis and Adenomyosis.

Adenomyosis and endometriosis are similar gynecological diseases that decrease sexual quality of life and, in the case of endometriosis, satisfaction in couple relationships. This study aimed to assess sexual quality of life and couple satisfaction in women diagnosed with adenomyosis (AD) or deep infiltrating endometriosis (DIE). The study population included three groups of couples: one composed of 58 couples in which the woman was diagnosed with AD by transvaginal ultrasound (AD group), a second group comprising 55 couples in which the woman was diagnosed with isolated DIE by transvaginal ultrasound (DIE group), and a third group composed of 60 couples in which the women did not have AD or endometriosis (non-AD/DIE group). All women completed the Sexual Quality of Life-Female (SQOL-F) questionnaire, and all the couples completed the Dyadic Adjustment Scale (DAS). Sexual quality of life was significantly worse in women with AD or DIE compared with non-AD/DIE controls. Dyadic adjustment was significantly worse in the AD and DIE groups compared with the non-AD/DIE group. AD and DIE may impair quality of sexual life and couple relationships. Clinicians should be aware of this issue when treating women with AD or DIE.

Mid-term results of the Remeex® readjustable sling for female complex stress urinary incontinence and sonographic hypomobile urethra.

INTRODUCTION AND HYPOTHESIS: We aimed to evaluate the results of a readjustable sling (Remeex® system) among a selected group of women with complex stress urinary incontinence (SUI) with sonographic hypomobile urethra and assessing failure-related risk factors. METHODS: Observational, longitudinal, prospective cohort study, including patients who underwent surgery with the Remeex® system. The primary outcome was a binary outcome in change of one level or more of the severity of urinary incontinence symptoms according to the intervals of the Incontinence Questionnaire-Short Form (ICIQ-UI-SF) score (mild, moderate, severe and very severe). Secondary outcomes were postsurgical complications, absolute ICIQ-UI-SF, 24-h pad weight test (24-h PT), urodynamic SUI and Patient Global Impression of Improvement (PGI-I) score to evaluate subjective success. RESULTS: Among 120 women included, after surgery we found a 70% subjective success rate, a 76.7% decrease of urinary incontinence severity and a mean reduction of the 24-h PT of 109.6 ± 291.4 g. Women with post-surgical decreased severity of incontinence had lower mean body mass index (BMI) and 24-h PT than those without incontinence severity changes with statistically significant differences (p = 0.028 and p = 0.027, respectively). A logistic regression model demonstrated that a 1-point increase of BMI increased the risk of persistence of incontinence severity after surgery by 19% (OR = 1.19; 95% CI: 1.01-1.41; p = 0.040), and an increase of 10 g in the pre-surgical 24-h PT represented a 3% rise of the aforementioned risk (OR = 1.03; 95% CI: 1.01-1.06; p = 0.034). CONCLUSIONS: In patients with complex SUI and sonographic hypomobile urethra, use of a readjustable sling (Remeex® system) led to improvement of SUI. Patients with a greater BMI and pre-surgical 24-h PT showed worse results after surgery.

HE4 might be a more useful tumor biomarker to detect malignancy in patients with ovarian endometrioma when malignancy is suspected.

OBJECTIVE: To analyze the utility of carbohydrate antigen (CA)125 and human epididymis protein 4 (HE4) to detect malignancy in women with ovarian endometriosis, when ovarian cancer is suspected and ultrasonography results are inconclusive. METHODS: Women who underwent surgery between 2015 and 2019 for ovarian endometriosis or for adnexal masses, with a final diagnosis of ovarian carcinoma (clear cell and endometrioid) were included in this retrospective study. The women were divided into three groups: ovarian endometriosis (OE), ovarian carcinoma without endometriosis (OC), and ovarian carcinoma with endometriosis (OC + E). Adnexal masses were assessed preoperatively by transvaginal ultrasonography according to the International Ovarian Tumor Analysis (IOTA) simple rules, and CA125 and HE4 blood levels were obtained. RESULTS: Of 208 women, 45 had malignancy, 16 in the OC + E group and 29 in the OC group. According to transvaginal ultrasonography, 13 were classified as undetermined risk of malignancy: OC group: 3, OE group: 3, and OC + E group: 7. When we compared the tumor biomarkers, significant differences in HE4 but not in CA125 levels were found between the groups. CONCLUSIONS: When ovarian malignancy is suspected in patients with ovarian endometriosis, HE4 is a more useful tumor biomarker to diagnose OC when ultrasonography results are inconclusive.

Genitourinary Syndrome of Menopause Assessment Tools.

New therapeutic options are being considered to treat genitourinary syndrome of menopause (GSM), such as vaginal laser, ospemifene, or prasterone, but there is no explicit agreement in the scientific community for its use. Some concerns have arisen on how to evaluate the improvement of GSM symptoms. In 2003, the FDA suggested possible end points for this purpose: change in severity of symptoms, change in vaginal pH, and change in vaginal maturation index (VMI). Contrarily, the most common assessment tools used to quantify severity and improvement of GSM nowadays are the visual analog scale of GSM symptoms, the vaginal health index, and the female sexual function index. In our opinion, subjective and objective variables to evaluate GSM can be differentiated, and not many of the considered objective outcomes are used in the recent literature assessing GSM. There is the possibility that some therapies present only subjective improvement, giving place to a possible placebo effect that is not being evaluated. To conclude, there is a demand to evaluate whether vaginal pH and VMI are enough to assess objectively GSM changes or new objective approaches should be audited.

Assessment of quality of sexual life in women with adenomyosis.

This study aimed to assess the impact of adenomyosis (AD) on different domains of sexual life. The study population included three groups: one composed of 68 women diagnosed with AD by transvaginal ultrasound, a second group comprised by 65 women diagnosed with isolated deep infiltrating endometriosis by transvaginal ultrasound and a third group including 70 women without AD or/and endometriosis. All participants completed the Brief Profile of Female Sexual Function (B-PFSF), the Female Sexual Distress Scale (FSDS), and the Sexual Quality of Life-Female (SQOL-F) questionnaire. Compared with non-AD/DIE controls, women with AD present significantly lower scores of the B-PFSF and the SQOL-F questionnaires and higher FSDS questionnaire scores (p < .0001). There were no differences between the groups of AD and deep infiltrating endometriosis. Clinicians should be aware that the quality of sexual life may be affected in patients with AD. Early diagnosis and multidisciplinary management would contribute to preventing impairment of sexual quality of life in these patients.

Paraaortic sentinel lymph node detection in intermediate and high-risk endometrial cancer by transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR).

OBJECTIVE: We aimed to evaluate the accuracy of sentinel lymph node (SLN) mapping with transvaginal ultrasound-guided myometrial injection of radiotracer (TUMIR) to detect lymph node (LN) metastases, in patients with intermediate and high-risk endometrial cancer (EC), focusing on its performance to detect paraaortic involvement. METHODS: Prospective study including women with preoperative intermediate or high-risk EC, according to ESMO-ESGO-ESTRO consensus, who underwent SLN mapping using the TUMIR approach. SLNs were preoperatively localized by planar and single photon emission computed tomography/computed tomography images, and intraoperatively by gamma-probe. Immediately after SLN excision, all women underwent systematic pelvic and paraaortic lymphadenectomy by laparoscopy. RESULTS: The study included 102 patients. The intraoperative SLN detection rate was 79.4% (81/102). Pelvic and paraaortic drainage was observed in 92.6% (75/81) and 45.7% (37/81) women, respectively, being exclusively paraaortic in 7.4% (6/81). After systematic lymphadenectomy, LN metastases were identified in 19.6% (20/102) patients, with 45.0% (9/20) showing paraaortic involvement, which was exclusive in 15.0% (3/20). The overall sensitivity and negative predictive value (NPV) of SLNs by the TUMIR approach to detect lymphatic involvement were 87.5% and 97.0%, respectively; and 83.3% and 96.9%, for paraaortic metastases. After applying the MSKCC SLN mapping algorithm, the sensitivity and NPV were 93.8% and 98.5%, respectively. CONCLUSION: The TUMIR method provides valuable information of endometrial drainage in patients at higher risk of paraaortic LN involvement. The TUMIR approach showed a detection rate of paraaortic SLNs greater than 45% and a high sensitivity and NPV for paraaortic metastases in women with intermediate and high-risk EC.

Impact of Adenomyosis on Women's Psychological Health and Work Productivity: A Comparative Cross-Sectional Study.

Background: Quality of life in adenomyosis (AD) patients has been poorly investigated. Previous data suggest that AD has negative impact on the quality of life in these women. Materials and Methods: From September 2018 to December 2019, all consecutive female premenopausal patients aged ≥18 years diagnosed with AD by transvaginal ultrasound (TVU) were invited to participate in a comparative cross-sectional study. The Short Form-36-item (SF-36) health questionnaire and the Hospital Anxiety and Depression Scale (HADS) were administered. Work productivity and activity impairment were assessed using the Work Productivity and Activity Impairment Questionnaire: General Health version (WPAI:GH). Data obtained from these patients were compared with women with normal-appearing myometrium in the TVU recruited during routine gynecological visits. The study was approved by the Clinical Research Ethics Committee of the Hospital Clinic (reference HCB/2018/0919). Results: One hundred three patients with AD and 214 without AD were analyzed. Patients with AD compared to those without AD showed significantly lower scores in all domains of the SF-36 questionnaire and mean (SD) higher scores in the HADS questionnaire for anxiety (10.06 [3.04] vs. 6.92 [2.98], p < 0.001) and depression (6.39 [3.89] vs. 2.74 [2.01], p < 0.002). Significant differences (p < 0.001) were also found for the percentages of absenteeism (12.2% vs. 1.1%), presenteeism (31.1% vs. 11.4%), overall work productivity loss (38.2% vs. 12.4%), and activity impairment (55.7% vs. 9.9%). The presence of AD was associated with higher yearly estimated indirect costs of €5161.32 (€7928.0 vs. €2460.8, p < 0.001). Conclusions: AD negatively affects women's health-related quality of life, psychological health, and work productivity, with impairment at work and daily activities, and higher risk for anxiety and depression.

Transperineal anal sphincter complex evaluation after obstetric anal sphincter injuries: With or without tomographic ultrasound imaging technique?

OBJECTIVES: "Significant" obstetric anal sphincter injuries (OASIS) have been defined as visible defects of at least 30° in at least 4/6 slices using tomographic ultrasound imaging (TUI) with transperineal ultrasound (TPUS). The objective of this study was to assess if TUI is mandatory for the evaluation of OASIS. METHODS: Patients with a history of OASIS were evaluated by performing 3D-endoanal ultrasound (EAUS) and 3D-TPUS with and without TUI. Any damage to the internal (IAS) or external (EAS) anal sphincters was recorded and scored using the Starck's and the Norderval's systems. Intraobserver and inter-techniques correlations were calculated. RESULTS: From September 2012 to May 2015, 63 women, mean age 32.5 ± 4.6 years, with OASIS (3a: 26 pts., 41.3 %; 3b: 26 pts., 41.3 %; 3c: 6 pts., 9.5 %, 4: 4 pts., 6.3 %, "button hole" tear: 1 pt., 1.6 %). Inter-technique and intraobserver correlations were excellent (TUI: k = 0.9; sweeping technique: k = 0.85; EAUS: k = 0.9) in determining OASIS. Using the Starck's Score, excellent correlation was found for both TPUS modalities (TUI: k = 0.86; sweeping technique: k = 0.89). However, for the different individual parameters, the correlation was moderate for EAS depth (TUI: k = 0.44; sweeping technique: k = 0.5) and good for IAS depth (TUI: k = 0.7; sweeping technique: k = 0.78). Similar results were found using the Norderval's classification. CONCLUSIONS: OASIS can be assessed by TPUS without TUI technique, dragging the rendered box and following the anal canal from the anal verge to the anorectal junction in the longitudinal plane and describing findings.