This study evaluates the efficacy and toxicity of dose-dense weekly paclitaxel and carboplatin as neoadjuvant chemotherapy in locally advanced cervical cancer (LACC). We collected 23 cases of LACC treated with weekly paclitaxel and carboplatin for nine cycles: 20 patients had complete or partial response to chemotherapy and were submitted to surgery, 3 with poor response received chemoradiation therapy. Pathologic examination showed complete response in four patients, myometrial invasion <50% in nine and >50% in seven patients, parametrial involvement in two, vaginal metastasis in one and lymphovascular space invasion, with positive margins, in another case. Despite seven patients had radiological evidence of lymph nodes involvement at diagnosis, only one had nodal metastases. Five patients showed grade 3-4 of hematologic toxicity.

Objectives: The aim of this study was to investigate the accuracy of transvaginal sonography (TVS) and contrast-enhanced magnetic resonance-colonography (CE-MR-C) for the pre-surgical assessment of deep infiltrating endometriosis (DIE). Methods Ninety women were prospectively enrolled for a suspicion of DIE. All patients underwent a TVS and a CE-MR-C performed blindly, before laparoscopy. The sites of DIE examined by both imaging techniques were: recto-vaginal septum, pouch of Douglas, utero-sacral ligaments, vesico-uterine pouch, bowel, bladder and vagina. The presence of adhesions, the involvement of adnexa and of a previous abdominal scar, in case of a clinical suspicion, were also evaluated. TVS and CE-MR-C findings were compared with laparoscopic and histological results. Results Endometriosis was confirmed by laparoscopy in 95.6% of cases (86//90). In 82.2% (74/90) of patients there was DIE. The global accuracy, sensitivity, specificity, positive predictive values, negative predictive values, positive likelihood ratios and negative likelihood ratios were 89.2%, 81.1%, 94.2%, 89.6%, 89.0%, 13.9 and 0.2 for TVS, 87.2%, 71.1%, 97.1%, 93.7%, 84.6%, 24.4 and 0.3 for CE-MR-C. CE-MR-C allowed to diagnose all cases of bowel involvement; the accuracy for infiltration and stenosis was 100%. The accuracy of TVS for recto-sigmoid nodules and infiltration was 91.1% and 88.9%. Conclusions Both techniques showed satisfactory results. TVS appears a powerful, simple, feasible, cost effective tool for preoperative staging of DIE. CE-MR-C is an "X Ray free" technique, which could be reserved for cases with deep infiltrating rectosigmoid lesions, for the prediction of stenosis and involvement of the upper part of colon and small intestine. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

We read with interest the article by Mittal et al [1], “Diagnostic criteria for distinguishing endometrial adenocarcinoma from endometrial complex atypical hyperplasia”. The article is noteworthy not only for diagnostic aspects but also for clinical repercussions. We report our clinical experience on the diagnostic accuracy of hysteroscopy with regard to atypical endometrial hyperplasia. All hysteroscopies were performed using a continuous-flow office hysteroscope with a 5F working channel. The biopsy forceps has a diameter of 5F and jaws of 5 mm in length. The forceps features small teeth on both sides of the jaws to retain the obtained tissue. With the combination of this kind of forceps and adequate technique, a very large amount of biopsied endometrial tissue (mean, 5.7 mm2 measured in 2 dimensions on histologic section) was sampled [2]. We compared the hysteroscopic findings (including targeted biopsies) with the histologic findings obtained after hysterectomy. On the basis of histologic examination of endometrial biopsy during a period of 10 years, we had 29 cases of atypical endometrial hyperplasia. Of these, 14 cases (48.3%) were found to be endometrial carcinoma with atypical endometrial hyperplasia at the hysterectomy. All carcinomas were endometrioid carcinomas, except for 1 case of adenosquamous carcinoma. Endometrioid carcinomas were well differentiated except for 2 cases, which were poorly differentiated. The myometrial invasion was present in the inner third of the uterus in 2 cases of endometrioid carcinoma. In the 14 cases of endometrial carcinoma diagnosed by hysterectomy, the image-based diagnosis by hysteroscopy led to a suspicion of endometrial carcinoma. The biopsies did not confirm the suspicion but revealed an atypical endometrial hyperplasia. The problem may be due to the amount of the biopsy, even when properly executed, because it was performed in a targeted manner. In our clinical perspective, we appreciate all effort to establish morphological criteria in biopsies to distinguish endometrial adenocarcinoma from atypical endometrial hyperplasia. If there is any doubt and the operator has a suspicion of endometrial cancer, then we will definitely suggest the repetition of the biopsy: this is the peculiarity of hysteroscopy [3]. Other “blind” techniques of endometrial biopsy (dilatation and curettage, Novak, Vabra, Pipelle) cannot suggest any suspicion and, thereupon, cannot suggest any repetition of the biopsy.

BACKGROUND: Incarceration of the fallopian tube is a rare condition. Symptoms are often misleading, making proper diagnosis difficult because of nonspecific clinical presentations. We report a case of cornual pregnancy occurring 7 months after the treatment of an incarcerated fallopian tube. We believe that the abnormal cornual implantation of the gestational sac was due to myometrial reconstruction of the uterine wall. CASE: A primigravid woman treated for the incarceration of a fallopian tube was subsequently found to have a cornual pregnancy in a septate uterus. The cornual pregnancy was successfully aborted after laparoscopic myometrial reconstruction, and a metroplasty allowed a subsequent pregnancy. CONCLUSION: This hazardous type of ectopic pregnancy can be managed with systemic administration of methotrexate. If the cornual pregnancy is correctly identified at an early stage, this medical management can be attempted and offers the potential advantage of avoiding surgery and increasing the likelihood of preserving fertility.

PURPOSE: This study assessed the diagnostic accuracy of pelvic magnetic resonance (MR) imaging completed by MR colonography for the preoperative evaluation of deep pelvic endometriosis in patients undergoing laparoscopic surgery. MATERIALS AND METHODS: A total of 143 patients (mean age 34.3 ± 5.1 years) with a clinical suspicion of deep pelvic endometriosis were assessed by pelvic MR and MR colonography. All patients underwent laparoscopic surgery 3-10 weeks after the MR examination. The presence, location, number and extent of endometriotic lesions were evaluated. Data obtained with MR were compared with surgical findings. MR sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and diagnostic accuracy values were calculated for each site by considering the laparoscopic and histological findings as the reference standard. RESULTS: Laparoscopy confirmed the presence of endometriosis in 119/143 patients (83%); in 76/119 (64%) deep pelvic endometriosis was diagnosed, whereas in the remaining 43/119 (36%), superficial peritoneal implants and endometriomas were found. In 32/119 (27%) patients, intestinal lesions were detected. MR had sensitivity, specificity, PPV, NPV and diagnostic accuracy values of 67-100%, 85-100%, 83-100%, 84-100% and 84-100%, respectively, in recognising lesions located in different pelvic sites. CONCLUSIONS: MR imaging combined with colonography is a highly accurate tool for characterising deep endometriotic lesions in patients scheduled for laparoscopic surgery. In particular, MR colonography has very high accuracy in detecting colorectal involvement.

OBJECTIVE: To investigate the contribution of contrast-enhanced MR-colonography (CE-MR-C) for the diagnosis of intestinal endometriosis. METHODS: One hundred and four women with suspected endometriosis were prospectively enrolled. All patients were subjected to MRI consisting of two phases: pelvic high-resolution MRI (HR-MRI) followed by CE-MR-C after colonic distension using a 1.5-liter water enema and injection of 0.15 ml/kg of 0.5 M gadolinium-DTPA with T1w high-resolution isotropic volume (THRIVE) and balanced turbo field echo (BTFE) images. HR-MRI and CE-MR-C were considered as two datasets, which were independently reviewed by two radiologists with 12 and 2 years' experience respectively. The presence of deep pelvic endometriotic lesions with particular attention to colorectal involvement was recorded. RESULTS: MRI findings correlated with laparoscopy in all cases. Thanks to CE-MR-C images, sensitivity, specificity, PPV, NPV and accuracy for diagnosis of colorectal endometriosis increased from 76%, 96%, 84%, 93% and 91%, to 95%, 97%, 91%, 99% and 97% for the most experienced radiologist and from 62%, 93%, 72%, 89% and 85%, to 86%, 94%, 82%, 96% and 92% for the less experienced radiologist; moreover, the interobserver agreement increased from 0.63 to 0.80 (Cohen's K test). CONCLUSION: CE-MR-C allows easier recognition of colorectal endometriosis and higher interobserver agreement.

OBJECTIVES: To evaluate the effect of bladder flap formation (BFF) during caesarean section (CS) on the uterine scar, assessed during repeat CS. STUDY DESIGN: One hundred and fifteen women undergoing their first CS were divided into two groups: 58 women had a CS with BFF (Group 1) and 57 women had a CS without BFF (Group 2). During the repeat CS, four specimens from the uterine scar from the first CS were collected from each woman, and evaluated by light microscopy and transmission electron microscopy (TEM). RESULTS: Adhesions were found in 28 (48.3) women in Group 1 and 14 (24.1%) women in Group 2 (p<0.01). Of the women with adhesions in Group 1, 20 (71.4%) had mild adhesions and eight (28.6%) had severe adhesions. Of the women with adhesions in Group 2, eight (57.1%) had mild adhesions and six (42.9%) had severe adhesions. Light microscopy revealed significant differences in submesothelial fibrosis (39.6% vs 12.2%; p<0.01) and neo-angiogenesis of the mesothelial stroma (46.5% vs 21%; p<0.01) in Groups 1 and 2, respectively. TEM revealed more specimens with inflammatory cells in Group 1 compared with Group 2 {mean 29.7 [standard deviation (SD) 1.3] vs 18.2 (SD 1.9) patients; p<0.01}. CONCLUSION: BFF during CS leads to an inflammatory and fibrotic reaction, resulting in inflammation reactive and regenerative processes, mesothelial hyperplasia and submesothelial fibrosis. CS without BFF reduces the inflammatory processes and the subsequent intraperitoneal adhesions and adhesions between the bladder and uterus.

Sex hormonal variations have been shown to affect functional cerebral asymmetries in cognitive domains, contributing to sex-related differences in functional cerebral organization. The aim of this study was to investigate spatial attention by means of a bisection line test and computer-supported attention task during the menstrual cycle in healthy women compared to men, in basal condition and under Transcranial Direct Current Stimulation (TDCS) of the left parietal cortex. Women were studied during the menses, follicular and luteal phases, ascertained by transvaginal ultrasounds. In basal conditions, women showed a clear deviation toward the right in the bisection line test during the menstrual phase, similarly to men. The midpoint recognition in the computer-supported attention task was not influenced by the menstrual cycle for women, while men showed a significant increase in errors toward the left side. The anodal activation of the left parietal cortex did not affect the line bisection task, while in men it reduced the total amount of errors in midpoint recognition observed in the computer supported attention task. The hand-use effect demonstrated by the bisection-line test could be influenced by estrogen fluctuations, while the right hemisphere prevalence in spatial attention appears to be gender-related and scarcely influenced by the menstrual cycle. The left parietal cortex seems to exert a scarce effect on hand-use effect, while its activation is able to revert sex related right hemisphere supremacy.

The accuracy of sonographic estimation of birthweight in suspected macrosomic fetuses is compromised by the imprecision of the biometrical measurements. This prospective study evaluated the performance of an equation based on linear measurement of the soft tissue above the external side of the fetal femur. The performance of this algorithm was compared with two classical algorithms. Sonographic measurements were taken within 48 h before of delivery. Sixty-two patients with fetuses with suspected macrosomia were enrolled. The studied formulas were compared between them and showed a significant correlation with birthweight (p < 0.0001) and satisfactory statistical performances (r > 0.9). The new formula showed a reduced standard deviation that means a lower internal error in the prediction. This study supports the potential of this new approach for the estimation of birthweight in large fetuses based on sonographic linear measurements only.

Uterine abnormalities, including congenital pathologies, polyps, submucous leiomyomata, intrauterine adhesions, and chronic endometritis, have been reported in 21 to 47% of patients undergoing in vitro fertilization cycles. The position of hysteroscopy in current fertility practice is under debate. Although there are many randomized controlled trials on technical feasibility and patient compliance demonstrating that the procedure is well tolerated and effective in the treatment of intrauterine pathologies, there is no consensus on the effectiveness of hysteroscopic surgery in improving the prognosis of subfertile women. However, in patients with at least two failed cycles of assisted reproductive technology, diagnostic hysteroscopy and, if necessary, operative hysteroscopy is mandatory to improve reproductive outcome. Office hysteroscopy is a powerful tool for the diagnosis and treatment of intrauterine benign pathologies. It is a simple, safe, reproducible, effective, quick, well-tolerated, and low-cost surgical procedure, with no need for an operating room

Purpose. To define if MRI findings in patients with deep pelvic endometriosis (DPE) may be predictive for the need of bowel resection. Material and Methods. A retrospective survey of 196 pelvic MRIs of women who received laparoscopic procedures for DPE was carried out. A pelvic MRI was performed in all patients: it consisted in T2w-TSE sequences in axial, sagittal, and coronal planes and T1w and THRIVE sequences in the axial plane; the exam was completed by MR-Colonography. Intestinal lesions were measured in short and long axis and the degree of stenosis was established. A multivariate logistic regression was used to identify the predictors of intestinal resection. Results. 57/196 patients received an intestinal resection. Multivariate logistic regression demonstrated a predictive value of short axis (Odds-Ratio = 2.29, ) and stenosis (Odds-Ratio = 1.20, ). ROC analysis showed that a cut-off value of 11 mm for the short axis and 30% for the stenosis may correctly classify, respectively, 96,94% (sensitivity 92,9% and specificity 98,56%) and 97,96% (sensitivity 94,74% and specificity 99,3%) of the cases. Conclusion. The presence of an endometriotic rectal nodule > 11 mm in short axis causing a stenosis > 30% in pelvic MRI reliably predicts the need of a rectal resection.

PURPOSE: To compare the outcomes of embryos selected via time lapse monitoring (TLM) versus those selected with conventional methods of selection in subfertile women undergoing ICSI. METHODS: The study population (239 women) was classified into two groups, based on the monitoring method used: Group 1 (TLM) and Group 2 (conventional monitoring). Groups were compared according to the clinical and ICSI cycle characteristics and reproductive outcomes, while transfers were performed at day 2 or 3. Subgroup analyses were performed, in women of both groups according to age and clinical parameters, and in embryos of Group 1 based on their cellular events. RESULTS: There was a statistically significant difference between the two study groups with regard to the outcome parameters, favoring Group 1 and especially in women >40 years of age. No differences were found in subgroup analyses in participants of both groups, regarding the stimulation protocol used, number of the oocytes retrieved and type of subfertility, while in Group 1 the percentages of "in range" cellular events were higher in certain divisions in ages 35-40, non-smokers, and the GnRH-agonist group, and in embryos that resulted in pregnancy. CONCLUSION: Morphokinetic parameters of early embryo development via TLM are related to the characteristics of subfertile patients and associated with ICSI outcomes.

Successful embryo implantation is a complex process that involves multiple biological mechanisms and reciprocal interactions between the embryo and the proliferated endometrium. In this review, we provide an informative contribution on the pathways underlying the beneficial nature of endometrial injury toward improving implantation rates of embryos conceived and through in vitro fertilization. The evidence published to date are in favor of inducing local endometrial injury in the preceding cycle of ovarian stimulation to improve pregnancy outcomes in women with unexplained and recurrent implantation failure. Endometrial injury triggers a series of biological responses but the findings suggest that no particular pathway is solely adequate to explain the association between trauma and improved pregnancy rates rather than a cluster of events in response to trauma which benefits embryo implantation in ways both known and unknown to the scientific community

Aim: To propose a functional in vitro fertilization (IVF) prediction model to assist clinicians in tailoring personalized treatment of subfertile couples and improve assisted reproduction outcome. Materials and Methods: Construction and evaluation of an enhanced web-based system with a novel Artificial Neural Network (ANN) architecture and conformed input and output parameters according to the clinical and bibliographical standards, driven by a complete data set and ``trained'' by a network expert in an IVF setting. Results: The system is capable to act as a routine information technology platform for the IVF unit and is capable of recalling and evaluating a vast amount of information in a rapid and automated manner to provide an objective indication on the outcome of an artificial reproductive cycle. Conclusion: ANNs are an exceptional candidate in providing the fertility specialist with numerical estimates to promote personalization of healthcare and adaptation of the course of treatment according to the indications.

MicroRNAs (miRNAs) have recently emerged as important regulators of gene expression stability. In the endometrium, miRNAs are involved in the dynamic changes associated with the menstrual cycle, implicated in implantation and in reproductive disorders. We performed a review in an attempt to assess the potential biological pathways linking altered miRNAs profiles with in vitro fertilisation (IVF) failure. Crucially, as miRNAs appear to have a significant role in the course of reproduction, they are excellent research candidates with the potential to enable a better understanding over the underlying molecular activities that prevent implantation and further progression of the embryo. Further steps include in-depth pathway mapping of the implantation process and the characterization of the respective miRNAs and associated links. The efficiency of any intervention should determine whether miRNA profiling could possibly be adopted in routine practice to substantially improve the diagnostic accuracy and, in parallel, the directed treatment of the next-generation IVF.

PURPOSE: The accuracy of sonographic estimation of birth weight (EBW) is compromised by the precision of the biometrical measurements and the quality of the algorithms. This prospective study was to evaluate technical aspects to derive new equations for the EBW. METHODS: Three consecutive phases were carried out (1) to recruit a homogenous population, (2) to derive eight new algorithms using a multiple stepwise mathematical/statistical method, and (3) to test the accuracy of the developed equations. Only those patients with a singleton pregnancy who delivered within 48 h from the scan were considered for the analysis. RESULTS: The study population was made of 473 women. Four polynomial, two square root and two logarithmic algorithms were derived from a balanced study group of 200 women selected from the original study population. These formulas were subsequently applied and compared between them and showed a significant correlation with birth weight (p < 0.0001) and satisfactory statistical performances (r > 0.9), nevertheless they performed similarly to other equations previously published. CONCLUSIONS: The present findings define better the limitations associated with the intrinsic properties of algorithms and highlight that the possibility to improve the precision of sonographic measurements remains the only point at issue to increase the accuracy in the prediction of birth weight.

The authors studied the presence of substance P (SP) and vasoactive intestinal polypeptide (VIP) and their related fibers in the lower uterine segment (LUS) in 133 women undergoing cesarean sections (CS) during active labor. These were divided into 2 groups: women undergoing repeat or first CSs. Specimens were collected from the LUS and were evaluated by light microscopy and by immunohistochemistry, for the morphometrical quantification of the SP and VIP fibers in the LUS. The SP amount was higher in the post-CS scar, while the VIP amount decreased: nerve fibers contained an SP amount of up to 13 ± 2.6C.U., while nerve fibers contained a VIP amount of up to 7 ± 1.9 C.U. The SP amount counts 10 ± 1.5% of the total Bodian fibers, and the ratio of the VIP is 10 ± 1.8% of their total amount. In normal conditions only 6.61 C.U. of the Bodian surface is occupied by SP related nerve fibers in contrast to 6.63 C.U. of the total surface by VIP; the amount of SP increased up to 13 ± 2.6C.U., while it decreased in the LUS previous scars. The SP levels are higher in repeat CS, while the VIP levels are reduced in the LUS. The increase of SP is probably linked to the attempt to achieve cervical ripening in a post-CS LUS, with the possible consequences of dystocia during vaginal birth after CS. Nevertheless, the decrease of VIP probably affects the relaxation of the internal uterine orifice, compromising the LUS formation and cervical ripening

Cesarean section (CS) is now the most common major surgical procedure performed on women worldwide. A CS can be performed by either suturing or not suturing of the visceral peritoneum. Creation of the bladder flap is an integral step of the standard cesarean section. The bladder flap is made by superficially incising and dissecting the peritoneal lining to separate the urinary bladder from the lower uterine segment. It's still debated whether the formation of bladder flap is advantageous or not. If the uterine incision is made slightly above the vesicouterine peritoneal fold, the loose connective tissue between the uterus and the urinary bladder allows spontaneous descent of the bladder. Evidence on the role of the bladder flap in cesarean section is very limited. At present, it remains to be established whether there is any advantage in dissecting the bladder from the lower uterine segment during cesarean section.

In this report, we propose an intervention capable of improving IVF outcomes in subfertile women with poor ovarian response. This intervention derives from anecdotal data and observations in our daily practice, but most importantly from trials on experimental models and subfertile women with Polycystic Ovarian Syndrome (PCOS). Our hypothesis suggests that transvaginal induction of trauma to the ovary in the cycle preceding IVF should benefit poor ovarian responders and their lowered pregnancy rates by increasing - at least - the number of retrieved oocytes during oocyte retrieval. Up-to-the minute data show that, via this means, there is a unique response of the ovarian surface epithelium and stroma to the induced trauma. The potential pathways of this beneficial response involve an improvement of the raised gonadotrophins to act either through the mechanical reduction of the size of the ovary or through alterations of the hormonal profile by lowering LH, inhibin and local androgen concentrations through hypothalamic-pituitary axis feedbacks, the induction of increased blood flow to the ovaries, a differentiated local immune reaction and a non-elucidated as yet role of reactive oxygen species. In this report, we also describe the technique and the associated possible negative points while we try to point out the needed research steps to ensure its efficiency before it enters daily clinical practice

A common anatomical consequence of low-segment cesarean section is the presence of a pouch on the anterior uterine wall that can be detected by sonography or hysteroscopy. Different suturing techniques have been compared (single vs double layer) and showed no substantial differences. This prospective longitudinal study was aimed at evaluating the outcome of the cesarean scar, comparing two different types of single-layer sutures by transvaginal ultrasound and hysteroscopy.

No abstract available

FIG. 1 is a front isometric view of a hysteroscope in accordance with the new design; FIG. 2 is a side view thereof; FIG. 3 is a top view thereof; FIG. 4 is a bottom view thereof; FIG. 5 is a rear view thereof; and, FIG. 6 is a front view thereof.

A medical instrument for endoscopic procedures that is provided with a hollow shaft, such that at least two channels are configured in the shaft and the channels can be coupled on the proximal end with supply conduits. To create a medical instrument of the aforementioned type which is of simple structure and ensures secure connect ability, it is proposed according to the invention that the proximal end of at least one first channel positioned in the shaft and the distal end at least one supply conduit that is to be coupled with this first channel are configured with respect to their geometric structural design in such a way that this first channel and the corresponding supply conduit can be coupled only with one another.

FIG. 1 is a front elevational view of the shaft for a medical instrument in accordance with the new design; FIG. 2 is a side elevational view of a shaft for a medical instrument of FIG. 1; FIG. 3 is a top elevational view of a shaft for a medical instrument of FIG. 1; FIG. 4 is a bottom elevational view of a shaft for a medical instrument of FIG. 1; FIG. 5 is a front end elevational view of a shaft for a medical instrument of FIG. 1; and, FIG. 6 is a rear end elevational view of a shaft for a medical instrument of FIG. 1.

FIG. 1 is a front elevational view of a shaft for a medical instrument in accordance with the new design; FIG. 2 is a side elevational view of the shaft for a medical instrument of FIG. 1; FIG. 3 is a top elevational view of the shaft for a medical instrument of FIG. 1; FIG. 4 is a bottom elevational view of the shaft for a medical instrument of FIG. 1; FIG. 5 is a front end elevational view of the shaft for a medical instrument of FIG. 1; and, FIG. 6 is a rear end elevational view of the shaft for a medical instrument of FIG. 1.

FIG. 1 is a front elevational view of a shaft for a medical instrument in accordance with the new design; FIG. 2 is a side elevational view of the shaft for a medical instrument of FIG. 1; FIG. 3 is a top elevational view of the shaft for a medical instrument of FIG. 1, FIG. 4 is a bottom elevational view of the shaft for a medical instrument of FIG. 1; FIG. 5 is a rear end elevational view of the shaft for a medical instrument of FIG. 1; and, FIG. 6 is a front end elevational view of the shaft for a medical instrument of FIG. 1.