Abstract AIM: To investigate whether perioperative outcomes of class III/type C laparoscopic radical hysterectomy (LRH) for cervical cancer (CC) are influenced by neoadjuvant chemotherapy (NACT). PATIENTS AND METHODS: Data of consecutive patients, affected by locally advanced-stage CC, undergoing NACT plus LRH were matched 1:2 with consecutive patients, affected by early-stage CC who underwent LRH without NACT. RESULTS: Twenty and 40 patients underwent NACT with LRH and LRH aIone, respectively. Demographic characteristics were balanced between groups. Number of lymph nodes yielded, parametrial width and length of vaginal cuff were not influenced by preoperative administration of NACT. Patients undergoing NACT plus LRH experienced slightly higher blood loss (225 vs. 200 ml; p=0.05) than patients in the control group, but had a similar operative time and length of hospital stay. No between-group differences in transfusion and complications rates were observed (p>0.2). CONCLUSION: The administration of NACT does not affect the surgery-related outcomes of LRH

Abstract OBJECTIVE: The objective of this study was to evaluate how the administration of different adjuvant therapies influences the risk for developing recurrences in the para-aortic area in endometrial cancer (EC) with positive pelvic and unknown para-aortic nodes. METHODS: We retrospectively evaluated the data of 58 patients with EC affected by stage IIIC1 who had undergone pelvic but not para-aortic lymphadenectomy from January 1, 1990 to December 31, 2011. Survival outcomes within the first 5 years after surgery were assessed using the Kaplan-Meier model. RESULTS: Chemotherapy plus radiotherapy, chemotherapy only, and external radiotherapy only were administered in 12 (23%), 18 (34%), and 23 (43%) patients, respectively. Five (9%) patients, who were selected to forego adjuvant therapy due to poor performance status, were excluded from the analysis. Disease-free and overall survivals assessed at 5 years were 54%, and 61%, respectively. All para-aortic recurrences were observed among the patients with endometrioid EC, whereas no cases of para-aortic recurrences were found in patients with nonendometrioid histology (5/36 (14%) vs 0/17 (0%); P = 0.16); the latter were more likely to develop distant (hematogenous, peritoneal, and distant lymphatic) recurrences (P = 0.09). Type of adjuvant therapy was the only factor influencing para-aortic failure: chemotherapy (± radiotherapy) reduced the rate of para-aortic node recurrence in comparison with pelvic radiotherapy as a sole modality (P = 0.01). However, adjuvant therapy did not influence the 5-year survival outcomes (P > 0.05). CONCLUSIONS: In the absence of local treatment (ie, para-aortic lymphadenectomy and radiotherapy), the administration of chemotherapy seems effective in reducing recurrences in the para-aortic area among patients with stage IIIC1 endometrioid EC

Approximately 70-80% of endometrial carcinomas, type I carcinomas, are associated with endometrial hyperplasia, hyperestrogenism, and expression of estrogen receptor (ER). The aim of this review was to clarify the role of ER in endometrial diseases carcinoma. The estrogens exert their effect via two estrogen receptor: α and β. The ERs modulate transcriptional process by binding directly to the estrogen response elements (ERE) located in the target gene, or in non classical mode through protein-protein tethering with other transcription factors. There are also orphan receptors (their natural ligands have not been identified). Among this group, estrogen receptor-related receptors (ERRs) were identified by their sequences similar to those of ERs. Since the ERRs have shown a high similarity in DNA binding domain with ERs can interfere with estrogen signalling strengthening the hypothesis of an estrogen-ER-ERR crosstalk. Recently, the ERs and estrogen enzymes emerge as pharmacological targets in different disorders, as well as ERRs, and they may represent the reliable biomarkers in endometrial disease.

Ewing sarcoma-primitive neuroectodermal tumors (ES/PNETs) constitute a family of neoplasms characterized by a continuum of neuroectodermal differentiations. ES/PNET of the uterus is rare. There are 48 cases of ES/PNET of the uterus published in the literature as far as we know. We describe a case of Ewing sarcoma of the uterus occurring in a 17-year-old woman presenting with a two-month history of pelvic pain. After surgical excision and microscopic, immunohistochemical, and electron microscopy examination, the diagnosis of Ewing sarcoma of the uterus was suggested. This report will discuss the diagnosis and surgical and clinical management of Ewing uterine sarcoma in young women, according to the available literature. In spite of the rarity of ES/PNETs, they should be taken into account in the differential diagnosis of uterine neoplasms in young women.

Objective: To evaluate whether the addition of finasteride (a 5 <-reductase inhibitor) to conventional protocol of ovarian stimulation with gonadotropin can improve ovarian follicular growth in polycystic ovary syndrome (PCOS) women who did not respond to previous stimulation with gonadotropin alone. Design: Double-blind randomized study. Setting: Outpatient in an academic research environment. Patient(s): Thirty-six PCOS patients in whom the previous multifollicular stimulation protocols with gonadotropin failed. Intervention(s): The patients were randomly assigned to two treatment groups: group 1 underwent ovarian stimulation with recombinant FSH (rFSH) plus finasteride, and group 2 received rFSH alone. When the dominant follicle reached a mean diameter of 18 mm, hCG was administered and finasteride withdrawn. Main Outcome Measure(s): Ovulation rate in women with PCOS. Result(s): Follicular growth and ovulation occurred in eight patients in group 1, whereas no cases were detected in group 2. Conclusion(s): This study confirms that hyperandrogenism interferes with follicular growth and suggests that administration of finasteride during ovarian stimulation with rFSH improves ovulation rate in selected hyperandrogenic anovulatory women. (Fertil Steril (R) 2010; 94: 247-9. (C) 2010 by American Society for Reproductive Medicine.)

Abstract OBJECTIVES: Megacystis (MC) is rare and often associated with other structural and chromosomal anomalies. In euploid cases with early oligohydramnios, prognosis is poor mainly due to pulmonary hypoplasia and renal damage. We report our experience of the past 20 years. METHODS: A retrospective review of cases with prenatally diagnosed MC was performed. Complete prenatal as well as postnatal medical records from 1989 to 2009 were reviewed focusing on diagnostic precision, fetal interventions [vesicocentesis (VC), vesicoamniotic shunt (VAS)], short- and long-term outcome, and potential prognostic factors. RESULTS: 68 cases were included. Follow-up was available in 54 cases (9 girls and 45 boys including 3 cases with aneuploidy). We found 39 isolated MC at sonography (5 girls and 34 boys). 24 fetuses with isolated MC underwent VC and VAS at 19.6 ± 6.3 and 20 ± 4.9 weeks of gestation, respectively. Survival rate was higher in male than in female fetuses (51 vs. 33%). Renal problems occurred in 4/14 prenatally treated fetuses and in 1/10 when cases with prune belly syndrome (PBS) were excluded from the analysis. CONCLUSIONS: Our study shows that a careful selection of cases with MC excluding fetuses with PBS and early treatment has still the potential to improve outcome.

Abstract OBJECTIVE: To evaluate surgery-related outcomes of laparoscopic (LH) and vaginal hysterectomy (VH) in patients with a history of previous cesarean section (CS). STUDY DESIGN: Data on 289 consecutive patients with a history of CS undergoing VH (n=49, 17%) and LH (n=219, 76%) were collected. Basic descriptive statistics, univariate and multivariate analyses were performed to evaluate surgery-related outcomes. A propensity-matched algorithm was applied in order to reduce allocation biases between groups. RESULTS: Patients undergoing LH were more likely to have a history of multiple cesarean sections (44% vs. 18%; p=0.001). Additionally, uterine weight was greater among patients undergoing LH than VH (median weight: 235 (range, 45-2830) vs. 150 (range, 40-710)g; p<0.001). Three patients in each group experienced procedural bladder injuries (3/219 (1%) vs. 3/49 (6%); p=0.07; RR: 1.65; 95%CI: 0.74, 3.68). The rate of grade 3 or worse postoperative complications was balanced between LH and VH (1% vs. 0%; p=1.00). Patients undergoing LH experienced a shorter length of hospital stay in comparison to patients undergoing VH (1 vs. 2 days; p=0.02). Considering the overall population, we observed via multivariate analysis that age (OR: 1.003 (95%CI: 1.001, 1.004) per 10-year increase in age; p=0.002), VH (OR: 17.80 (95%CI: 1.762, 180,378); p=0.01) and number of cesarean sections≥2 (OR: 27.70 (95%CI: 1.976, 388,285); p=0.01) increased the risk of developing bladder injuries during hysterectomy. CONCLUSIONS: LH is a safe and feasible procedure in patients with previous CS, and it is associated with a low bladder injury rate.

This article aimed to determine sexual behaviors among female and male adolescents in northern Italy. An anonymous self-administered questionnaire evaluating sexual attitudes was distributed in middle and high schools in northern Italy. Adolescents between 13 and 19 years of age were asked to participate at the survey. The study group included 664 participants. Overall, 164 (25%) adolescents had had at least one sexual intercourse. Among adolescents who have had sexual intercourse, 90 (55%) use condoms, 25 (15%) use hormonal contraception, and 49 (30%) do not use any contraception method. A total of 559 adolescents (84%) participated in school-based sexual education programs. This group had better knowledge on sexually transmitted diseases and contraception methods in comparison with adolescents who have never participated in such educational programs (p <.05), and no difference in high-risk sexual behaviors was observed (p = 1.0). School-based sexual education programs improve knowledge of sexual transmitted diseases and contraception methods. However, this knowledge does not correlate to high-risk sexual behaviors reduction.

Objective: To determine whether decreased estrogen receptor alpha (ER-alpha) expression in endometriotic lesions could be balanced by an increased expression of estrogen receptor-related receptors (ERRs). To evaluate whether ERR-alpha expression is influenced by hormonal change in fertile and menopausal women. Design: Prospective controlled study. Setting: University Hospital, Department of Gynecology. Patient(s): Twenty-five women: 20 women of reproductive age with (n = 10) and without (control; n = 10) endometriosis and 5 menopausal women. Intervention(s): Real-time polymerase chain reaction (qPCR). Immunohistochemistry. Main Outcome Measure(s): The ER and ERR expression levels were studied by reverse transcriptase-qPCR, ELISA, and immunohistochemistry using endometriotic and normal endometrial tissues. The ERR-alpha protein distribution was performed by immunohistochemistry in fertile and menopausal women. Result(s): Increased levels of ER-beta were associated with ER-alpha, ERR-alpha, and ERR-gamma reductions in ectopic tissue but not in eutopic and normal endometria. Similar levels of ERR-beta were found in women with and without endometriosis. The ERR-alpha expression was similar in proliferative and secretory endometrial samples, whereas a down-regulation of this receptor was found in atrophic tissue. Conclusion(s): Our data confirm the up-regulation of ER-beta as the principal receptor involved in the progression of human endometriosis. In addition, we found that ERR-alpha seems to be unresponsive to hormonal changes during the menstrual cycle. (Fertil Steril (R) 2011;96:102-6. (C)2011 by American Society for Reproductive Medicine.)

Objectives: The aim of this study was to analyze perioperative and long-term survival outcomes after either laparoscopic or open abdominal staging for apparent early-stage ovarian cancer. Methods: Data of consecutive women with early-stage ovarian cancer undergoing comprehensive laparoscopic staging between 2003 and 2010 were matched with a historical cohort of patients undergoing open surgery. Five-year survival outcomes were analyzed using the Kaplan-Meier method. In addition, a systematic review of the literature and meta-analysis of comparative studies was performed Results: A total of 35 women undergoing staging via laparoscopy were compared with a cohort of 32 patients undergoing open surgery. Baseline characteristics were similar between groups. Spillage occurred in 6 and 4 patients in laparoscopic and open group, respectively (P = 0.59). Patients undergoing laparoscopy experienced longer operative time (P < 0.001), shorter hospital stay (P = 0.03), and lower postoperative complication rate (3% vs 28%; P = 0.005) than patients undergoing staging via open surgery. The median (range) follow-up period was 64 (37-106) and 100 (61-278) months for case and control, respectively (P < 0.001). Five-year disease-free survival (P = 0.12, log-rank test) and overall survival (P = 0.26, log-rank test) were not influenced by surgical approach. Pooled analyses of the literature results corroborate our results suggesting an improvement of perioperative results in the laparoscopic group in comparison with the open abdominal one. In comparison with open surgery, laparoscopy did not influenced spillage (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.35-1.73) and upstaging rate (OR, 0.7; 95% CI, 0.38-1.27). No between-group differences in survival were observed (OR, 0.5; 95% CI, 0.21-1.21). Conclusions: Laparoscopy upholds open surgery in long-term oncologic control, reducing morbidity.

Abstract OBJECTIVE: To evaluate whether the administration of local anesthetic (LA) reduces pain in comparison with forced coughing (FC) for the execution of colposcopically guided biopsies (CGBs). STUDY DESIGN: Data of 100 consecutive patients undergoing CGBs with the use of LA or FC were prospectively evaluated. Procedure-related pain was assessed with the use of a 100-mm visual analogue scale. RESULTS: Fifty-one and 49 patients had CGBs using LA and FC, respectively. No between-group differences were observed in terms of pain related to speculum insertion, CGBs and pain recorded after the procedures (p>0.05). However, patients in the LA group experienced pain related to cervical injection for administration of anesthesia (mean (±SD): 12.4 (±1.6)). Operative time was longer in the LA than in the FC group (7.2 (±0.2) vs. 5.0 (±0.1)min; p<0.001). CONCLUSIONS: FC should be preferred over LA. Although CGB-related pain levels do not differ, the omission of intracervical injection is associated with undoubted advantages

OBJECTIVE: The purpose of this study was to assess myocardial function of fetuses who were exposed to intraamniotic infection compared with fetuses of uncomplicated pregnancies by the application of tissue Doppler and strain rate (SR) imaging. STUDY DESIGN: We evaluated the right ventricular function of fetuses with preterm premature rupture of membranes and proven intraamniotic infection (n = 12 fetuses) and healthy fetuses (n = 27). Tissue Doppler velocities during early diastolic relaxation (E(m)) and atrial contraction (A(m)) and early diastolic SR were measured as indices of diastolic function, whereas the peak systolic strain and SR were used as parameters of systolic function. RESULTS: Fetuses with intraamniotic infection exhibit impairment in both diastolic and systolic performance, which was characterized by increased diastolic compliance (increased E(m)/A(m) ratio, increased early diastolic SR compared with the control fetuses), decreased systolic contractile function (reduced systolic strain and SR), and longitudinal myocardial dyskinesia. CONCLUSION: New echocardiographic tools suggest that fetal heart is a target organ in the context of intraamniotic infection.

Abstract INTRODUCTION: Although growing evidence suggests the beneficial effects of a nerve-sparing (NS) approach to surgery in cervical cancer patients, only limited data on NS laparoscopic radical hysterectomy (LRH) are available, and no studies have investigated the effects of NS-LRH on sexual function. AIM: This study aims to determine whether the implementation of NS-LRH impacts on sexual function in cervical cancer patients. METHODS: Sexually active cervical cancer patients undergoing type C (class III) LRH between 2004 and 2013 were enrolled in this prospective study. MAIN OUTCOME MEASURES: Preoperative and postoperative sexual function were assessed using a validated questionnaire, the Female Sexual Function Index (FSFI). The FSFI evaluates desire, arousal, lubrication, orgasm, satisfaction, and pain. RESULTS: Forty patients undergoing radical hysterectomy (20 conventional LRH vs. 20 NS-LRH) represented the study group. Baseline characteristics were similar between groups (P > 0.05). No differences in preoperative FSFI scores were recorded (P > 0.05). We observed that both LRH and NS-LRH worsened postoperative FSFI scores (P < 0.001). However, patients undergoing NS-LRH had higher postoperative FSFI scores than patients undergoing LRH (21.3 ± 9.4 vs. 14.2 ± 12.5; P = 0.04). Considering postoperative domain scores, we observed that desire, arousal, orgasm, and pain scores were similar between groups (P > 0.05), while patients undergoing NS-LRH experienced higher lubrication (3.4 ± 2.3 vs. 1.7 ± 2.2; P = 0.02) and satisfaction (4.6 ± 3.9 vs. 2.8 ± 2.2; P = 0.004) scores in comparison with patients undergoing conventional LRH. No between-group differences in survival outcomes were found. CONCLUSIONS: Both conventional LRH and NS-LRH impact negatively on patients' sexual function. However, the NS approach impairs sexual function less, minimizing the effects of radical surgery

Introduction: Ovarian cancer is highly sensitive to chemotherapy but also shows a high rate of recurrence and drug resistance. These negative outcomes mostly depend on altered apoptotic pathways, making the design of new therapeutic strategies based on the induction of other types of cell death highly desirable. Several lines of research are now addressing cancer-specific features to specifically target tumor cells, thus reducing adverse effects. In this light, a great deal of attention has been devoted to the metabolic reprogramming occurring in cancer cells, which display increased levels of glycolysis compared with their normal counterparts. We recently showed that inhibition of p38 alpha impairs key metabolic functions of colorectal cancer cells, inducing growth arrest, autophagy, and cell death both in vivo and in vitro. These effects are mediated by a switch from hypoxia-inducible factor 1 alpha (HIF1 alpha) to forkhead transcription factor O (Fox)-dependent transcription. Methods: We first characterized p38 expression in OVCAR-3, A2780, and SKOV-3 ovarian cancer cell lines. Then, we treated these cells with the p38 alpha/p38A-specific inhibitor SB202190 and performed a morphological, proliferation, and survival analyses. Finally, we studied HIF1 alpha and FoxO3A expressions and signaling pathways to evaluate their role in SB202190-induced effects. Results: p38 alpha blockade induces the formation of intracellular autophagic vacuoles and reduces growth and viability of ovarian cancer cells. As in colorectal cancer, the underlying molecular mechanism seems to rely on a shift from HIF1 alpha- to FoxO3A-dependent transcription, which is promoted by the activation of the adenosine monophosphate-activated protein kinase pathway. Conclusions: These data corroborate the hypothesis that pharmacological modulation of genes involved in cancer-specific homeostasis, such as p38 alpha, might be exploited to design new therapeutic approaches to cancer treatment.

Pentalogy of Cantrell (PC) is a rare congenital syndrome involving the abdominal wall, sternum, diaphragm, pericardium, and heart. The embryonic period in which PC develops coincides with that of umbilical cord (UC) formation. The aim of the following study was to address the question of whether PC is associated with UC pathologies. Four cases, prenatally identified between 2002 and 2008, were enrolled in this study. Umbilical cord pathologies defined as single umbilical artery, short cord, or UC with atypical coiling pattern were retrospectively assessed on stored ultrasound images and from autopsy reports. The literature regarding PC and UC pathologies was reviewed. Three singleton pregnancies and 1 monoamniotic twin pregnancy with twin reversed arterial perfusion sequence were reviewed. All had a normal karyotype. Three showed the classical PC stigmata, with ectopia cordis. One fetus had no ectopia cordis; this case had a normal UC, whereas all others fetuses showed a short UC with atypical coiling pattern. Of 26 publications dealing with PC, the UC was described in only 8 cases, 7 of which were abnormal. There seems to be a strong correlation between the PC and UC abnormalities, in particular in cases with ectopia cordis. We speculate that the insult leading to the classical malformations of PC and UC abnormalities is the same or the sequence of malformations itself may alter the early fetoplacental blood flow and therefore the normal development of the UC angioarchitecture.

Background: To verify the feasibility of ovarian stromal evaluation and correlate ovarian parameteres (echogenicity and volume) with hyperandrogenism, and both cardiovascular and metabolic risk factors in PCOS. Methods: Twenty four young PCOS patients and twelve age-matched control women were enrolled. Diagnosis of PCOS was based on the Rotterdam criteria. Ultrasound ovarian study included ovarian volume, stromal volume, stromal area and stromal area/total ovarian area ratio (S/A). Concerning hormones, insulin, LH, FSH, estradiol, androstenedione, testosterone, DHEAS, 17-hydroxy-progesterone, and SHBG were measured during the early follicular phase (days 2-5). Cardiovascular risk factors were represented by fasting plasma levels of glucose, lipids(total and HDL-cholesterol), plasminogen activator inhibitor 1 (PAI-1), von-Willebrand factor (vWF), and adiponectin. Carotid intima-media thickness (C-IMT) was measured as a parameter of cardiovascular risk. Results: A positive correlation between the S/A ratio and plasma levels of testosterone (p < 0.05) and androstenedione (p < 0.05) was found. The stromal volume, stromal area and S/A ratio were also significantly and positively correlated with PAI-1, and vWF levels, and with IMT in PCOS women (P < 0.05). Conclusions: This study shows that the ultrasound measurement of ovarian stroma is a predicting factor of hyperandrogenism degree, prothrombotic factors and cardiovascular risk in patients with PCOS.

Abstract BACKGROUND: Identification of peri-operative variables predicting postoperative morbidity may improve postoperative patients' care. We aimed to identify patients' characteristics and operative factors predictive of early (≤ 30-day) and late (≤ 6-month) morbidity in cervical cancer patients undergoing surgery plus external beam radiotherapy (EBRT). METHODS: We studied 45 propensity-matched patient pairs (90 patients) undergoing laparoscopic radical hysterectomy (LRH) plus EBRT vs. abdominal radical hysterectomy (RAH) plus EBRT. Basic descriptive, multivariable and artificial neuronal network analyses (ANN) were used to design predicting models influencing outcomes. RESULTS: Baseline characteristics of the study populations were similar. Patients undergoing LRH experienced lower blood loss (200 (range, 10-700) vs. 400 (range, 100-2000) ml; P < 0.001), shorter length of hospital stay (4 (range, 1-10) vs. 8 (range, 5-52) days; P < 0.001) and similar operative time (235 (± 67.3) vs. 258 (± 70.2) min; P = 0.14) than patients undergoing RAH. We observed that, at multivariate analysis, open approach correlated with overall (OR: 1.2; 95%CI: 1.03-1.46), early (OR: 1.14; 95%CI:0.99-1.3) and late (OR: 1.13; 95%CI: 1.001-1.28) postoperative complications. CONCLUSIONS: Open approach is the main predictor for developing morbidity among cervical cancer patients undergoing radical hysterectomy followed by adjuvant radiotherapy. Laparoscopic surgery enhances peri-operative surgical results and minimizes the occurrence of late complications

Objective: To identify factors predicting for recurrence in vulvar cancer patients undergoing surgical treatment. Methods: We retrospectively evaluated data of consecutive patients with squamous cell vulvar cancer treated between January 1, 1990 and December 31, 2013. Basic descriptive statistics and multivariable analysis were used to design predicting models influencing outcomes. Five-year disease-free survival (DFS) and overall survival (OS) were analyzed using the Cox model. Results: The study included 101 patients affected by vulvar cancer: 64 (63%) stage I, 12 (12%) stage II, 20 (20%) stage III, and 5 (5%) stage IV. After a mean (SD) follow-up of 37.6 (22.1) months, 21 (21%) recurrences occurred. Local, regional, and distant failures were recorded in 14 (14%), 6 (6%), and 3 (3%) patients, respectively. Five-year DFS and OS were 77% and 82%, respectively. At multivariate analysis only stromal invasion >2 mm (hazard ratio: 4.9 [95% confidence interval, 1.17-21.1]; P=0.04) and extracapsular lymph node involvement (hazard ratio: 9.0 (95% confidence interval, 1.17-69.5); P=0.03) correlated with worse DFS, although no factor independently correlated with OS. Looking at factors influencing local and regional failure, we observed that stromal invasion >2 mm was the only factor predicting for local recurrence, whereas lymph node extracapsular involvement predicted for regional recurrence. Conclusions: Stromal invasion >2 mm and lymph node extracapsular spread are the most important factors predicting for local and regional failure, respectively. Studies evaluating the effectiveness of adjuvant treatment in high-risk patients are warranted

Objective: The aim of this study was to achieve pregnancy in a woman with premature ovarian insufficiency (POI) by means of estrogen pretreatment, a combination of estrogen therapy and gonadotropin ovarian stimulation, and intracytoplasmic sperm injection (ICSI). Methods: A 34-year-old woman with POI who failed to achieve follicular growth in two previous ovarian stimulation protocols using high doses of gonadotropins alone underwent an ICSI trial after estrogen pretreatment (ethinyl estradiol 0.05 mg three times a day for 10 d) followed by estrogens (at the same dose) and recombinant A-follicle-stimulating hormone (250 IU/d for 12 d). Results: Delivery of a healthy female baby was achieved. Conclusions: Stimulation with gonadotropins plus estrogens after pretreatment with estrogen can be considered a useful intervention in women with POI trying to conceive.

Uterine myomas are the most common benign growths affecting female reproductive system, occurring in 20-40% of women, whereas the incidence rate in pregnancy is estimated from 0.1 to 3.9%. The lower incidence in pregnancy is due to the association with infertility and low pregnancy rates and implantation rates after in vitro fertilization treatment. Uterine myomas, usually, are asymptomatic during pregnancy. However, occasionally, pedunculated fibroids torsion or other superimposed complications may cause acute abdominal pain. There are many controversies in performing myomectomy during cesarean section because of the risk of hemorrhage. Nevertheless, the majority of indication arises before labor and delivery due to acute symptoms leading to a discussion regarding the need for intervention during pregnancy. Therefore, we present a case of successful multiple laparotomic myomectomy at 17 + 2 weeks of gestational age and a systematic review of the literature in order to clarify the approach to this pathologic condition and its effect on pregnancy outcome.

Abstract Vaginal cuff dehiscence is a rare, but potentially morbid, complication of total hysterectomy and refers to separation of the vaginal cuff closure. The term vaginal cuff dehiscence is frequently interchanged with the terms of cuff separation or cuff rupture. All denote the separation of a vaginal incision that was previously closed at time of total hysterectomy. After dehiscence of the vaginal cuff, abdominal or pelvic contents may prolapse through the vaginal opening. Bowel evisceration, outside the vulvar introitus, can lead to serious sequelae, including peritonitis, bowel injury and necrosis, or sepsis. Therefore, although prompt surgical and medical intervention is required to replace prolapsed structures, the main problem remains the reconstruction of vaginal vault. In case of recent hysterectomy, vaginal reparation only requires the approximation of vaginal walls, including their fascia, while if dehiscence occurs after a long time from hysterectomy, the adequate suspension of the vaginal vault has to be taken into consideration. In this report we describe the case of a postmenopausal patient, undergoing surgical emergency because of the evisceration of an intestinal loop through a dehiscence of vaginal vault, after numerous reconstructive vaginal surgeries for vaginal prolapse. This paper analyzes clinical circumstances, risk factors, comorbidity, and clinical and surgical management of this complication