Search Results (47)

Background: Bacterial vaginosis (BV) is considered the most common cause of vaginal discharge, which is related to several public health issues, such as an increased risk for sexually transmitted infections, pelvic inflammatory disease, pregnancy-related problems such as abortion, stillbirth or premature birth, and tubal factor infertility. BV is not considered an infection but an imbalance in the vaginal microbiota, characterized by a substitution of the normal Lactobacilli flora by anaerobe. Reducing resistance against infections by several mechanisms, including bacterial homeostasis, stabilization of acid pH, inhibition of pathogens adhesion by polyamine degradation, production of anti-inflammatory molecules, surfactants, and antimicrobial substances like hydrogen peroxide, acids, and bacteriocins. Approximately half of women with BV can experience symptoms, which mainly include vaginal malodor, fishy discharge, stinging sensation, and increased vaginal pH. The treatment of BV is based primarily on promoting Lactobacilli restoration and eliminating dangerous microbiota with antibiotic therapy. However, there is a high rate of recurrence and relapse. Objective: Based on the current literature, this review aims to propose a list of ten BV hallmarks: dysbiosis, inflammation, apoptosis, pH basification, mucosal barrier integrity, pathway activation, epithelial damage, genomic instability, oxidative stress (OS), and metabolic reconfiguration. Conclusions: Understanding the causes of BV and the pathogenicity mechanisms is critical for preventing and improving the current therapeutic management of patients. Full article

Background/Objectives: An 80-year-old man was admitted to our department after a salvage radical cystectomy for actinic cystitis due to radiotherapy for prostate cancer. He presented with a two-month history of feculent debris in the right stoma and deteriorated general conditions, after a long past medical history of recurrent complicated urinary infections. Methods: Computer tomography (CT) of the abdomen revealed a ureterocolic fistula along the right ureteral pelvic tract. A right percutaneous nephrostomy tube was placed. Due to multiple previous surgeries, several lines of intravenous antibiotic therapies and the overall condition of the patient, a conservative management was preferred. Results: A bovine serum albumin-glutaraldehyde (BioGlue^®) adhesive was inoculated into the right ureter through the stoma to close the fistula. After 24 months, the patient remained asymptomatic with negative follow-up imaging. Conclusions: Given the uniqueness of the management of a ureterocolic fistula, this case offers insight into conservative treatment in frail patients not suitable for major surgery. Full article

Endometriosis, a prevalent gynecological condition affecting 10–15% of reproductive-age women, involves the growth of endometrial-like tissue outside the uterine cavity. This chronic inflammatory disease can significantly impact fertility by disrupting ovulation, tubal transport, and implantation. Clinical manifestations vary widely, ranging from asymptomatic cases to severe pelvic pain, dysmenorrhea, and dyspareunia. Accurate diagnosis remains challenging, often requiring a combination of patient history, clinical examination, and imaging studies. This paper will discuss the clinical approach to endometriosis during a first-line gynecological appointment, focusing on patient history, including detailed assessment of menstrual, pelvic, and bowel symptoms, and clinical examination; thorough gynecological examination, including abdominal and pelvic palpation, speculum examination, and bimanual examination; imaging evaluation (particularly of the role of ultrasound in identifying and characterizing endometriotic lesions, including the use of the #ENZIAN classification for deep infiltrating endometriosis and evaluation of fertility impact); and discussion of the Endometriosis Fertility Index (EFI) as a tool for assessing fertility potential. This comprehensive approach aims to guide clinicians in identifying and managing endometriosis effectively, improving patient outcomes and optimizing fertility management strategies. Methods: A literature search for suitable articles published from January 1974 to 2024 in the English language was performed using PubMed. Results: Endometriosis is associated with infertility rates ranging from 20% to 68%, with mechanisms including pelvic adhesions, chronic inflammation, and immune dysregulation. The revised American Society for Reproductive Medicine (rASRM) classification and #ENZIAN classification were identified as essential tools for staging and characterizing the disease. Transvaginal ultrasound (TVS) demonstrated high diagnostic accuracy for deep infiltrating endometriosis, with a sensitivity of up to 96% and specificity of 99%. EFI emerged as a valuable predictor of natural conception post-surgery. Additionally, the review underscores the frequent co-occurrence of adenomyosis in women with endometriosis, which may further compromise fertility. Despite advancements in imaging techniques and classification systems, the variability in symptom presentation and disease progression continues to challenge early diagnosis and effective management. Conclusions: Endometriosis is a prevalent gynecological condition affecting women of reproductive age and is associated with infertility. This paper describes the diagnostic approach to endometriosis during a first-line gynecological appointment, focusing on clinical history, physical examination, and the role of imaging, particularly ultrasound, in identifying and characterizing endometriosis lesions. The adoption of standardized classification systems such as #ENZIAN and EFI enhances disease staging and fertility prognosis, allowing for tailored treatment strategies. Despite improvements in non-invasive diagnostic methods, challenges persist in correlating symptom severity with disease extent, necessitating continued research into biomarkers and novel imaging techniques. Additionally, the frequent coexistence of adenomyosis further complicates fertility outcomes, underscoring the need for comprehensive management strategies. Further research is needed to enhance early detection strategies and optimize fertility preservation techniques for affected women. Full article

Postoperative adhesions represent a major medical challenge and are associated with serious health and economic consequences. 4DryField^® PH (PlantTec Medical GmbH, Lueneburg, Germany) is a starch-based medical device designed both to prevent adhesions and for hemostasis. This paper explores methods to successfully apply it in gynecological surgery, leveraging the authors’ extensive clinical experience. We provide detailed insights into best practices that benefit most patients with conditions such as endometriosis, along with practical tips and guidance on optimizing application and dosage. Our real-world clinical experience across various indications, supported by published data, demonstrates significant patient benefits: reduced adhesion formation, better recovery, less pain, and improved fertility. Patient acceptance and satisfaction are notably high. The device can be applied to surgical wounds as a powder for hemostasis and transformed into a gel in situ or as a premixed gel when adhesion prevention is prioritized. Specific advantages for each method are demonstrated by case studies. When used correctly, 4DryField PH is safe and effective, especially for larger wound areas with a high risk of reoperation and adhesion formation and when pregnancy is desired. It offers great versatility due to its use as either in situ gel or premixed gel with different viscosities. Despite some remaining gaps in clinical evidence and ongoing studies, our personal clinical experience suggests significant benefits with minimal risks. Therefore, we have no concerns regarding the broad use of 4DryField PH in gynecology and other surgical disciplines. Future research should focus on patient-reported outcomes and health economic benefits to support reimbursement efforts. Full article

Endometriosis is a chronic, estrogen-dependent inflammatory disease characterized by the presence of endometrial tissue outside the uterus, causing pelvic pain and infertility. Infertility arises mainly due to inflammatory mediators in the peritoneal fluid, contributing to local hypoestrogenism, which appears to exacerbate chronic inflammation and sensitize pelvic nerves. Local hypoestrogenism within endometriotic lesions contrasts with the systemic estrogen-dependent nature of the disease. This localized reduction in estrogen levels, resulting from an altered hormonal response, can contribute to the altered immune response and inflammation characteristic of endometriosis, potentially exacerbating tissue damage, promoting fibrosis, adhesions, and endometrioma formation that distort pelvic anatomy, and affecting fertility. Chronic pelvic pain and dyspareunia further complicate conception in affected women. In vitro fertilization (IVF) and laparoscopic surgical excision of endometriotic lesions are the two primary management options for endometriosis-related infertility, although current data provide limited guidance on when to prefer one approach over the other. It is generally accepted that treatment strategies must be individualized according to the patient’s wishes, symptomatology, age and the preferences of the woman and the couple. Timely intervention and structured follow-up for symptomatic women wishing to conceive may maximize conception rates within two years post-surgery, while minimizing the need for repeated interventions, which should be avoided. On the other hand, first-line IVF is particularly viable in cases of unoperated deep infiltrating endometriosis in asymptomatic women, or for those ineligible for or opposed to surgery. This review aims to evaluate the most recent data on endometriosis-related infertility to identify evidence-based key points that can enhance tailored management in clinical practice. Full article

As the incidence of colorectal cancer (CRC) increases among younger adults, the need for discussions regarding treatment-related infertility is growing. The negative impacts of gonadotoxic chemotherapy and pelvic radiation are well documented, but the role that surgical intervention for CRC plays in infertility is less clear. Additionally, treatment-related infertility counseling occurs infrequently. This review provides an overview of the connection between abdominal and pelvic surgery on male and female infertility and elucidates the role of surgeons in counseling to alleviate psychological distress in newly diagnosed patients. A review of the literature revealed that pelvic surgery leads to increased adhesion formation, which is known to be associated with female infertility. Furthermore, nerve damage from pelvic surgery has significant implications for ejaculatory issues in males and sexual dysfunction in both males and females, which ultimately impact pregnancy success. Patients have significant distress related to treatment-related infertility, and pre-treatment fertility counseling has been shown to alleviate some of this psychological burden. Nevertheless, many patients do not receive counseling, particularly in surgical clinics, despite surgeons often being the first providers to see newly diagnosed non-metastatic patients. Efforts should be made to enact protocols that ensure fertility conversations are being had with patients in surgical clinics and that patients are being referred to fertility specialists appropriately. This patient-centered approach will lessen the psychological burden placed on patients during a vulnerable time in their lives. Full article

Pelvic inflammatory disease is an infectious condition affecting women’s upper genital tract, including the uterus, fallopian tubes, and ovaries. It primarily arises from an infection that spreads upward from the lower genital area. The relationship between chronic pelvic pain and coexisting conditions is a key focus in its diagnosis and treatment. This type of pain is also considered a form of reflex dystrophy, involving both neurological and psychological components, the first line treatment consists in antibiotherapy. For patients with complex or severe pelvic abscesses, surgical intervention may be considered in selected cases. The primary surgical techniques employed are open and laparoscopic surgery, both aimed for abscess removal. MRI or Doppler ultrasonography may be employed when there is a suspicion of adnexal torsion, adenomyosis or deep pelvic endometriosis, especially if the ultrasound results are unclear or inconclusive Laparoscopic surgery has increasingly become favored by both healthcare professionals and patients. Moreover, laparoscopy has emerged as the most valuable tool for diagnosing chronic pelvic pain. The approach to treating pelvic abscesses in women of reproductive age depends greatly on clinical assessments, individual patient factors, and the desire to preserve fertility. However, laparoscopy may present technical difficulties in patients with severe pelvic abscesses, particularly those with extensive adhesions or a closed-off pelvic area, requiring advanced surgical expertise. Women with associated conditions such as endometriosis often experience a more severe form of pelvic inflammatory disease, which is less responsive to antibiotics and more frequently requires surgical resolution. The surgical treatment should be performed individualized to the clinical condition of the patient and the time of intervention must be carefully chosen. Full article

Objective: This prospective study investigated the feasibility of performing laparoscopic pelvic surgery under spinal anesthesia and analyzed the intraoperative side effects, like pain, nausea, and vomitus, of 915 patients. Methods: The implementation and performance of laparoscopic surgery under local anesthesia on 915 patients (out of a total of 3212 who underwent laparoscopic pelvic surgery under spinal anesthesia) were analyzed in relation to BMI (body mass index), obesity, pain during surgery, amount of intraperitoneal mmHg CO₂ gas pressure, and surgical complications. Results: BMI > 30, intra-abdominal adhesions, increased duration of the operation, bleeding, and increased intraperitoneal CO₂ pressure were statistically significant as the main causes of pain during laparoscopic surgery under spinal anesthesia. Underweight patients, on the other hand, had less pain when intra-abdominal pressure increased compared to those of normal weight. The appearance of pain, nausea, and vomitus occurred in 10.3% of patients, and these events were easy to manage and treat. They did not affect the surgeon’s work or the course of the operation. Conclusions: In light of these observations, we are proposing spinal anesthesia for laparoscopic surgery as the first choice in patients who have no contraindications. To the best of our knowledge, this clinical study constitutes the largest clinical observation and dataset concerning spinal anesthesia in laparoscopic pelvic surgery. Trial registration: ISRCTN38987, 10 December 2019. Full article

Uterine rupture is a rare and life-threatening condition. It usually occurs in patients with uterine scars (most commonly for a previous myomectomy or caesarean section), but it can also affect an unharmed uterus. This complication is more frequent in the third trimester and during delivery. There is not yet a recognised method of prediction of uterine rupture and the ultrasound features still need a consensus. In this article, we have reported a case of uterine dehiscence diagnosed by a pelvic ultrasound and magnetic resonance (MRI) at 24 weeks of gestation. The finding was confirmed intraoperatively at the caesarean section at 29 weeks of gestation. The 40-year-old patient has had a previous pregnancy complicated by uterine rupture at 22 weeks of gestation, following six previous abdominal surgeries for stage IV endometriosis, diffuse and nodular adenomyosis, and pelvic adhesion syndrome. The early detection of uterine dehiscence allowed us to prolong the pregnancy and perform a subsequent fertility-sparing surgery, reducing maternal and neonatal morbidity and mortality. Our case report proves that women with severe endometriosis/adenomyosis are at a high risk of uterine rupture and scar dehiscence. The antenatal ultrasound can describe a uterine dehiscence (even in asymptomatic patients) and prevent complications. Full article

Background: The greatest risk for the occurrence of the placenta accreta spectrum (PAS) is represented by uterine scars, which most frequently result after cesarean sections. Uterine rupture is a rare condition and appears mainly in the third trimester of pregnancy. The association between these two conditions is extremely rare in the first trimester of pregnancy. Methods: We performed a systematic review of abnormal placental adhesions and spontaneous uterine ruptures in the first trimester of pregnancy. We also reported a case of spontaneous uterine rupture in a 12-week pregnancy that presented with massive hemoperitoneum and hemorrhagic shock. Results: A 33-year-old patient with two previous cesarean sections, at the twelfth week of pregnancy at the time to this visit to the emergency room, presented with syncope and intense pelvic–abdominal pain. A clinical examination and ultrasound scan established the diagnosis of hemoperitoneum and hemorrhagic shock. Surgical exploration was performed, uterine rupture was identified, and hemostasis hysterectomy was necessary. The histopathological results showed placenta percreta. There have been eight reported cases of spontaneous uterine rupture in the first trimester of pregnancy associated with PAS. In these cases, it was found that 62.5% of the patients had undergone at least one cesarean section in the past; in 75% of the cases, hysterectomy was performed; and, in 87.5% of the cases, the presence of placenta percreta was confirmed. Conclusions: A high rate of cesarean sections determines the increase in the incidence of placenta accreta spectrum disorders. The possible life-threatening complications caused by this pathology can be observed in early pregnancies. Full article

A 40-year-old female patient presented to a secondary facility with dull lower abdominal pain and a persistent low-grade fever. Her laboratory results showed elevated inflammation markers. A CT scan revealed two abscesses in the lesser pelvic region in direct contact with the apex of the appendix, the posterior wall of the uterus, and the right-side appendages. The patient responded well to intravenous antibiotics, and an MRI scan revealed the cause to be an appendiceal rupture. The patient was scheduled for an appendectomy. The procedure started laparoscopically but had to be converted to an open one with a midline infra-umbilical incision in order to protect the right appendages. A standard appendectomy was conducted, and the histology report revealed rupture of the appendix with concomitant wall inversion in the context of fibrous adhesions as well as obstruction due to a fecalith. Patient recovery and follow-up were excellent. Acute appendicitis, while frequently encountered in surgical practice, can present a diagnostic conundrum when it manifests in an atypical manner. This unique form of inversion appeared to confer a protective role against peritonitis, primarily through the mechanism of obstruction occurring centrally to the rupture. We suggest that this case should be included in current classifications as a partial inversion of the appendix after rupture and inflammation. Full article

Soft tissue defects, such as incisional hernia or pelvic organ prolapse, are prevalent pathologies characterized by a tissue microenvironment rich in fragile and dysfunctional fibroblasts. Precision medicine could improve their surgical repair, currently based on polymeric materials. Nonetheless, biomaterial-triggered interventions need first a better understanding of the cell-material interfaces that truly consider the patients’ biology. Few tools are available to study the interactions between polymers and dysfunctional soft tissue cells in vitro. Here, we propose polypropylene (PP) as a matrix to create microscale surfaces w/wo functionalization with an HBII-RGD molecule, a fibronectin fragment modified to include an RGD sequence for promoting cell attachment and differentiation. Metal mold surfaces were roughened by shot blasting with aluminum oxide, and polypropylene plates were obtained by injection molding. HBII-RGD was covalently attached by silanization. As a proof of concept, primary abdominal and vaginal wall fasciae fibroblasts from control patients were grown on the new surfaces. Tissue-specific significant differences in cell morphology, early adhesion and cytoskeletal structure were observed. Roughness and biofunctionalization parameters exerted unique and combinatorial effects that need further investigation. We conclude that the proposed model is effective and provides a new framework to inform the design of smart materials for the treatment of clinically compromised tissues. Full article

Endometriosis is a chronic condition characterized by the presence of abnormal endometrial tissue outside the uterus. These misplaced cells are responsible for inflammation, symptoms, scar tissue and adhesions. Endometriosis manifests mainly in three patterns: superficial peritoneal lesions (SUP), ovarian endometriomas (OMA) and deep infiltrating endometriosis (DIE). It also exhibits atypical and extremely rare localization. The updated 2022 guidelines of the ESHRE recommend using both ultrasound and magnetic resonance imaging (MRI) as first-line diagnostic tests. Currently, MRI provides a more complete view of the pelvis anatomy. The aim of our review is to provide radiologists with a “map” that can help them in reporting pelvic MRI scans in patients with endometriosis. We will illustrate the usual and unusual localizations of endometriosis (categorized into compartments) using post-operative imaging, and we will focus on the role of MRI, the main sequences and the use of contrast agents. Full article

This study aimed to demonstrate the feasibility of ureteral navigation using intraoperative indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging during complex laparoscopic or robot-assisted gynecologic surgery (LRAGS). Twenty-six patients at high risk of ureteral injury with complex pelvic pathology (CPP) due to pelvic organ prolapse (POP), multiple myomas, large intraligamentary or cervical myoma, severe pelvic adhesions, or cervical atresia underwent LRAGS. All patients underwent cystoscopic intraureteral ICG instillation before LRAGS and ureteral navigation under NIRF imaging intraoperatively. Both ureteral pathways were identified from the pelvic brim downwards through NIRF imaging in all patients, even though some were not visualized under the white light mode. The fluorescent ureters were visualized immediately after the beginning of surgery and typically lasted for >5 h during surgery. There were no cases of iatrogenic ureteral injury. The hemoglobin decrement was 1.47 ± 1.13 g/dL, and no transfusion was required. In our study, both ureters in all patients were identified with ICG-NIRF imaging during LRAGS, and these techniques made surgeries easier and safer. Despite the CPP, there was no ureteral injury or transfusion following surgery. Further prospective studies are needed to introduce intraoperative ureteral guidelines for ICG-NIRF imaging during LRAGS with CPP. Full article

The actual prevalence of superficial endometriosis is not known. However, it is considered the most common subtype of endometriosis. The diagnosis of superficial endometriosis remains difficult. In fact, little is known about the ultrasound features of superficial endometriotic lesions. In this study, we aimed to describe the appearance of superficial endometriosis lesions at ultrasound examination, with laparoscopic and/or histologic correlation. This is a prospective study on a series of 52 women with clinical suspicion of pelvic endometriosis who underwent preoperative transvaginal ultrasound and received a confirmed diagnosis of superficial endometriosis via laparoscopy. Women with ultrasound or laparoscopic findings of deep endometriosis were not included. We observed that superficial endometriotic lesions may appear as a solitary lesions, multiple separate lesions, and cluster lesions. The lesions may exhibit the presence of hypoechogenic associated tissue, hyperechoic foci, and/or velamentous (filmy) adhesions. The lesion may be convex, protruding from the peritoneal surface, or it may appear as a concave defect in the peritoneum. Most lesions exhibited several features. We conclude that transvaginal ultrasound may be useful for diagnosing superficial endometriosis, as these lesions may exhibit different ultrasound features. Full article