Alessandro Ginetti

Ovarian remnant syndrome: an unsuspected diagnosis - Facts, Views and Vision in ObGyn

Several complications can occur during laparoscopic gynecological surgery. The insertion of trocars and the induction of pneumoperitoneum are essential steps, but they can still pose potential risks during laparoscopic surgery. Bowel injuries are the most common during gynecological procedures as a result of thermal damage and trocar placement, while vessel injuries may carry a high mortality rate. Gynecologic surgeons should be aware of the risks associated with laparoscopic procedures and be able to prevent and treat potential complications. We conducted a literature search using three electronic databases (Pubmed/MEDLINE, Google Scholar, Embase) from inception to May 2024 to identify the most common intraoperative gynecological laparoscopic complications, including those related to trocar insertion, bowel, urinary, and vessel injury. The aim of this narrative review is to describe the most common complications during gynecological laparoscopic surgery and to outline the safety rules and techniques necessary for their prevention and treatment.

Endometrial cancer is the most common gynecological neoplasm with an increased incidence in the premenopausal population in recent decades. This raises the problem of managing endometrial cancer in fertile women who have not yet achieved pregnancy. In these women, after careful selection, hysterectomy may be postponed in favor of conservative management if specific requirements are met. The latest evidence is focused on early endometrial carcinoma, endometrioid histotype, Grading 1, with no evidence of myometrial infiltration. Few clinical trials have opened this possibility also for women with an endometrial cancer Grading 2 diagnosis. There are still questions about the best medical therapy, dosage, route, and duration of treatment. Oral progestins or levonorgestrel-releasing intrauterine devices appear to be the options associated with the best outcome in terms of complete response and lower recurrence rates. Other options include the use of GnRH analogues, surgical hysteroscopy, or metformin, in a therapeutic approach that takes into account the characteristics of the patient. The pursuit of pregnancy should start as soon as two consecutive endometrial biopsies are obtained 3 months apart from each other; it is recommended to refer the patients to ART centers to maximize the success rate. After having reached the fulfillment of the reproductive desire, surgical radical treatment is still recommended.

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.

Adenomyosis is a chronic, hormone-related disease characterized by the presence of the endometrial glands and stroma within the myometrium. This condition can manifest in various features, focal or diffuse adenomyosis or as an adenomyoma, and it may involve different uterine walls (posterior, anterior, and/or lateral walls). The disease can also be classified into different degrees, as mild, moderate and severe, which can be associated with more intense symptoms, although this correlation is not always directly proportional. In fact, adenomyosis can be asymptomatic in about a third of cases or it can significantly impact patients’ quality of life through painful symptoms, such as dysmenorrhea and dyspareunia, abnormal uterine bleeding—particularly heavy menstrual bleeding—and potential effects on fertility. Historically, adenomyosis has been considered a disease primarily affecting premenopausal women over the age of 40, often multiparous, because the diagnosis was traditionally based on surgical reports from hysterectomies performed after the completion of reproductive desire. Data on the presence of adenomyosis in adolescent patients remain limited. However, in recent years, advancements in noninvasive diagnostic tools and increased awareness of this pathology have enabled earlier diagnoses. The disease appears to have an early onset during adolescence, with a tendency to progress in terms of extent and severity over time. Adenomyosis often coexists with endometriosis, which also has an early onset. Therefore, it is important, when diagnosing adenomyosis, to also screen for concomitant endometriosis, especially deep endometriosis in the posterior compartment. The aim of this narrative review is to investigate the prevalence of different types and degrees of adenomyosis in younger patients, assess the associated symptoms, and describe the most appropriate diagnostic procedures for effective therapeutic management and follow-up, with the goal of improving the quality of life for these young women.

Uterine leiomyomas are the most common benign uterine tumors in women and are often asymptomatic, with clinical manifestation occurring in 20–25% of cases. The diagnostic pathway begins with clinical suspicion and includes an ultrasound examination, diagnostic hysteroscopy, and, when deemed necessary, magnetic resonance imaging. The decision-making process should consider the impairment of quality of life due to symptoms, reproductive desire, suspicion of malignancy, and, of course, the woman’s preferences. Despite the absence of a definitive cure, the management of fibroid-related symptoms can benefit from various medical therapies, ranging from symptomatic treatments to the latest hormonal drugs aimed at reducing the clinical impact of fibroids on women’s well-being. When medical therapy is not a definitive solution for a patient, it can be used as a bridge to prepare the patient for surgery. Surgical approaches continue to play a crucial role in the treatment of fibroids, as the gynecologist has the opportunity to choose from various surgical options and tailor the intervention to the patient’s needs. This review aims to summarize the clinical pathway necessary for the diagnostic assessment of a patient with uterine fibromatosis, presenting all available treatment options to address the needs of different types of women.

To evaluate the feasibility of hysteroscopy with morcellator without anesthesia and the diagnostic accuracy of 2D, 3D and power Doppler transvaginal sonography (TVS) in patients with abnormal uterine bleeding (AUB). This was a retrospective study including women with AUB. All patients underwent 2D, 3D and power Doppler TVS evaluation of the uterine cavity, and patients with suspicion on ultrasound (US) of endometrial pathology (EP) underwent hysteroscopy with morcellator without anesthesia. The painful symptomatology was assessed during the procedure using a visual analogue scale (VAS). Additionally, histological evaluation was performed. A total of 182 women underwent US imaging, of whom 131 (72%) had hysteroscopy. 130/131 patients completed the hysteroscopic examination with good compliance (VAS <4). One patient (0.8%) was unable to complete the procedure due to nulliparity and cervical stenosis. Of the 130 patients the US diagnosis was confirmed in 120 (92.3%), while in 10 patients (7.7%) the hysteroscopic diagnosis was different from the US diagnosis. Histological examination confirmed benign endometrial polyps in 115/130 patients (88.5%), while premalignant conditions were diagnosed in 3/130 patients (2.3%) and malignant conditions in 2/130 (1.5%). Of the 10 patients with endometrial thickening, two were diagnosed with a malignant condition. This study confirmed the feasibility of managing patients with AUB and suspicion of EP using "see-and-treat" hysteroscopy with morcellator without anesthesia. This procedure has the potential to yield desired outcomes while minimizing pain and discomfort, presenting a feasible outpatient approach for both treating and preventing endometrial carcinoma without requiring anesthesia.

Endometriosis has a prevalence of 10% worldwide in premenopausal women. Probably, endometriosis begins early in the life of young girls, and it is commonly diagnosed later in life. The prevalence of deep infiltrating endometriosis (DIE) in adolescence is currently unknown due to diagnostic limits and underestimation of clinical symptoms. Dysmenorrhea is a common symptom in adolescents affected by DIE, often accompanied by dyspareunia and chronic acyclic pelvic pain. Ultrasonography—either performed transabdominal, transvaginal or transrectal—should be considered the first-line imaging technique despite the potential for missed diagnosis due to early-stage disease. Magnetic resonance imaging should be preferred in the case of virgo patients or when ultrasonographic exam is not accepted. Diagnostic laparoscopy is deemed acceptable in the case of suspected DIE not responding to conventional hormonal therapy. An early medical and/or surgical treatment may reduce disease progression with an immediate improvement in quality of life and fertility, but at the same time, painful symptoms may persist or even recur due to the surgery itself. The aim of this narrative review is to report the prevalence of DIE in adolescents, describe the pathogenetic theories and discuss the management in adolescent women, including the challenging road to diagnosis and the treatment alternatives.