Comparison of the ESHRE-ESGE and ASRM classifications of Müllerian duct anomalies in everyday practice

STUDY QUESTION: Does the European Society of Human Reproduction and Embryology–European Society for Gynaecological Endoscopy (ESHRE–ESGE) classification of female genital tract malformations significantly increase the frequency of septate uterus diagnosis relative to the American Society for Reproductive Medicine (ASRM) classification? SUMMARY ANSWER: Use of the ESHRE–ESGE classification, compared with the ASRM classification, significantly increased the frequency of septate uterus recognition. WHAT IS KNOWN ALREADY: The ESHRE–ESGE criteria were supposed to eliminate the subjective diagnoses of septate uterus by the ASRM criteria and replace the complementary absolute morphometric criteria. However, the clinical value of the ESHRE–ESGE classification in daily practice is difficult to appreciate. The application of the ESHRE–ESGE criteria has resulted in a significantly increased recognition of residual septum after hysteroscopic metroplasty, with a possible risk of overdiagnosis of septate uterus and problems for its management. STUDY DESIGN, SIZE, AND DURATION: A prospective observational study was performed with 261 women consecutively enrolled between June and September 2013. PARTICIPANTS/MATERIALS, SETTING, AND METHODS: Non-pregnant women of reproductive age presented for evaluation to a private medical center. A gynecological examination and 3D ultrasonography were performed to assess the anatomy of the uterus, cervix and vagina. Congenital anomalies were diagnosed using the ASRM classification with additional morphometric criteria as well as with the ESHRE–ESGE classification. We compared the frequency and concordance of diagnoses of septate uterus and all congenital malformations of the uterus according to both classifications. The morphological characteristics of septate uterus recognized by both criteria were compared. MAIN RESULTS AND ROLE OF CHANCE: Of the 261 patients enrolled in this study, septate uterus was diagnosed in 44 (16.9%) and 16 (6.1%) patients using the ESGE–ESHRE and ASRM criteria, respectively [relative risk (RR)(ESHRE–ESGE:ASRM) 2.74; 95% confidence interval (CI), 1.6–4.72; P < 0.01]. At least one congenital anomaly were diagnosed in 58 (22.2%) and 43 (16.5%) patients using the ESHRE–ESGE and ASRM classifications (RR(ESHRE–ESGE:ASRM), 1.35; 95% CI, 0.95–1.92, P = 0.1), respectively. The two criteria had moderate strength of agreement in the diagnosis of septate uterus (κ = 0.45, P < 0.01). There was good agreement in differentiation between anomaly and norm between the two assessment criteria (κ = 0.79, P < 0.01). The percentages of all congenital malformations and results of the differentiation between the anomaly and norm were obtained after excluding the confounding original ESHRE–ESGE criterion of dysmorphic uterus (internal indentation <50% uterine wall thickness). The morphology of septa identified by the ESHRE–ESGE [length of internal fundal indentation (mm): median 10.7; lower–upper quartile, 8.1–20] significantly differed (P < 0.01) from that identified by the ASRM criteria [length of internal fundal indentation (mm): median, 21.1; lower–upper quartile, 18.8–33.1]. Internal fundal indentation in 16 out of 44 (36.4%) cases was <1 cm in the septate uterus by ESHRE–ESGE and met the criteria for normal uterus by ASRM. LIMITATIONS AND REASONS FOR CAUTION: The study participants were women who visited a diagnostic and treatment center specialized in uterine congenital malformations for a medical assessment, not from the general public. WIDER IMPLICATIONS OF THE FINDINGS: Septate uterus diagnosis by ESHRE–ESGE was quantitatively dominated by morphological states corresponding to arcuate uterus or cases that were not diagnosed as congenital malformations by ASRM. Relative overdiagnosis of septate uterus by ESHRE–ESGE in these cases may lead to unnecessary overtreatment without the expected benefits. The ESHRE–ESGE classification criteria should be redefined due to confusions in the methodology. Until the criteria are revised, septate uterus should not be diagnosed using this classification system and it should not be used as an eligibility criterion for hysteroscopic metroplasty. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by Jagiellonian University (grant no. K/ZDS/003821). The authors have no competing interests to declare

Role of morphologic characteristics of the uterine septum in the prediction and prevention of abnormal healing outcomes after hysteroscopic metroplasty

STUDY QUESTION: Can morphologic measurements (width, length and surface area) of the uterine septum predict healing-dependent abnormal anatomic results [ARs; residual septum (RS) and intrauterine adhesions in other locations (IUA-OLs)] after complete hysteroscopic metroplasty (HM)? SUMMARY ANSWER: Significant predictors of ARs are the septal width and, to a lesser extent, septal surface area. WHAT IS KNOWN ALREADY: Anatomic results after hysteroscopic metroplasty have very large variation. A RS >1 cm and IUA-OLs can aggravate reproductive outcomes, resulting in the need for reoperation. New criteria for diagnosing a uterine septum according to the European Society of Human Reproduction and Embryology (ESHRE) and European Society for Gynaecological Endoscopy (ESGE) have been suggested (ESHRE-ESGE criteria). Autocross-linked hyaluronic acid gel (autocross-linked polysaccharide) has an antiadhesive effect. STUDY DESIGN, SIZE, DURATION: A prospective, observational cohort study was performed with 96 women consecutively enrolled between 2007 and 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women who had uterine septum and previous miscarriage or infertility presented for evaluation at a university hospital, private hospital or private medical center were included. Preoperative septal width, length and surface area were determined with three-dimensional sonohysterography. Women were treated by hysteroscopy in a standardized manner with three- or four-dimensional transrectal ultrasound guidance (complete resection). Patients received either no adhesion barrier (49 patients) or adhesion barrier with autocross-linked polysaccharide (47 patients). Anatomic results were assessed with three-dimensional sonohysterography and second-look hysteroscopy. Healing-dependent ARs were reported using both American Society of Reproductive Medicine (ASRM) criterion of RS length >1 cm (ASRM>1 cm criterion) and ESHRE-ESGE criteria. Univariate and multivariate logistic regression were used to identify predictors of RS, IUA-OLs and ARs. MAIN RESULTS AND ROLE OF CHANCE: In patients who had no adhesion barrier, ARs were diagnosed in 11 of 49 patients (23%) using the ASRM > 1 cm criterion and in 20 of 49 patients (41%) using the ESHRE-ESGE criteria for RS [odds ratio (OR)(ESHRE-ESGE:ASRM), 2.4, P = 0.05]. In the patients who had autocross-linked polysaccharide, ARs(ASRM) (>) (1 cm) were diagnosed in 2 of 47 patients (4%) and ARs(ESHRE-ESGE) in 4 of 47 patients (9%). RS(ESHRE-ESGE) was diagnosed significantly more often than RS(ASRM) (>) (1 cm) 19 of 96 (20%) versus 5 of 96 (5%) in all patients (OR(ESHRE-ESGE:ASRM) (>) (1 cm) = 4.5, P < 0.01). In patients who had no adhesion barrier, logistic regression with ASRM > 1 cm and ESHRE-ESGE criteria showed that the width and surface area were predictors of ARs. Models adjusted by patient group confirmed the significance of width as a predictor of ARs(ASRM) (>) (1 cm) [OR for width, 3.5 (P < 0.01); OR for group, 0.22 (P < 0.01)], width as a predictor of ARs(ESHRE-ESGE) [OR for width, 2.2 (P < 0.01); OR for group, 0.26 (P < 0.01)] and surface area as a predictor of ARs(ASRM) (>) (1 cm) [OR for surface area, 1.5 (P < 0.01)]; OR for group, 0.32 (P < 0.01). In patients who had autocross-linked polysaccharide, these predictors were not significant. Receiver-operating characteristic curves showed cutoff values for ARs(ASRM) (>) (1 cm) (septal width, 3.42 cm; septal surface area, 4.68cm(2)) and ARs(ESHRE-ESGE) (septal width, 3.42 cm; septal surface area, 3.51cm(2)). LIMITATIONS AND REASONS FOR CAUTION: Patients were enrolled in the adhesion barrier group in a time-dependent, consecutive and non-randomized manner. WIDER IMPLICATIONS OF THE FINDINGS: A wide septum and large surface area may be indications for adhesion barrier. The use of autocross-linked polysaccharide reduces the risk of ARs. The ESHRE-ESGE criteria may cause greater frequency of recognition of RS than the ASRM > 1 cm criterion, which could result in more frequent reoperations with use of the ESHRE-ESGE criteria, possibly without any significant effect on reproductive performance. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by Jagiellonian University (grant no. K/ZDS/003821). The authors have no competing interest to declare

Influence of vaginal biocoenosis on the presence of persistent atypical squamous cells and atypical glandular cells in Pap smear – a 3-year study

Abstract Aim of the study: the evaluation of influence of abnormal vaginal biocoenosis on presence and maintenance ASC and AGC in Pap smears. Methods: The study group consisted of 242 non-pregnant women (25-65 years of age): 207 women (4.96%) with atypical sqamous cells and 35 (0.7%) with atypical glandular cells. In all women the vaginal flora was assessed by Nugent scale. Results: Vaginal flora was normal in 157 (75.8%) and pathological in 50 (24.1%) women with ASC. In the ASC subgroup, the highest proportion of physiological vaginal flora was observed in 151 patients (77.4%) with ASC-US, in comparison to 44 (22.6%) with ASC-H, in which the percentage of women with normal or abnormal flora was the same (50%vs 50%). This difference was statistically significant. In case of AGC, vaginal culture was physiological in 23 (65.7%) women, and in 12 (34.3%) abnormal vaginal flora with features of the inflammation. The statistically significant influence of abnormal vaginal flora on the presence of atypical endometrial and endocervical cells was not observed. Conclusions: We did not observed any influence of abnormal vaginal flora on the presence, regression and progression of ASC and AGC

The risk of endometriosis-associated malignant transformation in a scar after cesarean section : a case report and a review of literature.

Zezłośliwienie ogniska endometriozy w powłokach brzusznych jest bardzo rzadkie. W literaturze opisano dotychczas 50 takich transformacji. Niniejszy artykuł przedstawia opis przypadku 45-letniej kobiety z rakiem endometrioidalnym, który rozwinął się na podłożu ogniska endometriozy w bliźnie po cięciu cesarskim. Czas od wykonania cięcia cesarskiego do wykrycia nowotworu wynosił 22 lata. Pacjentka zgłosiła się do Poradni Ginekologii Onkologicznej Szpitala Uniwersyteckiego w Krakowie z 15-centymetrowym guzem powłok brzusznych zlokalizowanym w regionie blizny po cięciu cesarskim. W wykonanych badaniach obrazowych: tomografii komputerowej jamy brzusznej i miednicy mniejszej oraz badaniu ultrasonograficznym stwierdzono lity guz w powłokach z naciekiem na mięśnie proste brzucha oraz przerzuty do węzłów chłonnych pachwinowych i biodrowych zewnętrznych lewych. W związku ze stopniem zaawansowania u chorej włączono chemioterapię neoadiuwantową. Ze względu na rosnący odsetek cięć cesarskich należy wziąć pod uwagę również możliwość wzrostu częstości występowania transformacji nowotworowej ogniska endometriozy w powłokach brzusznych.Malignant transformation of endometriosis in the abdominal wall is very rare. Only 50 cases have been described in literature so far. We present a case of a 45-year-old woman with endometrioid cancer, which arose from focal endometriosis in a surgical scar after cesarean section. The time elapsed between cesarean section and the diagnosis of cancer was 22 years. The patient reported to the Clinic of Gynecologic Oncology of the University Hospital in Krakow with a 15-cm abdominal wall tumor located in the region of cesarean section scar. Imaging modalities (abdominal and pelvic computed tomography and ultrasound) showed a solid tumor in the abdominal wall with invasion to abdominal muscles as well as inguinal and external iliac lymph node involvement. Due to the stage of the disease, the patient was put on neoadjuvant chemotherapy. In the light of increasing rates of cesarean section, an increased risk of malignant transformation of endometriosis in the abdominal wall should be considered

Vertical transmission of HPV in pregnancy. A prospective clinical study of HPV-positive pregnant women

Introduction: Human papillomavirus (HPV) is the most common sexually transmitted infection. Data reporting vertical transmission of HPV from the mother to the fetus are inconsistent and scant. Vertical transmission may occur by hematogenic route (transplacental), or by ascending contamination, or through the birth canal, which may result in the dreaded and rare laryngeal papillomatosis. Infected sperm at fertilization is a potential route of infection, too. Objective: The objective of the study was to evaluate the rate of vertical transmission of HPV in HPV-positive pregnant women to their newborn infants, as well as the risk factors of HPV vertical transmission. Material and methods: The clinical material was provided by 136 pregnant women, aged 18-45 years. Out of this group, 30 (22.05%) women with abnormal Pap test and positive DNA HPV test were prospectively observed. Neonatal status, i.e. DNA HPV from the nasopharyngeal smear, was recorded in all infants during the perinatal period. The conventional Pap test was performed with the cervix brush in all women. The Bethesda 2011 classification system was applied. Results: An average C Reactive Protein (CRP) concentration in the studied pregnant women was 11.6083 (Std Dev – 12.93). The most frequent cytological findings in the cervical smears from the examined women were ASCUS, n=13 (43.3%), then – LSIL, n=10 (33.3%), HSIL- n=5 (16.7%) and AGC- n=2 (6.7%). In the neonates, the presence of LR HPV DNA was detected in 9 cases (30.0%) and HR HPV DNA in 7 cases (23.3%). Fourteen neonates (46.7%) tested HPV DNA negative in the perinatal period. Conclusions: HPV infection (incidental or chronic) is observed in approximately 22% of pregnant women from the Małopolska province. Neonatal HPV infection in HPV-positive women was observed in 53.3% of the subjects. CRP concentration > 10 mg/dl in the serum of pregnant women statistically significantly (p 0.001) reduces the risk of vertical transmission of HPV from the mother to the fetus

Etiology and risk factors of pelvic organ prolapse and urinary incontinence.

Wzrost świadomości zdrowotnej kobiet i dążenie do zachowania odpowiedniej jakości życia sprawiają, że zaburzenia statyki narządów miednicy mniejszej i nietrzymanie moczu należą do częstszych przyczyn zgłaszania się kobiet do ginekologa lub urologa. Problemy związane z tą patologią od prawie dwóch dekad są tematem wielu badań. Zaburzenia statyki i nietrzymanie moczu często współistnieją ze sobą i - wbrew panującym do tej pory poglądom - wymagają specjalistycznego podejścia diagnostycznego oraz terapeutycznego. Prawidłowe przeprowadzenie procesu diagnostyczno-terapeutycznego wiąże się z koniecznością poznania i zrozumienia przyczyn tych schorzeń oraz powiązanych z nimi zaburzeń anatomii i funkcji. Około 33% pacjentek operowanych z powodu zaburzeń statyki wymaga reoperacji, co może świadczyć o tym, że podczas pierwotnego leczenia nie ustalono i nie zaopatrzono wszystkich defektów. Dokładna lokalizacja uszkodzeń w zakresie struktur dna miednicy mniejszej oraz znajomość czynników ryzyka ich wystąpienia mogą zmniejszyć odsetek powtórnych operacji. Ma to niewątpliwie duże znaczenie w odniesieniu do starzenia się populacji, gdyż wzrastać będzie liczba kobiet dotkniętych tymi schorzeniami, a to z kolei będzie się przekładać na obniżenie jakości ich życia.Due to the increased health awareness of women and their desire to maintain appropriate life quality, pelvic organ prolapse and urinary incontinence are the most common reasons for reporting to a gynecologist or a urologist. Problems associated with this pathology have been the subject of research for more than two decades. Pelvic organ prolapse and urinary incontinence often coexist and, contrary to previous beliefs, they require specialist diagnostic and therapeutic approaches. Proper diagnostic and therapeutic process requires knowledge and understanding of these conditions as well as the associated anatomical and functional anomalies. A revision surgery is needed in about 33% of patients receiving surgical treatment due to pelvic organ prolapse, which may indicate that the primary treatment failed to identify and manage all defects. Precise location of pelvic floor damage and knowledge on its risk factors may reduce the rates of revision surgeries. Considering the ageing of the population, this is undoubtedly of great importance as the number of women presenting with these conditions will continue to grow, which will translate into reduced quality of life

Pelvic exenteration in modern gynecologic oncology : own experiences

Cel pracy: Analiza wskazań do zabiegu wytrzewienia oraz powikłań śród- i pooperacyjnych, na podstawie przypadków z jednego ośrodka ginekologii onkologicznej w ostatnich 5 latach. Materiał i metody: Szczegółowy przegląd dokumentacji medycznej pacjentek, u których wykonano zabieg wytrzewienia miednicy mniejszej w ciągu ostatnich 5 lat (od roku 2014 do 2018). W przeglądzie nie uwzględniono wytrzewień z powodu raka jajnika. Analizie poddano wskazania do zabiegu, wiek operowanych, lokalizację i typ histologiczny guza, przebyte wcześniej leczenie, stan sprawności i współchorobowość, cel i rodzaj zabiegu, czas trwania zabiegu, powikłania wczesne i późne wg klasyfikacji Claviena–Dindo, sposób odprowadzenia moczu, osiągnięte marginesy operacyjne. Wyniki: W okresie od początku 2014 do pierwszej połowy 2018 roku wykonano 8 zabiegów wytrzewienia miednicy mniejszej – 5 z intencją wyleczenia, 3 paliatywnie. Połowę chorych stanowiły przypadki wznowy raka sromu. Średni czas trwania zabiegu wyniósł 315 minut, średni czas pobytu w oddziale – 24,38 dnia. Wczesne powikłania pooperacyjne o różnym stopniu ciężkości wystąpiły w każdym operowanym przypadku, w tym powikłania ciężkie (IIIb–V wg Claviena–Dindo) u 5 kobiet (62,5%). Nie odnotowano zgonu we wczesnym okresie pooperacyjnym. Powikłania późne zaobserwowano łącznie u 6 pacjentek (75,0%), w tym jeden zgon 11 miesięcy po egzenteracji paliatywnej. Wnioski: Zabieg wytrzewienia miednicy mniejszej pomimo postępu w opiece okołooperacyjnej łączy się z wysokim ryzykiem powikłań, często zagrażających życiu. Każdy przypadek kwalifikujący się do tak radykalnego zabiegu operacyjnego należy traktować indywidualnie, a sama procedura powinna zostać przeprowadzona w ośrodku dysponującym odpowiednią kadrą i sprzętem medycznym.Aim: Analysis of indications for the procedure of exenteration, and intra- and postoperative complications, based on cases from a single gynecologic oncology center over the past 5 years. Material and methods: Detailed review of medical records of female patients who underwent pelvic exenteration surgery over the last 5 years (2014–2018). The review excluded cases of exenteration for ovarian cancer. The analysis included indications for the procedure, age of operated patients, location and histological type of tumor, prior treatment history, performance status and comorbidities, purpose and type of procedure, duration of operation, early and late complications according to the Clavien–Dindo classification, method of urinary diversion, and achieved surgical margins. Results: A total of 8 pelvic exenteration procedures were performed between early 2014 and mid-2018, including 5 procedures with the intention to cure, and 3 palliative procedures. Half of the cases involved patients with recurrence of vulvar cancer. The mean duration of the procedure was 315 minutes, while the mean duration of stay in the hospital ward was 24.38 days. Early postoperative complications of varying severity occurred in each operated case, with severe complications (grades IIIb–V based on the Clavien-Dindo classification) observed in 5 women (62.5%). There were no deaths in the early postoperative period. Late complications were observed in a total of 6 women (75.0%), including one death 11 months after palliative exenteration. Conclusions: Despite advances in perioperative care, pelvic exenteration is associated with a high risk of complications which are often life-threatening. The eligibility of patients for this radical surgical approach should be assessed on a case-by-case basis, and the procedure itself should be carried out in a medical center with properly trained staff and medical equipment